Insurer revoked HIV patients' coverage

[BenBurch]

It just sounds so unlikely. They'd be able to deny all claims for things like breast and cervival cancer, and they don't seem to do that. Even one insurer doing that seems an awful stretch.

Rolfe.

This was a terrible insurer. She said they denied claims for all sorts of reasons. Her employer picked it because it was the cheapest they could find.

This was in the mid 1980s, BTW.

 

[Rolfe]

The problem goes back that long?

It's so bizarre, and yet so long ago now, I suppose the only possible reaction is to shake head.

I still don't really understand why there hasn't been a popular move to sort all this out long ago.

Rolfe.

 

[pgwenthold]

I've read tons of similar stories, and they send a chill down my spine. I don't understand how all the US posters who seem so happy with their great coverage can be sure something like this could never happen to them.

"He had AIDS! I ain't no homo."

I think the problem is that too many people not only do not feel concerned, they think the ratbastage got what was coming to him.

 

[ARubberChickenWithAPulley]

I had a good read at it, and indeed it's interesting and thoughtful. It almost sounds, though, as if she's arguing in favour of the "death panels". Is $620,000 too much to prolong a cancer patient's life for eight years, mostly happy? Absolutely not, I'd say. And I think any universal healthcare system would agree. That's paid for by maybe a dozen contributors who had a sudden stroke or something and took very little out of the system.

I didn't get that she's arguing in favor of "death panels," she is contemplating the philosophical question of "how much is a day of life worth." Or even, "How much is a chance of an extra day of life worth." Or two days. Or two weeks. Or two years. It's a hard question that I'd imagine even universal healthcare systems face. If a doctor said to me, "Your wife has a 50% chance of living an extra week, but the treatment costs a million dollars," I'd take it. I'd probably take it if it were an extra day. I'd probably take it if it were 10 million dollars and a 10% chance. Obviously, things don't get broken down that cleanly in real life, but I think it's that type of question she was contemplating. At some point, every system says "no more."

This is a particularly salient point in the U.S. where care is very expensive. One strong driver of that expense is that the U.S. tends to adopt newer technologies very quickly (i.e. when they're still very expensive, but not necessarily with enough of an improvement in effectiveness to justify the early adoption). So the question of, "We have this nice new drug/procedure that might be 25% more effective, but costs 10X as much, and this older drug which is mostly effective but 1/10 the price, is it worth it?" and things of that nature is also, IMO, what she is pondering.

And then again, they apparently didn't pay $620,000, but only about $230,000, because the insurance company screwed a very good deal out of the providers.

I'm not sure why you chose the word "screwed" here unless it has a different connotation in British English. Insurers negotiate prices on behalf of their members. It's part of what I pay my premiums for them to do. They do so before any treatment is given. It's not like the hospital handed the insurer a bill for $620,000 and the insurer said, "Screw you, we're only paying $230,000." The hospitals usually have a contract in place with the rates defined. I do think there is a little funny math on both sides, though. No business in their right mind would give anyone a 60+% discount across the board unless they were absurdly marked up to begin with. I'd imagine the hospitals mark things way up knowing they are going to negotiate down, then they can say to the insurer, "Look we're giving you a HUGE discount!" and then the insurer can go to their members and advertise and say, "Look we negotiated this HUGE discount!" I had a bill for a test, and the bill was for $700+, and minus the insurer discount, it ended up being about $90. That's an 80%+ discount! A hospital might offer some procedures at a loss and recoup them with other procedures, but an 80% discount? It's ridiculous. Incidentally, on average, government programs (e.g. Medicare and Medicaid) "screw" providers worse than private insurance on rates.

The argument really seems to be about whether this should be an individual decision, or one mandated by society, and in the former case, what do you do about the people who didn't chip in, for whatever reason.

And that's the issue with the "I shouldn't be forced to have health insurance if I don't want it" argument (for the people who legitimately can afford it but choose not to). Okay -- if you don't want to have insurance, then you get what you can pay for. You're accepting the risk that if you get a disease or injury that you can't pay for, we're not going to treat you. Of course, it's unlikely that most people would accept that when push came to shove and they were facing the possibility of dying of cancer or lying on the side of the road after a car accident (and as a society, we shouldn't accept it either). They'd demand the treatment. So let's be realistic and have them pay into the system.

The writer didn't really highlight how much of the cost was incurred in the last few weeks, but I think that's maybe the bigger issue.

She didn't give the full last few weeks, but she does say that the final three days cost $14,022 and the four days before that was $43,711 so that's a little over $57,000. Of course, it doesn't say if that's before or after the insurer discount.

However, they had genuine hope of getting the cancer into remission again, so I wouldn't say it was unjustified at all. Also, it's only by making that extra effort with the poor-prognosis cases that the new treatments can be refined and turned into something that's really worth having.

It seems like in her case it was the right thing to do. $230,000 as a whole doesn't strike me as a huge amount in a case like that, and that was $230,000 over several years.

I think it's actually a shame that the family had to think of all this in monetary terms, even if they weren't paying most of the bills.

I don't get the impression she was worrying about it a lot at the time. She looked back and wondered about it. But I don't have a problem with thinking about it in monetary terms. When we had our baby, I wanted to know how much the birth and extra hospitalization cost, even though I didn't pay for most of it. But maybe I'm just the curious type.

At one point, the relative usefulness of spending that money on Terence rather than on vaccines for children in Africa was questioned. My reply to that is, if you're going to make that comparison, then there are a lot of things we should give up in order to vaccinate these African children, before we take medical treatment away from cancer patients.

Well, she states she would do it again. She was commenting on how he might think if he knew how much it cost. But yeah, in general that argument is bunk... if we all got smaller houses, shut off our TV and Internet and cell phone services and bought cheap cars, we could give all that money to poor African children, I'm sure.

 

[ARubberChickenWithAPulley]

This was a terrible insurer. She said they denied claims for all sorts of reasons. Her employer picked it because it was the cheapest they could find.

This was in the mid 1980s, BTW.

I should point out that in many cases (though by no means all), it is the employer itself rather than the insurance company that is making the substantial decisions. Many large employers self-insure (I think 55%-60% of Americans with employer-based insurance are under a self funded arrangement right now. I'd guess it was lower in the 80's since HMOs were much bigger then). The employer pays all the bills, and the employer decides what is covered and not covered. The insurance company isn't insuring anything -- they're just the administrator. However, when your claim is denied, it will come from the insurance company. So the insurance company essentially takes the role of the proverbial "shot messenger" for the employer -- but it is the employer who is the actual insurer.

I had to explain this to my mother when she was having all kinds of trouble with a workman's compensation issue (not health insurance, but same type of arrangement): She couldn't figure out why her company seemed to be actively supporting the insurance company rather than her. And it was likely because... it was the employer that was actually the "insurer" to begin with.

 

[Magyar]

. The pharmacist checked on the computer and told him that unfortunately he wasn't covered. "And I'm afraid it's quite expensive - over $400."

It was then explained to the BBC interviewer that the caller had lost his job, so was no longer covered by health care insurance, so just as he'd lost his income, he was going to have to find a lot of money to pay for the medication he was on.

It's not just rescission that can screw people.

Rolfe.

To be fair - YEA MAJOR sarcasm alert - if you had insurance through your employer you are eligible for COBRA (which by the way was just one of many things that passed through congress as reconciliation act which is the 'R' in cobra and what the republicans are whining/lying about in trying to defeat the health care bill)

But COBRA runs anywhere from 1000-1500 dollars a MONTH because you have to pay your share as well as the employers. SO after you lose your job you COULD spend half of your unemployment checks on keeping your health insurance YEA for republican personal responsibility and the free market.

 

[technoextreme]

This was systemic, deliberate, and apparently intended to wear down a seriously ill customer so that he died or gave up before they had to pay any money. How many other people did the strategy work with?

It nearly worked with my grandpa and his pacemaker battery. The insurance ****ed around with the battery check scheduling so much that his doctor essentially admitted that they are committing insurance fraud just to make sure that people don't drop dead from a dead battery.

 

[Rolfe]

To be fair - YEA MAJOR sarcasm alert - if you had insurance through your employer you are eligible for COBRA (which by the way was just one of many things that passed through congress as reconciliation act which is the 'R' in cobra and what the republicans are whining/lying about in trying to defeat the health care bill)

But COBRA runs anywhere from 1000-1500 dollars a MONTH because you have to pay your share as well as the employers. SO after you lose your job you COULD spend half of your unemployment checks on keeping your health insurance YEA for republican personal responsibility and the free market.

I noticed COBRA wasn't mentioned, but then, knowing how much it often costs, I could imagine it just isn't in the frame in many examples.

Rolfe.

 

[Rolfe]

I didn't get that she's arguing in favor of "death panels," she is contemplating the philosophical question of "how much is a day of life worth." Or even, "How much is a chance of an extra day of life worth." Or two days. Or two weeks. Or two years. It's a hard question that I'd imagine even universal healthcare systems face. If a doctor said to me, "Your wife has a 50% chance of living an extra week, but the treatment costs a million dollars," I'd take it. I'd probably take it if it were an extra day. I'd probably take it if it were 10 million dollars and a 10% chance. Obviously, things don't get broken down that cleanly in real life, but I think it's that type of question she was contemplating. At some point, every system says "no more."

This is a particularly salient point in the U.S. where care is very expensive. One strong driver of that expense is that the U.S. tends to adopt newer technologies very quickly (i.e. when they're still very expensive, but not necessarily with enough of an improvement in effectiveness to justify the early adoption). So the question of, "We have this nice new drug/procedure that might be 25% more effective, but costs 10X as much, and this older drug which is mostly effective but 1/10 the price, is it worth it?" and things of that nature is also, IMO, what she is pondering.

Indeed, but that reasoning is exactly the reasoning behind the so-called "death panels". This idea seemed to spring from NICE, which assesses whether new drugs are cost-effective before OKing them to be prescribed on the NHS, and the concept of the QALY, which they use to do this. Just how much benefit (the Quality Ajusted Life Year) is this expensive drug going to achieve?

In the NHS, these discussions are open and public, and they're taken by panels of senior doctors who have no involvement with the patients in question so that they will be as objective as possible. Sometimes there's no obvious "right" answer, and aggrieved patients ask for a judicial review, and sometimes they win.

But the entire philosophical argument that writer is going through is pretty much a layman's description of the QALY, and how it informs the decision on just where to draw the line with hugely expensive drugs with limited benefit in terminally-ill patients. It is this decision process that was morphed into OMG rationing and OMG death panels by the anti-reform lobby.

I'm no expert, but I think £140,000 for eight years good-quality life in a middle-aged man with a young family is a snip of a bargain.

I'm not sure why you chose the word "screwed" here unless it has a different connotation in British English. Insurers negotiate prices on behalf of their members. It's part of what I pay my premiums for them to do. They do so before any treatment is given. It's not like the hospital handed the insurer a bill for $620,000 and the insurer said, "Screw you, we're only paying $230,000." The hospitals usually have a contract in place with the rates defined. I do think there is a little funny math on both sides, though. No business in their right mind would give anyone a 60+% discount across the board unless they were absurdly marked up to begin with. I'd imagine the hospitals mark things way up knowing they are going to negotiate down, then they can say to the insurer, "Look we're giving you a HUGE discount!" and then the insurer can go to their members and advertise and say, "Look we negotiated this HUGE discount!" I had a bill for a test, and the bill was for $700+, and minus the insurer discount, it ended up being about $90. That's an 80%+ discount! A hospital might offer some procedures at a loss and recoup them with other procedures, but an 80% discount? It's ridiculous. Incidentally, on average, government programs (e.g. Medicare and Medicaid) "screw" providers worse than private insurance on rates.

Probably just a difference in semantics. My point really was that the $620,000 figure was smoke and mirrors. If arrangements were in place so that list price was never going to be paid, then list price is irrelevant. Probably almost nobody pays list price. The price to discuss is the price it actually costs.

And that's the issue with the "I shouldn't be forced to have health insurance if I don't want it" argument (for the people who legitimately can afford it but choose not to). Okay -- if you don't want to have insurance, then you get what you can pay for. You're accepting the risk that if you get a disease or injury that you can't pay for, we're not going to treat you. Of course, it's unlikely that most people would accept that when push came to shove and they were facing the possibility of dying of cancer or lying on the side of the road after a car accident (and as a society, we shouldn't accept it either). They'd demand the treatment. So let's be realistic and have them pay into the system.

Precisely. These people should have no right to force their fellow-citizens to choose between either denying them care and watching them die in distressing, aviodable circumstances, and freely donating the resources needed to treat them.

Maybe these guys are cool with just turning their faces to the wall and dying if they lose the bet, but they should have no right to force their neughbours to let them do it.

She didn't give the full last few weeks, but she does say that the final three days cost $14,022 and the four days before that was $43,711 so that's a little over $57,000. Of course, it doesn't say if that's before or after the insurer discount.

It seems like in her case it was the right thing to do. $230,000 as a whole doesn't strike me as a huge amount in a case like that, and that was $230,000 over several years.

I don't get the impression she was worrying about it a lot at the time. She looked back and wondered about it. But I don't have a problem with thinking about it in monetary terms. When we had our baby, I wanted to know how much the birth and extra hospitalization cost, even though I didn't pay for most of it. But maybe I'm just the curious type.

As I said, all these considerations and decisions are right there in the open in the NHS, and I imagine other universal healthcare systems as well. Senior consultants and medical ethicistsand people like that have had all these debates times without number.

Well, she states she would do it again. She was commenting on how he might think if he knew how much it cost. But yeah, in general that argument is bunk... if we all got smaller houses, shut off our TV and Internet and cell phone services and bought cheap cars, we could give all that money to poor African children, I'm sure.

As I said, I think it's not even questionable, as a good use of resources. The "oh dear my husband died anyway, what else could that money have bought" is understandable in a grieving widow, but if it's a serious question, there are many many things we should be giving up to vaccinate African children before the cancer treatment of a man like Terence.

Rolfe.

 

[Darat]

...snip...

In the NHS, these discussions are open and public, and they're taken by panels of senior doctors who have no involvement with the patients in question so that they will be as objective as possible. Sometimes there's no obvious "right" answer, and aggrieved patients ask for a judicial review, and sometimes they win.


...snip...

And you have to keep in mind that in the UK just because NICE has not approved something does not mean that your local NHS trust won't provide the treatment. An example of this was Herceptin, some local NHS trusts were providing it even though NICE hadn't approved it, see: http://www.guardian.co.uk/society/2006/feb/18/cancercare.health for more details.