Affordable Care Act Scene 2 - Insurance Premiums

Parent Cafe
5561

<p>GP, if a drug is accepted and needed to treat a disease, and is not available in a generic format, the insurance will have to cover it. They can’t just decide to deny someone the accepted medical treatment for a disease because it costs a lot. </p>

<p>The issue will come up with new and experimental drugs, or drugs being prescribed off label (for conditions other than the ones they are approved for), or for situations when the patient wants the brand name but there are generic alternatives available – or there are accepted medical alternatives and a lack of consensus research to support the idea that a new and expensive brand name drug is any more effective than the old stuff.</p>

<p>But in my mind it makes no sense to be reading the drug formulary when I don’t need any drugs – because how would I know what mattered? And there are always new drugs being introduced on the market, and old drugs going off patent, so the landscape will change from year-to-year anyway.</p>

<p>Also - it’s just me, but I’m very averse to using medications unless it is absolutely necessary. So I’m going to have to have a pretty serious illness, and be pretty sure that drug X is going to help me, before that would be something that would impact me. If my doctor prescribed a drug that the insurance company wouldn’t pay for, that would be a red flag for me that would lead me to question my doctor or do my own research. I just don’t trust the drug companies and I hate the way that drugs are advertised and promoted. So I don’t think I would ever “need” an expensive brand name drug that my insurance wouldn’t pay for – I think more likely I would have a doctor recommend a drug, I’d read up on and decide I’d rather start with a more conventional treatment. </p>

<p>So I understand fully why someone who is already being prescribed a particular medication would want to check to make sure that its on the formulary. But it’s not an issue that’s likely to affect me.</p>

5562

<p>Calmom, sometimes the insurance company will want you to use one brand name drug over another for a particular condition, while your doctor thinks the one he is prescribing is more effective or may have less side effects. If the preferred drug is not in the formulary, then you will have to fight with the insurance company (which is a hassle) to approve the non-formulary drug. Obviously, the more expensive drug is likely to be excluded from the formulary. </p>

<p>You’re right you can’t know the future and what drugs you may need sometime in the coming years, but I think it would be useful to see if the 2014 formulary has been reduced and by how much. It would also be interesting to compare the BS formulary for the more popular drugs with Anthem’s.</p>

5563

<p>But I wouldn’t know what drugs even mattered on the list. And there are many reasons why a drug might not be included on a formulary-- not just cost. There are always new reports and new research coming out. That’s why I tend to be so skeptical – one year everyone is singing the praises of Vioxx, and then it comes out that it’s killing people. Insurance companies make decisions based on data – they do consider cost, but they also are going to look at effectiveness. If a more expensive drug is significantly more effective at treating a condition than a less expensive counterpart, then the more costly drug can be more cost-effective, because the patient recovers and can cease the medication sooner. </p>

<p>I’m also pretty skeptical of doctors – so I wouldn’t care what my doctor “thinks” about a drug, I’d want to see the research. I know that pharmaceutical reps visit doctors and give out free samples, and also speak at conferences that the doctors attend, and that the doctors are essentially exposed to a lot of promotion – so the doctors opinion can be influenced heavily by that exposure.</p>

<p>I did actually look at the drug formulary list. It was filled with a bunch of names of drugs I didn’t recognize. </p>

<p>So I understand your point, it just isn’t something that applies to me.</p>

5564

<p>You are right not to necessarily trust the doctor, but it is a leap of faith to trust the insurance company anymore than your doctor. I always assume the insurance company is more concerned with its costs than my health!</p>

5565

<p>I don’t have much faith in insurance companies either, but I trust drug companies least of all, and I’m concerned about the influence the drug companies have over doctors. </p>

<p>See:
[Drug</a> companies influence prescribing, study finds | Reuters](<a href=“http://www.reuters.com/article/2010/10/19/us-doctors-influence-idUSTRE69I6DK20101019]Drug”>http://www.reuters.com/article/2010/10/19/us-doctors-influence-idUSTRE69I6DK20101019)</p>

<p>[Pharmaceutical</a> industry is main influence in GP prescribing | BMJ](<a href=“http://www.bmj.com/content/326/7384/301.1]Pharmaceutical”>http://www.bmj.com/content/326/7384/301.1)</p>

<p>[Drug</a> Company Gifts to Doctors](<a href=“http://www.scu.edu/ethics/publications/submitted/morreim/prescribing.html]Drug”>Prescribing under the Influence - Markkula Center for Applied Ethics)</p>

<p>[Internet</a> Scientific Publications](<a href=“Internet Scientific Publications”>Internet Scientific Publications)</p>

<p>I could easily post a list of 50 links instead of 4-- it’s a huge problem. </p>

<p>So my view is something like this: if an insurance company refuses to pay for drug X, there must be some controversy or question about drug X. If the only reason is that drug X is more expensive than drug Y, and drug Y is used to treat the same condition… then I probably would want drug Y anyway. </p>

<p>Keep in mind I’m buying a high deductible plan! If my insurance doesn’t kick in until I’ve spent $4500, and I have a choice between a drug that costs $50 and one that costs $300… I’m going to want the $50 drug. Obviously if the doctor tells me I need a drug that costs $3000 a month, then I’ll run through the deductible and the insurance will be on the hook … but I’m going to be pretty cost-conscious up until that point.</p>

<p>I do think that the need for regular, expensive medication is one area where patients may really benefit from going with a higher premium, lower or no-deductible plan. If you know that you need a regular prescription that costs $3000 a month, but only a $50 copay, you are going to want that copay to kick in as early as possible. And of course you are going to check the formulary to make sure your meds are covered. </p>

<p>But I’m just not in that position personally - so it doesn’t make a lot of sense for me to be looking at the drug formularies. I mean, its not a matter of counting up which drugs Blue Shield will pay for compared to Anthem-- even if someday I need a particular drug, I’m not going to need 30 drugs or 50 drugs, its just going to come up with the specific drug that I need, and I have no way of anticipating what that will be, or even if the drugs that are on the market now to treat a specific condition will be the drugs of choice down the line. </p>

<p>By the way, even though I don’t take meds myself, I do have my DOGS on pricey medication. One of my dogs is on Trifexis**, which costs a LOT – which is why I have only one dog on it. It’s a heartworm preventive combined with a medication that kills fleas – but when I put dog #1 on it, I noticed that dog #2 stopped getting fleas, too. So I put dog #2 on an alternative, cheaper product without the flea-zapping part. </p>

<p>I pay WAY more in health care costs for my dogs than for me, plus I have doggy insurance (but the pet insurance doesn’t pay for routine care). I also have a way better relationship with the vets than with my own doctor – I’ve used the same group practice for 25 years.</p>

<p>I started thinking about this because I usually buy the dog meds online to save money.</p>

<p>(** I do have to admit that I asked my vet about Trifexis after seeing the ads for it… so much for my skepticism of the pharmaceutical industry. But the dog who is on the drug has problems with itching & scratching & doesn’t handle topicals well, and obviously it’s imperative to keep her free of fleas)</p>

5566

<p>“Same here about receiving info about the rollover and new pricing. I can imagine some could assume that was that- and wouldn’t realize they could go to another source to compare pricing and plans.”</p>

<p>The insurance companies “conveniently” left out any other information, but with the announcement a few weeks ago about extension of grand-fathered plans, they are now required to inform about other alternatives as well as the deficiencies in the grandfathered plan in relation to ACA compliant plans. </p>

<p><a href=“U.S. Unveils Letters Insurers Must Send About Health Plans - The New York Times”>U.S. Unveils Letters Insurers Must Send About Health Plans - The New York Times;

5567

<p>

</p>

<p>I’d just like to corroborate the above comment. As an employer, albeit a very TINY employer, our cost of healthcare this year is $13,536 per family. In our employees imaginations, they probably think of it as a $3,000 a year cost…because that’s what THEY pay (and we pay the rest.)</p>

<p>So, for a couple earning $64,000 who do NOT have employee coverage and who WOULD have to pay 22-25% of their income (which is true, they WOULD have to pay about $1200/mo by my calcs, unsub) there IS in fact an option “just as good” as former NON-compliant, cheap insurance.</p>

<p>It’s called CATASTROPHIC – because in this case, the cost of premiums are in excess of 9.5% of income. You pay the OOP max and then are covered. The advantage of catastrophic is that under ACA, THERE ARE NO LIFETIME CAPS OR LIMITS.</p>

<p>So really – for those who like their odds – at the end of the day, this is no LESS protective than a substandard, capped pre-ACA, el cheapo plan ;)</p>

5568

<p>All pre-ACA plans were not sub-standard simply because they didn’t cover the now required list of minimums. That’s a myth. There will be people worse off. That’s a fact. Maybe more will benefit. That remains to be seen. But those hurt will probably still be unhappy and who can blame them?</p>

5569

<p>

</p>

<p>Not all, but probably most. A 2007 survey of employer-sponsored health insurance coverage by the Kaiser Family foundation found that a majority (55%) of people covered by employer-sponsored plans were subject to lifetime caps. I haven’t seen a comparable figure for the individual insurance market but my guess is that percentage would be even higher. Lifetime caps were insidious; the insurance company in effect said, “We’ll insure you unless you get really sick, in which case you’re on your own.” That’s pretty much just the opposite of what insurance should do. And of course they had other ways of achieving the same result, such as going back and discovering that your current severe medical needs could be traced to a pre-existing condition, in which case they were off the hook for covering you.</p>

<p>No doubt some people are worse off financially in the post-ACA market, but I also suspect many of those complaining about losing policies they “liked” just aren’t aware of how vulnerable they were under those policies.</p>

5570

<p>90 percent of individual health insurance plans had some kind of caps pre ACA.</p>

5571

<p>dstark, that 90% was not happening in Ca. Very few plans have been capped since 2010. Prior to 2010, I had a $6 million lifetime cap. I always said if I needed more than $6 million of care, then feel free to pull the plug or take me to the Golden Gate Bridge so I can go for a swim.</p>

<p>“advantage of catastrophic is that under ACA, THERE ARE NO LIFETIME CAPS OR LIMITS”</p>

<p>Where did you see this? This isn’t correct.</p>

5572

<p>GP, ACA has been in effect since 2010. Why do you think insurance companies started started removing caps? Because these companies are so altruistic?
Ok… Maybe I should give the insurance companies some credit. Insurance companies renoved caps in some plans before the deadline.</p>

<p>Do you have any information that caps were not prevalent in Cal before 2010?
My plan did have a cap in 2011. Did not have one in 2012. We switched plans. My annual cap would have been too low for a friend of mine. She had a million dollar bill one year as I said before.
My anecdotes…</p>

<p>I am not calling Anthem today. I havent decided how I am going to deal with my out of state kid.</p>

5573

<p>“But those hurt will probably still be unhappy and who can blame them?”</p>

<p>I don’t blame them for being unhappy. I do blame them if they react by automatically opposing any national policy that makes them unhappy without looking at the big picture. I think citizens of a free nation ought to be willing to consider whether some personal inconvenience or expense may be worth while if it prevents millions of people from suffering pain, death, and bankruptcy. The national conversation currently offers a lot of knee-jerk opposition as well as some thoughtful reactions that take the big picture into account.</p>

5574

<p>I know some people had annual caps, but in my 20 years of buying individual policies, I never had an annual cap. There is no way I would have ever bought such a policy.</p>

<p>Read an article today that the National Association of Realtors is upset with the 3.8% Medicare Obamacare tax. They are lobbying Congress to exempt real estate sales. There goes your Obamacare surplus.</p>

5575

<p>“I am not calling Anthem today”</p>

<p>Your day has brightened considerably.</p>

5576

<p>:).</p>

<p>I think buying policies without annual caps was smart on your part.</p>

<p>People always have ‘good’ reasons why the other guy should be taxed. :)</p>

5577

<p>“Where did you see this? This isn’t correct.”</p>

<p>Do you have a link showing that? I have looked and found nothing with says catastrophic plans will continue to have a lifetime limit. </p>

<p>And as the others have noted, the lifetime limit was removed under ACA beginning in 2010. It was gradual. I think it started at $2M in 2010 and has increased yearly since then, until Jan '14 when all lifetime limits are removed (unless one opts to keep a grandfathered plan which has limits.)</p>

5578

<p>“The national conversation currently offers a lot of knee-jerk opposition as well as some thoughtful reactions that take the big picture into account.”</p>

<p>I guess I know which side you think I am on. :)</p>

5579

<p>Without re-finding the article, I remember reading that removing the lifetime caps wasn’t a big deal for insurance companies because not many people exceeded them anyway.</p>

5580

<p>Good point, Bay. Health insurance is not health care. I’ve had employer insurance I never even used. Worst case scenarios are unusual, that’s how insurance works.</p>