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Old 08-03-2016, 10:01 PM   #61
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Reading "Cancer: The Emperor of All Maladies" by Siddhartha Mukherjee, I learned of a watershed lawsuit brought by a cancer patient's estate against her insurer, who denied an experimental treatment. The patient won the lawsuit causing all insurers to allow this treatment, and an overnight burgeoning business in clinics offering this treatment. This experimental treatment was later found to be harmful, and quickly abandoned.

This is what Wikipedia has on this lawsuit.

...California woman diagnosed with advanced breast cancer. She requested her HMO to pay for High-Dose Chemotherapy and Bone Marrow Transplant (HDC/BMT) to treat her cancer. Her health maintenance organization, Health Net, declined her request, stating this therapy was an unproven, experimental therapy. She ultimately received her BMT after raising $212,000, but died eight months later, aged 40.

Her estate sued and received $5 million due to the denial. Subsequent research proved that HDC/BMT was a harmful treatment for breast cancer patients, and it is no longer used.

By September 1994, the Federal Employees Health Benefits Program, which covers employees of the United States' federal government, began requiring all of its health plans to pay for HDC/BMT for advanced breast cancer. The State of California subsequently passed a law requiring health insurance to pay for HDC/BMT.

Subsequent research reportedly shows that HDC/BMT for advanced breast cancer does not extend life, worsens quality of life, increases the number of days hospitalized, and costs an additional $55,000.
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Humana contemplating pullout of some markets next year
Old 08-05-2016, 01:23 PM   #62
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Humana contemplating pullout of some markets next year

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Without cost control, how can this not happen? Private insurers do not work for free.

In a single-payer system, do government workers and bureaucrats work for free? In fact, if they do not take a profit and there's no competition, what is the incentive for them to control the costs?

There has to be cost control measures. Money supply is not unlimited, even for a government.


Long term there needs to be a solution...What I am about to say does not accomplish it, but does address the recent ACA spikes...1) People are not signing up in the numbers assumed..And I will take a wild guess it is the healthy ones that are not which hurts in the "cost sharing". 2) Also I have read (which makes sense) from insurance companies a very noticeable amount of "cheap bastards" are buying the insurance, getting their medical needs taken care of then dropping the coverage. A new found way to "cost shift". If you cant beat them, join them may have to be may mantra if situation deteriorates badly.


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Old 08-05-2016, 01:46 PM   #63
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Long term there needs to be a solution...What I am about to say does not accomplish it, but does address the recent ACA spikes...1) People are not signing up in the numbers assumed..And I will take a wild guess it is the healthy ones that are not which hurts in the "cost sharing". 2) Also I have read (which makes sense) from insurance companies a very noticeable amount of "cheap bastards" are buying the insurance, getting their medical needs taken care of then dropping the coverage. A new found way to "cost shift". If you cant beat them, join them may have to be may mantra if situation deteriorates badly.
This "gaming the system" is now commonly reported - so much so that I have doubts just how big an impact it has. People with chronic illness require ongoing care and can't jump in and out that easily. I haven't seen any reports that Medicaid has experienced a dramatic rise in costs due to a sudden influx of new sick patients. While I don't doubt that some people are gaming the system, there probably are other factors as well.

The fact that none of these claims by any insurance company have been publicly scrutinized or independently verified makes me believe there are other factors. I continue to believe the path to more functional health care insurance involves fewer, larger groups, and insurers must take all comers in a region, not cherry pick as they do today.
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Old 08-05-2016, 02:08 PM   #64
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I think your over thinking it... The eligible population enrolled is less than expected and sicker than expected...That has been reported pretty regularly....Toss out the risk corridors and this is why the rates are spiking now...Am I suggesting this is the cause for medical costs unsustainably high? Heck, no... Even if all healthy eligible people signed up and paid 12 months it would not solve the problem, or really even put a meaningful dent into the problem.
But my premiums have skyrocketed 300% in 19 months and this is not including next year which is sounding worse. Total US healthcare costs have not increased 300% in 19 months...Im just caught on the butt end of the cost shifting game.


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Old 08-05-2016, 03:18 PM   #65
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This "gaming the system" is now commonly reported - so much so that I have doubts just how big an impact it has. People with chronic illness require ongoing care and can't jump in and out that easily. I haven't seen any reports that Medicaid has experienced a dramatic rise in costs due to a sudden influx of new sick patients. While I don't doubt that some people are gaming the system, there probably are other factors as well.

The fact that none of these claims by any insurance company have been publicly scrutinized or independently verified makes me believe there are other factors. I continue to believe the path to more functional health care insurance involves fewer, larger groups, and insurers must take all comers in a region, not cherry pick as they do today.
I am kinda with you on this... from the reports that we used to get the people with no insurance would go into the emergency room and get treated and not pay... now they are saying that they are signing up for insurance and that is why our costs are going up.... REALLY? Is there a dramatic drop in the number of people that show up at emergency rooms? I do not know, but if not.... something else is going on...


BTW, my crappy BCBSTX plan does not seem to pay for the blood tests etc. that I had at my doc... I am still working to see if this can change, but from what I am hearing from the docs office they put the codes down how BCBS says and it is not covered on my normal doc visit.... I am paying much more in routine costs than I used to pay when I was insured at work... and except for the gvmt reimbursement my premiums are higher... and since BCBSTX does not get the gvmt payment they are getting the full amount for the insurance...
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Old 08-05-2016, 03:37 PM   #66
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I think in some cases the Insurance companies themselves are "gaming" the system. The insurance lobby is aggressively lobbying to go back to private healthcare for all, thus costing us (in my case) $4500 per month for my wife and me, as opposed to $1200 what we pay now before subsidies. Anyone that opposes healthcare for all and no pre-existing conditions needs their head examined. (Figure of Speech)
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Old 08-05-2016, 03:45 PM   #67
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....BTW, my crappy BCBSTX plan does not seem to pay for the blood tests etc. that I had at my doc... I am still working to see if this can change, but from what I am hearing from the docs office they put the codes down how BCBS says and it is not covered on my normal doc visit.... I am paying much more in routine costs than I used to pay when I was insured at work... and except for the gvmt reimbursement my premiums are higher... and since BCBSTX does not get the gvmt payment they are getting the full amount for the insurance...
I've had the opposite problem. My annual preventive exam is supposed to cover certain routine blood work. However, my doctor's office habitually miscodes the bloodwork so I end up getting a bill from the hospital because the insurer says it is not covered based on the doc office coding... I call the hospital and they blame the doc so I have to get the doc office to recode and resubmit to the insurer. This has happened twice in the last 18 months. I'm thinking of changing docs as a result of the hassles that I go through.

It should be covered... keep chasing it. Sometimes I think they intentionally miscode it to get revenue from consumers that they don't deserve since so few people will complain and even fewer will chase the problem down.
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Old 08-05-2016, 03:51 PM   #68
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I've had the opposite problem. My annual preventive exam is supposed to cover certain routine blood work. However, my doctor's office habitually miscodes the bloodwork so I end up getting a bill from the hospital because the insurer says it is not covered based on the doc office coding... I call the hospital and they blame the doc so I have to get the doc office to recode and resubmit to the insurer. This has happened twice in the last 18 months. I'm thinking of changing docs as a result of the hassles that I go through.

It should be covered... keep chasing it. Sometimes I think they intentionally miscode it to get revenue from consumers that they don't deserve since so few people will complain and even fewer will chase the problem down.


In my case a few years ago it was the opposite. It was the hospital that was the thieves... I got a bill from my insurance carrier several months later and it showed payment considerably less than what I paid up front (yearly blood work). I called the hospital and they admitted they had no intention of ever notifying me or crediting the money back. They said if I ever used their services again, they would credit the balance off of my bill. Uhm no, that isn't how its done, Hoss....So I made them cut me a check. If it wasnt for insurance company I would have never known I was getting ripped off.


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Old 08-05-2016, 03:51 PM   #69
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I take no issue with what you say, but I found his primary focus to be something different.

From the article:

"The country’s private health insurers have been doing a lousy job of controlling medical expenses for many years. It is the big failure of our multi-payer system that insurance company executives hope we will never catch on to.

The truth: Because we have many private insurers, none of them—not even the big ones like Aetna—have enough leverage with drug companies and huge hospital systems to strike a decent bargain on behalf of their customers. Yet we continue to be deceived by industry propagandists like I used to be and hold as a tenet of faith that competition among our many insurers will somehow magically control costs. (What insurers actually do is try to predict how much they think medical costs will rise in the future and jack up their premiums a few percentage points above that to ensure a profit.) "


My take is that his finger is pointed more at the greed of drug companies and larger hospital systems than insurance companies, and that with our current system, there is little to no negotiation with them related to cost containment.


We all talk about needing to control the cost of health care. HMO's were suppose to help with that when they started in the 1980's, but costs have continued to climb. So...how should costs be contained?
I guess we could quibble whether Potter's primary focus was his "bottom line" or his "the truth".

However, if he really believes that the private insurers are not big enough to strike a decent bargain with the drug companies and huge hospital systems then he should be very much in favor of the two proposed large health insurer mergers as the merged companies would have more leverage with providers. BTW, I think his belief that the large insurers don't have enough leverage to swing us a good deal is wrong, but whatever.
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Old 08-05-2016, 04:03 PM   #70
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The bottom line is 20% of the population consume about 80% of the total healthcare costs and a huge chunk of that is at the beginning and end of life. It costs a lot of money to save a life and keep one from dying. Personally, I would prefer a single payer with a VAT slapped on everything so even the booze drinking bum on the street contributes something. Though this does not address cost containment much. Though I am willing to have a single payer system it doesn't mean I think the insurance companies are the root of the mass problem. Seems a bit too simplistic for me, but that is just my opinion.


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Old 08-05-2016, 04:23 PM   #71
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Most countries with universal healthcare still allow private supplemental insurance. Obviously, the governments cannot give people everything that they want.

We need to keep that in mind.
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Old 08-05-2016, 04:28 PM   #72
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I've had the opposite problem. My annual preventive exam is supposed to cover certain routine blood work. However, my doctor's office habitually miscodes the bloodwork so I end up getting a bill from the hospital because the insurer says it is not covered based on the doc office coding... I call the hospital and they blame the doc so I have to get the doc office to recode and resubmit to the insurer. This has happened twice in the last 18 months. I'm thinking of changing docs as a result of the hassles that I go through.

It should be covered... keep chasing it. Sometimes I think they intentionally miscode it to get revenue from consumers that they don't deserve since so few people will complain and even fewer will chase the problem down.
Yes, the coding is the thing that creates this problem.... and they always blame the other person.... insurance says it is the doc, doc says it is the requirements of insurance...


It was fun when woman care was change to be 'free'.... doc changed something on DW and coded it... it was coded wrong... we tried many times to get it coded correctly.... finally had to get the insurance company and the docs office on the phone at the same time and the insurance company told them the CORRECT codes to use... bill went away....

When I had my colonoscopy and they said that if so and so happens I might have to pay the whole thing I said "Nope, if you code it correct I will not. I will NOT pay any bill if you code it wrong".... she looked at me like I was an alien, called someone over to 'talk to me' and I told them the same thing... seems they got the coding right!!!


The problem is that it can take over a year to get it right... it took 18 months to get my moms coding correct... the doc said they sent the correct insurance info to the lab and the lab said it was not... the lab would not let me give them the correct info and the doc office refused to send.... I just said they were never getting paid so they MIGHT want to get it straight so the insurance will pay them....
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Old 08-05-2016, 04:30 PM   #73
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In my case a few years ago it was the opposite. It was the hospital that was the thieves... I got a bill from my insurance carrier several months later and it showed payment considerably less than what I paid up front (yearly blood work). I called the hospital and they admitted they had no intention of ever notifying me or crediting the money back. They said if I ever used their services again, they would credit the balance off of my bill. Uhm no, that isn't how its done, Hoss....So I made them cut me a check. If it wasnt for insurance company I would have never known I was getting ripped off.


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LOL... that happened to me with my wife's foot... we paid $900 to much... when I finally got the EOB and called the hospital they said the person was out on maternity leave!!! Nope, we cannot do anything about it... I did get the check about 3 months later at least....
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Old 08-05-2016, 06:14 PM   #74
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I never pay anything before I get an EOB.... around here no medical providers demand it IME.... if a medical provider demanded that then I would walk out the door and go elsewhere.
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Old 08-05-2016, 08:25 PM   #75
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LOL... that happened to me with my wife's foot... we paid $900 to much... when I finally got the EOB and called the hospital they said the person was out on maternity leave!!! Nope, we cannot do anything about it... I did get the check about 3 months later at least....


Isn't it ironic that they don't seem to have the same cavalier attitude towards payment when its them who is owed the money?


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Old 08-05-2016, 09:13 PM   #76
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I never pay anything before I get an EOB.... around here no medical providers demand it IME.... if a medical provider demanded that then I would walk out the door and go elsewhere.
This was the hospital... none around here will let you in unless you pay upfront... so that means you would chose not to have the procedure done...



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Isn't it ironic that they don't seem to have the same cavalier attitude towards payment when its them who is owed the money?


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Oh yea.... pay right now or we will not let you in... but when it is time to give back money it is SLOW... or even no existent...
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Old 08-05-2016, 09:22 PM   #77
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This was the hospital... none around here will let you in unless you pay upfront... so that means you would chose not to have the procedure done...







Oh yea.... pay right now or we will not let you in... but when it is time to give back money it is SLOW... or even no existent...


PB, must get to go to some softie hospital outfit...This has about been my only dealings with a hospital since I entered the world naked..But this outfit was not going to draw anything from me until I paid "the fee" upfront.


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Old 08-16-2016, 06:25 AM   #78
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As reported in post #21, Aetna cancelled its 2017 ACA exchange expansion plans and would re-evaluate its participation in the 15 states they currently offer exchange plans.

Aetna has announced they will offer 2017 exchange plans only in Delaware, Iowa, Nebraska, and Virginia. They will continue to offer off-exchange plans in additional markets.

This currently leaves Pinal County, AZ (between Phoenix and Tucson) without an on-exchange plan for 2017.

Source: Aetna to Drop Some Affordable Care Act Markets - WSJ
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Old 08-16-2016, 07:00 AM   #79
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Here is Aetna's announcement News Releases - Investor Info | Aetna

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Aetna will reduce its individual public exchange participation from 778 to 242 counties for the 2017 plan year, maintaining an on-exchange presence in Delaware, Iowa, Nebraska and Virginia. The company will continue to offer an off-exchange individual product option for 2017 to consumers in the vast majority of counties where it offered individual public exchange products in 2016.
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Old 08-16-2016, 07:20 AM   #80
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I think in some cases the Insurance companies themselves are "gaming" the system. The insurance lobby is aggressively lobbying to go back to private healthcare for all, thus costing us (in my case) $4500 per month for my wife and me, as opposed to $1200 what we pay now before subsidies. Anyone that opposes healthcare for all and no pre-existing conditions needs their head examined. (Figure of Speech)
Well, we don't have healthcare (I'm assuming you mean insurance) for all now. I read like about 15% are still uninsured & some want to be uninsured by paying the non-insurance penalty - or tax as John Roberts calls it.

And we never had private healthcare for all previous to the ACA.

And no one knows what premiums would be in a totally private system, just what they were in the pre-ACA world.
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