<p>It’s not that I believe doctors are in favor of frivolous spending. It’s just that, as Hanna said, doctors are humans and their brains work like brains.</p>
<p>^ Agreed. And I added something you may not have read. The average primary care doctor in a group practice is not seeing much incentive to provide unnecessary treatment. The major incentive is the patients demands, and maybe avoiding an angry patient abusing her on some internet rating or forum. It is my impression that more doctors under code than over code, because the risk (of an audit) is just not worth it.</p>
<p>Anyway, I’m done. Just wanted to make a few points.</p>
<p>CF, a jury could very well disagree. My point is that the treatment decisions should be made only by the patient and her doctor.</p>
<p>Two years ago our company changed providers to a non-profit (Providence) here in Portland, and a year ago I changed to a cooperative teaching practice within that non-profit. What a joy it has been! Because I’m seen by an eager young thing (first-to-third year residents, one of whom is “my” doctor) and her supervisor has to approve her recommendations, I get a combination of enthusiasm and experience. And, one-by-one, we’re whittling down my health issues. As far as I can tell, this method actually costs considerably LESS than a more conventional practice.</p>
<p>I live in woo-woo central. Squared. The number of alternative treatment options available here could take your breath away (and some, like smudge cleansing before the sweat lodges probably would take my breath away) – but which of these treatments should be covered? There are doctors here who endorse or jointly cooperate with many different types of alternative medicine practictioners – just because a doctor endorses it, does that mean insurance should have to pay for it?</p>
<p>I think it is a real problem that we have so little medicine that is evidence based. But when it is you or one of your loved ones, no possibility seems too unlikely to try if it gives you a chance. </p>
<p>I went to a noted orthopedic specialty clinic for PRP injections when they were still new and not yet accepted. I paid out-of-pocket, and would probably do so again, because it was worth it to me. </p>
<p>Maybe we need a better mechanism for determining when a treatment or diagnostic is or isn’t effective, but that’s a problem that pervades US healthcare far beyond the affordable care act.</p>
<p>I believe a high percentage of the people who are in pull the plug situation are in medicare. So insurance companies will have no control over such situations.</p>
<p>It is a slippery slope to say open up insurance to say there are no preconditions or limits and then say don’t take any heroic measures based on some actuarial tables for cost benefit. Then ACA will be toilet paper like people here claim the current insurance is.</p>
<p>I don’t think most people want to undergo treatments that aren’t going to be effective or at least have a reasonable chance of being effective.</p>
<p>Wow… Quite a few comments about my uncle. The doctors told the family that there was a small chance of success. The family said small is better than zero so do the stents. If the family said no… There would have been no procedure. The doctors did believe there was a chance of success. They were trying drug therapy too. The uncle did not want to die. This was at Kaiser. </p>
<p>Zoosermom, that was a sad story. </p>
<p>I see some good things with Kaiser. I like how easy a patients medical history can be looked at. It saved a friend of mine’s son’s life. Initially they thought the son had a drug overdose. He was really having seizures. He was an epileptic. When Kaiser doctors saw the son’s history, Kaiser reacted quickly. Otherwise the son would be dead.</p>
<p>I like how Kaiser is treating my dad for family care. Didnt like that Kaiser missed my dad’s gall bladder condition. </p>
<p>I know a neurologist at Kaiser that is top notch. Also this neuro surgeon at Kaiser is quite good. I dont like that surgery for a tumor can be put off for a couple of months.</p>
<p>The other thing about Kaiser is they have a lot of the top technology, but I noticed that UCSF can get up to the minute mris during surgery. I dont think Kaiser has this. Because the brain can move during surgery, I have read that up to the minute mris are helpful.</p>
<p>Ok… That is my Kaiser talk and no, I have never had brain surgery and there is nothing wrong with my brain. I can see the need for UCSF, but I think for most cases Kaiser can do a good job.</p>
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<p>Aside from the issue of fraud, there is also some potential of checking up via medical records, I would imagine. You would be amazed what people say to their doctors, very few people seem to lie consistently, so if there is any check & balance involving EMR, that would likely catch it.</p>
<p>There is well known software company in Houston which has a non-smoker policy and they are self insured. I had a smoker colleague who tried to join them 15 years ago and they gave him 2 weeks to quit smoking and decide whether he can take up that job (big pay jump of 25-30%). </p>
<p>10 days later, he figured it was too hard to give up and told the other company he could not quit smoking and stayed back with us. :p</p>
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This is NOT true. (I’m about 95% sure on this – I do have an analogous IRS memo to support this view, and I won’t believe otherwise until someone shows me an official doc like a regulation or IRS opinion that says so). </p>
<p>The HSA deduction stands as always.</p>
<p>The reason is that you do NOT (and never have) get a deduction based on premiums for the policy. You get the deduction based on the money you deposit to the HSA account, and you are not allowed to apply that money to premiums.</p>
<p>So when you buy the HSA your premium is X. If you are entitled to a subsidy (Y), then your premium is X minus Y. </p>
<p>Whether or not you also deposit money ($) into your separate HSA bank account is entirely your choice. You can buy an HSA and deposit -0- or you can buy an HSA and deposit the max allowed. </p>
<p>But either way, the HSA deposit is money coming from your pocket - it is in no way related to the subsidies. So it is still a deduction that you can take.</p>
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<p>The HSA deduction may be taken into consideration to reduce income to qualify for the subsidy. I do have documentation for this – the [url=<a href=“https://www.coveredca.com/PDFs/English/paper_application/CA-SingleStreamApp_66MAX_092713.pdf]Covered”>https://www.coveredca.com/PDFs/English/paper_application/CA-SingleStreamApp_66MAX_092713.pdf]Covered</a> California application form<a href=“Attachment%20E,%20page%2026”>/url</a> specifically lists “Health savings account deduction” it as one of the deductions from income that can be listed while calculating income.</p>
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<p>In NorCal…but service in SoCal is sparse outside of West LA.</p>
<p>Yeah…I am talking about a limited SF area…</p>
<p>Have no clue about So Cal…</p>
<p>Parachuting in late after only reading the last 80 posts or so…</p>
<p>As to whether young people will buy policies, an anecdote: When my oldest son aged out of our family coverage (pre-Obamacare) in his early 20’s, and before he had a job with health care coverage, he made it clear that he saw no reason to get insurance. I could not debate the logic of his choice, but I made it just as clear that since I would feel obligated to bankrupt myself to pay for his care if he were seriously injured, so he had to obtain a catastrophic policy which I would pay for to cover my own interest. So I see that as a potential market, although I suspect the pool is smaller with the 26 year old coverage now mandated.</p>
<p>As to the “who decides” issue, I’ve stated before: If you’re spending your own money, buy whatever care you want. If you’re using “pooled” funds contributed by everyone, a rational system needs to be in place, and it can’t just be “whatever the patient wants.” My personal anecdote: Far more medical care money was spent on my MIL in the six months after she was diagnosed with terminal cancer in her 80’s than in her entire previous life - not counting palliative care. Why? Nothing that was done had any chance of curing her cancer, it might have just extended her painful last weeks.</p>
<p>I think it’s neither irrational nor cruel to include age-based criteria for the expenditure of public (or pooled) funds. Millions for a 30 year old mom? I have no issue with that. Artificial hips for a senile 90 year old? That’s a question that should be addressed. At the least, the public/pooled financial contribution for other than beyond and/or palliative care should be tapered based on age. </p>
<p>And before you start on the death panels and your 90 year old aunt Tillie - if you want to pay for it yourself, go for it. If you want others to help pay for it - well, this is an area I’m comfortable being really money-centric in. Public funds should be prioritized, and that shouldn’t be a priority.</p>
<p>Kluge, under that logic why should I pay for the poor guy who is grossly overweight, drinks too much and leads a very unhealthy lifestyle. The pooled money can be spent much more effectively elsewhere.</p>
<p>I didn’t notice anyone complaining when Ted Kennedy went to Duke University to have an experimental operation for his brain tumor using pooled money, or are we just selectively applying your criteria for spending our healthcare dollars.</p>
<p>GP, if you want others to pay for you, then you need to play by the group rules. You are always free to pay out of pocket for specialized services in excess of what the insurance provides. </p>
<p>I find it puzzling that you seem to be concerned about access to specific facilities that are more expensive than others and are not near to you, and yet at the same time you have in the past sought to reduce premiums by purchasing higher deductible plans. To me, that is an indication that you did not believe you would meet the deductibles – which in turn suggests that your typical out-of-pocket costs are low (or at least low enough so that it did not make a difference to you to switch from the $3500 to $5200 per person deductible 2 years ago, a move that would have shifted an additional $3400 of costs onto you if you indeed had high end costs. Obviously you have not been currently using those facilities at a level that makes it cost-prohibitive to opt for out-of-network services on occasion.</p>
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<p>Your analogy is faulty, because drugs and procedures work really well on that guy. The insulin works, the statins work, the heart operations work if he has a heart attack and survives it. So in terms of effectiveness, that guy, if he is young, can benefit from high-tech medicine.</p>
<p>Now you would be right to say that he wouldn’t need any of these treatments if he were to slim down and quit smoking. True. But that’s different from saying the treatments are ineffective. They work. It’s just that they are only necessary because he leads an unhealthy lifestyle.</p>
<p>I just had a point to share about the HSA. I changed to an HSA recently. I am contributing $ to the account in case I need it to meet my deductible/out of pocket maximum. I have 2 DD’s one in undergrad and one in law school. I just discovered that my HSA contribution cannot be used for my older D unless she is a dependent on my taxes. She is dependent this year (just graduated in May) butshe will be independent for 2014 taxes since she is supporting her own way through law school. </p>
<p>She can set up her own HSA - but that is not financially feasible while in school. As dumb as it sounds she may be better off getting a subsidized plan on the exchange. If she were to do that (which I don’t think she would) I would assume she would be a resident of the state where she attends school?</p>
<p>The other issue I am wondering about is - how do we cover our students in other states? I specifically chose my current plan because it “worked” in the two out of state locations. Next year I may not be so lucky to have that option when our plans come up for renewal.</p>
<p>There are lots of people in their 80’s and 90’s who, after long hospitalizations, pull through and do just fine. Former President George H. W. Bush is one. My mother is another.</p>