The Sad Case of the Patient Protection and Affordable Care Act

[FlagDUDE08]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Fish-I only can really comment with any expertise on medicie. But it has been my experience that everything the government gets involved with ends up costing more. And usually exponentially more than they either promised or figured. I wonder what hammer prices are going for now paid by the US government? or toilet seats for that matter?

If you consider turbulence in airplane requirements and associated testing, around $50,000.

It always helps when you can profit from that.

[DrDemento]

Re: The Sad Case of the Patient Protection and Affordable Care Act

If you consider turbulence in airplane requirements and associated testing, around $50,000.

It always helps when you can profit from that.

FDude: I haven't mentioned it but i have seen medicine from both sides of the coin. I spent most of my life in private practice. But i also spent active duty time in the US Army medical corps-and then 25 years in the active reserves. In addition I attended at 2 separate VA hospitals-one in Albany NY and one in Boston Mass. I have gotten to see the best and worst of all of these situations.

[joecct]

Re: The Sad Case of the Patient Protection and Affordable Care Act

If you consider turbulence in airplane requirements and associated testing, around $50,000.

It always helps when you can profit from that.

The hammer costs $5, but the associated overhead is what drives the price through the roof. Ditto for the toilet seat, but the Birch John Society has a FOIA suit to disclose the true costs.

[FreshFish]

Re: The Sad Case of the Patient Protection and Affordable Care Act

I wonder what hammer prices are going for now paid by the US government? or toilet seats for that matter?

Not sure if my source was serious or pulling my leg...I was told once by someone who would know that the apparently inflated cost of the hammer, etc. was actually a way to funnel money to covert operations without disclosing it in the official budget. They'd pay the regular hammer price, not the disclosed contract price, and then stash the excess in secret accounts.

[brookyone]

Re: The Sad Case of the Patient Protection and Affordable Care Act

First, let me apologize for my earlier snark. that was uncalled for. You are definitely not one of the [redacted] that makes life miserable for anyone who dares to disagree with them.

Not too worry. I wasn't offended.

As for looking in the right places, in my own experience all available programs for healthcare coverage for those without access via more conventional routes are handled through the counties. When contacting state agencies one is referred to an office per county of residence...most often located in a county government center. To my knowledge those county offices have access to every available program within the state...with required forms / applications...and case workers. All the available programs I'm familiar with through state / county obviously have requirements and criteria for acceptance. Naturally there are income and asset limits as well as additional criteria for various programs. All applicants MUST meet those requirements or they are ineligible. I should mention I'm talking about Minnesota and that's the only state I'm familiar with. Long story short, the reality is there are large numbers of families and individuals, including loads of chronically ill who can't meet or satisfy those criteria, yet can't access health insurance privately. It's very easy, and commonplace to fall between the cracks. Many, many do. All kinds of circumstances that can eliminate any eligibility. Requirements for things like continuous coverage under prior group plan. COBRA benefits you can't come close to affording. Income and asset limits...prior earnings if unemployed...all with extremely low maximum / thresholds well below the poverty level. There's a large gap between meeting those requirements and being in a position to afford, or buy private insurance. These are not circumstances isolated to a small number of people. Rather, a major cause of ending up with so many uninsured.

My experience was back in 2005. Checked the Minnesota State Health Care website which doesn't indicate big changes since then. States are strapped for resources and I don't think capable of accommodating all who are uninsured or to date, unable to purchase privately.

[leswp1]

Re: The Sad Case of the Patient Protection and Affordable Care Act

You're chronically ill, eh?

I struggle with your attitude toward those who can't access care. Perhaps I am wrong but the impression I get is you are a young guy without much financial distress and nothing that challenges your sense of immortality. It does not take much to put you in a place where all your preparations would leave you in the same boat as those you dismiss.

FF: I have to repeat something i posted a while back-In my 45+ years in Medicine-I cannot recall anyone in the locations where I have been in practice either refused necessary medical care or not receive medical care in any emergency situation that arose regardless of ability to pay or insurance status. And I have mostly practiced in what would be considered blue collar environments. I am sure such cases do exist-but I personally have never seen one. There are of course some people(perhaps a lot of people) who just do not feel any responsibility to take care of themselves and their family and choose not to seek that care.

Unfortunately I can tell stories of those who go to the ER with emergent issues, are stabilized but testing and treatment is deferred after the person is stabilized. They tell the patient to call and make the appt the next day and of course when they call they are advised they need cash on the barrel before they can schedule.

In tthe last 3 days of practice I have seen 5 people who are currently working but not taking their meds for HTN, diabetes, COPD, psych illness because they cannot afford the copayment required to mail away for the 3 months required in insurance plan. THey can afford the month copay at pharm but not the chunk for 3 months. The insurance penalizes them for going to the local pharm with a huge co-pay. This means no insulin, no BP meds, no meds for depression, no inhalers. These people are fully stable when correctly treated. 2 of them have been to the ED with huge co-payments due to undertreatment in the past couple of months. Now they can't afford meds at all.

First, let me apologize for my earlier snark. that was uncalled for. You are definitely not one of the [redacted] that makes life miserable for anyone who dares to disagree with them.

Second, that doesn't surprise me. There were plenty of things that were commonplace 25 or 30 years ago that made a lot of sense and were reasonably affordable that have since disappeared. At one time, for example, you could get a health insurance policy with a $25,000 deductible at a very inexpensive rate (people used them to "wrap around" other coverage that had caps or benefit limits). those are all gone now. At one time, an individual could buy health insurance through his/her trade association at group rates. Those seem to have disappeared as well.

The long-time professionals in the field (Dr. D, Mrs. Les, etc) have all pointed out a pretty clear and direct correlation: the more government gets involved in health insurance regulation, the fewer choices we have and the more expensive they become. yet somehow the answer always is "more government involvement"?? and then the cycle repeats itself anew, and guess what the response is? yeah.

"when will we ever learn?"

Please don't lump me in with those who feel the government involvement is the cause of all things. My impression is the private insurance companies are much more arbitrary and skilled at denying care and denying payment for care delivered under whatever pretext they want.

[DrDemento]

Re: The Sad Case of the Patient Protection and Affordable Care Act

I struggle with your attitude toward those who can't access care. Perhaps I am wrong but the impression I get is you are a young guy without much financial distress and nothing that challenges your sense of immortality. It does not take much to put you in a place where all your preparations would leave you in the same boat as those you dismiss.

Unfortunately I can tell stories of those who go to the ER with emergent issues, are stabilized but testing and treatment is deferred after the person is stabilized. They tell the patient to call and make the appt the next day and of course when they call they are advised they need cash on the barrel before they can schedule.

In tthe last 3 days of practice I have seen 5 people who are currently working but not taking their meds for HTN, diabetes, COPD, psych illness because they cannot afford the copayment required to mail away for the 3 months required in insurance plan. THey can afford the month copay at pharm but not the chunk for 3 months. The insurance penalizes them for going to the local pharm with a huge co-pay. This means no insulin, no BP meds, no meds for depression, no inhalers. These people are fully stable when correctly treated. 2 of them have been to the ED with huge co-payments due to undertreatment in the past couple of months. Now they can't afford meds at all.

Please don't lump me in with those who feel the government involvement is the cause of all things. My impression is the private insurance companies are much more arbitrary and skilled at denying care and denying payment for care delivered under whatever pretext they want.

Les: My experience with the insurance companies over many years is that they at times might set standards to deny coverage but normally base much of their decisions on what our esteemed government does with Medicare. Once Medicare determines that something should not be covered, or that only a generic should now be covered (instead of a branded drug), or that some test is not indicated, or that you have to do procedure A before you get to do B-then the major insurers jump right on board and follow suit. Perhaps even adding further to the restrictions.

As far as patients not affording their medications-I am sure there are some cases-When it happens to mine i usually call the drug company directly and get samples for them or discount cards(as long as they are not on Medicare or Medicaid or live in Massachusetts-for some reason those patients are inelligible for the cards). I do get royally upset however when after all these efforts and we DO get their medications for them-they either do not take them or even worse-I meet them out in the local Best Buy and they just purchased a new 65" Samsung LED 3D TV. it happens more often than i would like to report. Some of these patients have their priorities in the wrong place. I even had one case where a very successful young executive for a large oil company was pleading with Jenny in the office to lower our fee on a surgical case (non emergent for sure) because he had insurance with a large co pay. We were all set to actually perform it gratis until Jen saw him go out to his car to get something and she saw him go unlock his new BMW 750! It taught me a valuable lesson-things are not always as they seem.

edit-It has been stuff like this that added reasons to my desire to semi retire. The bigger reasons though as I mentioned were government and insurance company control and interference with our ability to provide the best care for everyone.

[brookyone]

Re: The Sad Case of the Patient Protection and Affordable Care Act

As far as patients not affording their medications-I am sure there are some cases-When it happens to mine i usually call the drug company directly and get samples for them or discount cards(as long as they are not on Medicare or Medicaid or live in Massachusetts-for some reason those patients are inelligible for the cards). I do get royally upset however when after all these efforts and we DO get their medications for them-they either do not take them or even worse-I meet them out in the local Best Buy and they just purchased a new 65" Samsung LED 3D TV. it happens more often than i would like to report. Some of these patients have their priorities in the wrong place. I even had one case where a very successful young executive for a large oil company was pleading with Jenny in the office to lower our fee on a surgical case (non emergent for sure) because he had insurance with a large co pay. We were all set to actually perform it gratis until Jen saw him go out to his car to get something and she saw him go unlock his new BMW 750! It taught me a valuable lesson-things are not always as they seem.

While I don't doubt this occurs for a second I really don't think the vast majority who seek / need prescription medication assistance fall into this category. There are chiselers everywhere for sure.

I had to rely on drug manufacturer prescription assistance programs when the wonderful HMO decided they weren't going to pay for immunosuppression drugs a month after receiving an organ graft. The transplant surgeons sent the HMO a dozen letters informing the HMO suits I needed the drugs to remain alive. The response was I could take the drugs...they just weren't going to pay for them. Between five and six K a month for the drugs...I can still take them, I just have to buy them myself. Righto. Still perfectly willing to accept the premiums with their annual increases though. You want death panels? It's spelled HMO.

The pharmaceutical companies saved my butt. Have to acknowledge their magnanimous efforts for many in similar circumstances...though I'm not a huge fan of many pharmaceutical company practices either.

[FlagDUDE08]

Re: The Sad Case of the Patient Protection and Affordable Care Act

I struggle with your attitude toward those who can't access care. Perhaps I am wrong but the impression I get is you are a young guy without much financial distress and nothing that challenges your sense of immortality. It does not take much to put you in a place where all your preparations would leave you in the same boat as those you dismiss.

I love how you think I haven't had tough times. It isn't true. The fact of the matter is, though, that I'm not going to feel sorry for myself. Life will continue as much as I'm searching for a pause button. It's not the situation that defines a person. It's what the person makes of the situation.

[RStarr]

A system that doesn't want to change

Great film...could be better, yes, but should at least be mandatory.

http://m.youtube.com/watch?v=89nnsWZhkI4
http://m.youtube.com/watch?v=1Sp4Y_DNMYk

[leswp1]

Re: A system that doesn't want to change

Les: My experience with the insurance companies over many years is that they at times might set standards to deny coverage but normally base much of their decisions on what our esteemed government does with Medicare. Once Medicare determines that something should not be covered, or that only a generic should now be covered (instead of a branded drug), or that some test is not indicated, or that you have to do procedure A before you get to do B-then the major insurers jump right on board and follow suit. Perhaps even adding further to the restrictions.

As far as patients not affording their medications-I am sure there are some cases-When it happens to mine i usually call the drug company directly and get samples for them or discount cards(as long as they are not on Medicare or Medicaid or live in Massachusetts-for some reason those patients are inelligible for the cards). I do get royally upset however when after all these efforts and we DO get their medications for them-they either do not take them or even worse-I meet them out in the local Best Buy and they just purchased a new 65" Samsung LED 3D TV. it happens more often than i would like to report. Some of these patients have their priorities in the wrong place. I even had one case where a very successful young executive for a large oil company was pleading with Jenny in the office to lower our fee on a surgical case (non emergent for sure) because he had insurance with a large co pay. We were all set to actually perform it gratis until Jen saw him go out to his car to get something and she saw him go unlock his new BMW 750! It taught me a valuable lesson-things are not always as they seem.

edit-It has been stuff like this that added reasons to my desire to semi retire. The bigger reasons though as I mentioned were government and insurance company control and interference with our ability to provide the best care for everyone.

I too have had those who are crying poverty but have enough to smoke, get their nails done and drip gold jewelry. Over the years I have seen this less and am seeing more of the people who do have their priorities in the right place but financially are unable.

Your post from the other day regarding the change since the gov't started Medicare/aid was very thought provoking. When things were all private insurance or self pay the repetoire of what could be offered as far as meds and intervention was limited compared to now and from what I can remember were not as expensive. Early in my career our office reduced rates/ got veggies/fruit etc or bartered in some way with those in need. We had samples of meds that we could give and the pharm co had ways to access for those in need altho that was not predictable. Patients could apply for free care at the hospital for tests and admission but that did not wave the cost of the other Docs etc. The complexity of care was certainly much less. If you had a stroke/MI no one put something in your vessel to rotorouter a clot or repair an aneurysm. Many of the things that would kill you or at least leave you very incapacitated now have treatments that are quite expensive either with pharmaceuticals or intervention but are considered standard.

When I started practice things were in place so I do not know what it was like before the safety net. I remember the change the 80/20 to the HMO concept but that came very early on. I can't envision a way that could consistantly provide care to people in need with the current cost of care if there was no net. The net seems to work for those in poverty but fails abysmally here for the working 'poor'. The patients I see who can't afford care would be significantly more stable and probably less costly if they lived somewhere with socialized medicine.

If we were to revert to a completely private system how would that work? If you could revamp things how would you? I would love to hear your opinion.
(seriously asked)

I love how you think I haven't had tough times. It isn't true. The fact of the matter is, though, that I'm not going to feel sorry for myself. Life will continue as much as I'm searching for a pause button. It's not the situation that defines a person. It's what the person makes of the situation.

You may have been through tough times but obviously not something insurmountable. Not every situation has a solution because you have the fortitude to try hard to overcome it or have the right attitude. That is only in the fairy tales. There are some situations that do not have solutions and the lack of solution is life altering/threatening. To imply otherwise is not particularly realistic.

[FreshFish]

Re: A system that doesn't want to change

Over the years I ... am seeing more of the people who do have their priorities in the right place but financially are unable.

For about a year, I worked as an office assistant to an attorney who specialized in pre-packaged bankruptcy filings. The single biggest cause of personal bankruptcy back then was uninsured medical bills.

When things were all private insurance or self pay the repetoire of what could be offered as far as meds and intervention was limited compared to now and from what I can remember were not as expensive. Early in my career our office reduced rates/ got veggies/fruit etc or bartered in some way with those in need. We had samples of meds that we could give and the pharm co had ways to access for those in need altho that was not predictable. Patients could apply for free care at the hospital for tests and admission but that did not wave the cost of the other Docs etc. The complexity of care was certainly much less. If you had a stroke/MI no one put something in your vessel to rotorouter a clot or repair an aneurysm. Many of the things that would kill you or at least leave you very incapacitated now have treatments that are quite expensive either with pharmaceuticals or intervention but are considered standard.

yes, this is a very concrete example that illustrates just how myopic and foolish it is to say that increases in health care costs above the rate of inflation is somehow a "problem." We are getting more in increased value in return for what we pay; ask anyone who today gets arthroscopic surgery compared to the scar that was left behind 25 years ago from knee surgery and they'll tell you that quality and value are better today relative to the cost than it was then!!

When I started practice things were in place so I do not know what it was like before the safety net. I remember the change the 80/20 to the HMO concept but that came very early on. I can't envision a way that could consistantly provide care to people in need with the current cost of care if there was no net. The net seems to work for those in poverty but fails abysmally here for the working 'poor'. The patients I see who can't afford care would be significantly more stable and probably less costly if they lived somewhere with socialized medicine.

If we were to revert to a completely private system how would that work? If you could revamp things how would you? I would love to hear your opinion.
(seriously asked)

Again, I'm not attributing the "myopia" to you but to general social perceptions: there has never been a completely private system ever, and so there would be no "reversion" to it. To me the true question is what is the "proper" level of involvement of government relative to other parts of society. Look at Catholic Charities for example, or the Mormon Church, or Aid Association for Lutherans, or any of the other non-governmental, non-private sources of assistance. It seems pretty clear to me as an observer close to the front lines for nearly 35 years that increased government involvement leads to increased difficulties, not fewer. Of course that is not to say that government has no role whatsoever; that's merely a tired old trope that the "progressives" trot out whenever people say they've "gone too far": they try to pretend that the only alternatives are either their latest intrusion into heretofore private space, or nothing at all.

[FlagDUDE08]

Re: A system that doesn't want to change

You may have been through tough times but obviously not something insurmountable. Not every situation has a solution because you have the fortitude to try hard to overcome it or have the right attitude. That is only in the fairy tales. There are some situations that do not have solutions and the lack of solution is life altering/threatening. To imply otherwise is not particularly realistic.

When did I say anything about a solution? Look, anyone who thinks there's a solution to everything is naïve. What I said was that what defines you is what you do with the situation. That doesn't mean to solve it.

[FreshFish]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Requirements for things like continuous coverage under prior group plan. COBRA benefits you can't come close to affording.

You hit the nail on the head, so to speak. One of the single biggest problems we have today is over-reliance on employer-sponsored group health insurance plans.

Ironically, this outcome is a direct result of prior government meddling that should be a cautionary tale, yet somehow, whenever well-intentioned yet poorly-thought-out government meddling creates unintended consequences, the so-called "solution" always seems to be increased government meddling!

During WWII, about 25% of the domestic economic production was for military purposes (and the private sector did a fantastic patriotic job of organizing itself, by the way: kudos to FDR for setting aside his typical statist impulses to request voluntary cooperation instead: it produced far better results! ). The problem: 100% of the money was still here. That created tremendous inflationary pressure.

The government response: wage and price controls (there was an entire gov't department dedicated to it, with checklists and inspectors and everything). Since companies were prohibited from increasing wages, they resorted to offering expanded fringe benefit packages (tax deductible, naturally) to retain and reward their employees. Naturally, once the war ended, this distortion remained behind.

It's not at all difficult to envision how an economy-wide individual insurance pool priced at group rates with periodic "open enrollment" windows would replicate the same outcome without the distortions caused by the disparity of treatment between "self-employed / in transition" with "employed by someone else." The Federal employees' health insurance program works like this already, and many state government employees' health insurance programs also work this way.

So if we already have an example of how this can operate, and both the employees and employers are happy with the result, why not merely replicate this success on a broader scale?

[SJHovey]

Re: The Sad Case of the Patient Protection and Affordable Care Act

edit-It has been stuff like this that added reasons to my desire to semi retire. The bigger reasons though as I mentioned were government and insurance company control and interference with our ability to provide the best care for everyone.

A friend of mine is a family practice doctor. He was, at one time, practicing in a small clinic with some friends of his. A number of years ago he moved over to join the Mayo Clinic Health System. We were talking one night and he was lamenting the loss of the small practice he had with his friends. I asked him why he had made the move. He said when they started, their practice could get by with about 1.5 administrative staff people per doctor. He said it's easily 4.5-5.5 per doctor now, and was a prime reason why he felt he was "stuck" where he didn't really want to be. I found that sad.