<p>We think he had a heart attack after he was home with us. But what I fault them for is, it turns out that people in his frail state of health, and already with heart problems, are at risk for heart attacks during and after surgery. So why didn’t they at least tell us what to watch out for? He wasn’t recovering after the surgery, but we didn’t realize it was because he also had had a heart attack. I guess we were supposed to know, but we didn’t.</p>
<p>CF, this lack of coordination in care has been very obvious to me of late, particularly with my vantage of hang lived in a different country a decade prior. I think anything that will disincentivise or otherwise curtail ineffective treatments and redundancies in care will ultimately be a good thing.</p>
<p>People are perhaps unnecessarily concerned about “rationing” as my own experience of philosophic rationing (eg under a single payer system) seems to benefit the patient – and not actually end up rationing per se. </p>
<p>For example, in Cda, my osteosurgeon made a strong case “against” a complicated and risky back surgery that does not generally produce improved outcomes. He mapped out all the risks, and suggested that I attempt alternate therapies. But I ultimately had t he option to proceed with surgery had I chosen. Twelve years later, the strategy has proven pretty effective. </p>
<p>I think it helps to have a provider at least conscious of predicted efficacy and outcomes, which tends to happen when they have to justify the procedure. 
(Or to be held accountable or the results.) </p>
<p>While one would hope that members of the medical profession would naturally have this view, the economic structure hasn’t generally rewarded this kind of medical conservatism. So perhaps having some form of governance will help.</p>
<p>I’ve never understood the fear of rationing. We’ve always had rationing of medical care in this country. It’s based on who is rich enough or lucky enough to have good insurance.</p>
<p>I’m not surprised that texaspg’s cardiologist friends don’t want to believe that they’ve been spending the last N years implanting useless stents in their patients; they don’t want to believe that some 50% of cardiac stents are worthless in that the patients would have done just as well with drug therapy instead of surgery. </p>
<p>It’s not just that cardiac surgery is lucrative, though it certainly is. But more important, they honestly believed they were doing the right thing. No one wants to find out they’ve been harming people with unnecessary treatments. That has got to be hard to accept.</p>
<p>And I don’t blame texaspg for believing her cardiologist friends. They’re doctors. They’re skilled surgeons. How can a lay person question a doctor?</p>
<p>But here’s the thing: this is not a matter of opinion. There is a fact of the matter here. Either stents in non-acute cases work, or they do not. We have reams of data here, and many experiments. We can look at the data, in a clear-eyed way, and discover whether this treatment is effective.</p>
<p>Texaspg, before you agree to a stent, I urge you to look at the data yourself:</p>
<p>[Coronary</a> Stenting for Non-Acute Coronary Disease Compared to Medical Therapy | TheNNT](<a href=“http://www.thennt.com/nnt/coronary-stenting-for-non-acute-coronary-disease-compared-to-medical-therapy/]Coronary”>Coronary Stenting for Non-Acute Coronary Disease Compared to Medical Therapy – TheNNT)</p>
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<p>“I’m not surprised that texaspg’s cardiologist friends don’t want to believe that they’ve been spending the last N years implanting useless stents in their patients; they don’t want to believe that some 50% of cardiac stents are worthless in that the patients would have done just as well with drug therapy instead of surgery”</p>
<p>Why are you making any of your issues about my friends? If you have not noticed, I was making a JOKE asking for a stent now since I HAVE SOME FRIENDS in case there is an expected rationing of surgeries.</p>
<p>None of my beliefs about anything need to be attributed to my friends. Just like you, I have my own brain and can think things through about what is right for me. </p>
<p>Bottomline - I expect to get be able to get the treatment I need when I need it just as kmcmom mentioned it. If I did not believe specific doctors were honest with me, I have enough education and wherewithal to get three other opinions to make the right choice.</p>
<p>I think you ought to get the treatment you need when you need it. I don’t think you should get any treatment you ask for, though. And I’m quite sure that you don’t think the other people who have the same insurance you do should get any treatment they ask for, either, if it’s unnecessary. </p>
<p>Insurance can’t work that way. Paying an insurance premium can’t give you a blank check to have any treatment you can conceive of. We don’t have a bottomless pool of money to spend on health care, so we need to get smart and stop doing expensive things that don’t work.</p>
<p>However, insurance does work that way, i.e., if patient and doctor agree on a treatment, the insurance pays as long as the company has defined the benefit with the copays, out of pockets etc. </p>
<p>It is also not the insurance company that is having the bottomless pool, it is the company I work for. They are the ones paying the premiums for 350k people with our matching payments. They have been paying higher rates to the insurer when more of my colleagues need to be treated for preexisting conditions.</p>
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That’s not accurate and never has been. Insurance companies routinely refuse to pay for treatments that they deem inappropriate or ineffective. Here’s an example: [Insurance</a> Company Refuses Treatment that Will Save a Child’s Life - Yahoo! Voices - voices.yahoo.com](<a href=“Yahoo | Mail, Weather, Search, Politics, News, Finance, Sports & Videos”>Yahoo | Mail, Weather, Search, Politics, News, Finance, Sports & Videos) (it’s just the first one that came up for me in a Google search - in that case, the insurance company refused to pay for a particular treatment for a child with cancer due to “inadequate evidence in the peer-reviewed published clinical literature regarding its effectiveness.”</p>
<p>You generally see the insurance companies balking at new or cutting edge treatments – rather than something very commonly done such as a stent – but if the consensus of medical opinion shifted toward rejecting a previously-accepted treatment, it’s likely the insurance company would refuse to pay for it. </p>
<p>Here’s another example- which I dealt with recently, and which probably impacts a lot of people. My doctor would like my to have a bone density scan for osteoporosis. My insurance company will pay for that when I am 65, but I am only 59. However, I may qualify for the scan when I am 60, if I meet some additional qualifiers. (Must be below a specified weight, be at least 5 years post-menopause and have not received estrogen replacement therapy). So I don’t get to simply agree with my doctor that I want the test right now – I have to wait until the insurance company says that I meet the criteria for the test.</p>
<p>TexasPG, first the doctor and the patient both have to agree the treatment is appropriate, and then the insurance company has to approve. Just because it’s listed under coverage doesn’t mean the insurance company will automatically approve.</p>
<p>A perfect case in point is mental health - where the patient often doesn’t even have a say. Patient shows up in ER experiencing serious mental health issues, and is suicidal. The patient need inpatient treatment, and doctors find a bed in a local facility (or even their own hospital). The request is submitted to the insurance company, but must wait to transfer or admit the patient until they get approval from the insurance company. I’m not sure what would happen if they refuse (or in the age of caps, what would happen if the insurance comes back and says there is no remaining money), but it can happen.</p>
<p>“TexasPG, first the doctor and the patient both have to agree the treatment is appropriate, and then the insurance company has to approve. Just because it’s listed under coverage doesn’t mean the insurance company will automatically approve.”</p>
<p>I think I am already specifying that right? I am specifying a COVERED benefit. No one takes on something major without insurance approval unless they are in emergency. </p>
<p>Mental health coverage is not that good in US.</p>
<p>calmom - Some of the larger companies have changed the way they operate. They have opened up clinics inside offices, encourage the employees to go through age appropriate screenings that are generally recommended, trying to educate employees about staying healthy etc. </p>
<p>I am glad to say I keep getting asked to get a breast cancer screen even though my risk as a male is not that high.</p>
<p>Btw, we have annual healthfairs in a religious setting where the bone density screen is done free of charge.</p>
<p>There’s some shared responsibility in some of the examples here. All parties need to be sufficiently informed. It’s not simply what the doc wants, nor the patient. And, though many stories or examples tug heartstrings, I don’t think we should automatically throw out the value of statistics, in med care and how insurers evaluate. </p>
<p>In hand with that, it is very important to understand both the admit disclosures and those upon discharge. There is no “perfection” in medical care. It is constantly evolving.</p>
<p>Pretty interesting article on some of the challenges implementing the new health care system … [Backers</a> of health care law encounter hostility and blank stares as they seek to educate Texans - Nation - The Boston Globe](<a href=“Health law coverage can be tough sell in some states - The Boston Globe”>Health law coverage can be tough sell in some states - The Boston Globe)</p>
<p>texaspg writes:</p>
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<p>I thought we were talking about stents for non-acute cases, and whether the IPAB should eliminate paying for them. If IPAB did eliminate those payments, then those stents would no longer be covered benefits FOR MEDICARE. But the IPAB has no direct effect on the contract between you and your insurance company, if you are not covered by Medicare. If you still wanted a stent, and your doctor agreed, and the insurance agreed, you’d get your stent, even if Medicare stopped paying for stents.</p>
<p>Now, if Medicare stopped paying for those stents, probably insurance companies would also stop paying. But that would be the insurance companies prudently not paying for treatments that don’t work, not a government mandate.</p>
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<p>Yes, but there is covered, and there is covered. The policy doesn’t define what is covered, procedure by procedure. You and the insurance company could have a serious disagreement about whether something is or should be “covered”. For example, bone marrow transplants were accepted procedure for cancer treatment when certain insurers were still trying to deny coverage on the basis it was experimental treatment. </p>
<p>To use a personal story, I had an accident which took a chunk out of my cornea. I was rushed to the local hospital for emergency treatment. My insurance company denied coverage on the basis that the treatment wasn’t necessary. I finally got a hospital exec on the phone with the Aetna claims person before they finally admitted that yes, blindness was an outcome that it’s a good thing to avoid so ok I guess we’ll pay your bill.</p>
<p>haven’t read the whole thread BUT.</p>
<p>I’m a federal employee, been keeping my son on my FEHB BC/BS lower end plan for the past 2+ years since he graduated college. I have paid more in premium for him than he has used in medical care.</p>
<p>what I have always wished is that the federal govt would charge according to family size</p>
<p>A single parent & 1 child pays the same premium as a husband, wife & 5 kids.</p>
<p>that has always peeved me.</p>
<p>^^^sue, but paying the family upcharge must still be less than buying an individual policy for him, right?</p>
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<p>Great! That’s the way insurance is supposed to work, and that’s the way it will work for most people. </p>
<p>If we had heard the sad news that your son had received more in benefits than you had paid in premiums, then we would know that he had gotten sick or had an accident. That would not be a cause for rejoicing. Getting insurance benefits is bad, because it means something bad happened. </p>
<p>If insurance companies stupidly priced their policies so that healthy people paid about as much every year in premiums as they got back in benefits, then there would be no more money left for sick people.</p>
<p>CoveredCA - the exchange in California had notified brokers that their final rates would be up on August 1st. This was to give everyone some time to figure things out. </p>
<p>As of today…the rates are still not available.</p>
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<p>I would assume that the Federal employee unions could negotiate that aspect of the pricing to its members; they obviously choose not to…</p>
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<p>In fact they probably negotiated the contracts specifically to be the way they are, with everyone paying the same price despite family size.</p>