Concierge medicine or can't find a doctor

[Chip Sylverne]

But the benefit of the people who got insurance, isn't that being negated by the huge increases in premiums those folks are now seeing?

In reference to the "huge price increases". When the ACA was enacted, part of the deal for the insurance companies to participate was the establishment of risk corridors, essentially training wheel allowing losses to be reinsured and spread, for the underwriters until they could establish enough loss experience to accurately underwrite the new pool. When control of congress changed, the new congress cut off the risk corridor appropriation and reneged on the commitment to the underwriters after billions of dollars of losses had already been incurred.. The underwriters had no choice but to raise premiums, and or exit the individual market.

Since this was timed to coincide with an election year, I'll leave the motives up to the imagination. In the interest of full disclosure, I am a self-employed, a member of my family has a pre-existing condition and my only choice for coverage is the individual market through our MD state exchange. A simple process. Prior to its establishment, coverage had become essentially unavailable at any price. Even though it's expensive, at least with the ACA coverage could be had. High deductibles, I can take thàt hit. A million $ incident, I can't easily absorb. Now, once again, I will have to lose sleep wondering if a medical emergency will bankrupt me. I had hoped those days were over.

 

[airdale]

... I will have to lose sleep wondering if a medical emergency will bankrupt me. ...

OK, I guess that we are officially OT here.

I think the fundamental issue is this: Insurance is an inherently socialistic concept; everyone bands together to share the cost when some of the participants experience a negative event. Health insurance, fire insurance, car insurance, ... it is all the same idea.

But trying to implement this concept within a capitalistic framework has inherent problems. A capitalist running an insurance company is not there to facilitate shared risk, he/she is there to maximize profits. The way to do that is to control entry into the pool and, to the extent possible, to remove expensive members from the pool. So to the extent that they are successful at this, Chip can't sleep at night. (Incidentally, if you think "nonprofits" are not capitalist enterprises you haven't been paying attention to their executive salaries and to their country club facilities.)

It's purely theoretical, I know, but I think that the only way to implement the socialistic notion of health insurance is to go to single payer. I am conservative to the point where I donated to the libertarian candidate this fall, but (to paraphrase Churchill) I think that single payer is the worst system except for all the others that have been tried.

 

[Chip Sylverne]

I'm sorry for taking the thread OT. But previously it was mentioned that the whole system was taken out for 5% of the population. I felt I had to respond. We are real, and I'm one of them. I am one of you. I am not a taker, or a moocher, or one of "those people". I pay my way, I pay taxes, probably a lot more than a number of people on this board.The individual insurance market was a mess, and the ACA has been a lifeline. Now it appears to be on the brink of being decimated for a good long time.

 

[airdale]

I'm sorry for taking the thread OT. ...

If you interpreted my observation as criticism I am sorry that was not my intention. First, your comments were not the only ones that were somewhat OT. My first one would also qualify IMO. I made the observation with bit of a smile, sort of thinking: "Oh, good. This could go somewhere interesting."

 

[Chip Sylverne]

If you interpreted my observation as criticism I am sorry that was not my intention. First, your comments were not the only ones that were somewhat OT. My first one would also qualify IMO. I made the observation with bit of a smile, sort of thinking: "Oh, good. This could go somewhere interesting."

No worries, I didn't take any particular offense. And I agree, it would be nice to have reasonable discussions on such topics now and again.

 

[Everskyward]

Within MDVIP, there's a way to be referred to other MDVIP doctors without being members of both. So if you're a member of one, you can generally get referred in to see another.

In that case it seems like a better deal than I thought at first.

 

[weilke]

True. You used the word "since", instead of "because", so your statement is accurate. I've worked in medical billing. It was a catastrophe before, it's a catastrophe now. Obamacare wasn't the cause nor did it accelerate things.

Let me see. ACA made PQRS mandatory, meaningful use mandatory, the 'metal' scheme has caused deductibles to go through the roof and CMS has wrecked outpatient imaging. Other than that, you are right, it hasn't affected the administrative side much.

I don't consider medical billing a catastrophe. It's pretty straightforward. Network contracts and CMS rules are a catastrophe, and it's not getting better. One of these days we'll close the practice to Medicare and go the non-par all cash route. It's not the billing that's the problem, with universal reason codes and standardized insurer numbers it's pretty easy to figure out.

 

[Rushie]

There is some truth to that. We should just adopt universal care, like every single other first world nation, and move on.

Well we are going OT and I didn't know if that was allowed on this board. They got rid of SZ so I wasn't sure we could talk about anything that touched on politics at all. I don't want to get this thread locked down. It is a great discussion.

But I have to comment on this chart. What you seem to be saying is that universal care is not only cheaper, but better, because people live longer under it. But just because two things are together in a graph does not necessarily mean one of them causes the other.

The other way to look at it is the shorter the life expectancy, the sicker you are, and so the more you spend on healthcare. If that is true, that the U.S. is just sicker for whatever reason, then we'd spend more on healthcare whatever system we had.

Maybe we are sicker not because we don't have universal coverage, but because we're addicted to soda and really horrible types of food.

But the biggest thing that jumps out here, is that none of those other countries has the huge population of slave descendants. The inner cities with gang related youth death, and the worse outlook for blacks with diabetes and heart disease, a population that still has not recovered and assimilated into the mainstream and has far worse health stats. If you compare demographics by race and socio-economic status, then what does the graph look like?

There are vast cultural differences too, never mind genetics. Maybe the Japanese are blessed with genetic longevity. None of those countries, except maybe Canada, to my knowledge, move around millions of freight cars of corn syrup and wheat for processing to put on the grocery shelves, the way the U.S. does. These things have got to influence life expectancy and without controlling for these, it's really meaningless to draw any conclusions from this.

 

[Everskyward]

Well we are going OT and I didn't know if that was allowed on this board. They got rid of SZ so I wasn't sure we could talk about anything that touched on politics at all. I don't want to get this thread locked down. It is a great discussion.

We will allow it as long as it doesn't go down the road of partisan political bashing/defending... which is has somewhat.

So if you want it open, refrain from that.

 

[weilke]

In reference to the "huge price increases". When the ACA was enacted, part of the deal for the insurance companies to participate was the establishment of risk corridors, essentially training wheel allowing losses to be reinsured and spread, for the underwriters until they could establish enough loss experience to accurately underwrite the new pool. When control of congress changed, the new congress cut off the risk corridor appropriation and reneged on the commitment to the underwriters after billions of dollars of losses had already been incurred.. The underwriters had no choice but to raise premiums, and or exit the individual market.

The other option would have been to properly fund the law up front. As always in politics, it is much easier to pass something if you can leave it to others to pay for it (there is a famous Margaret Thatcher quote on this). The great fun will start once the startup funding for the medicaid expansion runs out yet the states are stuck with significantly expanded MA populations. MA already makes up a big portion of state budgets, eventually it will displace education and transport completely.

 

[Chip Sylverne]

Hard to properly fund the law up front without loss experience to underwrite a newly created risk pool. Risk corridors worked just fine for Medicare part D, even though initial losses were very high. Because congress left corridors in place long enough for underwriters to actually gain loss experience and underwrite the risk, the program has become sustainable. Insurance contracts take time for loss experience to develop so they can be profitably underwritten. The ACA underwriters were initially promised that time, then got kicked in the balls.

 

[coloradobluesky]

Our system isn't working very well primarily because we need to get costs down. The reason the US medical costs are so high are MANY. Law suit worries, not enough doctors being admitted to medical school, too many unnessary tests, drugs and procedures, expensive drugs, insurance company overhead and profit, the list goes on and on....

England has essentially the same health service quality as the US (maybe better) for HALF the price!!!!! HALF!!!!

 

[Dr. O]

Hmm, well I read three British newspapers every morning and I have a vastly different viewpoint than you of the superiority of the NHS - but that is not what I wanted to basically comment on.
I practiced as the only doc for the three townships around me for over 30 years. ACA was one of the reasons I decided to retire as a physician. And 2.5 FTE just to get 'something' out of the insurance company after you have rendered the service is a bit low.
On the concierge model, my daughter after 20+ years in practice changed her walk in clinic over to concierge 2 years ago - or rather tried to. The concierge part is working fantastic for her. Closing the walk in clinic all but caused a riot.
So, she is now running two practices, a full time concierge practice and a half day walk in clinic. What she did on the clinic side is refuse to accept insurance. It is cash at the window. She gives them a computer generated bill at the time of service with the ICDM codes, which they may submit to their insurer for reimbursement.
This is causing another near riot as these 'consumers' discover the true nature of the insurance company beast.
If more physicians would do this I am sure political pressure would rise to force the insurers to change their criminal denial of service shtick.

 

[Chip Sylverne]

That's all fine and good on the physician side of things, but what about prescriptions? Case in point, I had to fill a prescription for azythromycin for a family member. With insurance $20. Without, $280! And that's before the deductible is met. Without insurance, the patient is screwed.

My SIL is an OBGYN. The stories she tells of insurance company denials could bring tears to your eyes. But that's an issue of reform, not repeal. A walk in cash clinic might make sense, but my FIL just had a cardiac event that was easily $300k. That won't work on such a basis.

I've had my fill of both doctors and insurance companies of late.

 

[weilke]

Hard to properly fund the law up front without loss experience to underwrite a newly created risk pool.

The pricing data existed. Experience from the states that had high risk pools as well as from MA was that the sickest patients will choose the cheapest plans. Had the plans calculated premiums based on the historic loss data, much of the propaganda surrounding the program wouldn't have worked. Also, the .gov can always budget for more and not draw all the funds by the end of the fiscal year. Contrary to buerocrat lore, nothing bad happens if you haven't blown every last dollar in your budget by the fiscal years end.

Risk corridors worked just fine for Medicare part D, even though initial losses were very high. Because congress left corridors in place long enough for underwriters to actually gain loss experience and underwrite the risk, the program has become sustainable. Insurance contracts take time for loss experience to develop so they can be profitably underwritten. The ACA underwriters were initially promised that time, then got kicked in the balls.

Premium volume in the health insurance market is somewhere north of $600B every year. The unfunded portion of the risk corridors was $2.5B. The premium increases in the individual market included plans that were considered 'rich' plans under the risk corridor scheme. To claim that the stiff premium increases are the result of a politically motivated non-appropriation of the risk corridor subsidy is disingenuous.

I'm sorry for taking the thread OT. But previously it was mentioned that the whole system was taken out for 5% of the population. I felt I had to respond. We are real, and I'm one of them. I am one of you. I am not a taker, or a moocher, or one of "those people". I pay my way, I pay taxes, probably a lot more than a number of people on this board.The individual insurance market was a mess, and the ACA has been a lifeline.

Actually, you are part of a much smaller group than the 5%.

The 5% includes:
- beneficiaries of the medicaid expansion
- people who had small group health insurance before but were dumped from it when ACA came around when small employers moved to a pure defined contribution model.
- people who purchased individual coverage prior to ACA but were forced onto the exchanges when their insurers standardized operations to exchange plans only ('if you like your insurance, you can keep your insurance.....').

I have a family member who was in a similar situation as you. Uninsurable in the individual market due to age and preexisting conditions. As the person who wrote the checks, I am very familiar with the issue. This year was the second time I tried to buy insurance through coverMD but it was so awful, that I decided to go through a conventional broker instead.

Expanding medicaid wouldn't have required the wide ranging changes to the way healthcare is being delivered that the ACA is pushing through. Covering the single digit percentage of people locked out of the individual market due to age or pre-existing conditions didn't require those changes either. The reality is that people like you were used as the justification to ram through changes to the healthcare system some special interest groups wanted to see for their own financial benefit.

 

[weilke]

On the concierge model, my daughter after 20+ years in practice changed her walk in clinic over to concierge 2 years ago - or rather tried to. The concierge part is working fantastic for her. Closing the walk in clinic all but caused a riot.
So, she is now running two practices, a full time concierge practice and a half day walk in clinic. What she did on the clinic side is refuse to accept insurance. It is cash at the window. She gives them a computer generated bill at the time of service with the ICDM codes, which they may submit to their insurer for reimbursement.
This is causing another near riot as these 'consumers' discover the true nature of the insurance company beast.
If more physicians would do this I am sure political pressure would rise to force the insurers to change their criminal denial of service shtick.

I applaud your daughter for going all cash. It'll take a lot more docs to go that route for the public to understand that a professional service like healthcare costs money, no different from hiring a lawyer or accountant.

In the absence of network contracts and medicare rules, payment for medical services is pretty straightforward. If I think a particular service is worth $150, I collect that amount and put the money in the bank. I don't have to bill $400, wait 89 days, get $0 and have to go through two rounds of appeals to get $75.

 

[airdale]

... It'll take a lot more docs to go that route for the public to understand that a professional service like healthcare costs money, no different from hiring a lawyer or accountant. ...

Yes, that's another problem. Any time the benefits accrue to one group (patients) and the costs go to another (insurance) bad decisions get made, often by players in either group who don't understand that they are making bad decisions because they are not looking at both sides of the equation.

On the provider side, though, things are made worse by providers who rape private pay customers (and customers who are spending their own money through deductibles) by billing amounts that are hugely above what they routinely accept from insurance companies. I wouldn't mind paying $125 for something that the doc or hospital is paid $100 under insurance agreements, but it's rape to bill me $400 for the thing.

If we approached car insurance like we do medical insurance, we would be expecting the car insurance to pay for oil changes and tires. And it, too would become unaffordable for many.

 

[Everskyward]

Yes, that's another problem. Any time the benefits accrue to one group (patients) and the costs go to another (insurance) bad decisions get made, often by players in either group who don't understand that they are making bad decisions because they are not looking at both sides of the equation.

On the provider side, though, things are made worse by providers who rape private pay customers (and customers who are spending their own money through deductibles) by billing amounts that are hugely above what they routinely accept from insurance companies. I wouldn't mind paying $125 for something that the doc or hospital is paid $100 under insurance agreements, but it's rape to bill me $400 for the thing.

If we approached car insurance like we do medical insurance, we would be expecting the car insurance to pay for oil changes and tires. And it, too would become unaffordable for many.

A few years ago I had a blood test. The clinic swiped my credit card for about $1000, "in case my insurance didn't pay". I assured them it would, as I had already met my out of pocket expense for the year. The insurance did indeed pay... something like $125.

 

[weilke]

On the provider side, though, things are made worse by providers who rape private pay customers (and customers who are spending their own money through deductibles) by billing amounts that are hugely above what they routinely accept from insurance companies. I wouldn't mind paying $125 for something that the doc or hospital is paid $100 under insurance agreements, but it's rape to bill me $400 for the thing.

The 'funny money' system is the result of medicare rules, network contracts and the way how U&C charges are calculated. Without either, I could charge you a reasonable fee up front, have you pay cash and be done with it. As it stands right now, you have to make a decision whether you want to run an insurance and medicare practice or a cash practice. Mixing the two is financially risky.

 

[Rushie]

Hmm, well I read three British newspapers every morning and I have a vastly different viewpoint than you of the superiority of the NHS - but that is not what I wanted to basically comment on.
I practiced as the only doc for the three townships around me for over 30 years. ACA was one of the reasons I decided to retire as a physician. And 2.5 FTE just to get 'something' out of the insurance company after you have rendered the service is a bit low.
On the concierge model, my daughter after 20+ years in practice changed her walk in clinic over to concierge 2 years ago - or rather tried to. The concierge part is working fantastic for her. Closing the walk in clinic all but caused a riot.
So, she is now running two practices, a full time concierge practice and a half day walk in clinic. What she did on the clinic side is refuse to accept insurance. It is cash at the window. She gives them a computer generated bill at the time of service with the ICDM codes, which they may submit to their insurer for reimbursement.
This is causing another near riot as these 'consumers' discover the true nature of the insurance company beast.
If more physicians would do this I am sure political pressure would rise to force the insurers to change their criminal denial of service shtick.

Yes, the UK actually has a hybrid of NHS and private care, and most people who believe it's as good or better than healthcare in the U.S. do not seem to know this. We have a friend who just returned from living for a year in the UK with his wife and child and had plenty of opportunity to deal with their system. He told us there are two types of patients and they are given different levels of care; the regular ones, and the ones with private insurance. People who tell me healthcare in the UK is superior are either 1) ex pats who haven't lived there for 20 years, or 2) people who vacationed there and are basing their opinion on a single ER visit.

You hit on the basic problem with these consumer "riots". People feel entitled to free care, or to care at a price way under true value. This is why they want cheap premiums and then all the care they need at no extra cost. We have lost the idea of what insurance is supposed to be. It is meant to protect against catastrophic illness of the sort that would wipe out your life savings. It should never have become something you expect to cover routine visits or minor illnesses. No matter what type of system we have, as long as everyone expects to pay x in premiums but receive MULTIPLE TIMES x in care, the whole thing will collapse. You can't manufacture something out of thin air and that's what the masses now demand and are too stupid to understand isn't possible or sustainable if you attempt it.

 

[Rushie]

That's all fine and good on the physician side of things, but what about prescriptions? Case in point, I had to fill a prescription for azythromycin for a family member. With insurance $20. Without, $280! And that's before the deductible is met. Without insurance, the patient is screwed.

My SIL is an OBGYN. The stories she tells of insurance company denials could bring tears to your eyes. But that's an issue of reform, not repeal. A walk in cash clinic might make sense, but my FIL just had a cardiac event that was easily $300k. That won't work on such a basis.

Exactly my point of what insurance really should be. You need it for the $300K heart attack. But for a $5000 baby delivery, why not pay out of pocket? If you can't afford $5000 to get the kid into the world, you have no business having a kid. People will gladly pay two or three or four times that amount out of pocket for a CAR for Pete's sake. But for some reason everybody expects somebody else to cover the cost of getting their baby.

And the expectation that you should get an antibiotic for almost nothing. It's mind boggling how people forget that we are lucky to even have antibiotics. $280 out of pocket to kill a bacteria that can kill you or cause you permanent injury, we should be grateful the cost is that low, and we should gladly budget and save for such minor illnesses.

It's our expectations that are out of whack here. The math will never add up. We expect way more value for way less money and reality doesn't work that way.

 

[lbfjrmd]

Exactly my point of what insurance really should be. You need it for the $300K heart attack. But for a $5000 baby delivery, why not pay out of pocket? If you can't afford $5000 to get the kid into the world, you have no business having a kid. People will gladly pay two or three or four times that amount out of pocket for a CAR for Pete's sake. But for some reason everybody expects somebody else to cover the cost of getting their baby.

And the expectation that you should get an antibiotic for almost nothing. It's mind boggling how people forget that we are lucky to even have antibiotics. $280 out of pocket to kill a bacteria that can kill you or cause you permanent injury, we should be grateful the cost is that low, and we should gladly budget and save for such minor illnesses.

It's our expectations that are out of whack here. The math will never add up. We expect way more value for way less money and reality doesn't work that way.

indeed

 

[Chip Sylverne]

Exactly my point of what insurance really should be. You need it for the $300K heart attack. But for a $5000 baby delivery, why not pay out of pocket? If you can't afford $5000 to get the kid into the world, you have no business having a kid. People will gladly pay two or three or four times that amount out of pocket for a CAR for Pete's sake. But for some reason everybody expects somebody else to cover the cost of getting their baby.

And the expectation that you should get an antibiotic for almost nothing. It's mind boggling how people forget that we are lucky to even have antibiotics. $280 out of pocket to kill a bacteria that can kill you or cause you permanent injury, we should be grateful the cost is that low, and we should gladly budget and save for such minor illnesses.

It's our expectations that are out of whack here. The math will never add up. We expect way more value for way less money and reality doesn't work that way.

You misunderstand my point. It's not a matter of expecting to get the antibiotic for next to nothing, it's the extreme price disparity between buying the exact same product via two different methods. As I said, my deductible is almost $10k, and I'm fine with that. But because the drug is on the insurance company formulary, the price is negotiated.

 

[Everskyward]

The insurance companies are at an advantage to the individual when negotiating prices for things.

Also, I'm not sure of the "right" way to determine the price of a drug. From the drug company's perspective, it costs a lot to bring it to market, especially if the market is small. But how much should the end user pay?

 

[Chip Sylverne]

The pricing data existed. Experience from the states that had high risk pools as well as from MA was that the sickest patients will choose the cheapest plans. Had the plans calculated premiums based on the historic loss data, much of the propaganda surrounding the program wouldn't have worked. Also, the .gov can always budget for more and not draw all the funds by the end of the fiscal year. Contrary to buerocrat lore, nothing bad happens if you haven't blown every last dollar in your budget by the fiscal years end.



Premium volume in the health insurance market is somewhere north of $600B every year. The unfunded portion of the risk corridors was $2.5B. The premium increases in the individual market included plans that were considered 'rich' plans under the risk corridor scheme. To claim that the stiff premium increases are the result of a politically motivated non-appropriation of the risk corridor subsidy is disingenuous.



Actually, you are part of a much smaller group than the 5%.

The 5% includes:
- beneficiaries of the medicaid expansion
- people who had small group health insurance before but were dumped from it when ACA came around when small employers moved to a pure defined contribution model.
- people who purchased individual coverage prior to ACA but were forced onto the exchanges when their insurers standardized operations to exchange plans only ('if you like your insurance, you can keep your insurance.....').

I have a family member who was in a similar situation as you. Uninsurable in the individual market due to age and preexisting conditions. As the person who wrote the checks, I am very familiar with the issue. This year was the second time I tried to buy insurance through coverMD but it was so awful, that I decided to go through a conventional broker instead.

Expanding medicaid wouldn't have required the wide ranging changes to the way healthcare is being delivered that the ACA is pushing through. Covering the single digit percentage of people locked out of the individual market due to age or pre-existing conditions didn't require those changes either. The reality is that people like you were used as the justification to ram through changes to the healthcare system some special interest groups wanted to see for their own financial benefit.

Rather than refute your facts point by point, I'll simply refer you to this article.

http://angrybearblog.com/2017/01/wh...-increasing-faster-than-healthcare-costs.html

As far as your comments about special interests are concerned, isn't that part of the way legislation gets passed? There is not a single bill of any magnitude signed into law that somebody doesn't get something they lobbied for. Shocked, shocked to think that kind of thing goes on in Washington.

 

[Chip Sylverne]

Yes, the UK actually has a hybrid of NHS and private care, and most people who believe it's as good or better than healthcare in the U.S. do not seem to know this. We have a friend who just returned from living for a year in the UK with his wife and child and had plenty of opportunity to deal with their system. He told us there are two types of patients and they are given different levels of care; the regular ones, and the ones with private insurance. People who tell me healthcare in the UK is superior are either 1) ex pats who haven't lived there for 20 years, or 2) people who vacationed there and are basing their opinion on a single ER visit.

You hit on the basic problem with these consumer "riots". People feel entitled to free care, or to care at a price way under true value. This is why they want cheap premiums and then all the care they need at no extra cost. We have lost the idea of what insurance is supposed to be. It is meant to protect against catastrophic illness of the sort that would wipe out your life savings. It should never have become something you expect to cover routine visits or minor illnesses. No matter what type of system we have, as long as everyone expects to pay x in premiums but receive MULTIPLE TIMES x in care, the whole thing will collapse. You can't manufacture something out of thin air and that's what the masses now demand and are too stupid to understand isn't possible or sustainable if you attempt it.

My guess would be "regular ones" are still better off than having no system at all.

 

[Chip Sylverne]

The insurance companies are at an advantage to the individual when negotiating prices for things.

Also, I'm not sure of the "right" way to determine the price of a drug. From the drug company's perspective, it costs a lot to bring it to market, especially if the market is small. But how much should the end user pay?

That's a very good question, and one I surely don't have an answer to. But when you look at the amount of money companies spend marketing drugs, the patent games, and other piggybacking that goes on, it almost makes you ill. I did some digging into the very expensive Hep C drug at one time....what costs $80k here costs pennies in India, identical active compound but for a minor patent change that licensed the generic for Indian manufacturer.

 

[Rushie]

You misunderstand my point. It's not a matter of expecting to get the antibiotic for next to nothing, it's the extreme price disparity between buying the exact same product via two different methods. As I said, my deductible is almost $10k, and I'm fine with that. But because the drug is on the insurance company formulary, the price is negotiated.

You are right, and I apologize if I seemed to imply you yourself are whining about paying $280 for an antibiotic. You are correct about the disparity. I've had situations where the insurance wouldn't pay for whatever reason, and I say to the pharmacist, "Okay, I'll pay cash then," and the pharmacist says, "Fine. That'll be $790." And then I have to decide whether it's worth that much to get a pill that will make my cold sore go away a few days sooner. (If it's the week of my wedding, yes.)

In theory, that is how it should be. We should self ration our care based on whether it's worth the money for whatever, but in reality the pricing is not fair, if that money is being charged me to make up for some lack of reimbursement in another sector. And I think a lot of that goes on, and I also understand there are corrupt deals happening, like when drug companies conspired with the (not gonna name it because it's partisan) foundation to keep U.S. AIDS drugs high so that they could be low overseas so the foundation could take credit for treating sick AIDS patients in other countries.

I am honestly not starting a partisan political debate because I am SURE people on the other side have done similar things, just can't name an example off the top of my head. My point is that price fixing and deals are being made by the rich big companies and the elite powerful political class, that raises cost for us, the little people.

So in light of that, I won't say we need to suck it up and pay. I would say that only if the system were fair, but it's not. We're not living under a free market price system.

 

[Rushie]

I did some digging into the very expensive Hep C drug at one time....what costs $80k here costs pennies in India, identical active compound but for a minor patent change that licensed the generic for Indian manufacturer.

Our posts crossed. I wonder if there was a similar deal made for that drug too?

 

[weilke]

Rather than refute your facts point by point, I'll simply refer you to this article.

http://angrybearblog.com/2017/01/wh...-increasing-faster-than-healthcare-costs.html

That's a politically slanted opinion piece re-stating your argument. It doesn't refute any of the points I made using what you would call 'facts'.



When the law was being passed, we were told that among other things, the evil capitalist insurance companies making huge profits are what drives healthcare cost. One of the remedies were the co-ops who wouldn't pay their execs hundreds of millions in salaries and didn't have all these bowler hat wearing stockholders who mercilessly squeeze quarterly profits out of the companies. The co-ops, so the cheerful childrens drawing promised, would use all of their revenue to benefit the patient, not the company. Most of the coops priced their products way below the commercial payors with financial models based on the universally accepted actuarial concepts of 'hope' and with the intent to 'change how healthcare is delivered'. Unfortunately, at the end of the day, people still got sick and it looks like the folks who ran the commercial plans knew a thing or two about who to price things to cover expenses.




(Note: For full disclosure. One of my employers is an insurer that provides coverage through several of the federal exchanges. I am not involved in the HMO side of the company and anything I say is my opinion alone and does not reflect the position of the company.)

 

[Everskyward]

My point is that price fixing and deals are being made by the rich big companies and the elite powerful political class, that raises cost for us, the little people.

So in light of that, I won't say we need to suck it up and pay. I would say that only if the system were fair, but it's not. We're not living under a free market price system.

But there are also ethical and public health issues involved when you talk about the free market in relation to medicine. For example, controlling the spread of AIDS is in everyone's interest.

 

[weilke]

That's a very good question, and one I surely don't have an answer to. But when you look at the amount of money companies spend marketing drugs, the patent games, and other piggybacking that goes on, it almost makes you ill. I did some digging into the very expensive Hep C drug at one time....what costs $80k here costs pennies in India, identical active compound but for a minor patent change that licensed the generic for Indian manufacturer.

What is breaking the bank at most state medicaid plans right now are Sovaldi (sofosbuvir) and Harvoni (ledipasvir+sofosbuvir) which finally offer a chance for a cure for most patients with chronic Hep C. A course of treatment for both clocks in at around $90,000. That seems to be a lot of money, however the alternative is either liver failure or liver cancer, both of which are curable only by a liver transplant. Looking at medicares numbers for 2014, median reimbursement for a liver transplant (DRG-005) is $117,872 (followed by decades of chronic expenses for post-transplant care). I am thrilled that someone put up the money to develop these drugs. There is a high economic risk in drug approval projects. One bad study during the approval process and hundreds of millions in development cost are toast. There has to be the prospect of a payoff at the end if we want the research pharmaceutical companies to put up the money to develop new things. Sooner or later, other drugs will come into the market and eventually HepC treatment will come down to a lower level, whether that's 10k or 20k I don't know.

 

[Everskyward]

What is breaking the bank at most state medicaid plans right now are Sovaldi (sofosbuvir) and Harvoni (Ledipasvir) which is finally a cure for most patients with chronic Hep C. A course of treatment for both clocks in at around $90,000. That seems to be a lot of money, however the alternative is either liver failure or liver cancer, both of which are curable only by a liver transplant. Looking at medicares numbers for 2014, median reimbursement for a liver transplant (DRG-005) is $117,872 (followed by decades of chronic expenses for post-transplant care). I am thrilled that someone put up the money to develop these drugs. There is a high economic risk in drug approval projects. One bad study during the approval process and hundreds of millions in development cost are toast. There has to be the prospect of a payoff at the end if we want the research pharmaceutical companies to put up the money to develop new things. Sooner or later, other drugs will come into the market and eventually HepC treatment will come down to a lower level, whether that's 10k or 20k I don't know.

Will insurance companies or Medicaid pay for the liver transplant but not the drugs?

 

[weilke]

Will insurance companies or Medicaid pay for the liver transplant but not the drugs?

They pay for both.

For transplants, the criteria of when to operate are driven by UNOS, the congressionally chartered non-profit that facilitates the matching of donors and recipients. The main factor is the availability of organs, so most of the liver recipients are in pretty bad shape by the time they qualify.
State medicaid plans tried to do the same for treatment with the new generation of antivirals. This was effectively rationing as they basically waited for liver failure to come around before they approved treatment. As I understand it, there is no medical reason to do it, but if you have Xmillion in our medication budget and treating every hep C patient in year 1 would require 2X money, you have to make some choices.

 

[Everskyward]

They pay for both.

For transplants, the criteria of when to operate are driven by UNOS, the congressionally chartered non-profit that facilitates the matching of donors and recipients. The main factor is the availability of organs, so most of the liver recipients are in pretty bad shape by the time they qualify.
State medicaid plans tried to do the same for treatment with the new generation of antivirals. This was effectively rationing as they basically waited for liver failure to come around before they approved treatment. As I understand it, there is no medical reason to do it, but if you have Xmillion in our medication budget and treating every hep C patient in year 1 would require 2X money, you have to make some choices.

I was thinking that paying for the drug would be cheaper than paying for a transplant, but it seems the transplants are effectively rationed by the number of donors.

Also, if you have 1x in the medication budget but have 2x patients, it would seem that paying 1/2x each would be the way to go, but that would be a little hard to determine in advance. Also $45,000 would be as out of reach as $90,000 for many people.

 

[weilke]

I was thinking that paying for the drug would be cheaper than paying for a transplant, but it seems the transplants are effectively rationed by the number of donors.

Based on documents uncovered by a senate investigation, that's pretty much how Gilead set the price for the drug. They ran a couple of scenarios for prices between 50k and 115k and settled on 85 as the number where they make the maximal amount of money with a manageable risk of hordes with torches and pitchforks at their door.

Also, if you have 1x in the medication budget but have 2x patients, it would seem that paying 1/2x each would be the way to go, but that would be a little hard to determine in advance. Also $45,000 would be as out of reach as $90,000 for many people.

Just to clarify, this was from the perspective of state medicaid programs. Lets say you have $400 million in your budget and treating every HepC patient in year 1 would eat all of that money and then some, you have to find a way to spread it out over a couple of years. All the heart, cancer and HIV patients in your state aren't going to be thrilled if there is no money left to treat their conditions.

 

[Chip Sylverne]

The drugs Weilke refers to are those which I researched as well. Generics are available in India, but are unable to be sold here. The cost may very well come down over time, but meanwhile there are literally 2.9 million people in the US being "warehoused" without treatment, many many of which will not live to see the day.

Yet another triumph of profit over ethics.

 

[Palmpilot]

...actuarial concepts of 'hope'...
...intent to 'change how healthcare is delivered'....

It appears that we're now on course for a new brand of hope and change.

 

[Chip Sylverne]

That's a politically slanted opinion piece re-stating your argument. It doesn't refute any of the points I made using what you would call 'facts'.



When the law was being passed, we were told that among other things, the evil capitalist insurance companies making huge profits are what drives healthcare cost. One of the remedies were the co-ops who wouldn't pay their execs hundreds of millions in salaries and didn't have all these bowler hat wearing stockholders who mercilessly squeeze quarterly profits out of the companies. The co-ops, so the cheerful childrens drawing promised, would use all of their revenue to benefit the patient, not the company. Most of the coops priced their products way below the commercial payors with financial models based on the universally accepted actuarial concepts of 'hope' and with the intent to 'change how healthcare is delivered'. Unfortunately, at the end of the day, people still got sick and it looks like the folks who ran the commercial plans knew a thing or two about who to price things to cover expenses.




(Note: For full disclosure. One of my employers is an insurer that provides coverage through several of the federal exchanges. I am not involved in the HMO side of the company and anything I say is my opinion alone and does not reflect the position of the company.)

All it looks like to me is that the larger insurance companies had deeper pockets to absorb the losses without the promised reimbursements. No one was very good at estimating the losses, because the risk pool data for such large community rated pools did not exist, contrary to your false assertion. That was abundantly clear to anyone paying attention to the insurance executives at the time.

 

[Chip Sylverne]

You are right, and I apologize if I seemed to imply you yourself are whining about paying $280 for an antibiotic. You are correct about the disparity. I've had situations where the insurance wouldn't pay for whatever reason, and I say to the pharmacist, "Okay, I'll pay cash then," and the pharmacist says, "Fine. That'll be $790." And then I have to decide whether it's worth that much to get a pill that will make my cold sore go away a few days sooner. (If it's the week of my wedding, yes.)

In theory, that is how it should be. We should self ration our care based on whether it's worth the money for whatever, but in reality the pricing is not fair, if that money is being charged me to make up for some lack of reimbursement in another sector. And I think a lot of that goes on, and I also understand there are corrupt deals happening, like when drug companies conspired with the (not gonna name it because it's partisan) foundation to keep U.S. AIDS drugs high so that they could be low overseas so the foundation could take credit for treating sick AIDS patients in other countries.

I am honestly not starting a partisan political debate because I am SURE people on the other side have done similar things, just can't name an example off the top of my head. My point is that price fixing and deals are being made by the rich big companies and the elite powerful political class, that raises cost for us, the little people.

So in light of that, I won't say we need to suck it up and pay. I would say that only if the system were fair, but it's not. We're not living under a free market price system.

As far as "that foundation" is concerned, I am not up to speed. But that higher prices charged here for drugs sold overseas is common, actually encouraged. That's why Medicare prices are set by law and cant negotiate bulk pricing. The difference funds R&D egtc, or so the case was made by Bob Menendez, the Senator from the state of Pfizer.
Not nefarious but common practice.