Obama violating rights...STRUCK DOWN!

EdsonNascimento · August 2011

I will give you 2 stories. Some details are stricken for HIPAA reasons.

1. Middle aged woman has diabetes, CHF and had spinal fusion surgery. Keeps breaking bones in falls in their house. PCP doesn't have a clue what to do. Specialists have no ideas. Nurse from insurance company visits house - sees the patient has high steps in and out of the house b/c it's an older house and not under current code. HEALTH insurance company hires and pays someone to design and build an elaborate ramp (it actually had to loop around once b/c the stairs were so steep), and now the woman can get in and out of her house without any problem. BTW, elaborate privately designed ramps are not covered by insurance coverage. Patient's bill - $0. According to the woman - life changing. Would Canada's system even consider this (let alone pay for it)?

2. Young girl has a serious illness from birth. 2 Nuerosurgeons independently determine that a particular surgery is not recommended b/c the risks far outweigh the remotely possible reward (which would be temporary anyway). 3rd surgeon determines it's necessary, but in submitting the paperwork submits literature that STONGLY recommends that it is contra-indicated (As in not only is it unnecessary, but is detrimental). Now, the company only finds out about the first 2 doctor's findings b/c the 3rd surgeon submitted it with the medical record (that is, it was not the company denying - they never even saw a request - it was the doctors on their own). Now, the 3rd doctor is going to charge $750,000 for a service other equally qualified surgeons would do for $100,000. The company talks to the parents to expain the contra-indications. The parents (well, really the mother) is adamant about having the surgery even though the risks ranging from paralysis (somewhat likely) to death (not too remotely impossible) only have a 10% chance of mitigating any of the symptoms (and not curing anything). Now, I can certainly understand the mother being in this state. But, read that again. It's an ultra sad story. So, insurance company agrees to go ahead with surgery, but wants the parents and doctor to take full responsibility for outcomes (i.e. sign affidavits absolving company of possible outcomes) and do it for the "in network" price.

The parents are unwilling to sign and the doctor is unwilling to sign or do it for that price. During all this, the company offers to pay for a 2nd opinion at the doctor of the parents' choosing (Well, really this is the 4th opinion and 4th doctor of their choosing if you've been following). Complete refusal.

Who is acting in the patient's (the little girl's) best interest here? And if this were taking place in Canada, would any of this even be considered since the girl's projected life span is another 5 years if she's lucky? It is an extremely heart wrenching story. On top of which, the mother tells the nurse handling the case that she hopes she and her children die. The nurse is beside herself b/c she's trying to do right by the patient and this is what she gets. (and this nurse is the nicest person you'd ever hope to meet - I do not understand the parent going there).

Those are what the debate should be about.

EdsonNascimento · August 2011

Prince Of Dorkness wrote:

EdsonNascimento wrote:

Here's the (not so) funny part of this story - you blame the insurance company for this.

Oh... no, I don't.

I blame the entire system that's meant to make money and not make people well. This isn't an insurance company's fault.

And legally, they are required to provide treatment regardless of insurance. You should have reported them if you believe they provided sub-par service.

They did "treat" him. They gave him a few x-rays, some drugs and a sling.

Fair point on the first one. I think we all agree the system needs to be fixed. I just don't think single payer, Feds is the best option.

You are right about the "treat," but it sounds like malpractice. That is punishable.

Prince Of Dorkness · August 2011

EdsonNascimento wrote:

Fair point on the first one. I think we all agree the system needs to be fixed. I just don't think single payer, Feds is the best option.

You are right about the "treat," but it sounds like malpractice. That is punishable.

Well it would be if he wasn't a 21 year-old with no money for a lawyer going up against a huge hospital with a wing full of lawyers.

As far as your examples above.. yes, the Canadian system would handle those the same way.

EdsonNascimento · August 2011

Prince Of Dorkness wrote:

Coming from Canada.. I know that it just doesn't happen like that up there. Their system isn't built around wringing as much money from people as they can.

You are right about that, as well. They can't - Government fixes prices. And that's why I think the providers are misguided in pushing for that. They won't like that very much.

BUT, has the Government managed anything effeciently? So, what makes us think these fixed prices would be the best you could get? They could have a draconian system that basically scares any semi-intelligent person away from med school. But, that's no good either. Who CAN'T envision when the Gov't will overpay for everything and drive insurance rates (taxes) through the roof?

And in Canada, some of the best doctors simply opt out and create a premium driven private plan for rich folks.

EdsonNascimento · August 2011

Prince Of Dorkness wrote:

EdsonNascimento wrote:

Fair point on the first one. I think we all agree the system needs to be fixed. I just don't think single payer, Feds is the best option.

You are right about the "treat," but it sounds like malpractice. That is punishable.

Well it would be if he wasn't a 21 year-old with no money for a lawyer going up against a huge hospital with a wing full of lawyers.

As far as your examples above.. yes, the Canadian system would handle those the same way.

Right - I wasn't suggesting you sue them necessarily. Report it to the State. The Facility has to respond to EVERY report.

And if you did sue - you wouldn't be fighing the hospital - you'd be fighting the malpractice insurer.

Prince Of Dorkness · August 2011

EdsonNascimento wrote:

And in Canada, some of the best doctors simply opt out and create a premium driven private plan for rich folks.

In Canada.. I think that's illegal.

That said... fine. let the ultra rich get premium service. Just as long as everyone else has at least basic care.

keeponrockin · August 2011

EdsonNascimento wrote:

Prince Of Dorkness wrote:

Coming from Canada.. I know that it just doesn't happen like that up there. Their system isn't built around wringing as much money from people as they can.

You are right about that, as well. They can't - Government fixes prices. And that's why I think the providers are misguided in pushing for that. They won't like that very much.

BUT, has the Government managed anything effeciently? So, what makes us think these fixed prices would be the best you could get? They could have a draconian system that basically scares any semi-intelligent person away from med school. But, that's no good either. Who CAN'T envision when the Gov't will overpay for everything and drive insurance rates (taxes) through the roof?

And in Canada, some of the best doctors simply opt out and create a premium driven private plan for rich folks.

Honestly, in Canada, any time a relative has needed urgent care (heart attack/bypass, cancer treatment, etc..) they have been treated exceptionally quickly.

EdsonNascimento · August 2011

keeponrockin wrote:

Honestly, in Canada, any time a relative has needed urgent care (heart attack/bypass, cancer treatment, etc..) they have been treated exceptionally quickly.

US, too. I'm sure both countries can produce (unfortunate) horror stories.

fife · August 2011

[

i understand what you are saying but like i said before. who should have the power to determine that?

also sometimes what is considered unnecessary test are necessary. i remember back in the 80's and early 90's many women where not being test for HIV cause most people believed that it was just a gay man issues. i think we all know now that this is not correct.[/quote]

Doctors should determine what is necessary and what is not. Who wouldn't think that?

And who thinks insurance companies don't have DOCTORS doing that? That's the misinformed part. The media here has folks believing CFO's are. That is 100% incorrect. The insurance companies are regulated and must file all medical protocols with CMS (For Medicare) or the State (For Medicaid and Commercial/Individual). There are also stringent appeal rights, third party reviews, etc.

If they made decisions not based on medical criteria, they would be put out of business.

Are they perfect - no. But, anyone who thinks their pesonal doctor is - well - there's a bridge in Brooklyn I have for sale.

As for the HIV testing - that was not insurance protocol - that was common misconception. It happens all the time in life. And that "conventional wisdom" changed for the better.[/quote]

i have no doubt that insurance companies have doctors. and since you work in insurance, i just have a question for you. if a doctor is getting paid from the insurance company don't you think that maybe they might side more with the people who pay them? i don't know the answer to that and hope you can answer that. for me there seems to be a conflict of interest there.

fife · August 2011

EdsonNascimento wrote:

Prince Of Dorkness wrote:

Coming from Canada.. I know that it just doesn't happen like that up there. Their system isn't built around wringing as much money from people as they can.

You are right about that, as well. They can't - Government fixes prices. And that's why I think the providers are misguided in pushing for that. They won't like that very much.

BUT, has the Government managed anything effeciently? So, what makes us think these fixed prices would be the best you could get? They could have a draconian system that basically scares any semi-intelligent person away from med school. But, that's no good either. Who CAN'T envision when the Gov't will overpay for everything and drive insurance rates (taxes) through the roof?

And in Canada, some of the best doctors simply opt out and create a premium driven private plan for rich folks.

your also correct here. the government here in Canada does set the prices on what a doctor can charge for things. but to be honest, i know many doctors and they are not just scrapping by.

Sludge Factory · August 2011

fife wrote:

i have no doubt that insurance companies have doctors. and since you work in insurance, i just have a question for you. if a doctor is getting paid from the insurance company don't you think that maybe they might side more with the people who pay them? i don't know the answer to that and hope you can answer that. for me there seems to be a conflict of interest there.

Couldn't your same question be applied to mandated insurance that is handled by the government? Wouldn't it just put the government in the place of the insurance company as the payor?

fife · August 2011

Sludge Factory wrote:

fife wrote:

i have no doubt that insurance companies have doctors. and since you work in insurance, i just have a question for you. if a doctor is getting paid from the insurance company don't you think that maybe they might side more with the people who pay them? i don't know the answer to that and hope you can answer that. for me there seems to be a conflict of interest there.

Couldn't your same question be applied to mandated insurance that is handled by the government? Wouldn't it just replace the insurance company as the payor with the government?

no, as was mentioned before, i believe that any decision about your health should be decided by only you and your doctor. the government or the insurance company should not have a say it what you decide.

keeponrockin · August 2011

fife wrote:

EdsonNascimento wrote:

Prince Of Dorkness wrote:

Coming from Canada.. I know that it just doesn't happen like that up there. Their system isn't built around wringing as much money from people as they can.

You are right about that, as well. They can't - Government fixes prices. And that's why I think the providers are misguided in pushing for that. They won't like that very much.

BUT, has the Government managed anything effeciently? So, what makes us think these fixed prices would be the best you could get? They could have a draconian system that basically scares any semi-intelligent person away from med school. But, that's no good either. Who CAN'T envision when the Gov't will overpay for everything and drive insurance rates (taxes) through the roof?

And in Canada, some of the best doctors simply opt out and create a premium driven private plan for rich folks.

your also correct here. the government here in Canada does set the prices on what a doctor can charge for things. but to be honest, i know many doctors and they are not just scrapping by.

My family Doctor drives a benz and lives in the nicest/trendiest area of the city, he's doin alright!

EdsonNascimento · August 2011

fife wrote:

i have no doubt that insurance companies have doctors. and since you work in insurance, i just have a question for you. if a doctor is getting paid from the insurance company don't you think that maybe they might side more with the people who pay them? i don't know the answer to that and hope you can answer that. for me there seems to be a conflict of interest there.

Well, obviously, they look at things from a different perspective. But, all Medical Directors (the doctors at the insurance company) must be licensed in the State they are "practicing" and carry malpractice insurance like any other doctor (though it is cheaper).

They also must follow the clinical guidelines of the organization which must be submitted for review to the regulating (State or Federal) entity. These guidelines must cite source and relevance. There are 2 or 3 "standards" that are out there for general stuff, but most of these guideliness are based on AMA or specialty specific professional organizations that are populated by many more doctors that are "practicing" physicians than "insurance" doctors. All "denials" must be documented with reasons and source. They are "eligible" to be appealed and then have 3rd party review. It's a lot of work for an insurance company to deny something. So, this concept that they are denying for petty things is ridiculous. Yes, some poor decisions get made from time to time. And, there are checks and balances for that, also.

I know my organization denies very little (you'd be amazed at the %'s). Most times, our doctors will talk to the requesting physician and the requesting physician will withdraw/cancel the request. Now, you can look at that in some nefarious way. But, what happens many times it the requesing physician does not have all the information the insurer has. Or, the service isn't really necessary and just by asking a few questions the requesting physician admits as much. Or, doctors are just "caught" doing dangerous (there's no other word for it) things thinking nobody is watching.

One classic example is we track the history of GI scopes - we've had doctors request a 3rd or 4th colonoscopy on some poor guy within a single year. We bring this to their attention and they go - oh! I had no idea! We let them off with that when this very same doctor was the same one that did the 2 or 3 before. I don't know all the clinical details, but at some point, if it's not working, you gotta try something else.

Most good providers don't mind the oversight. They are confident in what they do, and answer the questions and move on with their lives.

EdsonNascimento · August 2011

fife wrote:

your also correct here. the government here in Canada does set the prices on what a doctor can charge for things. but to be honest, i know many doctors and they are not just scrapping by.

No doubt.

I will say this - in the US we could solve a lot of problems with 1 very simple fix - tort reform. I understand folks need remuneration when a doctor messes up. But, they don't need them and their progeny to be set for their and their future family's life b/c of a mistake. The damage should be covered. Punishment should be paid. But, enough is enough.

There are OB/Gyn's that basically spend 80% of their year paying their malpractice insurance b/c if 1 child gets born with some deformity and everyone must pay.

If we fixed tort reform and the premiums being paid on malpractice we'd see a significant drop in health care costs (and remove the lame excuse of defensive medicine that some weaker providers try to play off of).

keeponrockin · August 2011

EdsonNascimento wrote:

fife wrote:

your also correct here. the government here in Canada does set the prices on what a doctor can charge for things. but to be honest, i know many doctors and they are not just scrapping by.

No doubt.

I will say this - in the US we could solve a lot of problems with 1 very simple fix - tort reform. I understand folks need remuneration when a doctor messes up. But, they don't need them and their progeny to be set for their and their future family's life b/c of a mistake. The damage should be covered. Punishment should be paid. But, enough is enough.

There are OB/Gyn's that basically spend 80% of their year paying their malpractice insurance b/c if 1 child gets born with some deformity and everyone must pay.

If we fixed tort reform and the premiums being paid on malpractice we'd see a significant drop in health care costs (and remove the lame excuse of defensive medicine that some weaker providers try to play off of).

Can we have tort reform, and with the costs apparently lowered, then pay for a universal system.

I guess what I don't understand about the USA is why people have no problems paying to bomb the shit out of another country, but balk at having to pay so their neighbour won't go bankrupt if he gets sick.

EdsonNascimento · August 2011

keeponrockin wrote:

Can we have tort reform, and with the costs apparently lowered, then pay for a universal system.

I guess what I don't understand about the USA is why people have no problems paying to bomb the shit out of another country, but balk at having to pay so their neighbour won't go bankrupt if he gets sick.

Specious argument. Whether I agree with the war(s) or not is irrelevant. If we never spent another dime on foreign soil, I still don't think government run health care is the right way to go. One has nothing to do with the other. Just because I save money on the war effort doesn't mean I have to spend it on ineffecient government run health care.

Now, I guess I should clarify - when folks talk about universal coverage, they generally mean a government run health care system. If you wanted to pay for everyone and then have mandated managed care or something NY State Medicaid does this), then maybe. But, I'm guessing that's not what most folks intend. They just want plain old - I go to a doctor and I want someone (else) to pay for whatever I get type coverage. Which is NOT what Canada has.

EdsonNascimento · August 2011

keeponrockin wrote:

but balk at having to pay so their neighbour won't go bankrupt if he gets sick.

Most "uninsureds" could afford "sleep at night" coverage if they so desired. That is, high deductible, major medical style indemnity coverage. Nobody goes bankrupt because of a $5,000 deductible which quite frankly, most facilities would waive if they had a large enough hospital stay being paid for. But, folks decide not to. They can afford concert tickets, but not medical insurance to cover a catastrophe.

EdsonNascimento · August 2011

RFTC wrote:

sorry man, re. 'theres details missing here' i hope your joking.

re. the employer base HMO coverage, that was irrelevant, my wife was (at that time) a private contractor/1099 as are millions of other americans in the same boat. they gotta shop for a privately insured plan. sure there are catastrophic plans (which she did for 1 year), boy those are really fkd up.

I'm sorry. I didn't mean to offend. That just sounds odd to me. Is there a history of smoking? Family history of diabetes? Is there any other mitigating circumstances?

I'm not saying you are lying. I've just never heard of someone that young (assuming she gave birth such a short time ago) being denied coverage simply for high blood pressure. I guess I may have learned something new. So, thank you. My bad. And I certainly wrote it in the worst way possible.

fife · August 2011

EdsonNascimento wrote:

fife wrote:

i have no doubt that insurance companies have doctors. and since you work in insurance, i just have a question for you. if a doctor is getting paid from the insurance company don't you think that maybe they might side more with the people who pay them? i don't know the answer to that and hope you can answer that. for me there seems to be a conflict of interest there.

Well, obviously, they look at things from a different perspective. But, all Medical Directors (the doctors at the insurance company) must be licensed in the State they are "practicing" and carry malpractice insurance like any other doctor (though it is cheaper).

They also must follow the clinical guidelines of the organization which must be submitted for review to the regulating (State or Federal) entity. These guidelines must cite source and relevance. There are 2 or 3 "standards" that are out there for general stuff, but most of these guideliness are based on AMA or specialty specific professional organizations that are populated by many more doctors that are "practicing" physicians than "insurance" doctors. All "denials" must be documented with reasons and source. They are "eligible" to be appealed and then have 3rd party review. It's a lot of work for an insurance company to deny something. So, this concept that they are denying for petty things is ridiculous. Yes, some poor decisions get made from time to time. And, there are checks and balances for that, also.

I know my organization denies very little (you'd be amazed at the %'s). Most times, our doctors will talk to the requesting physician and the requesting physician will withdraw/cancel the request. Now, you can look at that in some nefarious way. But, what happens many times it the requesing physician does not have all the information the insurer has. Or, the service isn't really necessary and just by asking a few questions the requesting physician admits as much. Or, doctors are just "caught" doing dangerous (there's no other word for it) things thinking nobody is watching.

One classic example is we track the history of GI scopes - we've had doctors request a 3rd or 4th colonoscopy on some poor guy within a single year. We bring this to their attention and they go - oh! I had no idea! We let them off with that when this very same doctor was the same one that did the 2 or 3 before. I don't know all the clinical details, but at some point, if it's not working, you gotta try something else.

Most good providers don't mind the oversight. They are confident in what they do, and answer the questions and move on with their lives.

thanks. and i agree with you that doctors make mistake and will order the same tests a couple of times. happen to my mom here in Canada when she had cancer. i just have met to many people who have been deny some type of test that may have saved their lives but wasn't approved as the insurance company didn't believed that it was needed.

Obama violating rights...STRUCK DOWN!

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