Insurance company denies treatment for a 5 year old

[yllus]

You think Universal Healthcare would cover a drug not approved of by the FDA? :RoLL EYES:

An unapproved use is NOT the same as experimental therapy. The latter comes up for review for private insurance AND government health care.

I see the rate of rejection being no lower for government programs that private insurance. "UHC will cover this!" is bogus.

Both of you are correct.

In fact, a number of recent news stories I can recall here in Canada have had patients in need of treatment traveling to the U.S. because your FDA is quicker at approving new treatments than our counterpart agency (Health Canada) is.

 

[werepossum]

Could that be because people covered under medicare and medicaid are more likely to seek treatment for ailments that don't warrant treatment or in the case of the elderly, that won't increase quality of life or significantly increase longevity?

Maybe, in part. It's hard to say because those judgments are necessarily subjective. Or at least I've never seen a study purporting to answer that kind of question. That is the essence of the insurance company's refusal in this case, though - that this treatment is not proven to increase quality of life or significantly increase longevity.

 

[WhipperSnapper]

A lot of the percieved savings in administrative in Medicare vs Private insurance has to do with Medicare shoveling the costs onto the providers. Also the admin costs is a %. Avg private insurance per capita is about 2800 vs 6500 for Medicare. If it cost 150 bucks to process a claim the system with a lower avg cost will see a higher avg admin cost. I can gurantee you a lot of the paper pushers in those private insurance companies will be hired by a govt run program to perform the exact same job function.

And what % of the system is profit? Insurance companies last year cleared about 15-20 billion out of 2 trillion. We are talking pennies on a dollar.

If we were serious about saving money we would tackle fraud. There was a thread about 2 months ago that had a study that estimated about 250 billion dollars a year is wasted within the system due to fraud. That would be a bigger boon to the system than trying to eliminate 1% profit and 3% of admin costs.

What I'm proposing is to eliminate the claims system and policies all together. No one would be needed to process your claim and then pay the hospital and doctors in your name because the system wouldn't work that way. The government would fund the hospitals and pay the doctors (call it communized medicine). You would simply go to the medical facility and receive treatment (or be told to wait or be turned down if appropriate) with little paperwork involved. The upper class and the wealthy (or anyone) would be free to purchase private insurance plans or supplemental plans and to purchase privately-provided health care at private facilities if they wish.

Somehow, magically, other nations seem to be able to do it for a smaller percentage of GDP and reap the benefits of their systems. I'm not certain that the British system is better than the French system or that the French system is better than the Swiss or Taiwanese system. What is certain is that our current half-free market, half-socialized system is an abomination that has failed the public and needs to be completely overhauled.

What is your solution to our problem? What do you propose that we do? Under your system would the poor and lower classes die if they become sick? Would all but the solid middle class and the upper classes end up living in abject poverty as a result of the costs? Would a job loss or sickness end up leading to bankruptcy and poverty?

There's a lot of grumbling from people who want to keep our current system but few solutions coming from them other than to end lawsuits which won't go far to fix our problems anyway (firmly putting the costs of medical negligence onto injured persons) or to just let members of the lower classes suffer and die.

 

[Mxylplyx]

While it seems heartless, our medical payment model asks private companies to operate like an insurance company, and then not operate like an insurance company out of humanitarian concerns. This just goes to show how fucked up the whole system is. Medical insurance, in it's current form, needs to be done away with.

 

[Genx87]

What I'm proposing is to eliminate the claims system and policies all together. No one would be needed to process your claim and then pay the hospital and doctors in your name because the system wouldn't work that way. The government would fund the hospitals and pay the doctors (call it communized medicine). You would simply go to the medical facility and receive treatment (or be told to wait or be turned down if appropriate) with little paperwork involved. The upper class and the wealthy (or anyone) would be free to purchase private insurance plans or supplemental plans and to purchase privately-provided health care at private facilities if they wish.

So you want to socialize the providers as well? There will still be a claims process because a paper trail will be needed for auditing. Unless you want rampant fraud within the system.

Somehow, magically, other nations seem to be able to do it for a smaller percentage of GDP and reap the benefits of their systems. I'm not certain that the British system is better than the French system or that the French system is better than the Swiss or Taiwanese system. What is certain is that our current half-free market, half-socialized system is an abomination that has failed the public and needs to be completely overhauled.

I cant disagree with our system needs reform. It clearly does.

What is your solution to our problem? What do you propose that we do? Under your system would the poor and lower classes die if they become sick? Would all but the solid middle class and the upper classes end up living in abject poverty as a result of the costs? Would a job loss or sickness end up leading to bankruptcy and poverty?

Why do you always assume such a far fetched radical proposal when you talk to people with opposing views? Yeah, my plan includes a litmus test. No insurance and the secret police haul you away to the camps to be liquidated.

My system would look more like a HSA based private system with a private\public catastrophic option. The bottom line is we are dicsonnected from the costs of the system via a private\public run entitlement system. We need to involve some kind of demand curtailing mechanism. People using their own money will see the rate at which they utilize the system drop due to not wanting to visit the doctor because they have a cough. The catastrophic public option is there to cover people who have run through their HSA and require major medical treatment.

I still dont have a plan on rationing when it comes to scenarios like this thread. But it will need to be done because the other bullet point in my personal reform plan is end of life care. It's costs has to be contained. The majority of anybody's lifetime medical costs are in the final stages. Typically the last 24 months.

And of course there are other issues that need to be looked into including fraud, paperwork efficiencies, tort reform ect.

There's a lot of grumbling from people who want to keep our current system but few solutions coming from them other than to end lawsuits which won't go far to fix our problems anyway (firmly putting the costs of medical negligence onto injured persons) or to just let members of the lower classes suffer and die.

My grumbling comes from the fact the plan on the table as it stands doesnt address a damn thing when it comes to costs. In the end it is just a foot in the door for a bigger govt takeover that wont result in any meaningful reform on the system. Only more power to politicians to dictate our lives to us.

 

[Hayabusa Rider]

There is NO solution to increasing medical costs. The population is aging and the only way around it is Logan's Run's Carousel.

"Communizing" medicine or any other scheme isn't going to stop severe rationing if keeping costs down is the primary goal of "health care reform"

 

[BoberFett]

It's been proven to be less expensive in other first world nations. When you eliminate all of the paper pushers who have nothing to do with actually delivering health care to people--the insurance companies, medical billings people, insurance brokers, company benefits plan managers, etc., you can save a whole lot of money and enjoy increased efficiency.

It's been shown that the U.S. is currently spending 17% of its GDP on health care while leaving tens of millions of Americans uninsured or under-insured with the rest living in sheer terror of losing their jobs and health insurance while having hundreds of thousands of medical bankruptcies and businesses and an economy burdened by insurance issues.

In contrast, other nations spend a smaller percentage of their GDP on health care while having 100% coverage, zero medical bankruptcies, and businesses and economies that aren't burdened by insurance concerns.

How do you explain that? Basically, by removing all of the inefficiency inherent in our type of system, they're able to do all of that for a smaller percentage of GDP. Why can't the U.S. do the same?

Anyone concerned about this issue should watch this excellent PBS program that looks at other nation's health systems and how they do it:

http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

You think half of your medical bill goes toward paper pushing?

And what do you think the government does? That's an organization of nothing BUT paper pushers?

 

[BoberFett]

It's interesting that some people feel that the government would pay for this, but the cost of health care would decrease. A Mercedes at a Fiesta price tag. Nope.

Semantics 101:
Insurances generally cover medication which is generally accepted as safe and effective, but not officially approved for a particular indication. Happens all the time, and there's nothing wrong with the practice.

An unapproved use is NOT the same as experimental therapy. The latter comes up for review for private insurance AND government health care.

I see the rate of rejection being no lower for government programs that private insurance. "UHC will cover this!" is bogus.

It's tragic, but realize that the government isn't going to pick up the tab. The hospital is more than likely going to eat the cost because Medicaid requires the same process, and in almost all cases they do not provide retroactive payment. Their "expectation" is more of a hope than anything.

I did notice that LL mentioned suing the insurance company. I don't think that will work, however imagine trying to sue the government? Good luck with that.

This is a "sucks to be him" kind of thing. There is nothing anyone can really do.

The UHC crowd has two camps. They share their love for UHC, but there are two totally conflicting messages and they don't seem to realize it right now. They're just happy to see things moving that way.

One camp states that we will cut our costs in half by simply enacting UHC

The other camp states that nobody will ever die because everybody is treated for everything.

One of those groups is going to be severely disappointed. It's going to be amusing to watch them tear at each others throats.

 

[JD50]

The UHC crowd has two camps. They share their love for UHC, but there are two totally conflicting messages and they don't seem to realize it right now. They're just happy to see things moving that way.

One camp states that we will cut our costs in half by simply enacting UHC

The other camp states that nobody will ever die because everybody is treated for everything.

Both of those groups is going to be severely disappointed. It's going to be amusing to watch them tear at each others throats.

Fixed