Posted on 02/21/2007 7:39:44 AM PST by Rick Vassar
Today, Merck has decided not to pursue mandatory vaccinations of girls using Gardisal, citing - well nothing really, except they knew they were fighting a losing battle. It makes me wonder how much confidence they had in a drug that was touted as "100% effective" in the prevention in cervical cancer.
This brings up a broader point, and that is the state of health care in the United States today. In fact, in most instances, the direction of treatment is dictated by the patient's health insurer and not the doctor. The wisdom and the power does not come from any advance medical training or knowledge, but rather by the power of the purse and the reality that there is no tangible penalty for their decisions.
Let me explain. You go into a doctor, and he or she prescribes a course of treatment. You go to the insurance company, and they say they will not pay for it. Or you have the treatment done, and the insurance company pays only a small portion of the bill, citing their contract to pay only "usual and customary" expenses, a subjective standard set by the insurers themselves. You as the patient are required to pay the balance.
For most people, if they cannot afford, they decide on a less effective treatment, which in most cases does not alleviate the illness, and often leads to other maladies stemming from the more cost-effective alternative (or no treatment at all).
So let's say you decide to sue. Well, if your plan is covered under ERISA (Employee Retirement Income Security Act of 1974), you can only sue your health insurer in federal court. That's fine, except that it's difficult, expensive, and time consuming. And if and when you are able to get to court, the burden of proof is much higher in federal court, and in most cases, you can only collect for actual damages, or the amount of money the insurer should have paid in the first place.
In a nutshell - if you sue, you can't get to court. If you get to court, you can't win, and if you win, you won't get any money for your time, efforts or expenses.
So what do most people do? They sue their doctors in state courts, increasing the burden on the courts as well as the cost of malpractice insurance, to defend a case in which their course of treatment was not pursued for economic reasons.
Now I know that there needs to be constraints, but this system is not working. The article below illustrates the need for a change.
Universal health care is not an option. If you think health care is expensive now, what until it's free.
Let doctors be doctors. Prevention of future illness is key, not by mandatory vaccination, but through education and behavior.
Getting sick should be about getting better, and if that's the focus, I put my money on the doctors.
Rick Vassar
Sunday, February 4, 2007
Lyme Disease and the Real Reasons Health Insurers Will Not Pay to Treat Chronic Illness Right after college, I went to the doctor in my hometown for a routine checkup. The nurse came in, asked me a few questions, took my temperature, etc. She was really chatty up until she took my blood pressure. She then got noticeably quiet, wrote something down, and left in quite a hurry.
The doctor came in and gave me the news:
"Your blood pressure is 190 over 110, which is dangerously high. Do you have any idea how this could happen?"
You’re the doctor, I thought to myself.
Truthfully, though, at the time I was leading a lifestyle of reckless abandon and I was about 30-40 pounds overweight. There is also a history of high blood pressure and heart disease on both sides of my family, so there was a real concern here. Also, the doctor was a little creepy. But hey, I’m 21. Who dies of a heart attack at 21?
The doctor took my blood pressure again: 185 over 115. He was baffled.
"We need to get you on medication right away. We have this new stuff that will fix you right up." "No thanks", I said. I wasn’t real big on prescription medication at that time of my life. "What else you got?" "I’ll tell you what, lose 20 pounds and come back and see me."
Two or three years later, my mom asked me about my blood pressure. I shrugged my shoulders. Didn’t you go back to the doctor, she asked?
"Nope" I replied. "I still haven’t lost the 20 pounds."
In the 25+ years since that encounter, I have changed my lifestyle, lost the 30-40 pounds of excess weight, exercise regularly, and have been in relatively good shape. Recently, though, my blood pressure and cholesterol spiked, and now I am on some wonderful medications to control these potentially dangerous conditions.
What caused this change of heart concerning prescription medications?
Well, I’m just not as stupid as I used to be.
In my lifetime, which is closing in on the half century mark, I have seen remarkable medical breakthroughs. When I was a kid in the 1960’s, cancer meant death. Regardless of the type or extent of the disease, the result was invariably the same-death.
In the 1980’s, seemingly out of nowhere came HIV/AIDS. Another death sentence. Today, although there is a long way to go, cancer and HIV/AIDS are becoming treatable diseases to the extent that many who contract these awful diseases can not only survive but lead productive lives as well. We hear of medical breakthroughs and medical miracles seemingly every day. Front page news whenever it happens.
The problem is, buried somewhere in the back pages is the real truth: Health insurers are loath to pay for the procedures which could save you or a loved one from the ravages of these diseases. The issue is not whether you’re going to die. For the insurer, the question is whether you’re going to live. Curing the disease and dying from the disease have basically the same economic life. Chronic disease, though, can be really expensive.
For example, let’s look at Lyme disease. Lyme disease is transmitted by deer ticks and is an insidious disease which affects the central nervous system, the brain, and in some cases the heart, causing severe headaches, body aches, rheumatoid arthritis, and memory lapses. If caught in the early stages, most cases can be cleared up with a few weeks of antibiotics. If the signs are not recognized and the disease is able to establish itself in the body, it can be debilitating.
This disease is very difficult to diagnose and treat because there is not true validating test for the disease. Lyme disease is often misdiagnosed since its symptoms can be similar to other diseases. Many Lyme patients suffer years of invasive treatments that do no good due to misdiagnosis. When the correct diagnosis is made, many doctors will not treat Lyme patients.
Why?
Whether it’s a standard of care issue or just plain economics, it is increasingly difficult for Lyme disease patients to get the care they need. Since there is no true test, some insurers reject the notion of the existence of this disease, and will not pay for treatment. If the insurer does accept the diagnosis, they will limit the treatment to a few courses of antibiotics, which in most cases just isn’t enough.
I had no trouble whatsoever getting my blood pressure and cholesterol medication when it was prescribed. Was it because the insurer was concerned for my health?
Maybe. Or perhaps somewhere along the line, they figured out that it was a heck of a lot more cost effective to give me this medicine than to risk having to pay for the effects of a massive heart attack or stroke. Keeping me healthy by providing these medications is just good business.
The problem with Lyme disease is, although is can be tremendously debilitating, it is rarely fatal. It is more cost effective to deny or curtail coverage than to risk having to provide expensive treatments over the life of the patient. It’s better just to deny the nature or extent of the disease, or deny that it’s even a disease at all.
From a standard of care position, this philosophy is flawed at best. From an economic standpoint, it doesn’t make much since either. Lyme disease comes from a tick bite. Not all ticks carry Lyme disease, but Lyme disease is always transmitted by ticks. There is a distinctive bull’s eye rash which usually appears shortly after the bite. At that point, the disease can generally be stopped with a short round of antibiotics. Instead of denying the prevalence and/or existence of Lyme disease, I believe the insurers would be better served by providing public service campaigns on the subject in areas where the disease is concentrated.
How many of us have pulled ticks off of our pets or ourselves and thought nothing else of it? Public awareness can be the best strategy to mitigating the economic effects of Lyme disease to the insurer.
There is a nine year old girl in our neighborhood that came in from playing and her mother found a tick on her. Because the next door neighbor has the disease, and her mom saw the effects this disease had on this woman’s health and well being, the mom decided to take the nine year old in to the doctor.
Guess what? The little girl had Lyme disease. Two weeks of antibiotics and it was gone. If her mother hadn’t seen the effect a small tick bite had on her neighbor, she probably would have thought nothing of it. That decision could have been devastating.
In the case of Lyme disease, insurers should aggressively treat those whose condition has become chronic, and provide for public awareness campaigns to prevent future cases before they become chronic. Those who have it can get the treatment they need, and those who don’t have the disease should never get it. Seems like an economic and standard of care win/win to me.
Something’s gotta change. This is only one example of a disease that is being under treated only because it is under funded. In a world where medical miracles are being discovered every day, we as a society need to figure out a way to make these treatments available to those who need it the most.
It’s apparent that the health insurers will not do it on their own, so maybe it’s time for the federal government to get involved to mandate specific guidelines for chronic illness or to afford financial support to offset the ever increasing cost of healthcare. Voluntary programs won’t work, and state guidelines would vary too much, reducing their effectiveness. Perhaps the federal government needs to realize that although all these new treatments are wonderful, they do no good to anyone if they are uncovered and unaffordable.
I’m not sure what would be worse. Watching a loved one suffer or die from a chronic illness, or doing the same and knowing that treatment and/or a cure was available yet out of reach.
The real problem is that we ask health insurance to do too much, in the process handing over all our decisions and autonomy to them. Why do people need their insurance to cover regular doctor visits? Do people have their car insurance pay for oil-changes?
What we seem to want is for the medical community to provide us, on demand, the highest standard of care, without us having to pay an amount even close to what is commensurate with that standard of care, i.e. reimburse for the costs of all the employees, equipment, time, training, beds, and insurance involved. In fact we refuse to even look at the price (does anyone "shop around" based on price? no, we shop around based on doctor reputation, if anything), and to help us in this denial, we have our insurance hide the true costs of everything we choose from us, by covering or having "co-pays" for virtually everything from a lengthy hospital stay down to a tongue suppressor. And then we wonder why the market seems to fail in keeping prices down?
Infinite demand running up against finite supply is going to be rationed somehow, the only question is how. We could let the price do rationing. We could nationalize the entire industry and have the government do the rationing. Or we could do something in between - like the system we have, where prices don't really work and rationing is done through intermediaries based on statistics (and some government lobbying..).
In any event, rationing is inevitable, so whining about some of the symptoms of rationing (which is essentially what this/ese article(s) are about) is futile, if not utopian. So you want to "let doctors" make all healthcare decisions? Fine. Will you pay for the ramifications of whatever they decide, whatever course of treatment they propose? "Of course not", you say. Who then? "Insurance is supposed to pay for everything"?
Insurance is not a charity. They have to at least break even to continue to exist. If you take away all insurance companies' options which allow them not to lose money hand over fist, insurance companies will simply cease to be. There is no sense being in denial about this.
This article does not describe my experience, at all. I think it misperceives problems. Read the Cure.
Everything is designed by and for the new corporate monarchies. It does not matter whether it is health-care, banking, insurance, farming, manufacturing or politics. People no longer have any standing in world affairs. Everything is all about corporations. It is like the plot of an low budget science fiction movie, where the robot computers have taken over and enslaved the humans.
Removing the patient's control from his/her healthcare IS part of the problem.....just more of the socialization of America.
We let insurers "be the doctors" because if we don't they won't go into business.
Then why do we need doctors?
The insurance companies have it both ways. They can make standard of care decisions by withholding funding, and then state they had no impact on the level of treatment. If they are held to account, they hide behind the ERISA shield.
The point is that the doctors have been taken out of the decision making process by the insurers, and when the smoke clears, the doctors are held to account.
If you take away the ERISA shield, and allow patients to hold insurers accountable under state laws, the market will still work, but the insurers' actions would change dramatically.
Utopian? No. Reality? Yes
Typical lefty mentality. Whenever something seems to need "fixing," you would call Big Brother to the rescue! And that, in turn, would only make the system much worse than it is now.
The fact is that the Federal government is already too much involved in the health care system, and is itself responsible for many of the problems you mention.
When you use the word "insurer," you probably don't think even think of Medicare and Medicaid, I'd bet. Yet private insurers frequently follow the lead of Medicare in determining which medical treatments they will fund and which they won't. Decisions on patient's health and even life are all too frequently made from following a bureaucratic cookbook.
The whole system of "private" medical insurance in this country is largely an unpleasant consequence of the federal tax code.
The solution is not completely socialized medicine nor is it more government involvement, but rather an insurance system where more medical spending decisions are made by the patient and less by the insurer, public or private. This would include encouragement of a wider choice of insurance policies, including individually controlled health savings accounts.
As Ronald Reagan would say, government is the problem, not the solution!
Americans are too stupid to remain free.
When we go into an automobile showroom we don't let the salesman decide what we need and what we will pay.
But when we go into the doctor we let them decide everything and then blame insurers if turns out we didn't have coverage.
In my travels as an attorney I was shocked to find out that a medical tool company actually had a representative IN THE OPERATING ROOM telling the doctors how to use certain tools.
She was not a doctor, she had no training beyond the pharmacuetical company (she did have an MBA!) however the doctors were dependant upon her for the specialized tools.
It was little wonder there was litigation involved.
Doctors administer care and advise of potential treatments. Some potential treatments cost a lot of money. Someone has to pay for them. Yet nobody wants to pay for their own treatment.
So, we have set up, over the years, a system where "insurance" (it's not really proper insurance, it's something else) is expected to pay for everything (except in the case of the poor/old, then the government picks up the tab). This is an article complaining about insurance policies which are, basically, an inevitable outgrowth of having insurance companies participate in the system to the extent that they do.
You don't like this symptom, fine, then scale back what we use insurance companies for. Remove the tax-credit to employers for providing health insurance - decouple employment and health insurance altogether (it is really stupid, and a historical accident, that they are so linked). Have insurance be true insurance - that is, for actual catastrophes; get rid of this stupid expectation that insurance should cover everything on down to the tongue suppressors. Have people pay for most routine things out-of-pocket, 100% - stop hiding the costs of their care from people.
When that's been done maybe I'll listen to complaints about how the system could be improved further. But first things first.
The insurance companies have it both ways. They can make standard of care decisions by withholding funding, and then state they had no impact on the level of treatment. If they are held to account, they hide behind the ERISA shield.
By all means, get rid of the "shield", pass more regulations, force insurance companies to cover everything you think they should cover - knock yourself out.
Then watch as our premiums, particularly on middle-class people, rise and rise and rise. There is no free lunch.
The point is that the doctors have been taken out of the decision making process by the insurers, and when the smoke clears, the doctors are held to account.
Insurers tell doctors what they cover and how much they shall reimburse. If you're on an "insurance plan", don't be surprised that the care you are given corresponds, to some extent, to what your "insurance" company reimburses for. If you wish treatment in addition to that, pay for it!
If you take away the ERISA shield, and allow patients to hold insurers accountable under state laws, the market will still work, but the insurers' actions would change dramatically.
Sure. So would premiums. And then there'd be FR posts whining about that.
Essenitially "Duty to Die" has arrived.
"I am sorry the cost of your treatment and cure exceeds the good to society, you now may be afforded your choice of cost effective means of suicide for the benefit of society and Nancy Pelosi's Jumbo Jet expenses."
BTW..I'm not a medical company rep. Although I do happen to work in a hospital.
Just to clarify - I pay for my health care. Therefore, I will try to impact standard of care decisions because of the contractual relationship I have with the health insurer. Once it comes to litigation, the deck is stacked against the patient, and they know this.
I agree with you about ERISA. It a violation of states rights and should be changed to delete that interference with state insurance, tort, and other laws.
" It makes me wonder how much confidence they had in a drug that was touted as "100% effective""
Is that the only interpretation you can think of? Or even the likeliest?
No, but that's how it's been reported...
http://www.kvoa.com/global/story.asp?s=4928488&ClientType=Printable
Lorraine Rivera Reports
New vaccine said 100% effective against cervical cancer
That's an excellent rhetorical question. The same applies in many instances to physicians as well as hospitals. And that question has been relevant to HMOs ever since Kaiser (the "pioneer" HMO) was founded in the (c.) 1940s.
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