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16th February 2017, 12:58 PM | #481 |
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Is it your opinion that end-of-life care that extends a person's life for two weeks at a cost of $5,000,000 should never be curtailed? Just want to get a handle on why you deem it "entirely unacceptable", and what your view is on the situations in which it might come in to play. Once we've nailed that down, then we can talk about the statistics involved in insurance.
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16th February 2017, 05:45 PM | #482 |
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This is almost a bait-and-switch[wikipedia.org] tactic. The bait: "Sure the surgeon is in-network." The switch: "We're not going to tell you about the anaesthetist." In Canada and the UK, bait-and-switch is illegal.
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16th February 2017, 06:12 PM | #483 |
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The underlying problem is that there are so many hands in the till. It should be possible for a patient to be told "Your heart surgery/cancer treatment/whatever will cost $XX,000," and let the providers divvy it up among themselves. But when everybody bills separately for services and for every bandaid and aspirin, it's impossible for patients and even insurers to understand costs, let alone control them.
Journalist Stephen Brill wrote a lengthy, much discussed Time magazine article about hospital prices that he turned into a book. Short summary: Nobody understands them, they make no sense, and everybody's taking as much as they can get. http://www.nytimes.com/2015/01/11/bo...rill.html?_r=0 https://www.amazon.com/Americas-Bitt.../dp/B00LYXY05S |
17th February 2017, 02:32 AM | #484 |
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17th February 2017, 03:06 AM | #485 |
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19th February 2017, 01:01 PM | #486 |
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Iowans' views on Obamacare:
October: 32% success, 59% failure Now: 45% success, 46% failure That's a dramatic shift. |
19th February 2017, 01:14 PM | #487 |
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GOP strategy: Trump announces publicly the IRS should not pursue people who refuse to purchase health insurance.
Is it any wonder then that insurers will pull out? Or that premiums will go through the roof if insurers are covering people with big medial needs? |
20th February 2017, 01:28 PM | #488 |
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The decisions to pull out of the ACA market would have been made long before Trump's announcement. Rate and contract filings are around April. The business decisions would have been made between Feb and Mar of 2016. Most of those decisions had a lot more to do with some of the complex instabilities in the market dynamic than anything else.
Well heck, we knew that was going to happen back in 2010. That was a completely expected outcome of ACA. Actually, the increase has generally been viewed as being not as bad as initially expected. Of course, the initial expectation was pretty big, and ACA didn't actually shift Individual enrollment levels all that much... so it still went up a lot - just not by as much as we thought it was going to be! *** By "we" in this context, I'm speaking generally on behalf of the health actuarial community in the US. |
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21st February 2017, 04:28 AM | #489 |
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Mark Sanford admits Trump is full of ****. Not everyone will be covered by the ACA replacement and can't guarantee those that currently have health insurance will keep it.
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21st February 2017, 04:39 AM | #490 |
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21st February 2017, 09:17 AM | #491 |
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21st February 2017, 04:57 PM | #492 |
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21st February 2017, 05:26 PM | #493 |
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I wouldn't make any bets.
My desperate hope is that they back off from this foolhardy path to destruction, and actually put in the thought and planning that is needed. Even if they don't, if we're realistic... ACA passed in March 2010, but didn't truly go into effect until Jan 2014. And there was a LOT of stuff in ACA that was either purposefully incomplete or poorly thought out. So I'd say that you've probably got 3 years from when they draft and pass a replacement. But with this leadership... I'm not putting money on any of it. |
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22nd February 2017, 10:51 AM | #495 |
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22nd February 2017, 10:57 AM | #496 |
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This isn't about life time maxiumums. When do you let someone die from a disorder that costs say $10,000 a month to keep them a healthy productive citizen, they are going to hit that lifetime maximum of $5,000,000? That kind of chronic illness was certainly an issue with the kinds of lifetime maximums we had before the ACA, which was a hell of a lot less than 5 million.
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22nd February 2017, 11:02 AM | #497 |
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Each case should be examined on its own merits. I agree that end of life, palliative care can be expensive and, lets face it, not cost effective. I think lifetime care limits should absolutely not be applied in cases where the patient can continue treatment and achieve a decent standard of living. End of life decisions are difficult, yes. What I condemn is someone on their third course of Chemo, at the age of 45 being told that the insurance company that took their money isn't going to finance the treatment any more because they've hit the lifetime limit. I doubt it comes into play particularly often but for those effected it's unacceptable. ETA: I think, upon reflection that the difference is that in one instance decisions are made on how much the treatment will cost and in the other, part of the equation is considering how much the patient has already cost. The former absolutely must be considered. The latter should be of no note. |
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22nd February 2017, 11:06 AM | #498 |
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22nd February 2017, 11:39 AM | #499 |
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But it has to be of note; "should," is idealism. There are limited resources to spend. The average per capita spend on healthcare in the US is $9403 as of 2014. Now consider that patients pay (through premiums, copays, employer contributions, etc) about $4290/year in healthcare expenditures and it is easy to see that the amount patients pay into the system does not cover the amount each patient consumes, on average. Insurance companies and taxpayers make up the difference.
The solution obviously cannot be to limit premiums but not cap expenditures. |
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22nd February 2017, 12:22 PM | #500 |
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I imagine any country with UHC has a system to limit expenditure. It simply has to happen in any reasonable system. https://www.nice.org.uk/ |
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22nd February 2017, 12:33 PM | #501 |
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22nd February 2017, 01:02 PM | #502 |
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I think that beyond the politics, everyone recognizes that the issue of "when to pull the plug" has no simple answer- particularly when driven by economic considerations.
First, of course I can make up absurd expenditures: using a million dollars to buy a week of extra time for a brain dead patient. And easily the opposite- paying for a heart transplant for an otherwise healthy 12 year old. But that leaves quite a complicated range in between. It may have been easy for me, at age 40, to suggest that an expensive cancer therapy that would keep a 65 year old alive for a few more years was not economically justified. However my own current circumstances have radically changed my view of that particular scenario... What if it were just a year of extra time? Or just 6 months? Or one month? I dare say that most people, when it becomes personal and real rather than hypothetical, find that even a month or so of extra life is worth a lot of money to them, and they wouldn't be too happy if an insurance company, or a UHC system, was to tell them that that month wasn't worth the investment. As far as I can tell, even most 90 year olds wish fervently to become 90.1 year olds. And this applies to close relatives and friends- if there is a way to keep one's mom alive, even for a little longer and even if she is aged, one wants to be able to do so. Add to that the uncertainties of real life medicine- prognoses can be wrong. People given a few weeks to live have turned around and lived years. I know of two people who checked into, and then out of, palliative care and have gone one to live many months or years. Who should decide not to treat someone who may have a small, but real chance of recovery? And yet I also realize that there are diseases and stages of diseases in which death comes soon and there is no chance of recovery- the very terminal stages of cancer, or of certain kidney or liver diseases for example. One only hopes that the patient, their family, and their doctors in these cases have been realistic and have arranged do not resuscitate/no extreme measures orders. Yet even here, most people would be uncomfortable if forced to do so by an insurance company or a government based on monetary considerations of "worth." So it is complicated. Yes, a lot of money goes into treating people "near death." But some of that money went to people who, after treatment, did not die (or at least it wasn't clear that they were going to die). And how near death does one have to be? A few days? Okay, a big investment at that point still seems silly to me. A few months? Well, most people would want a few months. if they could have them without tremendous suffering. A few years? Sure! I know that I am largely stating the obvious, but perhaps my main point is that many of these issues look very easy to decide in theory and at the societal level, but then become very difficult when they become real and personal. |
22nd February 2017, 01:16 PM | #503 |
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I agree that inevitably there are limits to expenditures in health care no matter the funding source. What those limits are, and how to apply them, are the critical questions. Having a maximum lifetime cap makes no sense to me at all- it determines one's life span based on the expense of the treatments and not on their likely success. A kidney transplant at age 45 and a cancer diagnosis at age 52 might cap one's life time benefits at a point when the individual could easily have 30 more productive years to go if the money were available. Yet a comatose person in a hospital bed a few weeks from an inevitable death from a car crash might still have many hundreds of thousands of dollars available to them for meaningless treatment because they have been cheap to treat previously.
Someone expert in the issues has to consider each case, as 3point14 and others have noted. Having a UHC system seems to me to be the fairest way of attempting to achieve this based on medical considerations rather than on life time maxima. |
22nd February 2017, 01:24 PM | #504 |
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I am a bit confused by this- insurance companies clearly cannot be paying out more than they take in through premiums and copays, so there must be something I am missing as to these figures. Is it that the calculation of what "patients" pay though premiums, copays, employer contributions, etc. does not include non-patients? i.e. are the healthy people paying insurance, etc., during that time not counted? Is this just the normal socialization inherent to insurance- the cost of care for those unlucky enough to become sick each year is paid in part by the people lucky enough to stay well?
This of course seems fair to me. We all pay for fire and police protection and yet only a few of us will need it in any given year. |
22nd February 2017, 01:30 PM | #505 |
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22nd February 2017, 01:32 PM | #506 |
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And should past expenditures count against you, like you are perfectly healthy but had several very expensive conditions is the past should you get the same treatment as someone in exactly the same condition with much lower life time expenses?
You are looking at it solely as a cost benefit situation while life time maximums are more than just a cost benefit situation as they factor in past medical bills no matter what the cost benefit is in the current situation. So it means "Well because you beat cancer 5 years ago we are not going to treat your heart condition no matter what". |
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22nd February 2017, 02:50 PM | #507 |
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Those numbers reflect, for 2014, per capita health expenditures for the US and then spending per "consumer unit" on health care. I shouldn't have used the word, "patients," as it's actually consumer unit. I confused myself and I apologize. However, this actually makes the situation worse because "consumer unit" can represent individuals or households. So "per capita" spending by consumers on health care is much lower than what the nation as a whole spends on healthcare.
My point is that since patients only pay in a small portion of what is paid out, on average for the nation, insurance companies have to put caps on what they will pay out. We can't just raise taxes and have the government pay more and more of the expenses. Every insurance policy you buy has caps on how much they will pay out. If you want a higher cap, you pay more in premium. You can't force health insurance to violate basic economic principles without expecting premiums to rise. That was one of the flaws of ACA -let's just expand benefits, eliminate pre-existing clauses, ban premium differences based on risk and expect that everyone can keep their doctor and save money in the process. |
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22nd February 2017, 03:24 PM | #508 |
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I'd like to see more people get even basic health care
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22nd February 2017, 03:46 PM | #509 |
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22nd February 2017, 04:12 PM | #510 |
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My impression of UHC countries is that they evaluate a treatment and when and how it should be administered. Then that evaluation applies to everyone equally. So, if the patient falls into these guidelines then it is determined that treatment X would be an effective treatment, but if patient does not fall within the guidelines then treatment X would not be considered effective.
I could be completely wrong, since I'm not in any way associated with medicine or medical policy. |
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22nd February 2017, 04:24 PM | #511 |
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I am sorry but I remain confused. If health expenditures per capita are so much higher than what "health units" pay for health care, where does the difference come from? It can't be insurance companies if insurance premiums are including in what health units pay for health care. Taxes?
But beyond this- of course there are limits to what can be paid out for health care just like any other service, and these limits apply to either private (e.g. insurance) and or (i.e. government) funds. Just as there are limits to what an insurance company will pay out in for a car crash, or a government can pay for police protection or fire protection. But in health care, the connection between payment and someone's very life and they quality of life is especially close and direct. How one designs and implements these limits easily can mean who lives and who dies, who suffers terribly and who does not. So setting limits in this area must be done with very careful consideration of the impact on real people- not just an economic calculation. And I think that government is more likely to be able to do this effectively and ethically because it is not seeking a profit, and because through taxes it can "enroll" everyone (representing a large percentage of healthy people) to help pay for those in the population unfortunate enough to become ill, whereas voluntary health insurance companies always have to be concerned that they will attract only those who are ill or most likely to become ill. In fact I think your last paragraph very clearly supports this premise. It's not cheap to do this and the more and better coverage the more taxes (or premiums) need to go up. That is realism. People will have to decide how much health care they are willing to pay for in taxes. But this is not an impossible expectation: in countries with UHC (and even in the USA with Medicare) they have made these types of decisions. And I think that UHC can (and has) done this cheaper than the scattered, bizarre system currently prevalent in the USA. Just looking at the about of effort and time my doctors and insurance companies have to devote to the complicated paperwork involved now- how much money is that costing? |
22nd February 2017, 04:25 PM | #512 |
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22nd February 2017, 04:39 PM | #513 |
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Sure it does - you pull the plug when all the patient's assets have been stripped.
In a capitalist system you need to make money to survive. If you run out of money then you are dead, and there's a limited supply so... people don't become doctors to help others, they do it because doctors make more money. Why do they make more money? Because sick people will give up all their money to avoid dying. There is nothing anomalous about this - it's how Capitalism works! The only alternative is Socialism, but that is un-American so it is no solution. The answer is for everyone to become a doctor, then we can all make enough money to pay for our own healthcare. So what should Republicans do to replace Obamacare? Simply eliminate all regulations that prevent anyone from becoming a doctor! |
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22nd February 2017, 04:44 PM | #514 |
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Death panels!
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22nd February 2017, 05:12 PM | #515 |
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22nd February 2017, 05:15 PM | #516 |
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I don't understand your post. The snippet of discussion here was specifically about lifetime maximums.
That said, it might be worthwhile to read my initiating response, wherein I address the fact that some states and products had very low lifetime limits. I also reference my own personal opinion of low lifetime limits. |
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22nd February 2017, 05:20 PM | #517 |
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You have very good points, with respect to it being very complicated, and very personal.
My only quibble is coming from an actuarial perspective. When you are the 90 year old, wishing to be a 90.1 year old, I completely understand and respect your perspective. I'm not convinced, however, that your desire to be 90.1 should obligate other people to foot the bill for your 0.1 year extension. There is a point where we need to recognize that no matter the funding system, we're still asking other people to bear the financial burden of a very personal choice. |
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The distance between the linguistic dehumanization of a people and their actual suppression and extermination is not great; it is but a small step. - Haig Bosmajian |
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22nd February 2017, 05:23 PM | #518 |
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Without digging in to the numbers, I suspect the gap may be the amount being borne by society already: Medicare, Medicaid, VA, and Military. They're funded through taxes, so may not show up in the "what patients pay" piece of it.
There may be another explanation though. |
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The distance between the linguistic dehumanization of a people and their actual suppression and extermination is not great; it is but a small step. - Haig Bosmajian |
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22nd February 2017, 05:27 PM | #519 |
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Emergency room care for all is already a thing. But ERs only treat emergent events, and then their obligation is to stabilize the patient. An ER will stabilize you when you have a seizure because of a brain tumor; the ER will not provide chemotherapy.
True story and way TMI... Several years ago I had a uterine fibroid that hemorrhaged, and I almost died. I spent most of a day in the ER. They gave me fluids to stabilize my blood pressure so I wouldn't die and they did an ultrasound to diagnose the cause. But they did nothing else. The did not provide a blood transfusion, they did not consider surgery to address the underlying cause. ER access for everyone is already a thing, but it is not enough. |
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The distance between the linguistic dehumanization of a people and their actual suppression and extermination is not great; it is but a small step. - Haig Bosmajian |
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22nd February 2017, 05:47 PM | #520 |
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