[knittygirl1014]

Hi everyone,
I've been hearing a lot lately about how "cutting waste" from the health care system in the US is the way they are planning on paying for health care reform. Now, I'm all for reform, as I *have* insurance and still have racked up thousands of dollars in debt over the last couple of years trying to get the proper diagnosis. However, a lot of the chatter lately (news, pundits, etc) has been about how doctors run soooo many unnecessary tests. Well, if I had not pressured my doctors into "unnecessary" tests, I would still be very sick. The attitude that the doctor knows all and is in 100% control of your testing is dangerous, because they are not all as educated as we would hope. What about all the drugs that I was prescribed, paid for, and took unnecessarily because the proper tests were not done to begin with?
It is really unsettling to me that we could potentially be facing a system where we can't get the care we need simply because someone else thinks that the proper care is "wasteful." I still don't have an actual diagnosis even though I have been gluten free for 10 months and this makes me worry a little bit- if I were ever to be hospitalized, I hear getting gluten free food is very difficult, and I imagine it would be even harder without a "real" diagnosis.

Anyone else have opinions on this?

[Gemini]

knittygirl1014, on Nov 2 2009, 02:01 PM, said:

Hi everyone,
I've been hearing a lot lately about how "cutting waste" from the health care system in the US is the way they are planning on paying for health care reform. Now, I'm all for reform, as I *have* insurance and still have racked up thousands of dollars in debt over the last couple of years trying to get the proper diagnosis. However, a lot of the chatter lately (news, pundits, etc) has been about how doctors run soooo many unnecessary tests. Well, if I had not pressured my doctors into "unnecessary" tests, I would still be very sick. The attitude that the doctor knows all and is in 100% control of your testing is dangerous, because they are not all as educated as we would hope. What about all the drugs that I was prescribed, paid for, and took unnecessarily because the proper tests were not done to begin with?
It is really unsettling to me that we could potentially be facing a system where we can't get the care we need simply because someone else thinks that the proper care is "wasteful." I still don't have an actual diagnosis even though I have been gluten free for 10 months and this makes me worry a little bit- if I were ever to be hospitalized, I hear getting gluten free food is very difficult, and I imagine it would be even harder without a "real" diagnosis.

Anyone else have opinions on this?

I understand your concerns and if you know anything about socialized medicine, it gets downright scary, after what many Americans are used to here. However, there are many cases where unnecessary testing is done and I think this is what the government may try to address. I am not in favor at all of a government plan but I do think there have been a couple of ideas which sound sensible to me.

Pre-surgery testing has reached the ridiculous stage. All you need is a blood screen and a lung x-ray, like they used to do and now you have doctors who test for everything to cover their butts in case someone dies and there is the resultant lawsuit. Some people with multiple health problems may need to be screened a little more but many do not need all this testing and shouldn't have to undergo the majority of it.

We push physicals too often and do too many screening tests today. People have become so paranoid about their health and demand all these screening tests when they may not be warranted. Family history and other factors should be taken into consideration here and not have all members of the population undergo all of the same tests. It just isn't necessary and this could save millions of dollars. Medicine only got really expensive when all of this came into play. If you have symptoms which you are seeking answers for, then this is when testing is necessary. I doubt that many doctors will blow off tests if you come in with a complaint of diarrhea which is disrupting your life.

If the US models their plan after socialized medicine which exists in other countries, then it may be a problem. We have heard the complaints about long waits for tests and I hope this does not happen here. If a test can wait, fine, but if someone is sick and their lifestyle is impacted, no one should have to wait.

As for having Celiac, we are lucky in that we can always resort to a dietary trial for some answers. Do not be discouraged because you do not have a formal diagnosis. That can be a good thing, as far as insurance goes. People have been denied insurance because of Celiac Disease. I expect that to get worse.

As for being hospitalized, that shouldn't be an issue. You would tell them you need to eat gluten-free and refuse any food which isn't. Personally, I doubt I would eat hospital food anyway and have family members bring me something decent to eat from home. It isn't hard to cook up a gluten-free meal anywhere. You may not have any bread but it's easy to go without bread for a week or so. I do it all the time when I travel.

I also have good health insurance but have spend thousands on alternative care and testing because mainstream medicine is only so good. I think it's money well spent. It can be frustrating to not get the answers you want but if you have gone gluten-free and feel much better, then you know what the problem is. I paid for all my testing out of pocket and have my diagnosis but my insurance company has no copies of any testing...which I find very comforting! We will have to wait
and see what happens, I guess, but I am a little worried myself over how many more taxes we'll get hit with to pay for all of this!

[Nancym]

Right now the way things are you could lose your health insurance because you failed to tell them you had a stomach ache 10 years ago and they could refuse to pay any bills you racked up at all, deciding that you were trying to get covered for a pre-existing condition. And your recourse is basically to find another company to cover you which now you have a pre-existing condition and no one will.

Health care reform isn't going to eliminate insurance companies, they're going to still be there, but they are going to set rules about who they can refuse and stop all the nonsense like recission. There's also the potential for a government run option. I don't hear too many seniors or vets complaining about their government run health care. Besides, if we don't like the health care we end up with we can always kick people out of office until they fix it. Hard to do that with private companies...

And of course, people don't get all the tests they want with private insurance either. I suspect things won't change a whole lot and that gluten issues will still be self-diagnosed fairly often like it currently is. Just so long as I can continue to utilize companies like Enterolab to do my own testing, I'll be fine with that.

[knittygirl1014]

Well, let me clarify. I'm not afraid of socialized medicine, or a government run program. I got medicaid benefits for a short time when I was in college and it was great. I also had an HMO one time that I really liked, so that's not really the issue. Even if I stick with the insurance company I have now, new (possible) laws that would encourage doctors to run FEWER tests could still get passed. I guess that is my concern- how do they plan to cut waste from a system they don't control? The government-run option is just that, an option. What about people who stay with private insurance? It seems like the private system is exactly what they are planning to target in terms of waste. With all due respect to Nancym, I don't want to have to turn to a private company to run my own tests.
I'm also not contesting the fact that there are a ton of unnecessary tests being done- especially to avoid malpractice suits- but in the future WHO is going to decide what is unnecessary? I'd like to say I hope it's left up to the medical professionals and not someone sitting behind a desk doing pre-approvals, but I don't have a whole lot of confidence in that either! Especially with some of the doctors I've seen...

It would be great to hear from some international people who have government health care too!

[Gemini]

Quote

Right now the way things are you could lose your health insurance because you failed to tell them you had a stomach ache 10 years ago and they could refuse to pay any bills you racked up at all, deciding that you were trying to get covered for a pre-existing condition. And your recourse is basically to find another company to cover you which now you have a pre-existing condition and no one will.

I didn't have a lot of tests run in years past because no one wanted to do anything other than an upper GI and ultrasound. I went for Celiac symptoms starting 25 years ago, before endoscopies were in existence. There is no paper trail. I went to a private physician and paid out of pocket and got much better health care.

I am not saying that this particular aspect of health care doesn't need fixing (pre-existing conditions) but the current system we have is not bad, if you find the right doctor. Also, I think that part will go away and private companies will not be allowed to do so because everyone has a pre-existing condition. Americans are in bad health and there are so few people who can boast they are 100% healthy with no issues. They'll go out of business all on their own if they refuse to cover that many people.

Quote

There's also the potential for a government run option. I don't hear too many seniors or vets complaining about their government run health care. Besides, if we don't like the health care we end up with we can always kick people out of office until they fix it. Hard to do that with private companies...

Actually, I hear lots of people complain about Medicare. You also have to have supplemental insurance because Medicare doesn't cover everything. Many doctors around where I live no longer accept Medicare because they don't get paid enough money to make it worth their while. I don't blame them either. Doctors are highly skilled and go to school for many years to become doctors. When I go, I want to see the best and will pay for that. That will become a huge problem in future if there is a public option.....access to good doctors will be restricted. You will not be able to see better doctors and go to better hospitals or it will be very hard to do so....you may have to wait a long time.

I live in Massachusetts and we are the model state for the national health care bill. It is not a distinction I am proud of. We are one of the highest taxed states in the nation. Ever since we were mandated to pay for health care for those without it, the run on the border has been unreal. Lots of illegals flocking here for their free health care, at the working families expense. We are being nickeled and dimed and squeezed hard by our government because now there is no money for anything else. The cost of living here has gone dramatically up due to all the new fee's and taxes.
A huge chunk of that goes to health care for everyone. I am in no way opposed to helping out my fellow American citizens at all but I will not pay for people who do not belong here. I honestly do not think most people have really thought this out and what it will mean to their paychecks.

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And of course, people don't get all the tests they want with private insurance either. I suspect things won't change a whole lot and that gluten issues will still be self-diagnosed fairly often like it currently is. Just so long as I can continue to utilize companies like Enterolab to do my own testing, I'll be fine with that.

I am in the camp where I now have a good doctor who runs any test I want but I am not overly demanding of tests that really do not need to be done. If I am feeling really good, which I am, there is no need to screen the hell out of me just because I am older. I base my screenings on common sense, like we used to, and not by age. That is one way to save some money. Let them screen those with strong family histories of certain diseases or insure more Americans on the money saved.

Whatever ends up happening, Americans have to think long and hard if they want to lose 15% of their paychecks and have increased taxes and fees to pay for it all. The money has to come from somewhere and if they want the same kind of care we are used to in this county, in blanket form for everyone, it's going to have a huge price tag, which will be felt. That scares me more than anything because I work for a living and it gets hard to save for retirement when your paycheck keeps shrinking.

[tarnalberry]

knittygirl1014, on Nov 2 2009, 01:48 PM, said:

Even if I stick with the insurance company I have now, new (possible) laws that would encourage doctors to run FEWER tests could still get passed. I guess that is my concern- how do they plan to cut waste from a system they don't control?

But doctors are CURRENTLY encourage to run fewer tests, because insurance companies - as they stand - do not want to pay for them, and will sometimes deny them (even for random reasons). There are still instances, however, of doctors just running ridiculous tests - and a celiac blood test if you've got GI issues isn't ridiculous. A head CT if you've got GI issues (well, certainly without *ANY* symptoms suggesting for one - and I'll grant you that celiac could well cause those symptoms) would be something they might try to eliminate.

There is a LOT that is done in the medical community for no other reason than to cover someones behind. (This is becoming only more apparent to me as I go through my pregnancy. The OB world is FULL of things done for no other reason than to have data to justify decisions in case the data is needed in a lawsuit.) That wouldn't be such a bad thing to get rid of. (Yes, I'm deliberately ignoring the "well, why don't we... instead" argument. Not a politics thread.)

[knittygirl1014]

I think this is really interesting to hear everyone's different viewpoint about it. Just illustrates the difficulty in getting a bill that everyone will be happy with (OK, that's impossible). I think doctors are currently encouraged to both run more and fewer tests now, depending on where the pressure is coming from. Yes, insurance sometimes deny things randomly, but because of the current system, the more procedures and the more patients doctors do, the more they get paid. Also, malpractice suits are really common, and they want to avoid those. Trust me, I used to work at a doctor's office and I have seen it.
As for there not being a paper trail, the only way that is possible is if you gave them a fake name when you went for your procedures. I suppose it's possible that those records won't make it to another doctor or to the insurance company, but if you don't tell them and they find out later, you can be sued for fraud.
I absolutely agree that I don't want my taxes going sky high, and yes the money has to come from somewhere. I just don't want the cost-saving to go to the opposite extreme and have doctors be penalized for running too many tests. Because then the patient is penalized too. I'm probably being overly worried, but it's just hard to find information about what's going on in "reform" right now, and I'm so busy!

[mushroom]

Let me speak as one who partakes of both the U.S. and the New Zealand health care systems. First off, I don't see anything too drastic happening to the American health care industry. The people would simply not permit it. Things are pretty entrenched the way they are, which is why Hillary Clinton's health reforms got nowhere--much too radical. The health insurance industry has a lot of power and will be applying a lot of pressure to maintain pretty much the status quo. The problem is how to provide for those who do not qualify for insurance under the U.S. system. So I suspect it will be an add-on, with some tightening of the rules of what insurers are allowed to do and not allowed to do, like cancelling policies if you get sick, not providing coverage for pre-existing conditions, etc. Sure, there will be some disincentives to casually conduct expensive procedures and tests on a CYA basis, and. inevitably, some changes to the medical malpractice laws (here speaking as one who used to work in med mal litigation). My bosses were always very selective in what cases they took, but there is a lot of junk med mal litigation out there. There will probably also be changes made to Medicare

Now let me tell you what health care is like in New Zealand, and I assure you you are not going to end up with this!!! We have a public socialized health system, and a parallel private system with often the same doctors in both. In other words, the doctors work for the public system but operate a private specialty practice on the side. You can choose your own GP, but need a referral to see a specialist (and there are not very many of them, although GP's are becoming scarce now as the old ones retire and the newly minted doctors see that you make lots more money as a specialist). GP visits costs about $40 (subsidized), prescriptions of PHARMAC-approved drugs cost $3, lab tests, x-rays, hospitalizations are free. Now the rub really comes in when you need to see a specialist, especially if it is for a condition for which you are likely to need surgery. You can "go private" (where you don't need a referral) and pay the $75-150 for the visit, and any lab work and x-rays will be covered, but then you are stuck if you need surgery. Then you have to go back and wait for an "official" visit to be evaluated under the public system. And at this evaluation you are awarded points toward qualifying for the medical procedure, whatever it is. Points are awarded based on degree of pain, disability, whether you are working or not, whether you are a primary caregiver, and I don't know all the other criteria. If you earn enough points you are put on a waiting list, and these lists used to be endless. Now they will only put you on the waiting list if you can be treated within six months (i.e., you need more points now to get on the list). Needless to say, if you are 80 years old and need surgery for cataracts, can still see well enough to do your daily chores (without chopping your finger off while cutting carrots) and have a partner who can drive you places, you will not score very high on the list.

There is also a private insurance system for which the premiums used to be relatively inexpensive, but which have gone up astronomically in the last ten years (commensurate with the difficulty of getting on the public list). There are several private hospitals, and if you are lucky enough to be able to afford the private insurance or got in before you had any pre-existing conditions it operates pretty much the way the U.S. system does. There is no employer-based health insurance, except that provided by the ACC (Accident Compensation Corporation--workers' comp with a twist). If you can afford it, you can have your cataract surgery done at a private hospital, probably by the same doctor who would do it in the public system.

ACC is funded by employers, by automobile registration, by sporting bodies (professional) and maybe some other source I can't think of at the moment. It works this way because we have no fault auto insurance, and injuries of any type, whether automobile, cutting your finger off while chopping carrots , breaking your ankle while playing rugby, or banging your head after tripping over the cat, are all covered by ACC. There are some copayments involved and some difficulty getting needed treatment, and the working population get precedence in a lot of things because there is great pressure to get them back to work and off disability paid by ACC. So we actually have three systems functioning alongside each other. Most of the time it works pretty well, except if you need cataract surgery or a knee replacement or other "optional" surgery. Obviously, if your mammo shows breast cancer you don't go on a long list, but sometimes post-surgery you still have to wait a few weeks to start radiation (we are short of radiation oncologists) and sometimes you are sent to Australia for radiation

This may help explain why my husband and I, even though we live nine months of the year in New Zealand, maintain our (former) employer-based Medicare supplemental insurance and pay our Medicare premiums, and visit the U.S. every summer for three months. Everyone in New Zealand thinks we are going off for a lovely holiday in the sun, but our time is mostly spent taking care of our health because we had too many pre-existing conditions (no, celiac was not one of them then) to qualify for private insurance here. I also come over to get Humira for my psoriatic arthritis because although it is a condition that is covered by PHARMAC I don't have enough "points" to qualify for the funding (i.e., I can still walk, have not scratched all the skin off my body, etc. ) and paying out of pocket it is $25,000 per year, more than enough to fund our three-month holiday abroad although bringing back a year's supply has in the past been an interesting customs experience, to say the least (like being on a border security TV program one year

So anyway, someone asked for some international experience--that's mine.

This is not meant to be a cautionary tale for you, but just to demonstrate that this is not the kind of system you are going to end up with after "health care reform."

[VioletBlue]

It's odd that you all picked up on testing as an issue with relation to health care reform. There are so many ways to cut expenses in the current health care "system" that have nothing to do with how many tests are run. It's kind of a non issue in reform. The real targets from what I've seen are excessive costs and the obscene profits most health care providers rake in while picking and choosing who they insure so they can further maximixe their obscene profits.

And I'd kill for ANY kind of health care plan at this point. I'm not picky, just give me something I can afford that will allow me to sign up inspite of my medical history. I'd be thrilled beyond words to have ANY option.

[mushroom]

VioletBlue, on Nov 6 2009, 08:24 PM, said:

The real targets from what I've seen are excessive costs and the obscene profits most health care providers rake in while picking and choosing who they insure so they can further maximixe their obscene profits.

Unfortunately, one of the biggest expenses in the US health care system are the obscene profits made by undetected fraud, especially in Medicare and Medicaid. Fraud exists everywhere, but it seems especially prevalent in the government health care programs (and, might I add, in the financial sector. too--which has impacted the whole world ) with the watchdogs falling asleep on the job, or insufficient of them to do the job. Cut out the costs of fraud and you might have an affordable program.

[Jestgar]

mushroom, on Nov 6 2009, 01:00 AM, said:

Unfortunately, one of the biggest expenses in the US health care system are the obscene profits made by undetected fraud, especially in Medicare and Medicaid. Fraud exists everywhere, but it seems especially prevalent in the government health care programs (and, might I add, in the financial sector. too--which has impacted the whole world ) with the watchdogs falling asleep on the job, or insufficient of them to do the job. Cut out the costs of fraud and you might have an affordable program.

I agree. This drives up malpractice insurance, increases the number of unnecessary tests, and drives physicians away from high (sue-) risk specialties, like obstetrics. My PCP told me that 1/3 of her salary goes straight to malpractice insurance. When you factor in medical school debt, it takes a while before an MD is even earning a livable wage. And they are, what, 30? by the time they get their first real job?

Makes you wonder why anyone would choose the profession.

[Gemini]

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As for there not being a paper trail, the only way that is possible is if you gave them a fake name when you went for your procedures. I suppose it's possible that those records won't make it to another doctor or to the insurance company, but if you don't tell them and they find out later, you can be sued for fraud.

There will not be any paper trail if a person pays for all testing and appointments in cash and keeps copies of the testing out of a PCP's hands. I went to a private doctor who does not use a computer for her patients records....she is not an HMO physician so isn't in the network. I had all my Celiac testing done this way and it was due to the lack of being able to get a timely appointment with a specialist
and nothing to do with having my insurance company find out. I was diagnosed through blood work and refused the biopsy....there was no need to do one.

They cannot sue you either if they cannot prove you have Celiac Disease. If you are healthy and following a strict gluten-free diet, anything else that may happen would not be linked to Celiac. At this point, if I were to be tested, everything would be negative as I've been gluten-free for so long. They can't prove I follow a gluten-free diet either. In today's world, you have to be selective about what you tell a doctor and what tests you agree to as we all know these can be held against you.

The other bright spot is I am in a group plan through my employer. Insurance companies in the US cannot refuse you coverage if you are in a group plan....that is how mine works. Obtaining insurance on my own might be another problem, if they knew I was a Celiac. I am also vested into the plan, which means they will have to cover me when I retire under their group plan. However, who knows what will happen if the government gets their hands into it.

[hermitgirl]

Wow this is a touchy topic. I am going to be brief. As a victim of private insurance, I have a strong desire to see changes made. I doubt that what has passed so far will go much further. This whole thing is a lose-lose situation and I really don't see it getting better any time soon. Yes, something needs to be done, but there is too much money involved. By the time anything goes into law, nothing will change. People will still die from not being able to afford medical care, people's lives will still be destroyed financially due to a medical situation. Insurance companies will still refuse testing. Doctors will still be frustrated, as will the patients.

[Traveller]

Because no one knows what the final bill will be, no one really knows what the impact will be. I speculate that doctors will face increased administrative headaches, increased liability premiums, and lower paychecks. Consequently we will have fewer doctors. The impact will be greatest on the gatekeeper GPs, who will have greater patient loads in addition to their greater headaches and reduced pay. Fewer doctors translates into longer wait times and more involuntary rationing of patient care.

We will also eventually havee a government run system. If the insurance companies continue to be villified, Congress will make sure they won't make enough profit to attract capital. They will die, and the government will step into the void. Then health care will be rationed by politics instead of insurance money. And with US budget deficits at record levels, service levels will be sacrificed for DMV-like efficiencies.

Doctor shortages and political rationing are a recipe for disaster. Yes, I'm pessimistic.

[psawyer]

I live in Canada, where we have had publicly funded health care for decades. It isn't perfect, but I would much rather have what we have here than what the US has.

We have no for-profit HMOs that decide who gets cared for, and who doesn't, based on a profit motive.

We don't worry about "pre-existing conditions." Everybody is covered to exactly the same extent. The 80-year-old with a heart attack will get the same treatment as a 35-year-old.

Not everything is covered. Drugs are not, whether prescribed or over-the-counter. Dental care is not covered. Routine eye care is not covered, nor are the glasses you may need. For all of these, private insurance is available. But again, the insurers may not disallow a claim due to a "pre-existing condition" (trip cancellation insurance is an exception).

If a test is covered by the public plan (and most are), then it will be done if your doctor deems it necessary. There is no prior review by an insurance administrator--it just gets done.

Drugs are still sold by pharmaceutical companies at a profit, so there is still money to be made by researching and developing new drugs. Private, for-profit, companies make and sell medical supplies and equipment. They are still thriving.

There are waits for many procedures. But I will take that in a moment over not being able to get them at all because I don't have insurance, or because my diabetes or celiac disease is a "pre-existing condition."