<p>"“You had not been getting better in a significant way,” Anthem explained in one letter sent directly to Melissa, then 14, in July 2012. “It does not seem likely that doing the same thing will help you get better.”</p>
<p>Desperate to get help for her daughter, Ms. Morelli sought the assistance of Connecticut state officials and an outside reviewer. She eventually won all her appeals, and Anthem was forced to pay for the care it initially denied. All told, Melissa spent nearly 10 months in a hospital; she is now at home. Anthem, which would not comment on Melissa’s case, says its coverage decisions are based on medical evidence."</p>
<p>One thing I hope will happen with the ACA is that we will ALL have to come to some consensus about what should be covered, with an understanding of the LOCAL risks and benefits. I might be more likely to want to pay for someone else’s mental health problem, if I knew it would be an overall benefit to my community.</p>
<p>There isn’t enough incentive in the ACA for people to buy insurance. The consequences for not getting insurance should be greater and enforcement should have real teeth. </p>
<p>I did some reading to see what the Heritage Foundation recommended in the late '80s when they came up with the household/individual mandate. I cannot find how they intended for the mandate to be enforced. Perhaps it is there and I missed it.</p>
How do you decide what is or isn’t worth the money? Maybe grandma could have 6 more months and that would allow her to see the next generation. Maybe she is still sharp as a tack, even though her diagnosis is terminal. Would there be an age cutoff? Income? The man who was my husband’s best man lost his wife at 34. She was diagnosed with breast cancer at 32 and it was so far gone and so widely spread that she was given three months and told to make her peace. She found another doctor who would use the heroic measures she wanted and she eventually lived almost 2 years. It cost a fortune, she suffered like a dog, but she was determined to hang on long enough to make sure arrangements were made for her autistic child and to ensure that her youngest child could remember her. I don’t think that was money wasted, but other people could have a different view.</p>
<p>I can see both sides of that situation, Shrinkrap. If I were the parent of that girl, I’d want her to get treated. But if it was me paying the bills, I’d want more evidence that the treatment was likely to be successful than a psychiatrist’s say-so.</p>
<p>What if the psychiatrist said it is not likely to help, but it is all we have? Of course I think 10 months at an amazing treatment facility would help; it’s the brief inpatient stays that I’m thinking of. </p>
<p>If the evidence said 10 months would help, would you be willing to pay for it?</p>
<p>How do you control costs? Money is limited. We can’t just pay for everything everyone wants, no matter how expensive it is and how unlikely it is to succeed.</p>
<p>These are difficult questions. But the answer can’t be to pay for everything everyone asks for. That’s impossible. And the answer can’t be to put a blank check in the hands of doctors and allow them to authorize anything they want, no matter how expensive.</p>
<p>When you bundle care, with a fixed payment per diagnosis, and you let doctors in on the savings, they do less care. So it looks like they are more free with someone else’s money than their own… as we all are. You can’t put cost control in the hands of people who don’t have an incentive to control costs.</p>
<p>“When you bundle care, with a fixed payment per diagnosis, and you let doctors in on the savings, they do less care.”</p>
<p>Or maybe they do care less? (smile)</p>
<p>From the link ;</p>
<p>"In late June, Mr. Barnhart’s department fined the state’s largest health plan, run by Kaiser Permanente, $4 million for deficiencies that limited access to mental health care under California law. "</p>
<p>Doctors make most of the spending decisions at Kaiser. Whatever. I would MUCH rather have someone to blame, than accept that responsibility by myself.</p>
<p>“Don’t insurance companies already make that call? They deny treatments because of inefficacy all the time.”</p>
<p>Yes, they do. Sometimes well, often badly.</p>
<p>Shrinkrap, consensus is the one thing I’m certain that we won’t get in the near term. In a country as big and diverse as ours, there’s really only consensus about things that have stood the test of time. When we’ve all grown up with the same insurance rules, they will seem intuitively correct to most of us. But whatever the cost-benefit-ratio rules are in the near and medium term, they will make a lot of people very unhappy.</p>
<p>Would I pay for something that wasn’t going to work? No. Would I pay for something that had a small chance of working? That would depend on how small the chance was, how expensive the treatment was, what the side effects were, and what the benefits would be if it did work.</p>
<p>Who would you give the authority (and I am asking only for your personal opinion) to decide “this far and no farther” or “this much and no more?” Would the patient’s views enter into the equation? If he wanted to continue treatment would that matter? If he wanted to discontinue a treatment that might prevent future costs later, would you force that?</p>
<p>I’m giving the doctors as much credit as I give other hard-working, well-intentioned professionals. I know that everyone has cognitive biases, and I don’t want to put my checkbook in the hands of people whose cognitive biases will lead them to overspend.</p>
<p>Those wonderful doctors who I’m supposed to trust implicitly are doing 30,000 unnecessary stent operations every year, at $30,000 a pop. Sorry, doctors have proven themselves to be unable to rein in unnecessary treatment, so someone else has to do it.</p>
<p>I don’t think there is much incentive for Healthy young people to get insurance. They are most likely to need medical care due to an accident. They will be treated in the ER, ICU and beyond. And when the bill comes due, they have no assets for the collection agencies to go after.</p>
<p>“Shrinkrap, consensus is the one thing I’m certain that we won’t get in the near term”</p>
<p>I agree, but I think it might be different at the local level. For example, within a community, physicians might be in a better position to find a way to work carved out mental health benefits in a way that people who don’t know each other cannot. Or maybe they will decide they don’t want to carve them out at all. Of course, I don’t think that has worked out well financially for the seriously and persistently mentally ill that only have commercial coverage.</p>
<p>I’m giving the doctors as much credit as I give other hard-working, well-intentioned professionals. I know that everyone has cognitive biases, and I don’t want to put my checkbook in the hands of people whose cognitive biases will lead them to overspend.</p>
<p>Those wonderful doctors who I’m supposed to trust implicitly are doing 30,000 unnecessary stent operations every year, at $30,000 a pop. Sorry, doctors have proven themselves to be unable to rein in unnecessary treatment, so someone else has to do it.</p>
<p>Regarding buying an exchange policy & subsidies, my understanding is that you cannot have both an HSA deduction and a subsidy, if you think you may be borderline in qualifying for a subsidy and, if not, you would choose an HSA, then you should make sure you buy an HSA qualified plan.</p>
<p>I can see a situation where the person can take the HSA deduction which then lowers their income enough to qualify for the subsidy, but then when they decide to take the subsidy instead, the loss of that HSA deduction would then make them subsidy ineligible.</p>
<p>Personally I recommend HSA plans and like others:</p>
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</p>
<p>I think that we all should take more responsibility for our own basic maintenance care, it ought to lower costs, if they could figure out a way to subsidized the HSA type of account without grand scale fraud. Most clients who have compared a high cost, high benefit plan vs. an HSA see that they come out money ahead with the HSA if they are generally healthy and have the money there should catastrophic health treatment be needed.</p>
<p>There was a famous case in California about 10 years ago. Health net refused to pay for a breast cancer drug it deemed to be experimental. The woman sued and won millions. However by the time of the verdict, she was dead. Does ACA insulate the insurers via the IPAB from such lawsuits over denial of care?</p>
<p>I’m with CF when it comes to financial incentives. Doctors are human beings. I try really hard to advise my clients not to buy more service than I think they need, but there’s no way I can know whether my interest in a large bill is subconsciously affecting me. None of us can.</p>
<p>“Who would you give the authority (and I am asking only for your personal opinion) to decide “this far and no farther” or “this much and no more?””</p>
<p>When this sort of thing has worked, it’s done by independent boards of doctors. They have to be appointed for set terms and paid a flat fee, not be employees of a hospital or insurance company. Then it can work, though of course their decisions still won’t make everyone happy.</p>
<p>Cardinal Fang, why do you keep referencing surgeons? Most doctors aren’t surgeons, and most care isn’t delivered by surgeons. I know plenty of doctors, and none of them seem to be in favor of spending frivolously. They might be uninformed, but I don’t think they are frivolous. The larger groups collect most of their money based on per member per month cost. Most physicians in California, and probably soon everywhere, are employees. They MIGHT be paid as a portion of what is collected on their behalf, but at Kaiser at least, they are paid a salary. Same is true at county, VA, prisons, and military facilities. There is nothing to be gained from unnecessary primary care.</p>
<p>For the record, I get $85 “a pop”, and that is partly because I negotiated hard for it. I am a little nervous about the provider lists here in California, because I would not accept less than that, and at least one company said I would be “missing out”. I know some insurance companies are fond of giving out my name anyway, or telling patients to call and see if I take the insurance their patients have, leaving ME to explain to this distraught person on the phone that I can’t help them</p>
<p>Good question, TatinG. I’m pretty sure the ACA doesn’t legislatively insulate the insurers via the Independent Payment Advisory Board. OTOH, I suspect that if the IPAB won’t pay for a treatment, it would be hard to win a denial of care lawsuit for that treatment.</p>