I still in shock that Roberts was the swing vote. He must have been converted by Kagan. If that's true, she's a badass.

Passenger54 posted:

I hear so many things on both sides that I don't know what to believe about the ACA.

I mean no offense when I say this, but I've never understood how people reach this position. Both sides of the argument are not equal in their wingnuttery. One is considerably more reasoned than the other, whatever its faults.

Those dressing up like minutemen screaming socialism do so because they have no substantive argument against the bill.

posted:

There are good parts to it, but at over 2,000 pages long does anybody really know what was in the bill? I do feel that something needed to be done about health care system in America, but I don't trust the Obama administration, or any politician for that matter. They only want you to believe they care about the american people. So who really believes that this will be good for americans? I hope that it will be.

There is no easy way to answer this. You could try reading the 2000 page document, but that wouldn't do you any good if you lack the legal or industry knowledge to understand it.

Put simply, the bill essentially ensures no one will be denied healthcare based on income or pre-existing conditions. This means, ipso facto, Medicare and Medicaid are going to cost more in revenue than they do already, which is sizable.

Will this be good for Americans?

That depends. Medicare doesn't offer the best coverage, but it is better than nothing. Those who have no insurance presently will therefore be better off under Obamacare. It will come at a price, however. While I would argue the price is generally worth it, there are some who would argue otherwise.

Riktor posted:

Passenger54 posted:

I hear so many things on both sides that I don't know what to believe about the ACA.

I mean no offense when I say this, but I've never understood how people reach this position. Both sides of the argument are not equal in their wingnuttery. One is considerably more reasoned than the other, whatever its faults.

Those dressing up like minutemen screaming socialism do so because they have no substantive argument against the bill.

posted:

There are good parts to it, but at over 2,000 pages long does anybody really know what was in the bill? I do feel that something needed to be done about health care system in America, but I don't trust the Obama administration, or any politician for that matter. They only want you to believe they care about the american people. So who really believes that this will be good for americans? I hope that it will be.

There is no easy way to answer this. You could try reading the 2000 page document, but that wouldn't do you any good if you lack the legal or industry knowledge to understand it.

Put simply, the bill essentially ensures no one will be denied healthcare based on income or pre-existing conditions. This means, ipso facto, Medicare and Medicaid are going to cost more in revenue than they do already, which is sizable.

Will this be good for Americans?

That depends. Medicare doesn't offer the best coverage, but it is better than nothing. Those who have no insurance presently will therefore be better off under Obamacare. It will come at a price, however. While I would argue the price is generally worth it, there are some who would argue otherwise.

Right at this moment nobody is denied healthcare based on income or pre-existing conditions, this already exists! Hospitals have to treat.

This is a good resource for information:
[www.healthcare.gov]

Subtitle F—Shared Responsibility for
Health Care
PART I—INDIVIDUAL RESPONSIBILITY
SEC. 1501 ø42 U.S.C. 18091¿. REQUIREMENT TO MAINTAIN MINIMUM ES-
SENTIAL COVERAGE.
(a) FINDINGS.—Congress makes the following findings:
(1) IN GENERAL.—The individual responsibility require-
ment provided for in this section (in this subsection referred to
as the ‘‘requirement’’) is commercial and economic in nature,
and substantially affects interstate commerce, as a result of
the effects described in paragraph (2).
(2) EFFECTSONTHENATIONALECONOMYANDINTERSTATE
COMMERCE.—øReplaced by section 10106(a)¿ The effects de-
scribed in this paragraph are the following:
(A) The requirement regulates activity that is commer-
cial and economic in nature: economic and financial deci-
sions about how and when health care is paid for, and
when health insurance is purchased. In the absence of the
requirement, some individuals would make an economic
and financial decision to forego health insurance coverage
and attempt to self-insure, which increases financial risks
to households and medical providers.
(B Health insurance and health care services are a
significant part of the national economy. National health
spending is projected to increase from $2,500,000,000,000,
or 17.6 percent of the economy, in 2009 to
$4,700,000,000,000 in 2019. Private health insurance
spending is projected to be $854,000,000,000 in 2009, and
pays for medical supplies, drugs, and equipment that are
shipped in interstate commerce. Since most health insur-
ance is sold by national or regional health insurance com-
panies, health insurance is sold in interstate commerce
and claims payments flow through interstate commerce.
June 9, 2010 (C) The requirement, together with the other provi-
sions of this Act, will add millions of new consumers to the
health insurance market, increasing the supply of, and de-
mand for, health care services, and will increase the num-
ber and share of Americans who are insured.
(D) The requirement achieves near-universal coverage
by building upon and strengthening the private employer-
based health insurance system, which covers 176,000,000
Americans nationwide. In Massachusetts, a similar re-
quirement has strengthened private employer-based cov-
erage: despite the economic downturn, the number of
workers offered employer-based coverage has actually in-
creased.
(E) The economy loses up to $207,000,000,000 a year
because of the poorer health and shorter lifespan of the
uninsured. By significantly reducing the number of the un-
insured, the requirement, together with the other provi-
sions of this Act, will significantly reduce this economic
cost.
(F) The cost of providing uncompensated care to the
uninsured was $43,000,000,000 in 2008. To pay for this
cost, health care providers pass on the cost to private in-
surers, which pass on the cost to families. This cost-shift-
ing increases family premiums by on average over $1,000
a year. By significantly reducing the number of the unin-
sured, the requirement, together with the other provisions
of this Act, will lower health insurance premiums.
(G) 62 percent of all personal bankruptcies are caused
in part by medical expenses. By significantly increasing
health insurance coverage, the requirement, together with
the other provisions of this Act, will improve financial se-
curity for families.

BULLSHIT! and isn't it ironic that this portion (for example) is basically written in language that the average person can understand, but as Riktor mentioned, if you are not educated in law and terms and they way policies are written, the average american cannot read this and totally understand what is being said in this Act (thanks for the link Rhett)
I guess my point is...for the middle class and below, it does not matter if you have health insurance when it comes to major life threatening illness or injury, if you choose to seek care to survive, you most likely will be filing bankruptcy.
This act makes it sound like the downfall of our whole health care system is the fault of those who have no means to acquire medical insurance, and that is so far from the truth it is sickening!

psss posted:

By significantly increasing
health insurance coverage, the requirement, together with
the other provisions of this Act, will improve financial se-
curity for families.

BULLSHIT! and isn't it ironic that this portion (for example) is basically written in language that the average person can understand, but as Riktor mentioned, if you are not educated in law and terms and they way policies are written, the average american cannot read this and totally understand what is being said in this Act (thanks for the link Rhett)
I guess my point is...for the middle class and below, it does not matter if you have health insurance when it comes to major life threatening illness or injury, if you choose to seek care to survive, you most likely will be filing bankruptcy.
This act makes it sound like the downfall of our whole health care system is the fault of those who have no means to acquire medical insurance, and that is so far from the truth it is sickening!

The cost shifting of the insurance premiums will drastically help those with lower incomes, as their deductibles can be 1/6 of their yearly salaries, if they have insurance at all. Tax deductions don't alleviate enough of the cost for it to really make a difference. Life-threatening illnesses and injuries may bankrupt people, as you say, however you should also consider that preventative medicine such as yearly physicals, cancer screenings, dental checkups, physical therapy, and the like is crucial to a person's long-term health. My physician recently told me that dental costs are ten times more expensive in the long run if you do not have regular checkups and preventative care, and even if that is an exaggeration it adds up to a lot.

The ACA isn't entirely geared toward targeting people who have no means for obtaining insurance. It also prevents people who have means and choose not to buy insurance from riding the system of charitable care that is required to be offered in many states. For some current information on a state-by-state basis, check out the Community Catalyst compendium of free and charitable care. The ACA appears to make this system obsolete.

posted:

True. How about you get into a motor vehicle accident, you have insurance, you go to the emergency room, you are then supposed to follow-up with regular doctors afterwards. Good luck finding a decent honest doctor who will take over your care! You will still get sent away because they don't want to get involved in your case. Just because you carry medical insurance does not mean you will receive appropriate medical care. In many, many, many situations.
I get so aggravated, I feel bad for young people, I don't know how they are ever going to make it in this world in this day and age. Our systems are so broken, and we are too small to try to help fix it, and that is a terrible feeling.

I'm not sure I get you here. You're correct that rising healthcare costs are only partially caused by uninsured patients, but it is a significant portion from what I've read.

If you're referring to the patient-physician relationship, it is notable that patients with health care are more likely to have physicians routinely involved in their healthcare. If you're talking about accountability of doctors, that is something that needs to be addressed. I feel the same distress at the state of healthcare, as I have for a long time, and this act isn't a fell swoop that will solve all our problems. Nonetheless, we have to deal with each problem in turn. From what I can gather, the ACA is a step in the right direction.

HurtNoMore posted:

Let's not forget that if you are uninsured, then you pay $20,000 for an apendectomy, but you insurer would have only had to pay $3000. This type of BS is legal under the guise of a quantity discount for insurers.

I can't speak to medical services, but I'm quite familiar with pharmacy reimbursement rates.

When your pharmacist fills a prescription, he submits an electronic claim to your medical plan's PBM (Pharmacy Benefits Manager). Within seconds, the pharmacy receives word from the PBM whether the claim has been paid or denied. If the claim is paid, the PBM instructs the pharmacy to charge the patient x, which may be a fixed rate or percentage of the total cost of the drug.

Now, technically the pharmacy bills the insurance company for the same cost they would bill an uninsured patient. Included in the data packet transmitted to the PBM is a figure called "Usual and Customary Charge", which reflects this cost. The insurance company, however, reimburses the pharmacy at a rate based on the Average Wholesale Price (AWP) of the particular drug. This rate is negotiated between the pharmacy and the insurance plan, but most of the ones I've seen hover around the (AWP-5%) range.

My employer charges in the neighborhood of $40.00 for a 30-day supply of Omeprazole 20mg Cap (one/day) to uninsured customers. Most insurance companies reimburse for less than $5.00 for the same drug, strength, quantity, and day's supply.

But this isn't a "discount" afforded to insurance companies for "buying in bulk". The insurance companies dictate what they will pay, and the pharmacies are generally in no position to bargain or haggle.

The most commonly-held commercial and medicare plans are contracted through three PBMs: Medco, Caremark, and Express Scripts. No pharmacy will risk being unable to fill for hundreds of plans because they don't like, say, Express Script's reimbursement rate on Olanzapine. So, they grit their teeth and bear it, attempting to make up for low reimbursement by charging uninsured patients through the fucking nose.

I can think of a few cases where certain reimbursement rates paid by certain PBMs weren't even enough to cover the acquisition cost of their respective drugs.

I've also heard doctors complain reimbursement rates for vaccinations is so low it has become unprofitable for small practices to dispense them.



Edited 1 time(s). Last edit at 07/01/2012 05:03PM by Riktor.

psss posted:

Riktor, I have a question. (sorry this is kind of off topic) but it seems you may have knowledge in this area, so maybe you can explain something I have wondered about.
True scenario- insured patient x prescribed 50mg Zoloft. A few weeks later prescribed higher dose 100mg. Patient notices (30) 50mg pills cost the same as (30) 100mg pills. Patient x doesn't feel good on 100mg, goes back down to 50mg. Mentions to prescribing doctor that the cost is the same for (30) 50mg and (30) 100mg, so asks doc to remain prescribing 100mg and patient will take 1/2 pill daily and end up paying the same amount of money, but get 2 months worth of meds. instead of one. Doc says he doesn't think he can do that. Nurse says...yes you can, Zoloft pill is a scored med. (for anyone who may not know, when a pill is scored, which is that little line indentation across it, basically means it can be broken in half. Some meds. cannot/ should not be broken in half for various reasons)
So anyways...all doctor would have to do is write script Zoloft 100mg take one half everyday. Doctor hesitant, has to be told, Listen do you realize how much money that would save this patient!?

Question: Why does 50mg and 100mg cost the same? When this is the case, why don't doctors write the scripts in a way that will save patient 50% out of pocket cost? makes no sense to me.

Do you have any insight?

Sure.

If the medication is being billed to insurance, the copay should be the same for both strengths. Most Pharmacy copay structures resemble this very basic model:

Tier 1 (Generics): $5.00 (e.g)
Tier 2 (Brand): $30.00
Tier 3 (Non-Formulary): $75.00
Tier 4 (Specialty): 33% of the total cost of the medication (based on the plan's standard reimbursement, not the pharmacy's usual and customary)

Zoloft is a brand-name medication, so whether the patient is receiving 50mg or 100mg, the copay is still going to be, for example, $30.00.


Also, copays are generally not dependent on dispensed quantities. A prescription for Zoloft 100 mg at #15/30-days likely costs the same as a #30/30 supply. Copays are, however, usually dependent on "days' supply". 60-day and 90-day supplies cost more than 30-day supplies.

Incidentally, Zoloft does have a generic alternative: Sertraline. Patient X's pharmacist should probably be dispensing Sertraline instead of Zoloft, so the patient may take advantage of the lower generic copay. Of course, I'm not familiar with pharmacy law outside the state of California. The rules may be different wherever Patient X lives.

As for Patient X's doctor, he is technically correct.

The doctor's orders are to take 50mg/day. In the state of California, a pharmacist could dispense the 100mg tabs, but they would have to do so within the confines of the doctor's orders. This means they could only dispense 15 pills for a 30-day supply.

If the physician were to write a script ordering Patient X to take 100mg at 1/day, only to instruct that the patient actually take 50mg/day, he would be guilty of insurance fraud, and patient X along with him.

The reason for this is simple enough. All insurance companies limit when you are able to refill a prescription. A patient must have consumed at least X% of the previous fill before the insurance company will cover another fill (generally, X is 75%). Given the directions, patient x should only be receiving 15 100mg tabs per 30 days or so. If the doctor changes the sig to 1/day, Patient X will be able refill the rx in half the requisite time.

In summary: the doctor is certainly able to change the sig to 100mg, but he also has to change the directions to half a day, so the dispensing quantity is #15/30 (again, in CA, pharmacies can do this without a change in signature). In the end, patient x would not benefit in any measurable way.

Now. If Patient X wants to save money on this med, he or she could always explore the mail order option. Most plans incentivize their mail order programs by offering special copays for 90-day supplies. Some plans will even dispense 90-day supplies for the cost of two 30-day retail copays (essentially, buy two months, get one free). There should be a mail order pharmacy phone number on the back of his or insurance card. If not, the customer service number should suffice.



Edited 1 time(s). Last edit at 07/01/2012 11:36PM by Riktor.

And another question: (lol I'm sorry) This is actually about someone I know personally.

Patient x has ESRD (end stage renal disease, dialysis 3 times a week) Pretty sure he is on disability. The wife works and is trying to finish a college degree (but having a hard time funding that) They have filed bankruptcy. Patient x is on kidney transplant list and nearing the top (he could be called in at any moment for transplant) But, patient x has been told that once he receives the transplant, he will be on meds. the rest of his life (the meds. that help the body not reject the transplant etc.) and that they can expect to have to come up with like 2,000$ a month for those? They can't manage that. It was suggested to them to hook up with some company that helps you manage fundraisers, where they (the company) collect 2% in return. But as patient x wife said, and it is true, our circle of friends is only so big and none of us are well off, realistically that is not gonna work.

Q: Do you know of any options, when it comes to meds. for someone in this situation?

Getting back on topic...Hopefully, ACA WILL make a difference for people in these situations also. I've been reading alot at this link Rhett posted www.healthcare.gov good link, I've learned alot.

But the .gov still scares me lol. Trust me, pretty scary what goes on, the only medical setting I have practiced in is as an employee of the government.

A good entry from Roger Ebert.

A shot in the dark

Catie and Caleb Medley went to the doomed midnight screening of "The Dark Knight Rises." It was a movie they'd been looking forward to for a year, her father said. Gunfire rang out. The bullets missed Catie, who was pregnant. Caleb was shot in the eye. On Tuesday, their son Hugo was born. Caleb is listed in critical condition, and the cost of emergency treatment for his head wound has already reached $2 million. The Medleys were uninsured.

According to a useful article in the Christian Science Monitor, "three of the five hospitals treating victims said Wednesday they will limit or completely wipe out medical bills." A fund has been established to help the Medleys, and it has passed $250,000. This is all heartening. But if Caleb Medley had been the victim of a drive-by shooting instead of the Aurora catastrophe, it's unlikely a hospital would have waived costs.


The Monitor observes: "Nearly one in three Coloradans, or about 1.5 million, either have no health insurance or have coverage that is inadequate... The highest uninsured rate was among adults between 18 and 34 and many of those injured in the shootings are in that age group."

In any other nation in the first world, the medical bills of the Medleys, including her stay in the maternity ward, would have been covered by Universal Health Care. But UHC (and its tentative first step as the Affordable Heath Care bill, or Obamacare) remains fiercely opposed by a vocal minority in the U.S., and the Republicans have vowed to repeal it in the next session of Congress, if they can.

I received more than 650 comments on my blog, "The Body Count," which was about gun control. I read all of them. Let's set guns aside for the moment. Many of the comments were about health care, and one of the arguments frequently heard was: "I don't want the federal government taxing me to pay for the medical costs of people who don't care enough to provide for their own costs."

A lot of Americans are discovering that it's not a matter of "caring." They can't afford good comprehensive health insurance, or are unable obtain it even if they could. Many readers write about the excellent health care benefits they get through their jobs. But young people entering the job market are discovering that many companies no longer offer health plans. Other companies have adopted a deliberate policy of laying off senior employees with health care, and replacing them with young uninsured people. Some help-wanted ads request "less than five years of experience."

In the meantime, the cost of health care continues to rise. Are you a little surprised that a man could run up $2 million in hospital costs in two days? A million dollars a day? What does that cover? I know from my own experience that hospitals overcharge steeply for some commodity products, like latex gloves, absorbent pads, feeding tubes, even gauze. When you order such generic products from an approved medical supply house, they're sometimes twice as expensive as the identical item on Amazon. But your insurance will only reimburse you for the supply house. It would rather pay more there than less on Amazon. Does that look to you like a cozy arrangement in the health industry?

But what about the idea of paying taxes to cover someone else's medical costs? That's always the way it's expressed; I rarely hear from people who don't want other people paying for their costs. In our imagination it's always other people who get sick. I have a reader who tells me he's never been sick a day in his life. I tell him that's interesting from an autobiographical point of view, but otherwise not relevant. I can assure him that unless he's killed in an accident, sooner or later he will most surely get sick, and sooner or later he will most surely die.

Are we our brothers' keepers? Many people who resort to scripture are under the impression that we are not. They forget that it was Cain who said he was not his brother's keeper, after murdering Abel. In a similar sense, if our fellow citizens die because they have no access to competent medical care, they argue that they are not their keepers.

They overlook Mark 12:31: "Thou shalt love thy neighbour as thyself." It seems to me that Universal Health Care is a powerful example of loving your neighbor as yourself.

I quote from the Bible for a particular reason. Many of the opponents of Universal Health Care identify themselves as Christians, yet when you get to the bottom of their arguments, you'll find them based not on Christianity but on Ayn Rand capitalism. Financial self-interest and the rights of corporations are more important to them than loving their neighbors. If millions of Americans cannot afford or obtain adequate health insurance, then that is somehow their own fault. There is a greater good to be served--the well-being of health care organizations and insurance companies.

Wealth itself is seen as a good. A rich man is somehow helping his society by growing richer. We must cut the taxes of the wealthy and increase the taxes of the middle class. It never occurs to those who support such tax policies that the very thing is happening that they fear so much: They are being taxed to support someone else--in this case, the rich, not the poor.

I believe that society benefits by improving the life of the average citizen. It benefits when everyone has access to health care. When I'm told "we can't afford it," why is it health care we can't afford, instead of tax cuts for the rich?

doofy posted:

All politics is local, and as much as I hate to make this about me, I will anyway.

I got a letter from my Heath insurer recently, it said under the Ava, that insures were required to use 80% of premiums toward actual health care costs, now because I am young, in great health, and have genes passed down from the GODs themselves, I do not need "health care" and now I am going to be reimbursed the remainder of what I did not use, they gonna write me out a big fat check, hellz yeah bitches!

Now my question is, how is my insurer going to provide healthcare for all the poor sick fucks that can't afford it when they are giving me back the vast majority of my premiums?

I think you are mistaken.

As I understand the law, insurers must spend 80% of their total subscriber fees on the totality of submitted claims (and quality-improvement measures), while only being allowed 20% for administrative costs and profits. Anything remaining at the end of the fiscal year is to be divided amongst all members.

I'm fairly certain they aren't required to do this per individual subscriber. In other words, you are being refunded because your insurer didn't put your monthly premiums toward claims submitted by other, less cost-effective members, not because you didn't need to go to the doctor.

doofy posted:

So what you are saying is that part of MY premiums are going to be reimbursed to other members? Even other wealthier members! So it's just a tax break for the "healthy wealthy"? WTF? And you guys want four more queers of this shit?

Is this another failed attempt at humor, or do you honestly not know how group health insurance works?

It's hard to tell with you sometimes.

doofy posted:

rationed healthcare, death panels, waiting lists for xrays, higher taxes, nothing good will come of this...

Did Michelle Bachmann log into your account?

Riktor posted:

doofy posted:

rationed healthcare, death panels, waiting lists for xrays, higher taxes, nothing good will come of this...

So the answer is "no", then.

Doktor shortages...

People like Doofy/T'Revor are one reason why the republican party went from being a party filled with thoughtful people (Nelson Rockefeller, George Romney, George H.W. Bush etc.) to what it is today--a party that prides itself on ignorance, i.e., no global warming, the denial of the theory of evolution in favor of creationism, the belief that Obama was born in Kenya, that Obama is a secret Muslim, that he's a socialist, etc.

Romney is a moderate at heart and he's intelligent. I wouldn't vote for him, but I'll give him that. The problem is that the republican party is filled with people like Doofy/T'Revor, so Romney has to cater to these folks. He can't run as a moderate, he has to pretend to be "severely conservative." If people like Romney would call out idiots like Michelle Bachmann, Rick Perry and Louie Gohmert, and if people like Doofus went back to being a crazy fringe, maybe the GOP could once again be respectable.

I know plenty of intelligent conservatives and I feel bad for them that they have idiots like Doofy in that big tent with them.

I realize that this post is off topic, but T'Revor has already taken over this thread anyway.