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How Medicare is failing. A case study.


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2009 Dec 6, 10:16am   8,519 views  69 comments

by PeopleUnited   ➕follow (2)   💰tip   ignore  

I'd like to share with you the story of a lady who lives in a small rural community. These are actual events of the past week. She recently turned 65 and became "eligible for benefits" under Medicare. This meant enrolling in Medicare part D for prescription coverage as well as Medicare A and B for hospital and medical expenses. It came time for her to get refills on her maintenance medications so she called her pharmacy. Under her new "coverage" she was told she would have to pay out of pocket for her prescriptions or go elsewhere because the independent pharmacy she has used for the past 15 years does not do Medicare D plans.

So she had her prescriptions transferred to a pharmacy in another town farther away, that does do Medicare D plans. This, only to have three of the medications denied by the Medicare plan, requiring a "prior authorization" by the physician (in case you are unfamiliar with the concept, basically the doctor has to do extra paperwork to justify the prescription for the medication he has already written for). Upon notice that the doctor will need to do a prior authorization, the doctors office notifies the patient that she will need to see the doctor before they can proceed. So she schedules and comes in for an appointment but before she even gets to see the doctor, she shows the receptionist her new "insurance" card. The receptionist tells her that Medicare is not accepted at this clinic. She will need to find a new doctor and is given some information on a clinic 25 miles away. After 15 years she is without a doctor, has a new pharmacy in a new town, but is still unable to get 3 of her maintenance medications without paying out of pocket for the full amount.

Some believe that we need to expand Medicare and use it as a model for everyone else. I'm sure this lady would disagree.

The providers have spoken, and they are saying they would rather lose patients than deal with Medicare. The regulations are onerous and the compensation for services is not fair. More and more providers are either closing shop or refusing to contract with Medicare. This results in loss of choice for Medicare patients and everyone else. Add to that the 75+ billion dollars lost to fraud, waste and abuse each year and you have a pretty good idea of what Medicare is doing for us and to us.

It is time to get government out of the health care business. This lady was better off without their "help", and you are too.

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26   bob2356   2009 Dec 7, 5:38am  

AdHominem says

Quack,
Since you love statistics. I thought I WOULD share some with you if it makes you feel all warm and fuzzy and safe to have “data”.
from http://www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf
In 1960 Private payer portion of health care expenditures was over 75%, with less than 25% being paid by Federal taxpayers. In 2007 private pay had fallen to under 54%, and government spending on health care had balooned to over 46% of all health care expenditures in the US.
During this same time the total amount of spending on health care in the US has ballooned from $27.5 billion to over $2.24 TRILLION. As government has gotten more and more involved in health care, costs have sky rocketed. Costs are up because government intervention has driven them up. And like a self fulfilling prophecy more and more people are becoming dependent on the government to “provide” for them.
What we need is a government that will protect us, so that we can provide for ourselves. Not a government that protects itself so that we can provide for the elites.

So there has been no price increases since 1960 except health care?? There has been no changes in health care to increase the prices since 1960? Do you even have the vaguest clue what the standard of care in 1960 was? You are a scientist of what, astology?

I have lived (not visited to see the Eiffel Tower, lived and worked) in France, Canada, and currently New Zealand. I can assure you the health care in those places is just fine. Better in some respects, worse in others. I can also assure you that people from first world countries are NOT coming to the United States for health care with the exception of very, very limited experimental procedures that are being done at the most advanced research centers and not available in other places. Try to get your US insurance carrier to pay for one of these, good luck. Lots of well off people from third world countries come to the US for health care because they can't go to any other first world country. Everyone else in the first world has public health care that is available only to the citizens of that country.
I agree with elliemae. You contradict yourself constantly.

27   PeopleUnited   2009 Dec 7, 5:51am  

Good, perhaps you could get together for some koolade. Talk about how great medicare is and stuff.

28   Leigh   2009 Dec 7, 6:49am  

I'm curious, what would her premiums be if she had to shop for health insurance like the rest of us? Or pick certain jobs based on benefits provided? Considering most of health care is used by this age group what would insurance companies do if they had to start covering these folks and all of their meds, hip, knee and valve replacements, the CABG's, the MI's, the strokes, etc. It's an expensive population.

Medicare was designed for a much shorter life expectancy and now that folks are living longer THANKS TO MEDICAL ADVANCES we are now seeing the effects. Someone's gotta pay for it.

How's this for a medical story not related to insurance at all. My spouse's great aunt suffered a stroke in Cuba, Alabama. Ambulance arrived and drove the 45 minutes to Meridian, MS only to find out there were no beds available so they then had to drive 2 hrs to Birmingham, AL. If you know anything about strokes and MI's timing of treatment is everything. Needless to say her outcome was not good as she dies a week later due to lack of timely care. Rural healthcare in general stinks.

29   Leigh   2009 Dec 7, 7:59am  

AdHominem,

I had a baby summer of 2006. Was paying about $350/month for family coverage. My out of pocket was about $500 TOTAL for prenatal care and delivery. Fast forward to this past March, another baby, this time paying $500/month in health insurance premiums (quite the increase, huh?) and my coverage has declined. My out-of-pocket this time around was $2,500.

Can I blame the government for the steep increases?

30   elliemae   2009 Dec 7, 10:52am  

AdHominem says

Oh, by the way. I like that you are now implying that it is her fault for living in a rural area. (she lives in the same town as the clinic that she has gone to for 15 years, but doesn’t do medicare) She should have gotten housing in the government approved tenements right comrade?

When one lives in a rural area, one often must do without.

But, let's play. Which Medicare plan does she have? Does she have a secondary? Does that secondary require pre-auth's? Did she choose her prescription plan based on her need? Which plan does she have? Does it have a mail-in pharmacy - 'cause they all do. That saves people who live in rural areas from going without their meds. Does her local clinic offer full service, including walk-ins? Did she discuss her insurance coverage with them prior to choosing her medicare plan?

Are you implying that people who live in rural areas don't qualify for section 8 housing? For publich housing programs? There are multiple programs that offer subsidies for people who live amongst us.

AdHominem says

Oh, by the way. I like...you...

You like me! Right now, you really like me!

31   PeopleUnited   2009 Dec 7, 12:36pm  

Leigh says

AdHominem,
I had a baby summer of 2006. Was paying about $350/month for family coverage. My out of pocket was about $500 TOTAL for prenatal care and delivery. Fast forward to this past March, another baby, this time paying $500/month in health insurance premiums (quite the increase, huh?) and my coverage has declined. My out-of-pocket this time around was $2,500.
Can I blame the government for the steep increases?

Obama, Osama, gubmint, capitalism, communism, the Jews, the Christians, the Moslems.Take your pick.

32   PeopleUnited   2009 Dec 7, 12:43pm  

elliemae says

AdHominem says

Oh, by the way. I like that you are now implying that it is her fault for living in a rural area. (she lives in the same town as the clinic that she has gone to for 15 years, but doesn’t do medicare) She should have gotten housing in the government approved tenements right comrade?

When one lives in a rural area, one often must do without. Right you are Comrade.
But, let’s play. Which Medicare plan does she have?
not sure.
Does she have a secondary? don't think so.
Does that secondary require pre-auth’s? Did she choose her prescription plan based on her need? Have no idea.
Which plan does she have? not sure. Does it have a mail-in pharmacy - ’cause they all do. Good point. That saves people who live in rural areas from going without their meds. well unless you need them today.
Does her local clinic offer full service, including walk-ins? walk ins yes, full service? like not sure.
Did she discuss her insurance coverage with them prior to choosing her medicare plan? No.
Are you implying that people who live in rural areas don’t qualify for section 8 housing? No only that for 15 years she was in a good situation. Now Medicare is making it not so good. For publich housing programs? There are multiple programs that offer subsidies for people who live amongst us. That is great. can I get some?
AdHominem says

Oh, by the way. I like…you…

You like me! Right now, you really like me!

33   Leigh   2009 Dec 7, 12:43pm  

Wow, thought we could have a good debate but I guess you ain't open to that? What do you think caused the spikes in healthcare costs in the example I gave.

34   PeopleUnited   2009 Dec 7, 12:48pm  

Many causes. Government intervention (including fraud, waste, abuse, and insulating patients from true cost resulting in demand-supply issues), expensive technology, inflation/lack of sound monetary system, private insurance that does much the same as public insurance and to a large extent is made possible by government intervention through tax breaks to employers that are not available to you and I.

35   kentm   2009 Dec 7, 1:34pm  

This thread is BS, right from the start.

Adhominen, Where does this woman live? Whats her name? Give me some info so we can verify this story. Anyway even if true its just one story taken out of any context and as you say facts lie when put in the wrong context right? Whats your context? And here's a verifiably true story related to the one you've spun: http://www.highbeam.com/doc/1G1-113694885.html "Article: Rural pharmacies say insurers squeezing them out of business." Pop quiz: who's the protagonist? Who's the victim?

36   4X   2009 Dec 7, 2:39pm  

The providers have spoken, and they are saying they would rather lose patients than deal with Medicare.

Right, common sense would lead me to believe this is because they want to charge top dollar. This has to be because the doctor wanted more money or did not want to deal with some extra steps. It would be self destructing to turn down good money.

This lady was better off without their “help”, and you are too.

Well, where else would a person on a fixed income buy affordable insurance? At this age insurance would cost here $750/mo.... I am curious, because not many elderly can afford to go out and spend $250 on a 15 minute visit either. Mind sharing your thoughts on how she was better off?

37   PeopleUnited   2009 Dec 7, 2:43pm  

kentm says

This thread is BS, right from the start.
Adhominen, Where does this woman live? Whats her name? Give me some info so we can verify this story. Anyway even if true its just one story taken out of any context and as you say facts lie when put in the wrong context right? Whats your context? And here’s a verifiably true story related to the one you’ve spun: http://www.highbeam.com/doc/1G1-113694885.html “Article: Rural pharmacies say insurers squeezing them out of business.” Pop quiz: who’s the protagonist? Who’s the victim?

I wish it wasn't true.

38   4X   2009 Dec 7, 2:43pm  

AdHominem says

Leigh says


AdHominem,
I had a baby summer of 2006. Was paying about $350/month for family coverage. My out of pocket was about $500 TOTAL for prenatal care and delivery. Fast forward to this past March, another baby, this time paying $500/month in health insurance premiums (quite the increase, huh?) and my coverage has declined. My out-of-pocket this time around was $2,500.
Can I blame the government for the steep increases?

Obama, Osama, gubmint, capitalism, communism, the Jews, the Christians, the Moslems.Take your pick.

@Leigh

No, this is due to the greed of the doctors, insurance companies, lawsuits and pharmaceutical companies. We the people need a government willing to go toe to toe against these entities.

39   PeopleUnited   2009 Dec 7, 2:45pm  

4X says

The providers have spoken, and they are saying they would rather lose patients than deal with Medicare.

Right, common sense would lead me to believe this is because they want to charge top dollar. This has to be because the doctor wanted more money or did not want to deal with some extra steps. It would be self destructing to turn down good money.

This lady was better off without their “help”, and you are too.

Well, where else would a person on a fixed income buy affordable insurance? At this age insurance would cost here $750/mo…. I am curious, because not many elderly can afford to go out and spend $250 on a 15 minute visit either. Mind sharing your thoughts on how she was better off?

She would have been better off if instead of "contributing" to social security she saved her money in a tax free health savings account or some other form of savings that she had control over and could benefit from personally. Instead she was forced to fund the bureaucracy that spent it years ago.

40   4X   2009 Dec 7, 2:49pm  

@Leigh @Adhom

I am still trying to figure out how the process works and how the process SHOULD work...any ideas?

41   4X   2009 Dec 7, 2:52pm  

AdHominem says

4X says



The providers have spoken, and they are saying they would rather lose patients than deal with Medicare.

Right, common sense would lead me to believe this is because they want to charge top dollar. This has to be because the doctor wanted more money or did not want to deal with some extra steps. It would be self destructing to turn down good money.

This lady was better off without their “help”, and you are too.

Well, where else would a person on a fixed income buy affordable insurance? At this age insurance would cost here $750/mo…. I am curious, because not many elderly can afford to go out and spend $250 on a 15 minute visit either. Mind sharing your thoughts on how she was better off?

She would have been better off if instead of “contributing” to social security she saved her money in a tax free health savings account or some other form of savings that she had control over and could benefit from personally. Instead she was forced to fund the bureaucracy that spent it years ago.

Supposing that she worked and wasnt dependent upon her husband, she would need to have saved up to 2 million dollars to ensure that she did not fall victim to expensive life saving treatments often needed by the elderly.

She would go bankrupt very quickly without low costs.

42   PeopleUnited   2009 Dec 7, 3:29pm  

XXXX

Yes, I agree, why not let Walmart take a crack at it? I am not really kidding. The government and medical elites have had a strangle hold on health care for too long. (for further explanation check out the post on the "Meet the unelected..." page.)

43   elliemae   2009 Dec 7, 10:19pm  

4X says

@Leigh @Adhom
I am still trying to figure out how the process works and how the process SHOULD work…any ideas?

One should walk into a clinic and receive treatment. If medication is prescribed, it should be provided. Health checkups should occur annually. An insurance claims manager shouldn't tell a doctor how much treatment to provide. No bonuses for denying benefits.

44   Leigh   2009 Dec 7, 11:31pm  

4X says

AdHominem says

Leigh says

AdHominem,

I had a baby summer of 2006. Was paying about $350/month for family coverage. My out of pocket was about $500 TOTAL for prenatal care and delivery. Fast forward to this past March, another baby, this time paying $500/month in health insurance premiums (quite the increase, huh?) and my coverage has declined. My out-of-pocket this time around was $2,500.

Can I blame the government for the steep increases?

Obama, Osama, gubmint, capitalism, communism, the Jews, the Christians, the Moslems.Take your pick.

@Leigh
No, this is due to the greed of the doctors, insurance companies, lawsuits and pharmaceutical companies. We the people need a government willing to go toe to toe against these entities.

Yeah, know it's not the guberments fault. This poster wants to blame the guberment for everything wrong in this country. I am an RN. I see who private insurance, big pHarma, lawsuits, etc play out every dang day. More later as I gotta get to work...

45   Leigh   2009 Dec 7, 11:35pm  

LOL, I heard the argument before. She should have been able to take all those SS and Medicare payments throughout her working years and invested in a HSA, stock market, etc. She should have control. LOL, Gee, look what's happened over the past ten years...'she' would have bought the biggest damn house she could (not) afford, place to new large SUV's in the garage and had manicures, vacations, Prada, etc....living large baby, it's the American way!

46   Leigh   2009 Dec 7, 11:36pm  

Let's get rid of fee for service for starters, the more procedures, labs, etc performed the more the doctor gets paid...but I really need to get to work...more later.

47   PeopleUnited   2009 Dec 8, 2:19am  

I believe in fee for service. As long as the person paying the fee is the person receiving the service.

48   Leigh   2009 Dec 8, 4:07am  

AdHominem says

I believe in fee for service. As long as the person paying the fee is the person receiving the service.

Which is not how it is today. I would like to go back to catastrophic insurance only and pay out of pocket for basic services and see what that does to health care. Would folks take responsibility for their own health. Maybe eat right and exercise to avoid diabetes and cardiovascular disease? It's been proven quite often that OTC ibuprofen works better than many name brand anti-inflammatories at a fraction of the cost.

49   elliemae   2009 Dec 8, 4:54am  

Leigh says

AdHominem says


I believe in fee for service. As long as the person paying the fee is the person receiving the service.

Which is not how it is today. I would like to go back to catastrophic insurance only and pay out of pocket for basic services and see what that does to health care. Would folks take responsibility for their own health. Maybe eat right and exercise to avoid diabetes and cardiovascular disease? It’s been proven quite often that OTC ibuprofen works better than many name brand anti-inflammatories at a fraction of the cost.

Nah, that wouldn't work. What about R.A. or M.S. or any number of diseases or diagnoses that require treatment? They're not catastrophic, unless you have them.

Yes, sometimes Ibuprofen works well - but sometimes it's not enough. I do believe that lifestyle diseases, such as obesity or come cardiac dx, should be addressed somewhere...

50   Leigh   2009 Dec 8, 5:00am  

elliemae says

Leigh says


AdHominem says

I believe in fee for service. As long as the person paying the fee is the person receiving the service.


Which is not how it is today. I would like to go back to catastrophic insurance only and pay out of pocket for basic services and see what that does to health care. Would folks take responsibility for their own health. Maybe eat right and exercise to avoid diabetes and cardiovascular disease? It’s been proven quite often that OTC ibuprofen works better than many name brand anti-inflammatories at a fraction of the cost.

Nah, that wouldn’t work. What about R.A. or M.S. or any number of diseases or diagnoses that require treatment? They’re not catastrophic, unless you have them.
Yes, sometimes Ibuprofen works well - but sometimes it’s not enough. I do believe that lifestyle diseases, such as obesity or come cardiac dx, should be addressed somewhere…

Yeah, I see your point. Besides, folks with chronic conditions rely on healthy folks as part of the insured mix, kind of like redistribution of health care dollars.

51   elliemae   2009 Dec 8, 5:10am  

Yes - and I'd like to thank you for that. :)

52   PeopleUnited   2009 Dec 8, 8:13am  

Did I just hear you say what we need is more redistribution of health care dollars (wealth)? I'm OK with you having that opinion. Just wanted to clarify.

53   elliemae   2009 Dec 8, 10:15am  

AdHominem says

I’m OK with you having that opinion. Just wanted to clarify.

I'm sure she lives & breathes for your approval. 'cause you're just so informed about everything & stuff. (thanks Nomo).

54   Leigh   2009 Dec 8, 10:15am  

AdHominem says

Did I just hear you say what we need is more redistribution of health care dollars (wealth)? I’m OK with you having that opinion. Just wanted to clarify.

Private insurance relies on redistribution of health care dollars (and the stock market). How much money could a private insurance company make if they only took on those 65 and older, or only those with breast cancer, or only those with BMI's above 30. When I worked at a small company our premiums spiked one year and the company said that it was due to heavy usage, we had quite a few older nurses and that year two were diagnosed w/ breast cancer, one had a hysterectomy, and one had a quad bypass, and two of the younger RN's had babies. When you are only talking about 100 nurses in this insurance group that's very expensive stuff going on there.

Someone's gotta pay for it.

55   Leigh   2009 Dec 8, 10:21am  

Which brings me to another point. I considered dropping to 24hrs per week which would mean I'd lose my health bennies. So I shopped around and discovered I could get the same coverage for half the price if I went with an individual/family plan via Lifewise. When I asked customer service why the big price difference he stated it was because of my family members' ages and overall general good health. When you are in a large company they take into consideration EVERYONE, all those old farts I work with and those overweight folks and the smokers, etc. So, yes, I am helping pay for those folks, too.

56   Leigh   2009 Dec 8, 1:16pm  

When my dad died after a very short battle with Multiple Myeloma, we were forced to flush all of his meds down the toilet in the presence of the hospice nurse. If I would have known this I would have denied that we had any left over. We flushed over a thousand dollars (out of pocket) worth of pain meds and anti-nausea meds. Complete waste. Why the hell did that have to be done.

How many other meds are sitting on people's shelves going to waste. I still have Percocet from my last delivery. What the heck am I gonna do with such a powerful pain killer.

Is there a redistribution center anywhere? Heck, I gave away gallons of my breast milk after discovering the long list of allergies my son was experiencing, why not prescription meds?

57   PeopleUnited   2009 Dec 8, 1:19pm  

Leigh,

I am all for VOLUNTARY wealth redistribution. Where I have a problem is when people are FORCED to do so.

58   PeopleUnited   2009 Dec 8, 1:21pm  

Leigh says

Is there a redistribution center anywhere?

It is illegal to re dispense medication in the US (Medical industrial complex hates competition). However I do believe there are missionary organizations that can take donations to the third world. Perhaps you could find one of them to take the meds.

59   Leigh   2009 Dec 8, 1:39pm  

So I guess I am not forced to get health insurance from my company but think about it. Throw Medicare out the door. Take all the money she had been contributing these past 40 years and put it toward private insurance after retirement. How much money do you think that would be? Would it be adequate to afford the premiums in the 'free market', imagine all of her pre-existing conditions. Would she have enough funds for 20 years of premiums, co-pays and deductibles, medications? And consider the premiums would be based on age and health.

In my mind, the 65 and older folks drain the health care dollars. Not only would their premiums be sky high but there will be much more scrutiny of where the dollars are going. Yes, private insurance has 'death panels' just ask any transplant doctor.

And yes, America get used to death being a part of life. You can't treat you body like sh!t then expect medicine to fix it all after a few weeks in the ICU. And you might have a living will but if your relatives aren't on the same page as you they will keep that heart of yours beating until the ethics board steps in. And with all the advances in medicine we can keep dead people alive a very long time. Who's gonna pay for it?

60   elliemae   2009 Dec 8, 1:46pm  

Leigh says

When my dad died after a very short battle with Multiple Myeloma, we were forced to flush all of his meds down the toilet in the presence of the hospice nurse. If I would have known this I would have denied that we had any left over. We flushed over a thousand dollars (out of pocket) worth of pain meds and anti-nausea meds. Complete waste. Why the hell did that have to be done.
How many other meds are sitting on people’s shelves going to waste. I still have Percocet from my last delivery. What the heck am I gonna do with such a powerful pain killer.
Is there a redistribution center anywhere? Heck, I gave away gallons of my breast milk after discovering the long list of allergies my son was experiencing, why not prescription meds?

Actually, the medications belonged to your father and all that she legally could do is ask you to dispose of them. If you refused, you have that right. However, you can't share them with anyone legally. And no clinic can take them. They can't be redistributed. I've worked with many patients' families who kept the medications, had their own scripts for the meds but wanted to save the $$$.

61   elliemae   2009 Dec 8, 1:53pm  

Leigh says

And yes, America get used to death being a part of life. You can’t treat you body like sh!t then expect medicine to fix it all after a few weeks in the ICU. And you might have a living will but if your relatives aren’t on the same page as you they will keep that heart of yours beating until the ethics board steps in. And with all the advances in medicine we can keep dead people alive a very long time. Who’s gonna pay for it?

There's a medical ethicist in Salt Lake City who advocated DNR's and end-of-life decisions; her husband was in a bike accident and she's kept him alive at quite the cost. She said it changed her view completely.

That's the problem - people are all for ending life when there's no quality, in theory. When it's them or their family members, it's different. I've seen people keep family members alive at all costs, even when the family member wanted different. It just plain sucks.

62   Leigh   2009 Dec 8, 1:56pm  

Oh, I understand that it is illegal to use a prescription med that isn't in your name but I find it wasteful to toss them when you know folks are struggling and deciding between meds and food and the heating bill. My spouse just mentioned that he's heard of specific, very expensive cancer meds being redistributed.

I just googled some terms and so far came up with this

http://www.ncsl.org/IssuesResearch/Health/StatePrescriptionDrugReturnReuseandRecyclin/tabid/14425/Default.aspx

http://www.medicalnewstoday.com/articles/24729.php

I'll need to read up on the specifics as I'd like to pass this info on to my patients if Oregon has similar laws.

63   PeopleUnited   2009 Dec 8, 4:18pm  

Leigh says

And with all the advances in medicine we can keep dead people alive a very long time. Who’s gonna pay for it?

Exactly. Who is going to pay for it? If we try to "save the world" it will bankrupt and kill us all.

But like I said, I am ALL FOR CHARITY. As long as it is optional.

64   PeopleUnited   2009 Dec 8, 4:21pm  

Leigh says

Oh, I understand that it is illegal to use a prescription med that isn’t in your name but I find it wasteful to toss them when you know folks are struggling and deciding between meds and food and the heating bill. My spouse just mentioned that he’s heard of specific, very expensive cancer meds being redistributed.
I just googled some terms and so far came up with this
http://www.ncsl.org/IssuesResearch/Health/StatePrescriptionDrugReturnReuseandRecyclin/tabid/14425/Default.aspx
http://www.medicalnewstoday.com/articles/24729.php
I’ll need to read up on the specifics as I’d like to pass this info on to my patients if Oregon has similar laws.

I'm not sure it is illegal to use it, but it is illegal to transfer it. Not to get into semantics though. I'm just saying if the law were enforced, it would be the person who transferred the drug that would be prosecuted (I believe).

65   tatupu70   2009 Dec 8, 8:20pm  

AdHominem says

I am all for VOLUNTARY wealth redistribution. Where I have a problem is when people are FORCED to do so

So, you're against car insurance then too?

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