"Skin in the game"

[ConnorEl]

Most likely, but not certainly, she would have died even if she got the drug.

Of course she didn’t think it was a life and death decision when she calculated to not pay what she probably considered to be a too high price for the medication—that the prescriber may have told her might shorten her illness a little.

It’s a fair point to debate is there and what might be fair prices for medical care.

 

[ChrisL68]

I make financial decisions re medical care all the time. A couple of years ago I fell in downtown winston-salem and twisted my ankle really bad. I wasn't sure if it was broken or a ligiament torn or something at the time. People around me were saying I should call an ambulance but I was like no way for the several hundred it would end up costing me. I hobbled back to work and hobbled to my car and got home and figured out after a day or so that it was just a really bad sprain.

 

[myDeaconmyhand]

Great twitter thread about insurance claims denials

 

[PhDeac]

But MDMH, how are insurance companies going to make all that money if they actually pay out claims?

 

[myDeaconmyhand]

But MDMH, how are insurance companies going to make all that money if they actually pay out claims?

For the record, I can substantiate these "anecdotes". When I worked for BCBS of NC, I spoke with providers every week who complained of not being compensated by us. They often didn't receive payment for months, if they got it. The reason I spoke with them directly was because they had stopped accepting BCBS Medicare/Advantage insurance, and my confused elderly customers didn't understand why. I spent the vast majority of my time battling with BCBS on behalf of their own damn customers on MEDICARE.

 

[myDeaconmyhand]

Oh, look at this anecdote
http://www.cnn.com/2018/02/11/health/aetna-california-investigation/index.html
"(CNN) - California's insurance commissioner has launched an investigation into Aetna after learning a former medical director for the insurer admitted under oath he never looked at patients' records when deciding whether to approve or deny care..."

"...Members of the medical community expressed similar shock, saying Iinuma's deposition leads to questions about Aetna's practices across the country.

"Oh my God. Are you serious? That is incredible," said Dr. Anne-Marie Irani when told of the medical director's testimony. Irani is a professor of pediatrics and internal medicine at the Children's Hospital of Richmond at VCU and a former member of the American Board of Allergy and Immunology's board of directors.

"This is potentially a huge, huge story and quite frankly may reshape how insurance functions," said Dr. Andrew Murphy, who, like Irani, is a renowned fellow of the American Academy of Allergy, Asthma and Immunology. He recently served on the academy's board of directors..."

 

[PhDeac]

Gotta admit not giving customers what they pay for is a very lucrative business model. #freemarket

 

[ImTheCaptain]

Great twitter thread about insurance claims denials

yeah but one time i got into a minor car accident and it turned out it wasn't that bad.

 

[ChrisL68]

Oh, look at this anecdote
http://www.cnn.com/2018/02/11/health/aetna-california-investigation/index.html
"(CNN) - California's insurance commissioner has launched an investigation into Aetna after learning a former medical director for the insurer admitted under oath he never looked at patients' records when deciding whether to approve or deny care..."

"...Members of the medical community expressed similar shock, saying Iinuma's deposition leads to questions about Aetna's practices across the country.

"Oh my God. Are you serious? That is incredible," said Dr. Anne-Marie Irani when told of the medical director's testimony. Irani is a professor of pediatrics and internal medicine at the Children's Hospital of Richmond at VCU and a former member of the American Board of Allergy and Immunology's board of directors.

"This is potentially a huge, huge story and quite frankly may reshape how insurance functions," said Dr. Andrew Murphy, who, like Irani, is a renowned fellow of the American Academy of Allergy, Asthma and Immunology. He recently served on the academy's board of directors..."

Z

 

[Biff Tannen]

I know it's not 100% effective, but are elementary school teachers in Texas required to have a flu vaccination.

LOL, forcing people to get vaccinated before going to school ? in Texas ?

 

[Deacon923]

You're right. It's almost as if some medications are set at a price point where the health insurance company can predict that a certain percentage of people who are prescribed those medications won't buy them. Makes perfect sense from a business perspective.

This deserves to be repeated.

 

[thatguy2016]

Roche Pharmaceuticals also deserves some scrutiny for its pricing of the drug in the first place, and its effectiveness in limiting the ability of competitors to bring a generic alternative to the market

 

[Louis Gossett Jr]

You mean like Relenza or Rapivab?

 

[thatguy2016]

You mean like Relenza or Rapivab?

its my understanding that those are not available for every form of Tamiflu; however, if they are, then the quoted price of $116 is probably incorrect

 

[Louis Gossett Jr]

Tamiflu is technically the generic and has been for awhile. The other two are an oral inhalation and IM based medicine. This thread however is a good case of pharmaceutical marketing which is some of the best out there. Most people first off are unaware of the other two period. Second and bigger problem, Tamiflu isn’t some miracle drug, in fact it’s a pretty shit drug by how it works.

 

[thatguy2016]

Tamiflu is technically the generic and has been for awhile. The other two are an oral inhalation and IM based medicine. This thread however is a good case of pharmaceutical marketing which is some of the best out there. Most people first off are unaware of the other two period. Second and bigger problem, Tamiflu isn’t some miracle drug, in fact it’s a pretty shit drug by how it works.

Tamiflu is the brand name for the generic oseltamivir, but yes, there are serious questions about its efficacy

 

[Louis Gossett Jr]

Also just because I was curious you can get Oseltamivir for 52 dollars at Walmart, so if it was a miracle drug there ya go. Want to get cheaper drugs and more discoveries, make a law that if you want your drug sold in the United States then research and other activities need to be a certain percentage of profits, and advertising is capped.

 

[avalon]

While canvassing last weekend I talked to a woman who emphasized that, even on Medicare, the 20% you have to pay can be a struggle for people who are trying to make ends meet. I'll admit my ignorance, I was not aware people on Medicare had to pay 20% of costs.

Discussed it with my boss who has parents on Medicare. He told me about what is known as the donut hole in Medicare drug coverage. From healthcare.gov:

Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a "donut hole"). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.

I know there are people here who know much more about healthcare issues than I do. To you I ask, WTF?

 

[ImTheCaptain]

i don't know, we also pay for new hips and knees for 90+ year olds

 

[CHDeac]

While canvassing last weekend I talked to a woman who emphasized that, even on Medicare, the 20% you have to pay can be a struggle for people who are trying to make ends meet. I'll admit my ignorance, I was not aware people on Medicare had to pay 20% of costs.

Discussed it with my boss who has parents on Medicare. He told me about what is known as the donut hole in Medicare drug coverage. From healthcare.gov:



I know there are people here who know much more about healthcare issues than I do. To you I ask, WTF?

The doughnut is sorta being phased out. I think by 2020 it gets lessened/eliminated though the recent budget CRs may have changed that. Some of the more enriched Part D plans include coverage through the doughnut hole now but of course they cost more in premium. The reason for the doughnut hole was a fiscal issue backed when it passed in 2003. Remember, on average the feds pay ~80% of the premium of Part D plans for people not receiving a low income subsidy. LIS folks also get enriched benefits on top of lower subsidies. So its an expensive program. Lots of people will note that Part D has largely worked well. Prices have been stable (and even decreasing) with lots of choices/competition. The big criticism of course is the lack of the feds negotiating with pharma though that tends to be a very complex issue.

Medicare does have cost share though the amount varies and there are no caps on oop costs. This is largely the original design from 1965. This too was a fiscal reality at the time. Lyndon Johnson famously said "dont let them show the Medicare cost projections more than 5 years out, otherwise it will kill this bill".

One of the advantages of Part C plans (Medicare Advantage ) is they have OOP caps (and embedded Rx coverage) so they tend to be quite popular, esp with lower income seniors. I think ~1/3rd of all Medicare beneficiaries are now enrolled on basically a private Medicare plan.,

Ironically, Medicare wouldn't be a complaint ACA plan. Go figure.