I’m talking about not paying for drugs/treatments that don’t work, that give no benefit or minimal benefit for anyone who tries them. There are back surgeries and heart surgeries out there where if you compare the people who had the surgery and the people who didn’t have the surgery a year later, you can’t tell a difference. The surgeries are useless. The people who had the surgery went through surgery and recovery for no benefit. The only benefit is to the surgeon. This is the low-hanging fruit.
I’m not talking about drugs that work for some, but not for others. I’m glad Rom is getting the $100,000 a year drug that works for some, but not for others. I hope the drug works for her, and I’m happy my tax dollars are supporting insurance for people like her.
I’m about to try an expensive drug myself, a drug for dry eyes, that only works for 40% of the people who try it, and that takes two months to show results. I hope it works for me, but there’s nothing better and no way to know if it will work without trying it.
But… if it turns out that with further research, this drug’s effects are a placebo, and the natural waxing and waning of dry eyes makes it seem like the drug was effective when actually it never was, we should stop paying for it, even though doctors swear that it helped their patients. And if with further research, it turns out the drug actually makes a difference, but the difference is teeny-- the patient’s eyes are better one random day a year, and the rest of the year their eyes are changed, say, then we should stop paying for it because the cost is not worth the benefit. [I don’t know how we could be that precise with this particular drug, but we can measure the effects of certain drugs, and detect effects that are measurable but not worth paying for.]
@JustGraduate I’m sincerely glad that the treatment is working so well for you.
But you raise two questions for all of us: Should every patient have access to every treatment available, no matter how likely or unlikely it is to work? From the individual’s perspective, the answer is obvious: Yes. But then comes the question of cost, and we as a society have to decide: If we’re going to let every patient have every treatment, how are we going to pay for it all? Americans think they’re taxed too much as it is.
I don’t understand why insurers aren’t required to put every single plan on the exchange. What difference does it make? If an insurer has an HMO plan that’s cheap, and a PPO plan that’s expensive, why not put both on the exchange and let people choose? Many people, especially people who have less money and are therefore subsidized, would choose the cheaper plan. Other people would choose the more expensive plan. What’s the problem?
I believe in California all plans have to be on the exchange. I like this a lot. The Fang family is not subsidized, and we go for a more expensive plan, but the exchange is terrific at letting me compare all the plans to see which one works for my family. It even does the arithmetic about whether a lower premium and higher deductible/copays is better, or the higher premium/lower deductible is better, for a family’s predicted usage. I check the arithmetic of course, but it turns out they seem to get it right.
Private insurance companies currently make a lot of money selling supplemental policies to the Medicare population. At least, I assume they make money since they’re not compelled to sell these policies. Whether it’s enough to stay in business, I don’t know.
But you’ve asked the question which has driven our health insurance policy-making for 70 years: How is [any given proposed change to public policy] going to affect the private health insurance industry’s bottom line? If the proposed change would harm them, the thinking has been, then it cannot be done; Americans’ health needs be damned.
I haven’t check recently (dodged bullet by keeping our out of compliance plan for one more year). But, when I was looking at the CA offerings for last year there was a definite difference between on and off exchange. BS had a PPO offering off exchange, but not on exchange. I don’t think all plans in CA need to be offered both on and off exchange.
From the article
But then CA has numerous precedents for not complying with federal law :O)
No plastic surgeon in my area (DC suburb) participates in any insurance program that I’m aware of - they all force you to go out of network to use one. Talk about frustrating. Before you get up in arms about this specialty being unnecessary, here they do mastectomy surgery alongside the breast cancer surgeon…you need both of them. Had a huge issue with my insurance paying and the plastic surgeon sent me a bill for the whole amount of $50k. That covered a 2 hour surgery, 2 pre-surgery consults (total 30 minutes), his surgery planning, and 3 post surgery consults (15 minutes each). And that was 5 years ago. Yikes - another what do people do without insurance example.
There is a lupus medicine that is currently being fast tracked. If approved by the FDA, it will be only the 5th drug to ever be approved for lupus by the FDA. Of the four currently approved, one is aspirin and one is a century old anti-malarial drug and steroids (all 3 of which I am or have been on). I have volunteered to be a participant in the new fast-tracked drug but was screened out because of my overlapping conditions If it does get approve and my rheum decides to try it with me, I’ll essentially be a guinea pig and I don’t know if my insurance will approve it.
I don’t believe this is a big expense but I’ll throw out another example of ridiculous (and harmful!) waste: antibiotics. All too often, antibiotics are prescribed to people who will not benefit from them because it appeases the patient.
I absolutely know that I am ridiculously expensive but I also know that my meds are grossly overpriced. But with lupus and other rare diseases, we just don’t really have options so we have to go with the expensive option or rely solely on treatments from the 1950s. But, without treatment, I can’t work, I’d lose my house, and eventually die after probably a very long, very expensive hospital stay. With treatment, I have a much better chance of continuing to pay into the system through what I do.
Again, I don’t know the answer. I don’t know if my societal contributions balance out what I cost to the “system.” All I know is that my disease does not have to be fatal but that my fate is pretty much in the hands of politicians and insurance companies… which stresses me out more than probably any other one thing in my life.
@dietz199 What? There are numerous cases of CA *insurance companies * breaking the law, both before and since ACA. When has the state itself broken the law?
We are in a state that is now down to one carrier on the exchange. They offer several different plans, but all have the same limited EPO network with zero out of network benefits. Not one of our current doctors are in this network. Not one. Ugh!
We are not subsidized and just want a choice to buy a PPO, POS, anything with a different or expanded network. Even finding individual off exchange offerings has been difficult. I think I finally found something that will somewhat work this year but it shouldn’t be this arduous a task.
Every year for the last 3 years, I have been notified that my existing plan will no longer be offered the following year and I have to go through this all over again. I don’t want to continue changing insurance and doctors yearly. I hope a better solution can be found.
That is a good example, JustGraduate.
Yes, reconstruction is absolutely a medical procedure, not a cosmetic one. Think how much less stressful that whole experience would have been if there were one nationwide network, and all providers were in it.
@my-3-sons Same thought experiment for you. One nationwide network, every provider in it. Wouldn’t that be nice?
I then gave a quote from the article saying as per the ACA, insurance companies are allowed to offer plans off the exchange which they do not offer on the exchange. That’s the federal law.
So,
IF :CA does not always follow federal law (the examples I gave) ,
AND: as per CF all CA plans have to be on exchange
Though not nearly of the same magnitude, my mom had to get eye surgery due to her Graves Disease. Her eye was protruding and it was at the point where it wouldn’t close in her sleep so the surgery was necessary. Insurance kept coding it as elective and it was nearly a year-long battle to get it covered. Thank the stars she only had to go through one surgery (which isn’t common- usually it takes 2-3 surgeries). [This was before the ACA]
I am so sad to read all that has had to be endured to get decent medical coverage and then get insurer to pay. I have had many battles getting insurer to pay what they are contracted to pay as well.
It is a slippery slope figuring what treatments SHOULD be paid for and what should not. CMS funded a large clinical trial recently, LOTT. All the researchers agreed that results were very mixed but the trial is being used as justification for rewriting international guidelines and denying a treatment that has previously been widely available and prolonging life and increasing exercise–supplemental oxygen for folks who desaturated below 88% while sleeping or exercising, even tho the trial had major flaws and didn’t show that there was no benefit to providing oxygen for these folks! It’s very concerning and scary to many of us that the results are being misused in this way. The same guidelines increase emphasis on prescribing expensive medications!
It turns out I was wrong about California law-- insurers can offer off-exchange plans that are not on the exchange. (That’s why I weaseled with “I believe,” but I should have just checked.)
The general point was right, though. State insurance regulations are allowed to be more restrictive than federal laws. In DC, there is no off-exchange market. For another example, by federal law, 64-year-olds can be charged no more than three times the premiums 21-year-olds are charged. But New York and Vermont have more restrictive laws; in those two states, everyone of all ages is charged the same. There is no contradiction here. New York and Vermont are not violating federal law.
Thanks for checking CF. So states CAN offer individual market off exchange plans but they are not required to do so. I think those states who have started to deal with the growing ACA issues by restricting the market even further are going in the wrong direction. That’s just IMHO.
In “Medicare for all”, some would buy supplemental private insurance, while some others would choose Medicare Advantage wrapping the entire benefit in a private plan. In “government employees benefits for all”, vouchers would be used on private plans.
If it does get approve and my rheum decides to try it with me, I’ll essentially be a guinea pig and I don’t know if my insurance will approve it.