How should health insurance be used?

[The Walk of the Penguin Mich]

Yeah, my mother remembers one gynecologist in our hometown in Ohio-she said every woman who went to him ended up getting a hysterectomy. And all 5 of us had tonsillectomies.

Once upon a time, this was considered the standard of care. I had this explained to me by a dentist once.

I have a mouth full of fillings. Did I really have this many caries? I have absolutely no idea. But the current paradigm in dental treatment at the time was to fill anything that *could* potentially be a cavity because then it was controllable. If it became a cavity, then they'd have to drill away at more tooth. Funny enough as all of these fillings are now pushing 40 years old and none have needed to be replaced.

I know that this happened with tonsillectomies too. There was a period of time where just about all kids got their tonsils removed.

Treatments change. Where once upon a time the first bout of tonsillitis would send someone to the surgeon for a tonsillectomy, now they wait to see if you get so many bouts of disease in a certain period of time. They now realize that doing a total hysterectomy on women can cause more problems than they solve, even though the current paradigm at the time was 'if you're done with the organs and you've got issues, yank it out'.

It is kind of interesting to see how things change over the years.

[telephus44]

Jan 20, 2011 20:25:11 GMT -5 @athena53 said:

Jan 20, 2011 18:58:42 GMT -5 ronbuck said:

Serious health care shopper here, but I carry only a catastrophic policy.....the first $5000/year is out of pocket. I am very careful about checking any medical advice I am given, starting with asking the doc a lot of questions about options, outcomes, and probibilities. In an emergency, I will pay whatever I need to. But so little in life is an emergency.
<snip>
It is awfully hard to make good consumer choices when we don't know what something costs. And there is no reason to keep cost reasonable if it is not a factor in consumer purchases.

I really think this is the way insurance should work, although the annual deductible could vary depending on income. In fact, a previous employer (sub of the Prudential in 1985-1995) had a plan with a deductible that varied depending on your salary.

I think health insurance should work as a small variant on this - the first X amount of dollars should be covered 100% - maybe $1000 - so that people who need to get a physical, or have a sinus infection, or whatever actually go to the doctors. After that, there should be a gap that you pay out of pocket, possibly depending on income - and then after that insurance kicks in again.

Say first $1000 is covered by insurance, you have to pay the next $9000 out of pocket, and anything over $10,000 is covered again. You could make the amount out of pocket depending on income if you wanted to.

I figure this would encourage people to go when they need to, but not abuse the system - it would reward people who are healthy, since if they contain their medical costs to the first X amount of dollars then they essentially "pay" nothing - and if someone does get hit with a pretty expensive illness it will cover that, too. Also, since you would know the max amount you'd have to pay out of pocket, you could plan for it.

[The Walk of the Penguin Mich]

Say first $1000 is covered by insurance, you have to pay the next $9000 out of pocket, and anything over $10,000 is covered again. You could make the amount out of pocket depending on income if you wanted to.

I figure this would encourage people to go when they need to, but not abuse the system - it would reward people who are healthy, since if they contain their medical costs to the first X amount of dollars then they essentially "pay" nothing - and if someone does get hit with a pretty expensive illness it will cover that, too. Also, since you would know the max amount you'd have to pay out of pocket, you could plan for it.

So many people with chronic conditions would wind up having to pay $9K/year out of pocket. If it's a one shot deal, that's one thing but many with chronic conditions would be paying that ALL the time. Also, it would likely cause people to skimp on doing needed tests to monitor their condition - possibly resulting in even more expensive treatment.

I'm looking at a hip replacement in a couple weeks, which will likely have OOP costs in the $5K range when all is said and done. This will be my third orthopedic surgery in 4 years, so according to your theory, I'd be paying $27K. Quite frankly, I don't have that kind of money hanging around and I doubt that many do.

[Deleted]

Jan 21, 2011 10:22:38 GMT -5 telephus44 said:

I think health insurance should work as a small variant on this - the first X amount of dollars should be covered 100% - maybe $1000 - so that people who need to get a physical, or have a sinus infection, or whatever actually go to the doctors. After that, there should be a gap that you pay out of pocket, possibly depending on income - and then after that insurance kicks in again.

We insurance geeks call this a "corridor deductible". I like your reasoning, but look what's happened with the SS prescription coverage "doughnut hole". Same principle and it's been a disaster. There were howls of anguish when people reached the point where they had to pay more out of pocket. One couple we know, who I thought was doing OK financially, told us that the wife was quitting her Boniva (bone-density supplement) for the rest of the year till they had coverage again in the new year.

[ronbuck]

Jan 21, 2011 10:31:46 GMT -5 The Walk of the Penguin Mich said:

I'm looking at a hip replacement in a couple weeks, which will likely have OOP costs in the $5K range when all is said and done. This will be my third orthopedic surgery in 4 years, so according to your theory, I'd be paying $27K. Quite frankly, I don't have that kind of money hanging around and I doubt that many do.

Mich1, first let me say best wishes on your surgery.

One of the reasons I Lille the high deductible insurance is that my savings in premiums more than covers my usual out of pocket expenses. I keep that extra money invested where it can grow.

For the typical "insured through work" person, the money spent on the employee's insurance is money which is not available as pay, so typically people are "paying" for their insurance via reduced wages. The real benefit to this model is it is tax free.

In a way this is very much like social security insofar as the employer contribution is paid for by reduced wages. It may be that many, or most, people can not be entrusted with budget/saving for health care just as they are not with retirement savings.

But I do think the current insurance model which hides medical costs from the consumer is partly responsible for the problem of escalating medical care costs. I liked the idea of HSAs because they make the consumer more aware of pricing, and informed consumers are better shoppers.

An illustration of this problem was presented by NPR a year or so ago talking about a "new" acne medication. The patient was using an older med to control acne at a cost to him of a $10 copay. The doctor suggested a new medication which would cost him a $50 copay. The drug manufacturer provided the dermatologist with coupons which would reduce the copay of the new med to the same $10 as with the original script. The difference between the original medication and the new was that the new one was a sustained release and taken only once a day. Same active drug. The dermatologist liked it because she believed patient compliance was better with a once a day treatment. The patient didn't care as long as it worked and didn't increase his copay. The drug company loved it because the price of the new drug was $600/mo rather than $60/mo with the original formula. The dermatologist didn't know the cost of either drug, she was just trying to do what was best for her patient. And the insurance company was trying to discourage use of the "new" drug by charging the higher copay. Which was why the drug company "generously" paid the difference by giving the coupons.

How, in situations like this, can anyone make a rational choice. What other product or service would we buy this way?

[Nazgul Girl]

Due to extremely high premiums and/or deductibles, I think that your health insurance should be used for whatever you want that you can get it to pay for. ( Ducks now ).

[Deleted]

Jan 21, 2011 11:22:20 GMT -5 Nazgul Girl said:

Due to extremely high premiums and/or deductibles, I think that your health insurance should be used for whatever you want that you can get it to pay for. ( Ducks now ).

I'm not sure how serious you are about this, but go ahead, Honey- have all the colonoscopies and mammos you want. Don't worry about the side effects of the scripts you take for every minor complaint. I hope you have a DVR or come good books to entertain yourself while you're waiting in endless docs' examining rooms, shivering in a paper "garment" till he/she is done with the patient before you.

Seriously- I prefer to err on the side of under-utilizing the medical system.

And ronbuck, the NPR example is exactly the stuff of my nightmares. People should know what the sticker price is for their meds. The decision on whether or not to take a particular med should be based on the possible benefits, the possible side effects, and whether the dollar cost makes sense.

[stillontheroad]

I'm a weird kind of person - I'm a hypochondriac who hates going to the doctor, so I worry about every ache or pain but I don't go to the doctor unless it's serious.

I have a health insurance plan that covers just about everything so I'm lucky not to have to make decisions based on money. I go to the doctor when I'm really worried about something and do whatever he recommends. He's not an overprescriber or a compulsive test-orderer, either.

If anything, he's the opposite. I was having intermittent abdominal pain a few months back and ended up going to the doctor twice and he never ordered any tests. Granted, the symptoms were minor (low-level pain, and nothing else - no fever, nausea, change in appetite, etc), but I would have thought the fact that it was happening every day for a few weeks would have warranted some kind of test. It ended up going away, though, so maybe he was right after all. I don't know.

[The Walk of the Penguin Mich]

I'm not sure how serious you are about this, but go ahead, Honey- have all the colonoscopies and mammos you want. Don't worry about the side effects of the scripts you take for every minor complaint. I hope you have a DVR or come good books to entertain yourself while you're waiting in endless docs' examining rooms, shivering in a paper "garment" till he/she is done with the patient before you.

Do you really think that people go in for mammograms and colonoscopies because they like being tested? Right now, the standard of care is a yearly mammogram after 40. A baseline colonoscopy at 50, and if you have no issues you don't have to have another one for 5-10 years. Both of these are screening exams to catch problems before they become more expensive problems.

My insurance company covers this standard of care, so yes.....I am going to get the tests run. Add to this that I also have colon cancer in my family so it's something that is a concern.

I have decent health insurance, but I cannot remember the last time I went to my GP for anything other than my twice a year blood pressure checks (so I can get refills on my meds), gyn or mammogram. If I get a cold, stomach ache or any other transient illness, I let it run its course. Unfortunately, I've spent more time than I want in an orthopedist's waiting room, but I'm thinking that being able to walk without pain is a pretty good reason to go.

[Poppet]

One son split his lip. Took him to the Doc in Box and they said "Go to the ER." Six hours of sitting in that pit hole, he finally got his 7 stitches. It cost $3,000 and yes, we have "health insurance." 3k was our portion of the bill. It actually cost more.

When he split his lip again in the same place about 2 weeks later I told him through clenched teeth that too bad, he'd have to stay that way cuz we weren't going through that rigamarole again. He healed just fine, by the way. The wait n see approach worked best in this case. ;D

When another son broke his wrist at school I thought, here we go to the 6 hour ER. Went to a Doc in the Box instead cuz school nurse recommended the place. They confirmed it was seriously broken and referred him straight to a specialist's office and thus avoided the ER altogether. Hallelujah!

I try to avoid the ER at all cost. Sometimes you can avoid it, sometimes you can't.

[Deleted]

Jan 21, 2011 13:03:11 GMT -5 The Walk of the Penguin Mich said:

Do you really think that people go in for mammograms and colonoscopies because they like being tested?

No- I was responding to the poster's facetious (I hope) remark that since insurance was so expensive they'd darn well get their money's worth out of it by using the medical system a lot.

[Gardening Grandma]

There are times when the patient knows something is wrong, but the doctor does not listen.

Indeed. A former neighbor went several times to her dr (one that is on our "ins co approved" list) telling him that something was wrong. She described symptoms and he blew her off telling her it was just the "aging process" (she was in her 60's). He ordered no tests - took a "wait and see" approach.
Short version - she had cancer and by the time they found it, it was too far advanced. She's dead.

[Deleted]

Jan 21, 2011 14:51:25 GMT -5 Gardening Grandma said:

She described symptoms and he blew her off telling her it was just the "aging process" (she was in her 60's).

I've already decided that "the aging process" is never going to be an acceptable answer for me. I've lived in this body for almost 58 years and, while I know that somehow I've gotten to the point that things don't work they way they did when I was 25, that's been gradual. If I feel there's been a more dramatic change over a shorter period, I will refuse to let a doctor dismiss it with "you're just getting older".

[Gardening Grandma]

I've already decided that "the aging process" is never going to be an acceptable answer for me. I've lived in this body for almost 58 years and, while I know that somehow I've gotten to the point that things don't work they way they did when I was 25, that's been gradual. If I feel there's been a more dramatic change over a shorter period, I will refuse to let a doctor dismiss it with "you're just getting older".

Same here.
Reminds me of another neighbor who went to his dr complaining of knee pain. The dr told him is was "just old age" and to be expected. The neighbor said, "But my other knee is just fine and it's the same age!".

[Deleted]

Jan 21, 2011 14:51:25 GMT -5 Gardening Grandma said:

Indeed. A former neighbor went several times to her dr (one that is on our "ins co approved" list) telling him that something was wrong. She described symptoms and he blew her off telling her it was just the "aging process" (she was in her 60's). He ordered no tests - took a "wait and see" approach.
Short version - she had cancer and by the time they found it, it was too far advanced. She's dead.

I had an acquaintance who went to the doctor due to painful cramping. Dr. kept telling her it was nothing. It was cancer, caught after she went to the emergency room, and she sadly passed away after fighting it for 5 years. It was cheaper to run the test and deal with it when she first went to the Dr. Fighting it for 5 years was expensive and the Dr. was sued. She was in her late 20's.

I don't like statistics much. I'll take the test.

[Nazgul Girl]

Re: How should health insurance be used?
« Reply #81 Today at 12:14pm »
--------------------------------------------------------------------------------

"Today at 11:22am, Nazgul Girl wrote: Due to extremely high premiums and/or deductibles, I think that your health insurance should be used for whatever you want that you can get it to pay for. ( Ducks now ).



I'm not sure how serious you are about this, but go ahead, Honey- have all the colonoscopies and mammos you want. Don't worry about the side effects of the scripts you take for every minor complaint. I hope you have a DVR or come good books to entertain yourself while you're waiting in endless docs' examining rooms, shivering in a paper "garment" till he/she is done with the patient before you.

Seriously- I prefer to err on the side of under-utilizing the medical system."



Athena, first of all, I'm not a Honey . But, Honey ( Right back atcha), it's just plain STUPID not to have regular mammograms and colonoscopies done. But I'm in the medical biz, read about 120 lengthy medical reports a day detailing some disaster or other, and have grown cautious. Besides, so far, the mammograms and colonoscopies have found two polyps and one mini breast tumor. I prefer to err on the side of living vs under-utilizing the health system. But whatever makes you happiest, HON....

[Frappuccino]

If I am going to take the wait and see approach, I will usually skip the initial doctor visit where he prescribes all of the tests in the first place. I will make the doctor appointment and follow his advice and tests if I am sick or in pain unlike ailments I've experienced in the past.

I tend to take my son to the doctor for almost all of his pains and illnesses though. Its hard to know if the pain he describes is just a cold or if it is something more serious if I can't feel the pains myself.

Those stories about the women with cancer are heartbreaking!! I hope the doctors who dismissed them get some karma for stealing these women from their families too early.

I have kaiser through my employer that costs $200/month for my son and I, and $15 co-pays per visit, so it's not too expensive if I go occasionally. But, it begins to add up when you have to keep going back for different tests and followups and prescriptions.

[Deleted]

What would have happened had your 'wait and see' turned out the opposite way? Then, rather than having the tests, going in for a quick appendectomy and gotten tossed out of the hospital 24 hours later. Instead, you wind up with a raging case of peritonitis, where you get put on expensive antibiotics and are hospitalized for a week. Any 'savings' for testing would automatically be eliminated due to the condition becoming much worse than if it had been caught early.

I took your wait-and-see approach when I had appendicitis. The year before I had had stomach pangs and gone to the ER. He diagnosed it as a kidney infection and pumped me full of antibiotics. The health insurance refused to pick up the cost. A year later I spent an agonizing night waiting on my doctor's office to open.

Even then he couldn't diagnose appendicitis. He sent me home and said if I threw up, go to the ER immediately. I did both. It had perforated, and I spent a week in the hospital.

Not only is your wait-and-see approach somewhat dangerous, but I want to warn you that there are two types of appendicitis. Most people think of acute appendicitis. I had chronic, which means it will reoccur.

Next time you have those stomach pangs, you might think the issue over again.

[Deleted]

Jan 21, 2011 20:13:50 GMT -5 Nazgul Girl said:

But, Honey ( Right back atcha), it's just plain STUPID not to have regular mammograms and colonoscopies done. But I'm in the medical biz, read about 120 lengthy medical reports a day detailing some disaster or other, and have grown cautious. <snip>

No argument from me here. Last mammogram was 2 weeks ago and even though my doc says I can wait 5 years till my next colonoscopy I'm going to be on his doorstep in 2.5 years because he found one polyp last time that had developed in the year since my last test. I'm in the property-casualty insurance industry so I've read some really bad Med Mal claims. I don't want to be one of them.

Still, I try to keep a balance between overtreating/overtesting and neglecting my health, and I try to accomplish as much as I can through exercise and a healthy diet.