Why do they call it "health CARE" when no one gives a flip?

[golfgal]

Here is another way to look at this"

Your company goes into negotiation with the insurance company. The insurance company offers them 10 plans to choose from 1 being not good, 10 be the best coverage ever. Your company picks plan 2 but adds a few things and takes off of few things that will be covered, kind of like al a carte in a restaurant.

The company will say we want to have the these things covered but we don't want to cover birth control pills, pregnancy, chiropractic care, what ever. The employees get what ever is covered. Then one employee goes to the Chiropractor and gets the explanation of benefits back and it isn't covered. They call the insurance company and they say "this isn't covered under your plan". People THEN assume that the insurance company isn't covering something when in fact, it is the company that picks and chooses what is covered/not covered.

 

[Lisa loves Pooh]

I undertsand your point. But regardless if my company chose them or not---the Insurance company made a decision for all clients. That is my point.

Kudo's to my company yes. BUt in some instances the coverage is stupid. ETA: I had to pay oop for my PT post knee surgery b/c my insurance wouldn't cover it b/c I reached my limit b/c it is limited per calendar year and not per incident/injury. It is what my company paid for. They do not have to pay for the privilege of not having Insurer veto power.


Your example would not happen with UHC. Whether I self insured or hubby worked for a different company but still had UHC.

Why can't you give credit to UHC for not playing doctor? The Insurers policy for all their insured is to not do what happened to your nurse friend.

 

[Lisa loves Pooh]

Here is another way to look at this"

Your company goes into negotiation with the insurance company. The insurance company offers them 10 plans to choose from 1 being not good, 10 be the best coverage ever. Your company picks plan 2 but adds a few things and takes off of few things that will be covered, kind of like al a carte in a restaurant.

The company will say we want to have the these things covered but we don't want to cover birth control pills, pregnancy, chiropractic care, what ever. The employees get what ever is covered. Then one employee goes to the Chiropractor and gets the explanation of benefits back and it isn't covered. They call the insurance company and they say "this isn't covered under your plan". People THEN assume that the insurance company isn't covering something when in fact, it is the company that picks and chooses what is covered/not covered.

Your missing my point--UHC will not veto any covered item if doctor says it is necessary. They will not play doctor for a covered item.

You are correct in what you say here as I had that trouble this past year with getting PT covered. I had two separate injuries--but once I reached my calendar year limit it did not matter.

But had I not reached my limit--the insurer wouldn't have said--"well we don't think your injury warrants PT so we will not cover you". as an example--which I thought was what the OP was referring to. I wasn't implying that UHC will cover anything and everything doctor deems necessary. There are limits of course--but evidently even within stated parameters--it was my understanding that some insurers were playing doctor and vetoing covered treatments.

I coudl have avoided all this--as I think I guess I misunderstood the OP.

 

[golfgal]

I undertsand your point. But regardless if my company chose them or not---the Insurance company made a decision for all clients. That is my point.

Kudo's to my company yes. BUt in some instances the coverage is stupid. ETA: I had to pay oop for my PT post knee surgery b/c my insurance wouldn't cover it b/c I reached my limit b/c it is limited per calendar year and not per incident/injury. It is what my company paid for. They do not have to pay for the privilege of not having Insurer veto power.


Your example would not happen with UHC. Whether I self insured or hubby worked for a different company but still had UHC.

Why can't you give credit to UHC for not playing doctor? The Insurers policy for all their insured is to not do what happened to your nurse friend.

HMO's are different then United, Blue Cross non-HMO plans though and that is the point. If you are in an HMO, your HMO will tell you what you can and cannot have. If you go with a regular insurance plan, like what you have, they won't tell anyone what they can and cannot have other then what the employer selects for coverage. It is a marketing tool that they are using to distinguish themselves from an HMO. It is nice but Blue Cross does it, Aetna does it, all the insurance companies do it for their non-HMO plans. It is like saying "Coke has carbonation". Well, yes they do but so does Pepsi and all the other soda's on the market.

 

[Lisa loves Pooh]

We are HMO with UHC.


I think I misunderstood the point of everything and thought that Insurers--HMO, PPO, and otherwise--were denying covered things.

I.e.--You have 10 PT visits..but they must be preapproved and only if we deem the injury worthy of requiring PT---will we pay for it. So you can't walk--and they can say "NO--you can learn on your own".

That is wrong. you either have coverage or you don't. I've had PPO and HMO and haven't had anything like that. If doctor deems medically necessary--then that is the end of that.

so never mind--I will bow out, I obviously don't know what I am talking about.

 

[golfgal]

We are HMO with UHC.


I think I misunderstood the point of everything and thought that Insurers--HMO, PPO, and otherwise--were denying covered things.

I.e.--You have 10 PT visits..but they must be preapproved and only if we deem the injury worthy of requiring PT---will we pay for it. So you can't walk--and they can say "NO--you can learn on your own".

That is wrong. you either have coverage or you don't. I've had PPO and HMO and haven't had anything like that. If doctor deems medically necessary--then that is the end of that.

so never mind--I will bow out, I obviously don't know what I am talking about.

Ok, now that you say you have an HMO, that does make a difference, it is a big deal for an HMO NOT to watch over a dr's shoulder over what they can and cannot do. We don't have an HMO now, we had a PPO with DH's old company and it was horrible. We had many things denied, including allergy medications, that weren't "necessary", ok my kid can't BREATHE but I guess that isn't all that important.

Our insurance company now reviews the claims against what is covered and what is not and pay the claims, that's it. I had a case where an office person with our clinic denied a referral for one of the kids to see their asthma dr. They wanted us to go see "their" asthma dr and this dr was in private practice. The only real problem was that they didn't HAVE an asthma dr. They couldn't really ever explain this one to me. I accused the office person of practicing medicine without a license and threatened to call the state medical board because of this issue. The real issue was this asthma dr was once part of their clinic and didn't like their way of doing business and went into practice on her own. Our insurance company stepped in for me and basically told them that this was covered and they had no issue with this and that took care of things.

 

[Lisa loves Pooh]

Aaahh--we are now on the same page.

I had a PPO once. I had a UTI--however at the time I discovered an issue it was in the overnight hours and was bad. I went to the ER. After the fact I noticed my insurance didn't cover ER UTI treatment. However--given teh nature of the situation and that I was just a tad away from getting a kidny infection--it was paid for by the PPO. I dont' recall the wording of the policy--but they probably meant standard UTI's or something if there is such a thing.


UHC charged us for an out of network Ped for when my daughter was born. However her standard doc was on vacation adn the backup had hospital privileges but we didn't know (as he didn't know) that without nursery privileges he coudln't see my doc. I was able to successfully contest that and they footed the out of network fees and I was only resposnible for in network. I think that did have something to do with our company operating a medical care center exclusively for their employees--I'm not sure what would have happened if I had used another in network provider and a similar thing happened.

Insurers however should not play doctor. It is rediculous. People shouldn't have to suffer for a covered problem and denied a covered treatment just b/c the insurer thinks it is not necessary.

 

[bicker]

I am not disagreeing that this guy should make some money but he makes more then DOUBLE the next highest paid executive in MN (including the execs of companies like 3M), it is just a little out of whack when people can't afford medical care.

I'm sorry but I don't see the logic of that line of reasoning. How much something costs has nothing to do with how valuable an executive is to the company providing that product or service. The value of an executive is related to how much profit that can be attributed to his leadership.

Corporations aren't part of the government. The government has the responsibility for social issues like the affordability health care. Corporations are only tools to deliver such services efficiently, while fostering a strong economy. Affordability won't be achieved by removing any incentive for people to invest in heath care providers. On the contrary, that will only result in a decrease in the quality of health care available.

If you want affordability, then you need to address affordability at that level: Make more money available to pay for those who cannot pay (raise taxes), or reduce the cost of service. Reducing the cost of service means paying doctors less (so the doctors go to other pursuits, and the people left doctoring are the ones who cannot get better jobs), limiting doctor's liability (so that when doctors make mistakes the people who suffer as a result don't get money to compensate for their pain and suffering), and/or reducing the services provided (having rules, and enforcing the rules, but of course that goes against the view some folks have of what is good health care).

Remarkably, reducing the pay of a CEO of a medical insurer won't do more than knock two or three cents off an individual's annual health care costs, and then, only temporarily, until that CEO finds a better job and a lesser person is put in charge of the company and efficiency goes down, investment in the company goes down, etc. That's not an answer. It's a smoke-screen intended to appeal to people's visceral nature to be biased against people who make a good salary. It's a form of deception, since it isn't really a practical solution to the problem.

 

[Zippa D Doodah]

I have learned much by reading this thread. So many of you know lots more about how insurance works than I do. Yet as I look at "how things happen", surely something is terribly wrong. There seem to be too many people without insurance because they cannot afford it. I could hardly say what the solution is. I think gov't-run health care would be a disaster. Bicker, you summed up what lots of problems would be with alternative solutions.

So are we all just stuck with teh way thinsg are? Maybe the best idea of all is to stay healthy so we don't have to deal with it.

 

[golfgal]

I'm sorry but I don't see the logic of that line of reasoning. How much something costs has nothing to do with how valuable an executive is to the company providing that product or service. The value of an executive is related to how much profit that can be attributed to his leadership.

Corporations aren't part of the government. The government has the responsibility for social issues like the affordability health care. Corporations are only tools to deliver such services efficiently, while fostering a strong economy. Affordability won't be achieved by removing any incentive for people to invest in heath care providers. On the contrary, that will only result in a decrease in the quality of health care available.

If you want affordability, then you need to address affordability at that level: Make more money available to pay for those who cannot pay (raise taxes), or reduce the cost of service. Reducing the cost of service means paying doctors less (so the doctors go to other pursuits, and the people left doctoring are the ones who cannot get better jobs), limiting doctor's liability (so that when doctors make mistakes the people who suffer as a result don't get money to compensate for their pain and suffering), and/or reducing the services provided (having rules, and enforcing the rules, but of course that goes against the view some folks have of what is good health care).

Remarkably, reducing the pay of a CEO of a medical insurer won't do more than knock two or three cents off an individual's annual health care costs, and then, only temporarily, until that CEO finds a better job and a lesser person is put in charge of the company and efficiency goes down, investment in the company goes down, etc. That's not an answer. It's a smoke-screen intended to appeal to people's visceral nature to be biased against people who make a good salary. It's a form of deception, since it isn't really a practical solution to the problem.

We don't live in a socialist/communist country and it is not the responsibility of the government to make things affordable. I think companies have a moral responsibility to do what is right and I don't think it is right for people to not be able to afford medical treatments (think elderly on a fixed income as an example) when the top executives are making 56+ million dollars/year. If the CEO is making that kind of money, what are the other top executives making? People whine about a superintendent of a school district making $100,000-200,000 a year but it is ok for this guy to make $56 million/year, you are still paying his salary too!

 

[Lisa loves Pooh]

One is working for the government and the other a for profit corporation.

The two are incomparable and the school officials salary as well as other goverment salaries should be blamed as it should be--on the government and not the success of a corporate CEO.

How much do grocery store CEO's make with all the hungry out there?

You want to be about unfair incentives--not for profit CEO's having mutil-million dollar incomes when the purpose of the company is charity.

I may not have the best business sense in the world--but it just seems so obvious to me.

 

[Blondie]

I think there are still many health care professionals and doctors who do care, but they have the insurance companies and the DEA breathing down their backs.

IMHO, I think the insurance companies have too many decisions in how medical care is dictated.

After my yearly GYN check up a few months ago, their procedure is to send you "up front" with your chart to check out (pay your co-pay, make another appt. etc.)

As I was waiting in line, I decided to flip through my chart. I was shocked to see several letters from my insurance company asking my doctor if it was "medically necessary" to be on an antibiotic for a UTI! We're not talking expensive meds here either. There were two other letters as well questioning the need to be on two other medications. Again, these are not expensive newer meds like Celebrex and others where pre-authorization is required.

Big brother is watching and it's your health insurance carrier.

 

[bicker]

We don't live in a socialist/communist country and it is not the responsibility of the government to make things affordable.

I agree completely, which makes your earlier statements even more mystifying.

I think companies have a moral responsibility to do what is right

Companies have a legal responsibility to do what is in the best financial interest of their owners. That is their moral responsibility.

 

[Disney Doll]

----------------------------

Sorry, but this truck a chord with me.. My DD was injured in a car accident on March 10th.. She sustained both neck and back injuries.. No one knows their own body than the person walking around in that skin.. DD knew there was a serious problem with her lower back and requested an MRI.. Of course they refused.. She saw her primary doctor 3 days later - still in terrible pain from both her neck and her back and again requested an MRI.. Nope - wouldn't do it.. Seven days later she was back to see her primary again - still in terrible pain.. He ordered an MRI of her neck, but not her lower back.. Finally she got fed up and went for a second opinion - got the MRI done and found out that she had 2 herniated discs.. So - for 21 days she was in horrid pain that wasn't being addressed because someone "else" knows her pain better than she does..

I don't believe in unnecessary tests either, but sometimes a little common sense would go a long way.. To still be in such severe pain for all that time it seems to me someone should have thought, "Hmmm..maybe we better check into this just in case.." She's having PT (in hopes of avoiding surgery) and meanwhile has wasted time out of work that could have been used for treatment.. Hopefully her Family Medical Leave Act won't run out before the treatments are completed and she's able to work..

Your daughter had a bad doctor, who
A. Wasn't a good diagnostician
B. Allowed him or herself to be a puppet of the insurance companies.

 

[Blondie]

Regarding the herniated discs, is it because of the insurance company calling into question the doctor's need to order certain tests? Could very well be.

I had a nasty fall and had been walking around in pain for quite a while. Didn't realize just how bad it was until after doing all the walking one does while at WDW.

I went to my doc with a print out (from Kneeguru.com, LOL) with what I thought was wrong with my knee. Jokingly he said to me "am I you're second opinion?" and I said "well...I guess you are!" Fortunatley for me, we can joke back and forth like this since I've known him forever.

I told him I knew something was wrong with my leg/knee, and something needed to be done. As previously stated, nobody knows your own body like you do.

He ordered an MRI without hesitation, and turns out I have a severe bone contusion and condromalacia.

I'm at the point now where I'll pay out of pocket (within reason ofcourse) if my insurance company denies treatment. Unfortunately, not everyone can do this and I feel for them.

 

[Disney Doll]

There are several facets to this issue. I have worked in several different areas of healthcare, including insurance, acute care and homecare.

1. Doctors- Many years ago, the doctor was considered to be God. If the doctor said "jump", everyone said "how high?" Unfortunately, power like this goes to one's head, and on the heels of power comes money. Many doctors started to order "possibly" unnneccessary procedures, in an effort to increase their paychecks. Many doctors started to "unbundle" charges for procedures...kind of like charigind a la carte. If the doctor was doing a procedure that entailed X, Y & Z, then instead of figuring out a reasonable amount for X,Y & Z, they began to charge separately for X & Y & Z, thus increasing their paychecks. There was a lot of abuse of the system, doctors didn't police each other...the "old boys" network kept things quiet and that went on for quite a while. In the late 80's when I worked for the insurance company, we had the ability to pull reports about specific doctors. I could pull a report about how many 15 minute office visits a particular doctor made with only our clients on a particular day. That report showed that these doctors were chargin for 50 15 minute office visits. keep in mind, this is 50 visits for only one insurance company, and you know that our clients were not the only patients they were seeing that day. So do you think the doctor was spending 15 minutes with each of our patients, if he saw 50 of them a day, in addition to other patients without our insurance? Obviously not. It would make the doctors day 27 hours long before he went to do the hospital visits.

2. Insurance companies- see the end of #1, to see why insurance companies started to decide that maybe they needed to "police" the doctors a bit more. So they did. And then they realized that by policing them, the company earned more profits. "Nuff said.

3. Patients- This is not in direct reference to anyone here on the DIS, so please don't take it personally, but patients these days are very well-informed and know how to work the system very well. They go to the doctor with a chest cold, and expect an antibiotic, a chest-x-ray, and numerous othe rinterventions for what is, essentially, a cold. I have no problem with patients be informed...as a nurse, I am one of the primary "informers" for patients, and i take that role very seriously. But in these days, we expect a "quick fix"...give me a pill and make it better. i don't want to have to diet, exercise, lose weight, follow guidelines etc...I want you to give me a pill or do a procedure and make it go away. And if yo don't, I'll sue you.

4. Lawyers- see the end of #3 and know that there is always an opportunistic lawyer who will tell you that you have a case when you really don't, and there is always a jury who will believe the "poor sick person" who was horribly harmed by the big mean hospital and money-grubbing staff.

I'm going to be real honest with you...I am not making a fortune being a nurse. I make a decent living which allows me to do what I want with the rest of my life. But if anyone thinks I am making $100,000 per year, you're wrong. I am also not in the business of trying to harm people. I am in the business of trying to help them, but sometimes all the "help" I can give isn't going to change the fact that we all get sick and die eventually. For some, it's early on in life, which is always tragic. For others, it is after a long life, which is probably less tragic but still painful for their loved ones.

Healthcare...the whoile continuum, is not easy. [/INDENT]

 

[LauraR]

All I can say is that if you think it is bad now, just wait until the government takes over.

Actually I don't think it could get much worse. We're paying 17% of our GDP on health care in this country, where other industrialized countries with nationalized health care are paying 6-8% (or less). And according to a study I read recently, our standard of care isn't even that great! I used to think our health care was so expensive because it was better, but apparently that's not true.

 

[C.Ann]

3. Patients- This is not in direct reference to anyone here on the DIS, so please don't take it personally, but patients these days are very well-informed and know how to work the system very well. They go to the doctor with a chest cold, and expect an antibiotic, a chest-x-ray, and numerous othe rinterventions for what is, essentially, a cold. I have no problem with patients be informed...as a nurse, I am one of the primary "informers" for patients, and i take that role very seriously. But in these days, we expect a "quick fix"...give me a pill and make it better. i don't want to have to diet, exercise, lose weight, follow guidelines etc...I want you to give me a pill or do a procedure and make it go away. And if yo don't, I'll sue you.
[/INDENT]

----------------------------

I agree with this 100%.. I know what is going on inside my body better than anyone and I will fight a doctor tooth and nail who wants to prescribe an antibiotic where it's really not needed; order tests that aren't needed just to cover his or her own butt; or tries to shove an antidepressant down my throat "just because"..

I know of one person in particular that runs to the doctor for every little sniffle and INSISTS on getting an antibiotic.. I feel vey sorry for that woman because there may come a day when she really needs one - to save her life - and it's not going to work because she has abused them for so many years..

The less I see of doctors, the better I like it..

 

[jgmklmhem]

----------------------------

I agree with this 100%.. I know what is going on inside my body better than anyone and I will fight a doctor tooth and nail who wants to prescribe an antibiotic where it's really not needed; order tests that aren't needed just to cover his or her own butt; or tries to shove an antidepressant down my throat "just because"..

I know of one person in particular that runs to the doctor for every little sniffle and INSISTS on getting an antibiotic.. I feel vey sorry for that woman because there may come a day when she really needs one - to save her life - and it's not going to work because she has abused them for so many years..

The less I see of doctors, the better I like it..

I see your point but a doctor isn't a mind reader either and it can be very hard to tell the difference between the person who does know their body well and the person who is just wanting more done for whatever unneeded reason. Many times the patients would present in the same way. Obviously your daughter was in a great deal of pain and needed tests done, but I would be willing to bet that 4-5 other people in your daughter's time frame also presented with something similar and didn't need the testing your daughter did. The hypochondriacs out there tend to jade the doctors and make it harder for us all.

 

[C.Ann]

. The hypochondriacs out there tend to jade the doctors and make it harder for us all.

--------------------------

I used to work in a doctor's office and it wasn't difficult at all for the doctor to determine who was the hypochondriac and who was the patient with an actual problem..

Ever hear the term "frequent flyer"?