Big

In his argument on CNN he says to Sanji Gupta (CNN's medical specialist): "As a doctor do you like the fact that when you have a patient suffering from illness you first have to call a person in some cubicle 1000 miles away (HMO) to ask for permission to help that patient?" Priceless!

RYou

Most HMOs have died. Long gone. Moore is critiqing a dead elephant. Most medical plans are now point of service plans with no referals required. You will pay a little more out of pocket for using docs not in the plan.

Big

What if your insurance doesn't adequately cover the procedure you require? Bye bye. Good luck paying $30K or more in medical bills.

RYou

I have yet to hear of a reputable plan that only pays part of an accepted procedure that isn't stated up front in the plan. Partial payments are fairly common in dental plans. It is the exchange for 100% coverage for taking care of your teeth through routine maintenance. Not funding any part of some experimental procedures is one thing, but funding only partial payment is near unheard of. It probably depends on if you buy Sam's Club Medical Insurance or real medical insurance and what your employer is willing to incloude in the plan. That one of the big issues with Wal Mart. Skimpy medical plan coverage purchased at a skimpy price to get media attention off of their backs.

When your employer buys medical insurance they are buying a package offered by the insurer. They have choices of what to include or exclude, cvost per employee value at different deductible levels.

When you hear stories like there it's not because the insurer refused the coverage, the employer opted not to include it in the package. Insurer basically become claim processors versus insurers.

When you purchase medical insurance as an indivdual you will be offered the same coverage options. X price for X coverage with deductible X, y price for deductible y, same as the options you are offered for acar insurance. Want the braodest coverage, thenyou'll pay a higher price.

Big

Having said all that the problem of many Americans not having the best possible insurance or any insurance at all still exists.

Spider

RYou,

I have had personal experience with insurance companies trying to weasel out of paying for covered procedures due to a technicality, or just denying payment in hopes that they will wear the patient down - but finally paying when they are pushed to the limit. When our insurance company denied my wife's bone marrow transplant, an attorney involved in the denial was overheard saying, "We'll probably pay this one, but not just yet." I'm not saying this is the rule for all companies, but it does happen often enough to be a problem. Many of my claim forms get "lost" and have to be refiled two or three times.

__________________
"Love never dies." The Beatles

Big

The whole idea that a patient has to sue to get available medical help is just sickening.

matclone

In his first message, Big referred to a process called pre-treatment review (or sometimes other names, depending on who you are), where someone has to call the insurer or health plan administrator to get the okay for the treatment. From my experience, this type of stuff is common if not universal in health and dental plans today. Sometimes it's de facto. The last time I went for a physical, my doctor told me we can do the physical part, or we can do the well-person part, but it can't be both. Last time I was at the dentist, I had to be approved for this or that.

Ryou responded to Big's message by referring to something else: the old practice of having to see your primary care physician to get a referral to a specialist.

As for the employer/insurer: they generally work together in administering the plan. The insurers design their products, or (as third party administrators (TPAs)) help employers design their plans to save money (because they are the experts on such). Part of this new thing in the 80s and 90s called managed care included pre-treatment review, pre-existing clauses and all the other little features that are supposed to save money. Inflation in health care costs exploded in the 80s and I don't think it ever stopped. Whether an insurer acts on its own behalf, or as a TPA for the employer, the health care consumer faces the prospect he will be refused treatment.

I've haven't seen Sicko, but reports are numerous. It's obviously more than about HMOs. Millions are without coverage at all. A big chunk of costs go to the middle man: insurers and TPAs, and this arguably could be eliminated. There is fraud, abuse, and inefficiency in having a plethora of different forms, procedures, plans, and adminstrators. Those are just a few of the problems. Our health care system, like our immigration system is broken on many different levels, and leveling blame on one party, or focusing just one aspect of the system, is short-sighted (unless your intent is to persuade by being short-sighted).

RYou

Sorry to hear about that situation Spider. Anytime it deals with a life situation we all wish they would side with patient. I'd be interested in knowing which insurer it was.

I'm not saying these situations don't happen, because they do, obviously. But, they are are more infrequent than MM wouldlead you to believe. The insurers have been saturated with bad faith claim losses that they extremely fearful of these cases. It is one of the reasons heath care insurance costs have been rising over the past 5 years versus the declines under HMOs. The HMOs cut too much out both from patient care and physician fees. They didn't achieve the results intended and thus we are now in a swing back toward the type of plans that were commonplace 30 years ago - with much higher prices.

Being close to the pricing and coverage deals that go on for large companies, I've expereienced the behind the door negotiation. There is one thing that is very clear and that is most big companies don't want to be hassled by coverage issues from employees. It's not good for employee retention and the turnover issue is far more expensive than 99.99% of the medical claims that getplaced by workers. Compaines still try to squeeze another nickel in savings but you are not hearing about the significant complaints you heard 10 years ago.

State legislation has had an impact also. States are now mandating optional services like artificial insemination be covered under these plans when they were excluded entirely 10 years ago.

Insurers are entitled to a profit too. Funding experimental care is not desired because if an insurer funds for one claimant they are hard pressed to not fund it for another in the eyes of the tort law.

Hospitals and physcians that offer experimental care are seeking some reimbursement for the costs incurred. A facility can't afford to fund all experimental care, it would never get offered if they had to absorb the cost.

I think few insurers consider bone marrow treatment be experimental these days. It has a proven success rate.

My brother has a rare disease that is a derivative of Amyotrophic Lateral Sclerosis, Lou Gehrig disease. All of his experimental care was offered and paid for by the U Penn System and the Johns Hopkins systems. Didn't cost him a dime and it wasn't successful either. His insurer would not fund any of it. There was no alternative.
However, the insurer did pay for the initial medical examinations by those physicians, 3rd 4th and 5th opinions even though he had been to others at NYU and Columbia that said there was no known solution.

The federal government funds an unbelievable amount of the experimental research that takes place through the NIH and NSF. Johns Hopkins University alone receives about $1 BILLION annually from the feds for medical research, much of it paid on basic speculation for an idea. (PS for you anti-Bushers, he has allowed the federal research funding budget to rise every year he's been in office, despite his dislike for specific type of stem cell research). If not for this funding, experimental medical care would never exist.

MM is promoting an issue that most already knew of. However, there is a change occuring among the more reputable insurers. I can't say the same for the smaller regional insurers.

Spider

It was Blue Cross/Blue Shield. I'm pretty sure it was before they became Anthem - it was about 13 years ago. Even though chemotherapy was covered and it is just a form of high dose chemoptherapy, they denied it because they said it was an experimental procedure, which is was not. After some legal wrangling, they agreed to pay for it, but said that this was a one time exception and that they would not cover it again for anyone under our plan.

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"Love never dies." The Beatles