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Post by Deleted on Nov 5, 2014 14:50:53 GMT -5
They're actually pretty cheap as far as medical tests go. I just had my first and it was $320.
I wonder if it is more that early screening means you catch more people in the early stages when it is treatable, but costs us more because now we are treating more people. In other words, are we saving lives with the preventative care, but spending more money to do it. Is it worth it if it means more lives are saved?
who knows but they are saying that some of what they're treating is so slow growing that women would have died from something else before dying from the cancer. they are also spending lots and lots of money on biopsies.
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Mardi Gras Audrey
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Post by Mardi Gras Audrey on Nov 5, 2014 14:51:06 GMT -5
I have lived in Canada all my life and I have no problems with the medical system here. Having gone through a life threatening health issue with my daughter for many years I have not a bad word to say about the treatment she received over the course of 5 years. The only problem I see is people who abuse the system, no matter what system you have there will be abusers. Having said that I am increasingly thankful that I do not have to deal with insurance companies over health issues. I can only imagine the extra burden that puts on families already stressed. I can't speak to the experiences in Canada but it sounds like the Canadian govt has it together a lot more than the US govt does. I wouldn't trust the US govt with my health care. I'm in the health care industry and getting things covered by govt insurance (Medicare, Medicaid) is a TOTAL NIGHTMARE! The private insurers are far more responsive, reasonable, and you can actually deal with a human to gt something covered. Medicare/Medicaid... calling them is like talking to a blackhole (that is after you sit on hold for 1 hour). CA Medicaid's "help desk" has a limit of 3 issues/questions per call. If you have more than that, they lie to you and tell you stuff that isn't true because you are over your "3 issues per call". (I found this out through personal experience). Medicare has some of the most ignorant rules ever. Part B (The govt outpatient part) will cover anti-nausea meds for someone going through Chemo. Sounds great, right? Except, they only cover it when it is done at the pharmacy within so many hours of the chemo procedure (I think it is 24 hours). So, if you live in a rural area and need to travel for chemo, you can't plan ahead and get your anti-nausea meds a few days before hand. Just what someone going through chemo wants to do right after the procedure.. hang out at the pharmacy waiting for their meds. Diabetes supplies (test strips, lancets, etc)? They will cover them but only if the prescription has an actual doc's signature. We use e-prescribing and verbal prescriptions for meds all the time (It is so much faster and more accurate than having a doctor write everything out by hand) but that isn't good enough for Medicare. They want an actual wet signature. So, while the govt is spending millions of $$ to push everyone into electronic health records and e-prescribing, they won't pay for meds/supplies done through this manner. The private insurers have no issues with e-prescribing... they pay because it is legitimate.
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milee
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Post by milee on Nov 5, 2014 14:52:08 GMT -5
in an effort to discuss and analyze facts - do you consider the system the way it was prior to the ACA, where many uninsured people would get their healthcare needs met by the ER, to be a better system than what we have now with the ACA? clearly you think the ACA is inadequate, so what tweaks would you make to it, to make it more efficient? IMHO, part of the problem is that we've attempted to put in a solution for a "problem" that there is no consensus on. It would make sense to step back and get a consensus (not agreement - that would be impossible) on what we think we're trying to provide here before we design solutions.
Is the consensus that everybody should have access to the exact same care as everybody else? Is the consensus that everybody should have access to basic care but not every single medical advance in existence? What constitutes basic care? Is the consensus that healthcare should be provided without considering cost or potential cost/benefit? Is the consensus that healthcare funding should be prioritized based on efficacy, age, other criteria?
Just some examples. But until we get some sort of framework that we're all working with, then it's hard to talk about solutions. Because addressing one issue often causes compromises or outright problems in another area.
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kittensaver
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Post by kittensaver on Nov 5, 2014 14:58:47 GMT -5
Research on annual mammograms for everyone is neutral at best... But my doc is highly upset that I won't do them... That's a covered procedure man... They are missing out. I don't think your doctor is worrying about missing out on some $$ by not getting your mammogram. If you think that is why your doctor cares/is upset, I would recommend getting a new doctor. Most doctors I know tend to err on the side of caution. They want to do the tests just to make sure and to double/triple check that you are okay. By recommending the testing, they want to make sure they have done all they can to ensure that thy see stuff coming. There also may be a small component of CYA for the doctor. Many people will refuse testing and then, if something comes up later, they get mad at the doctor because the doctor didn't "see the issue coming". They start talking about malpractice suits and how the doc is incompetent, all while failing to take responsibility for their part/decisions in the outcome. I don't think this applies in your case, OPED, but I'm sure your doc has had some history with patients who do that.
Well I for one have a medical group that is VERY concerned about me not engaging in an annual mammogram. They HOUND me with repeated robo-calls (I get 2 or 3 PER MONTH); they get in my face - literally - every time I show up for something else (which is not often) and confront me why I've not had "my annual exam." When I tell them I HAVE had my annual exam (thermography, done somewhere else because they do not do them), they do not accept the answer.
But dig little deeper, and you get to the heart of the matter: they are being paid (via a multi-million dollar research grant) to engage in a very large, multi-decade study on mammography. They have promised their funder to meet certain minimums (mammograms performed) as a part of this study. So every woman who refuses to get a mammogram puts their numbers (and thus their research) at risk. Do they care about me as an individual? I highly doubt it . . . FOLLOW THE MONEY. *blarg*
However - as always - YMMV.
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Mardi Gras Audrey
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Post by Mardi Gras Audrey on Nov 5, 2014 15:05:42 GMT -5
I don't think your doctor is worrying about missing out on some $$ by not getting your mammogram. If you think that is why your doctor cares/is upset, I would recommend getting a new doctor. Most doctors I know tend to err on the side of caution. They want to do the tests just to make sure and to double/triple check that you are okay. By recommending the testing, they want to make sure they have done all they can to ensure that thy see stuff coming. There also may be a small component of CYA for the doctor. Many people will refuse testing and then, if something comes up later, they get mad at the doctor because the doctor didn't "see the issue coming". They start talking about malpractice suits and how the doc is incompetent, all while failing to take responsibility for their part/decisions in the outcome. I don't think this applies in your case, OPED, but I'm sure your doc has had some history with patients who do that.
Well I for one have a medical group that is VERY concerned about me not engaging in an annual mammogram. They HOUND me with repeated robo-calls (I get 2 or 3 PER MONTH); they get in my face - literally - every time I show up for something else (which is not often) and confront me why I've not had "my annual exam." When I tell them I HAVE had my annual exam (thermography, done somewhere else because they do not do them), they do not accept the answer.
But dig little deeper, and you get to the heart of the matter: they are being paid (via a multi-million dollar research grant) to engage in a very large, multi-decade study on mammography. They have promised their funder to meet certain minimums (mammograms performed) as a part of this study. So every woman who refuses to get a mammogram puts their numbers (and thus their research) at risk. Do they care about me as an individual? I highly doubt it . . . follow the money. *blarg*
However - as always - YMMV.
I would go to a new doctor if that is how they are treating you. That is not appropriate and they should back off. I can say that medical groups and insurers are judged by CMS (Center for Medicare and Medicaid Services) on preventative testing measures. (So, yes this goes back to the govt). They have to meet a standard for getting people on preventative meds (diabetics on ACE Inhibitors for kidney health, on Aspirin for cardiovascular health, etc) and testing completed (Dexa scans for bones, yearly blood tests, etc). If they don't have the numbers and the patients getting this completed, they can face penalties from Medicare/medicaid payers. The govt says they aren't practicing "quality care" if these things aren't done. is even if the patient declines the treatment. So, again... this goes back to govt regulation penalizing them for things that are out of their control (The patient has the right to decline but you can still get penalized for the patient not participating).
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milee
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Post by milee on Nov 5, 2014 15:11:06 GMT -5
I can say that medical groups and insurers are judged by CMS (Center for Medicare and Medicaid Services) on preventative testing measures. (So, yes this goes back to the govt). They have to meet a standard for getting people on preventative meds (diabetics on ACE Inhibitors for kidney health, on Aspirin for cardiovascular health, etc) and testing completed (Dexa scans for bones, yearly blood tests, etc). If they don't have the numbers and the patients getting this completed, they can face penalties from Medicare/medicaid payers. The govt says they aren't practicing "quality care" if these things aren't done. is even if the patient declines the treatment. So, again... this goes back to govt regulation penalizing them for things that are out of their control (The patient has the right to decline but you can still get penalized for the patient not participating). Sounds like the ACO program isn't going as well as hoped.
online.wsj.com/articles/a-medicare-program-loses-more-health-care-providers-1411685388
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kittensaver
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Post by kittensaver on Nov 5, 2014 15:12:47 GMT -5
Well I for one have a medical group that is VERY concerned about me not engaging in an annual mammogram. They HOUND me with repeated robo-calls (I get 2 or 3 PER MONTH); they get in my face - literally - every time I show up for something else (which is not often) and confront me why I've not had "my annual exam." When I tell them I HAVE had my annual exam (thermography, done somewhere else because they do not do them), they do not accept the answer.
But dig little deeper, and you get to the heart of the matter: they are being paid (via a multi-million dollar research grant) to engage in a very large, multi-decade study on mammography. They have promised their funder to meet certain minimums (mammograms performed) as a part of this study. So every woman who refuses to get a mammogram puts their numbers (and thus their research) at risk. Do they care about me as an individual? I highly doubt it . . . follow the money. *blarg*
However - as always - YMMV.
I would go to a new doctor if that is how they are treating you. That is not appropriate and they should back off.
I can say that medical groups and insurers are judged by CMS (Center for Medicare and Medicaid Services) on preventative testing measures. (So, yes this goes back to the govt). They have to meet a standard for getting people on preventative meds (diabetics on ACE Inhibitors for kidney health, on Aspirin for cardiovascular health, etc) and testing completed (Dexa scans for bones, yearly blood tests, etc). If they don't have the numbers and the patients getting this completed, they can face penalties from Medicare/medicaid payers. The govt says they aren't practicing "quality care" if these things aren't done. is even if the patient declines the treatment. So, again... this goes back to govt regulation penalizing them for things that are out of their control (The patient has the right to decline but you can still get penalized for the patient not participating).
I can't. It's Kaiser Permanente, and the only carrier my employer offers .
I can't WAIT for the day when employers get OUT of the healthcare business!!!!!!!
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Mardi Gras Audrey
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Post by Mardi Gras Audrey on Nov 5, 2014 15:20:18 GMT -5
kittensaverAh, Kaiser.... yes, they are totally on the CMS quality measures bandwagon... They have people dedicated to getting preventative measures and outreach completed. They should be looking at your electronic file before calling you though. On the first call, the person you spoke to should have noted that in your record and they should be reviewing it before hassling you. Sometimes, stuff does get missed though because the electronic file has lots of notes and they may not be checking each note. I'm sorry you have to deal with that... just keep telling them no and stay strong!
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kittensaver
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Post by kittensaver on Nov 5, 2014 15:27:51 GMT -5
kittensaverAh, Kaiser.... yes, they are totally on the CMS quality measures bandwagon... They have people dedicated to getting preventative measures and outreach completed. They should be looking at your electronic file before calling you though. On the first call, the person you spoke to should have noted that in your record and they should be reviewing it before hassling you. Sometimes, stuff does get missed though because the electronic file has lots of notes and they may not be checking each note. I'm sorry you have to deal with that... just keep telling them no and stay strong!
Bother to look at my file before calling me?! HA! I wish! I have pointed it out to them until I'm blue in the face . . .much good THAT has done . I continue to get "your doctor is recommending this exam . . . your doctor has asked me to call you personally . . . (NOT) . . . " I WISH they cared about me (if they did, they would understand my individual choice to pursue a different screening procedure); they just care about their damned research. I'm so tired of being hounded that now I just ignore the calls.
Sorry for the rant . . . returning now to your regularly schedule thread . . .
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weltschmerz
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Post by weltschmerz on Nov 5, 2014 16:51:24 GMT -5
I'm not trying to be condescending, so I apologize for using a tone that suggested that. When we "talk" about these issues on the board, I think it's most productive to try to keep feelings out of the debate since those are so subjective. In trying to limit posting to facts, my tone probably sounds stilted.
Healthcare is so incredibly complicated that the level of complexity is one of the main reasons that I don't want government heavily involved. Our government's not good at dealing with facts, examining data, ignoring special interests and feelings and setting up efficient systems. If you want to interpret that as me wanting children to die in the streets, I can't stop you.
I have lived in Canada all my life and I have no problems with the medical system here.Having gone through a life threatening health issue with my daughter for many years I have not a bad word to say about the treatment she received over the course of 5 years. The only problem I see is people who abuse the system, no matter what system you have there will be abusers. Having said that I am increasingly thankful that I do not have to deal with insurance companies over health issues. I can only imagine the extra burden that puts on families already stressed. I'm also in Canada, and I have no complaints with our system here. Not only am I a nurse, but I've also been a patient...many times. I give excellent care and I've received excellent care. Having lived and worked in the USA as well, I must say that I prefer our system, hands down.
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shanendoah
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Post by shanendoah on Nov 5, 2014 19:24:41 GMT -5
On mammograms: Recent research suggests that most women do NOT benefit from annual mammograms. However, groups like Komen have very strong lobbying groups, and while most of the medical community recognized the validity of the research, they are unable to officially change the recommendations.
On healthcare demand: As I said before, one of the main goals of the ACA was to shift the demand from one supplier (ERs) to another supplier (PCPs, Urgent Care). The demand has always been there. People have always needed the care, the ACA just gives them an opportunity to seek affordable care BEFORE they have an emergent situation. Again, demand has not increased. Demand has shifted, and access has been increased via making care more affordable, but the demand has not changed.
On quality of healthcare being determined by ability to pay: We aren't moving toward this. This IS, and HAS BEEN, even before the ACA, the model of healthcare in the US. Have you ever taken a tour of an assisted living/skilled nursing facility? Quality of care based on financial solvency is pretty much right in your face in those locations. Those who can afford the best treatments get them. Those who can't, don't. The question is, is that they way it actually should be? And when it came to simply accessing basic care, the ACA's answer is no- everyone, regardless of financial status, deserves basic care. While some of the plans offered through the exchange (again, in WA, I can speak for no other state) are cadillac plans that offer coverage for everything, those are not the inexpensive plans. They cost. They cost a lot. In order to offer those (again, aimed at the large population of rather well-off independent contractors in our state), insurance companies had to offer the basic plans that are affordable to people getting subsidies, but both are available.
On consensus: For gods' sake, YES. Let's build some consensus. Let's have some actual conversations and come to the table with the plan of doing something. I don't know of a single person who supports the ACA who doesn't want to make it better. Let's do that. Please. I have the table and space for you right here. The problem is NOT that people who support the ACA don't want to make it better. It is that we don't have the time because we spend all of our time defending it's mere existence. But let's not forget that there are things the ACA did that there IS consensus around. Items that never get brought up by opponents of the ACA because they know those actually were good pieces, such as getting rid of "pre-existing conditions" clauses. (Though, as a note, my previous employer, as both a provider and an insurer, had access to a lot of data, and the data said trying to screen out and deny claims based on pre-existing conditions actually cost more than just covering those claims. But most places don't do the math.) There's also the ability to cover young adults on their parents' insurance until the age of 26, allowing those young adults (who otherwise wouldn't likely have coverage unless they were high risk) to have access to preventative care, AND add the dollars their parents are paying for their healthy asses to our risk pool, actually driving down costs for the rest of us.
On healthcare tied to employment: Honestly, I would be supportive of a single payer system. If we all just had Medicare, I'd take that in a heartbeat (though we'd need to change some of the Part D laws and NOT let Big Pharma just charge the government whatever they want for drugs). But if I can't get that, I would love for access to healthcare to stop being employment related. It was one of the things I was struggling with during my job search. A company I made it very deep in the process with was basically tying healthcare even more closely to employers, and that bothered me significantly. I do not believe that access to healthcare should be based on where one works/who one's employer is.
On for profit healthcare: I hate that healthcare is a for profit industry. I get why it is. I mentioned before that I think we need to reform our current medical education model, and one of the reasons for that is that I don't think becoming a doctor should result in huge debt. I have fewer problems with individual doctors running their practices, but the hospital systems make obscene amounts of money that have nothing to do with what they pay their staff or their actual costs. I worked for an organization that paid their doctors a salary. In my experience, that resulted in a lot less "let's test for this" just in case. C just spent an evening in the ER because we thought he might have had a heart attack. The EKG and bloodwork said that wasn't the case, but the x-ray showed an enlarged heart. ER doc said- you need to see a cardiologist. C went to his PCP (who is salaried). PCP looked at the records, listened to C describe his symptoms, and then listened to his lungs. We got a diagnosis of asthma, treatment for it, and told that if we don't see a difference in X amount of time, come back. But no random tests, no going to a cardiologist. Because asthma attacks can cause enlarged hearts. So yeah, I prefer salaried models for physicians, but I am against healthcare overall being "big" business or for profit.
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Mardi Gras Audrey
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Post by Mardi Gras Audrey on Nov 5, 2014 20:24:06 GMT -5
shanendoahYou say that demand has not increased but is shifted to the primary care setting. How do you explain this study if the demand in the ER was shifted to the outpatient setting? In 2008, Oregon initiated a limited expansion of a Medicaid program for uninsured, low-income adults, drawing names from a waiting list by lottery. This lottery created a rare opportunity to study the effects of Medicaid coverage by using a randomized controlled design. By using the randomization provided by the lottery and emergency-department records from Portland-area hospitals, we studied the emergency department use of about 25,000 lottery participants over about 18 months after the lottery. We found that Medicaid coverage significantly increases overall emergency use by 0.41 visits per person, or 40% relative to an average of 1.02 visits per person in the control group. We found increases in emergency-department visits across a broad range of types of visits, conditions, and subgroups, including increases in visits for conditions that may be most readily treatable in primary care settings.www.sciencemag.org/content/343/6168/263.abstractThis matches with what I have seen in healthcare settings in 2 states. The people with no copays and no skin in the game have no incentive to go to a primary care doctor when they can just go to the ER for "free". This is coupled with the fact that many PCPs limit the Medicaid patients in their practice where the ER HAS to deal with them... how would this shift the demand? The ACA dumped millions of people on Medicaid that previously weren't on it. Yes, there were people who got private insurance through the exchanges but a lot got Medicaid (at least from what I've seen in CA). One site said that 50% of the uninsured would be medicaid eligible if all states expanded Medicaid.
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shanendoah
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Post by shanendoah on Nov 6, 2014 0:52:10 GMT -5
Mardi Gras Audrey - You're trying to pretend because people didn't have access, they didn't have a need, or a demand, for healthcare. That's not true. Their need, their demand, was always there, but without any way to pay for the care, they were essentially barred access. ACA, and increased Medicaid coverage, finally opened up the doors so that they had access. Locking the doors and saying "nah nah nah, I can't hear you" to the people pounding on the other side of them doesn't mean those people and their needs don't exist. It means you've found it convenient to ignore them.
And since you yourself note that PCPs like to limit how many Medicaid patients they see, what are Medicaid patients supposed to do other than go to the ER when they need care? If I'm sick and need to see a doctor, and the PCP "can't" see me for another 6 weeks, or refuses to take me as a patient at all, then what am I supposed to do for care? I go to the ER. Yes, for something a PCP could treat, but the PCP won't see me. The ER will.
But, back to my original point. One of the goals of the ACA is to shift demand from ERs to PCPs by allowing people to have insurance that makes getting medical care affordable. And in WA, it was very clearly mandated that clinics not be able to tell that your insurance was "exchange" insurance, precisely so that clinics would not discriminate in that manner, and patients would actually be seen by PCPs. The fact that not all states included that in their implementation is a problem with the states, and perhaps a problem with doctors/clinics/hospital systems, not a problem with the ACA.
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Mardi Gras Audrey
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Post by Mardi Gras Audrey on Nov 6, 2014 1:13:37 GMT -5
Mardi Gras Audrey - You're trying to pretend because people didn't have access, they didn't have a need, or a demand, for healthcare. That's not true. Their need, their demand, was always there, but without any way to pay for the care, they were essentially barred access. ACA, and increased Medicaid coverage, finally opened up the doors so that they had access. Locking the doors and saying "nah nah nah, I can't hear you" to the people pounding on the other side of them doesn't mean those people and their needs don't exist. It means you've found it convenient to ignore them.
And since you yourself note that PCPs like to limit how many Medicaid patients they see, what are Medicaid patients supposed to do other than go to the ER when they need care? If I'm sick and need to see a doctor, and the PCP "can't" see me for another 6 weeks, or refuses to take me as a patient at all, then what am I supposed to do for care? I go to the ER. Yes, for something a PCP could treat, but the PCP won't see me. The ER will.
But, back to my original point. One of the goals of the ACA is to shift demand from ERs to PCPs by allowing people to have insurance that makes getting medical care affordable. And in WA, it was very clearly mandated that clinics not be able to tell that your insurance was "exchange" insurance, precisely so that clinics would not discriminate in that manner, and patients would actually be seen by PCPs. The fact that not all states included that in their implementation is a problem with the states, and perhaps a problem with doctors/clinics/hospital systems, not a problem with the ACA. I'm not pretending these people didn't have unmet needs before the ACA. What I am saying is the need varies and that, in my experience, the people that use the ER's inappropriately (for a hangnail, a cold, to get drugs like narcotics) tend to be the ones on Medicaid. Did they have hangnails and colds before the ACA? Yes they did. Did they have a way to go to the ER and pay no copay before? No, they didn't. I don't have any data on this- I can just say what I've seen working & volunteering in the health systems of 2 different states and speaking to other health care professionals. The people that had insurance but have a $100 copay for the ER wouldn't go for stupid stuff that could be taken care of at home. The uninsured wouldn't either (because they would be getting a fat bill for services). The ones on Medicaid with no copay? Sure, why not? It's "free" after all. This actually fits in well with what we know about economics. Whenever someone has no skin in the game (ie copays), they have no incentive to conserve resources or use things wisely. Look what happens to utilities when they are included with rent. You get people with open windows and cranked up heaters in Minnesota in December. Make them pay for their own utilities, suddenly "fresh air" isn't all that important. Why would we expect health care to be any different?
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shanendoah
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Post by shanendoah on Nov 6, 2014 2:09:58 GMT -5
You still haven't addressed your own statement that PCPs do their best to refuse to see Medicaid patients. If the PCPs refuse to see them, where, exactly, are they supposed to get care that isn't the ER? The other thing to take into consideration is that a number of adults on Medicaid are working poor. They don't have jobs with sick leave. Getting to a doctor during regular business hours could cost them considerably.
I once had a triage nurse annoyed at me for going to urgent care. I have recurring tendinitis in my shoulder. It flared up very suddenly one day, and while making my (very) short commute home, I realized I wasn't actually safe to drive. So, I got home and had C drive me to urgent care that night. The triage nurse wanted to know why I just didn't wait until the next day and call to TRY to get in with my doctor. (Please note, my urgent care provider is employed by the same organization that employs my PCP.) My reason, besides the fact that lifting my arm even close to horizontal to the ground was excruciatingly painful, was that I was not, in fact, safe to drive with that level of pain. So I would have to take the next day off work, call the doctor, see if I could even get an appointment that day (and there's no guarantee that I would) and then C would have to take off work early/go in late/leave in the middle of the day, something, to get me into the doctor.
So, I could live with the pain (which I totally knew what it was, and my PCP could certainly have treated it) for the night, missed a day of work, and caused my spouse to miss work, too. OR, I could go to urgent care that evening, get the pain killers that allowed me to function, and no one missed any work. I chose that option even though C and I both had good paying jobs with sick leave, and I, in fact, worked for my healthcare provider (it was an MCO). So what type of decision do I think someone who didn't have the options I had would make?
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973beachbum
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Post by 973beachbum on Nov 6, 2014 11:11:28 GMT -5
Mardi Gras Audrey - You're trying to pretend because people didn't have access, they didn't have a need, or a demand, for healthcare. That's not true. Their need, their demand, was always there, but without any way to pay for the care, they were essentially barred access. ACA, and increased Medicaid coverage, finally opened up the doors so that they had access. Locking the doors and saying "nah nah nah, I can't hear you" to the people pounding on the other side of them doesn't mean those people and their needs don't exist. It means you've found it convenient to ignore them.
And since you yourself note that PCPs like to limit how many Medicaid patients they see, what are Medicaid patients supposed to do other than go to the ER when they need care? If I'm sick and need to see a doctor, and the PCP "can't" see me for another 6 weeks, or refuses to take me as a patient at all, then what am I supposed to do for care? I go to the ER. Yes, for something a PCP could treat, but the PCP won't see me. The ER will.
But, back to my original point. One of the goals of the ACA is to shift demand from ERs to PCPs by allowing people to have insurance that makes getting medical care affordable. And in WA, it was very clearly mandated that clinics not be able to tell that your insurance was "exchange" insurance, precisely so that clinics would not discriminate in that manner, and patients would actually be seen by PCPs. The fact that not all states included that in their implementation is a problem with the states, and perhaps a problem with doctors/clinics/hospital systems, not a problem with the ACA. I'm not pretending these people didn't have unmet needs before the ACA. What I am saying is the need varies and that, in my experience, the people that use the ER's inappropriately (for a hangnail, a cold, to get drugs like narcotics) tend to be the ones on Medicaid. Did they have hangnails and colds before the ACA? Yes they did. Did they have a way to go to the ER and pay no copay before? No, they didn't. I don't have any data on this- I can just say what I've seen working & volunteering in the health systems of 2 different states and speaking to other health care professionals. The people that had insurance but have a $100 copay for the ER wouldn't go for stupid stuff that could be taken care of at home. The uninsured wouldn't either (because they would be getting a fat bill for services). The ones on Medicaid with no copay? Sure, why not? It's "free" after all. This actually fits in well with what we know about economics. Whenever someone has no skin in the game (ie copays), they have no incentive to conserve resources or use things wisely. Look what happens to utilities when they are included with rent. You get people with open windows and cranked up heaters in Minnesota in December. Make them pay for their own utilities, suddenly "fresh air" isn't all that important. Why would we expect health care to be any different? I used to be a health care insurance administrator and I promise you I saw this exact same thing all the time with the claims for the employer plans we administrated! We used to actually see them so much we would practically beg employeers to increase the copayment for ER's hoping it would change it. The reality though was that although we liked to rail about how they went to the ER at 11am on a tuesday the actual diagnosis wasn't that obvious based on the symptoms most of the time. Can anyone here actually say with certainty that the person who ended up having indigestion really wasn't having a heart attack given the symptoms can be pretty much the same? Kids end up being Dx'd with the flu but a bad case of the flu can last for 2 weeks, and the person feels like they are dying. And in fact lots of people do die every year from the flu and kids are more apt to go down hill very fast. While it seems obvious people are abusing the ER by going in for things that could be solved with Tums and bed rest, it really isn't that simple IMO.
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NomoreDramaQ1015
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Post by NomoreDramaQ1015 on Nov 6, 2014 11:31:09 GMT -5
The thing with ER care, as I have pointed out to DH numerous times, is that the ER is only required to stabilize you and then you are supposed to follow up with your doctor later for things that don't require immediate intervention.
So the question is do you want the person with a chronic condition continually going into the ER as things get progressively worse and worse requiring more time and expense on the part of the ER staff to treat?
Or should we offer them access to basic health care so their issue is caught quickly and treated before it gets out of control?
It's going to cost money either way, but with a DH and a MIL who use the ER as a walk-in clinic I've been able to really compare the costs of going to the ER vs (when applicable) going to the doctor's office.
I'd rather pay for people to go to a GP than rotate continuously thru the ER.
I don't want to think of how many thousands/millions of dollars have had to be spread out to compensate for my MIL's constant ER trips. I am surprised they haven't dedicated a room to her.
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Angel!
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Post by Angel! on Nov 6, 2014 12:18:22 GMT -5
So the question is do you want the person with a chronic condition continually going into the ER as things get progressively worse and worse requiring more time and expense on the part of the ER staff to treat?
With certain conditions such as asthma it is really easy for things to get out of control & end up in the ER if you aren't able to see a doctor & be on meds when needed. But it is really easy to avoid the ER with the occasional doctor's visit & meds.
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shanendoah
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Post by shanendoah on Nov 6, 2014 12:37:41 GMT -5
We were just in the ER for an asthma attack on Monday.
When you are a 40 year old male, who has never had an asthma attack before, that first one feels like a heart attack. (Compounded by the fact that we had an unexpected death in the family, via heart attack, just last week.)
C had known there was something going on with his lungs and was planning a visit to his PCP, but then, full blown attack, full blown ER visit. And once again, yes, for something that could have been handled by a PCP if there had been an awareness of what the issue actually was.
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Angel!
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Post by Angel! on Nov 6, 2014 12:46:10 GMT -5
We were just in the ER for an asthma attack on Monday.
When you are a 40 year old male, who has never had an asthma attack before, that first one feels like a heart attack. (Compounded by the fact that we had an unexpected death in the family, via heart attack, just last week.)
C had known there was something going on with his lungs and was planning a visit to his PCP, but then, full blown attack, full blown ER visit. And once again, yes, for something that could have been handled by a PCP if there had been an awareness of what the issue actually was. I don't think it is unusual to end up in the ER a few times when first having issues with asthma. I had to take DS1 to the ER when he was 2 & again when he was 4. The pediatrician still didn't want to diagnose him with asthma even after the second incident that left him hospitalized for 3 days (damn daycare didn't realize he wasn't doing well until he was so bad he could barely speak). She said they wait until there are 3 emergency incidents to diagnose. I went around her & took him to an allergist because I'm wasn't going to sit around waiting for a 3rd incident.
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NomoreDramaQ1015
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Post by NomoreDramaQ1015 on Nov 6, 2014 12:51:05 GMT -5
ERs are for emergencies and when in doubt absolutely you should go.
But let's say I am a diabetic. I have no insurance so I can't afford to go see a regular doctor so I get the tools I need to monitor my condition.
As such I am in/out of the ER constantly because my condition is out of control. And it will continue to be the case until I am dead.
If I have insurance I can get what I need to regulate my condition so I am not constantly having emergencies.
DH's ER visit cost $6850 pre-insurance. We paid $800 of that. There is no humanly way possible we could have paid $6850, at least not without having to make tiny payments for the rest of our lives.
That's a lot for hospitals to swallow. We have insurance so the hospital at least got that portion of the bill.
. Regardless of where these people go my premiums reflect their share of the costs. The ACA didn't cause that. If I was paying for just me my insurance would be darn near free since I only go for an annual exam. Instead my premiums are calculated to average out over all the employees on my insurance.
Hospitals also have to compensate for non-payers and people like my MIL. There is no way in hell medicare could be coming close to covering what all her ER visits cost. So hospitals have to spread those costs around to everyone. The ACA didn't cause that to magically spring into existence. We've always been paying for the unhealthy and the have nots. I'd rather pay so people can access the tools they need to keep chronic conditions in check than pay for ever escalating ER trips because things are not controlled
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Lizard Queen
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Post by Lizard Queen on Nov 6, 2014 13:13:22 GMT -5
We took DS1 to the ER once for what ended up being an ear infection. There's so much conflicting advice that, when it's a weekend, it's hard to know what to do. For example, if your baby has a fever over ___, take them to the ER to get checked out. So, we did (it's been a while, so I can't remember the exact temp.) Did we do the right thing? Hell if I know. I hate going to the ER, so it wasn't just on a whim. I think what would really help would be more medi-centers available and open in the off hours.
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Angel!
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Post by Angel! on Nov 6, 2014 14:40:27 GMT -5
I took DS1 to the ER once for what turned out to be a nosebleed In my defense all the blood was coming out his mouth & he had just had his tonsils removed. They made a very big deal about bleeding after the surgery. But, I still felt like a moron.
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Mardi Gras Audrey
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Post by Mardi Gras Audrey on Nov 7, 2014 1:29:58 GMT -5
The thing with ER care, as I have pointed out to DH numerous times, is that the ER is only required to stabilize you and then you are supposed to follow up with your doctor later for things that don't require immediate intervention.
So the question is do you want the person with a chronic condition continually going into the ER as things get progressively worse and worse requiring more time and expense on the part of the ER staff to treat?
Or should we offer them access to basic health care so their issue is caught quickly and treated before it gets out of control?
It's going to cost money either way, but with a DH and a MIL who use the ER as a walk-in clinic I've been able to really compare the costs of going to the ER vs (when applicable) going to the doctor's office.
I'd rather pay for people to go to a GP than rotate continuously thru the ER.
I don't want to think of how many thousands/millions of dollars have had to be spread out to compensate for my MIL's constant ER trips. I am surprised they haven't dedicated a room to her. I agree with you that people with chronic conditions should have a primary care doctor and some outpatient specialists who manage their care. My problem with the ACA is not that people need care. I get that.. I agree and think they should get the care they need. My problem is that the ACA did NOTHING to help them get care. Dumping 8 million people on Medicaid when the govt knows that there aren't enough primary care docs to handle the current number of medicaid patients is a disservice to the patients, the providers, and the whole system. The govt knows that their reimbursements suck and that the private insurers are propping them up/subsidizing the Medicaid/Care patients. But instead of owning it (and the problem it has created), they villify the "evil insurers" (for the high premuims) and "evil docs" (for not being able to see millions of Medi patients). The govt them reinforces it by adding MORE people to the Medicaid system, giving them "insurance" that requires no copay for things (So no incentive to conserve resources), and then encouraging people to think that they will get care because they have insurance . People in this country seem to think having health INSURANCE = having HEATH CARE. This is not a true statement. Insurance doesn't equal care, especially if you have insurance that pays nothing. I can write all the insurance policies I want to and say "I will cover everything at 100%" but if tell the providers I am going to pay them $1 for a procedure that costs $1000, what do you think is going to happen? The govt increased demand without increasing reimbursement rates or dealing with the supply side. All economists know that when you increase demand, prices usually go up until supply can match it. The problem in this case is that the prices are kept artificially low by the govt (No negotiation, just suck it up providers) so the providers have to either get out of caring for govt insured patients (which many are doing) or limit the number so they can have a more balanced payer mix. Either way, it decreases availability for HEALTH CARE for the patients who need it. I hope this long rant made my position a little clearer. I work in health care and try to get all my patients the best care we can. Watching the govt create all these problems really irritates me. I also hate seeing waste, knowing that when someone wastes resources (doctor's visits, medicines, etc), it just results in less for everyone else, making it difficult for the other people (of all payers) to get the care they need.
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Angel!
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Post by Angel! on Nov 7, 2014 11:53:02 GMT -5
The thing with ER care, as I have pointed out to DH numerous times, is that the ER is only required to stabilize you and then you are supposed to follow up with your doctor later for things that don't require immediate intervention.
So the question is do you want the person with a chronic condition continually going into the ER as things get progressively worse and worse requiring more time and expense on the part of the ER staff to treat?
Or should we offer them access to basic health care so their issue is caught quickly and treated before it gets out of control?
It's going to cost money either way, but with a DH and a MIL who use the ER as a walk-in clinic I've been able to really compare the costs of going to the ER vs (when applicable) going to the doctor's office.
I'd rather pay for people to go to a GP than rotate continuously thru the ER.
I don't want to think of how many thousands/millions of dollars have had to be spread out to compensate for my MIL's constant ER trips. I am surprised they haven't dedicated a room to her. I agree with you that people with chronic conditions should have a primary care doctor and some outpatient specialists who manage their care. My problem with the ACA is not that people need care. I get that.. I agree and think they should get the care they need. My problem is that the ACA did NOTHING to help them get care. Dumping 8 million people on Medicaid when the govt knows that there aren't enough primary care docs to handle the current number of medicaid patients is a disservice to the patients, the providers, and the whole system. The govt knows that their reimbursements suck and that the private insurers are propping them up/subsidizing the Medicaid/Care patients. But instead of owning it (and the problem it has created), they villify the "evil insurers" (for the high premuims) and "evil docs" (for not being able to see millions of Medi patients). The govt them reinforces it by adding MORE people to the Medicaid system, giving them "insurance" that requires no copay for things (So no incentive to conserve resources), and then encouraging people to think that they will get care because they have insurance . People in this country seem to think having health INSURANCE = having HEATH CARE. This is not a true statement. Insurance doesn't equal care, especially if you have insurance that pays nothing. I can write all the insurance policies I want to and say "I will cover everything at 100%" but if tell the providers I am going to pay them $1 for a procedure that costs $1000, what do you think is going to happen? The govt increased demand without increasing reimbursement rates or dealing with the supply side. All economists know that when you increase demand, prices usually go up until supply can match it. The problem in this case is that the prices are kept artificially low by the govt (No negotiation, just suck it up providers) so the providers have to either get out of caring for govt insured patients (which many are doing) or limit the number so they can have a more balanced payer mix. Either way, it decreases availability for HEALTH CARE for the patients who need it. I hope this long rant made my position a little clearer. I work in health care and try to get all my patients the best care we can. Watching the govt create all these problems really irritates me. I also hate seeing waste, knowing that when someone wastes resources (doctor's visits, medicines, etc), it just results in less for everyone else, making it difficult for the other people (of all payers) to get the care they need. States are allowed to charge premiums to those on Medicaid that are higher income (relatively speaking). States are also allowed to charge copays for those on Medicaid. I don't know about premiums, but I know my state has copays.
So states can resolve this issue, Medicaid does not have to be a free-for-all. Whether or not they are opting to do so is another issue entirely. But, they do have the means to do so.
ETA - some of the emergency use may be due to the schedule of those on Medicaid. Lower income jobs are going to have a lot less flexibility & they may not easily be able to schedule an appointment & take a half day off work to be seen for an issue.
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shanendoah
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Post by shanendoah on Nov 7, 2014 12:55:59 GMT -5
Mardi Gras Audrey - I get what your saying, and it's a legitimate concern, but the number of people who go into any profession is something that is outside of the government's control. So your argument basically reads (in the most unjust, least favorable view) "We barely have enough doctors to cover those of us who are middle class or higher, so until the government can force more people to become doctors, why should we risk our access to healthcare just so some poor people can see a doctor?"
I agree that our healthcare system NEEDS to be fixed, on so many levels. But the answer to fixing it is NOT to deny people access to care based on their income. It is not to "ration" healthcare based on your ability to pay (or obtain insurance to pay). It's just not.
So while your concern is very real and valid, and is most definitely something we need to consider in a comprehensive overhaul of healthcare in this country, as an argument against the ACA, the goal of which was to provide more people with ACCESS to healthcare, it reeks of classism.
As a note, I would be all for the government offering incentives like loan forgiveness to people getting their medical degree that agree to work X number of years with underserved populations, in immigrant communities, etc. Alaska, as a state, already had programs kind of like this (which is how we got the TV show Northern Exposure). Law schools have programs like this. A friend was able to apply for some loan forgiveness/assistance because he worked X number of years as a public defender. So there are things the government can do to incentivize more people to become doctors right now, with the current system. And the government can look at the current system of medical education and maybe change some rules/regulations, which I very much thinks to be done.
But none of those things help people who need access to healthcare right now.
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billisonboard
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Post by billisonboard on Nov 7, 2014 13:39:38 GMT -5
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Cookies Galore
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Post by Cookies Galore on Nov 7, 2014 13:43:35 GMT -5
Medicare funds the residency programs in this country. Congress hasn't changed the allocated funds since 1997. There are plenty of medical graduates in this country who aren't getting into residency programs because there aren't enough spots. You can't take USMLE Step 3 if you aren't in a residency program.
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Mardi Gras Audrey
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Post by Mardi Gras Audrey on Nov 7, 2014 15:50:54 GMT -5
Mardi Gras Audrey - I get what your saying, and it's a legitimate concern, but the number of people who go into any profession is something that is outside of the government's control. So your argument basically reads (in the most unjust, least favorable view) "We barely have enough doctors to cover those of us who are middle class or higher, so until the government can force more people to become doctors, why should we risk our access to healthcare just so some poor people can see a doctor?"
But none of those things help people who need access to healthcare right now. Actually, this isn't my argument at all. My argument is that the Medis should increase reimbursement rates to something similar to what the private insurers pay (right now they are at ~40% according to a obamacare website) so that the patients who have Medi insurance have a fair chance to access care. More doctors could open up more spots to Medi patients if reimbursements were on par with Private insurers. At that point, you will have equal access for all because reimbursement rates would be similar. Right now, you have INCREASED discrimination against the people with the Medi insurance because no provider can afford to have most of their patient mix on it. It would cause them to fold. This would increase access to care and get the patient load for various medical groups better evened out. Medicaid could also change their draconian rules to allow for more access to urgent care centers and other non-traditional providers (which would work better for the patients who cant get to a doctor's office M-F between 9 and 5). In CA, they have some of the dumbest rules ever. I can give you a perfect example. We had a huge surge in pertussis cases in the last 5 years. The schools mandated that kids couldn't go to school if they hadn't had a TDAP shot (It was like grades 6-12). Medicaid would only pay for these shots at a doctor's office or the county dept of health. They wouldn't pay for them at an outpatient pharmacy (despite these places being licensed for it and private insurers paying for it). I was working in a rural community that had ~3 small medical practices (2-3 providers each) and a ~6 pharmacies. The nearest Dept of Health office was ~45 minutes drive away in an area with no public transit. All of the kids that had private insurance had no problems getting their vaccines over the summer and going to school. Their insurance paid at the pharmacy (usually with no co-pay because vaccines fall under preventative). The Medicaid kids either had to try to squeeze into a doctor's appointment (not good in a rural town with a few providers) or scrape up the gas money to drive to the Dept of health (gas was $4 a gallon) so their kids could get vaccinated. This was a waste of resources. You don't need an MD to do a vaccine. A nurse, pharmacist, nurse practitioner or other provider can do that. Hell, in the military, a tech with a few months training does them. Why do they need an MD for that? It was sad. The facilities and providers were there but Medicaid wouldn't pay for the services. Instead, they made it a PITA for the patients and their families. A lot of kids missed school because their parents couldn't get them a doctor's visit in time or didn't have the gas money to get to the Dept of Health. ETA: i think they may have changed this year but I'm not sure. I know that when we were in the thick of the pertussis outbreaks, Medicaid was the one holding out on only reimbursing at the doctor's offices. What a disservice to your patients and the community as a whole. This was similar to what I've seen in other states. One state (down South), Medicaid wouldn't cover an urgent care visit (Clinic was open 7 days a week, 8 AM -10 PM) but would cover an ER visit. So, people went to the ER downstairs and sat there for days, waiting to be seen (Patients would tell us they had been there "since friday night"... it was Sunday afternoon). So, instead of a $40 clnic visit, Medicaid gets stuck with a $1500 ER bill. It was ridiculous.
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Post by The Walk of the Penguin Mich on Nov 7, 2014 17:04:36 GMT -5
A secondary issue with Medicaid (Medicare reimbursement falls under a different preview, it is not as much as private insurance, but not as bad as Medicaid) is that Medicaid patients are 3x (the last paper I read) as likely to cancel a scheduled appointment.
If you set your practice such that no more than half is Medicaid, if 1/3 cancel, on any one day, you are out significant $$. I know the dental clinic had horrible problems with this. These days, canceling without notice is likely to get you charged at least a nominal amount if you are privately insured. Those on Medicaid wouldn't pay, so the doctor's office is left with empty slots and no income.
About DTaP vaccinations, I would imagine some of this has to do with documentation records, and that is the reason that pharmacies are not an acceptable source. For the most part, vaccinations at a pharmacy are usually a one shot deal, where there is no need for the pharmacy to keep records for years after vaccinations. If you go to a health clinic, there is some requirement to maintain records. So Johnny changes schools, was vaccinated for DTaP at CVS 3 years previously and needs proof of vaccination. No proof = duplication of service that Medicaid is paying for a second, or third time.
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