Gov. Insurance would allow coverage for Abortion

[matt]

when did i ignore the end user or "drink the koolaid"? you make no sense in your assertion that i am ignoring the end user and getting half the story. i talk with lobbyists, MFR's, physicians, administrators, rn's, and various other facets of the system. you have no idea what you are talking about regarding my exposure to the system and all of it's parts. i see that patients are no longer looked at as patients and rather are looked upon as profit or loss. that is what the MMA did to the system.

do you ever have anything to say that is factual, insightful or supported by evidence regarding healthcare? if so i have yet to read it.

[paigesauce]

sprinkles love juice all over this thread.

love you matt!!!

[Ash]

What about covering the cost of birth control and not abortions?

[paigesauce]

what about pull out?

[vinnie97]

Originally Posted by matt

when did i ignore the end user or "drink the koolaid"? you make no sense in your assertion that i am ignoring the end user and getting half the story. i talk with lobbyists, MFR's, physicians, administrators, rn's, and various other facets of the system. you have no idea what you are talking about regarding my exposure to the system and all of it's parts. i see that patients are no longer looked at as patients and rather are looked upon as profit or loss. that is what the MMA did to the system.

do you ever have anything to say that is factual, insightful or supported by evidence regarding healthcare? if so i have yet to read it.

You're the one making this personal. You said not to believe the media or the extremists, but why should the White House's stance not be given the same scrutiny?

Your effort to derail the discussion by mentioning my contributions to this forum is duly noted. I pool pertinent information from elsewhere since I can't possibly know it all like your omniscient self. This is the last time I'll ever respond to one of your posts.

[matt]

Originally Posted by PETA

Private insurers will then have to compete against the gov't who sets even lower reimbursement rates than insurance companies. A prime reason for disparity in billing practices is that doctors who accept gov't programs try to make up for it from other patients with private insureds next up and cash payes often getting bent over a barrel. Long run private insurance won't be able to compete on a large scale and a two tiered system could well emerge. (more distinct than the one we have today)

okeydokey - done with my meetings today so here we go.

i find your comment to be factual only before the MMA was signed into law. as we all know the MMA changed the way reimbursement was paid out on drugs and administration codes within the clinical world. it took the reimbursement from AWP to ASP(Average Sales Price) +6% (well actually ASP +4% because the 2% prompt pay discount that we receive, the distributor, for paying our bill in 2 days instead of 30 is factored into the price as well - We currently have legislature that is in the house to correct this flaw). So in effect these clinics and their physicians are now working on a 4% margin which is dramatically different from the prior AWP system. this is a factor because of what you mentioned before. pre-MMA there was a lot more money to shift around to help take and cover those indigent patients, patients that could not pay their copay, and or charity cases. since the inception of ASP+6% there is certainly no way to help those in need of financial assistance around copays or charity cases, etc so off to the hospital they go to pay a higher fee schedule and burden the system.

another reason i disagree with your statement revolves around Medicare and its reimbursement rates being copied by every major insurance carrier. once ASP numbers are released quarterly the commercial payors (UHC, BCBS, Cigna, Aetna, etc) copy those numbers to lower the reimbursement they are to pay as quickly as possible. they see Medicare as the measuring stick when deciding what to reimburse regarding drug expenditures. one interesting thing to note is that the usual turnaround for a claim to be processed and paid is 14-30 days with Medicare. almost every private insurance company is running in the 60-90 day turnaround area. i shouldn't have to explain the cost of capital to show you that there is a benefit in going with a govt program like Medicare to be made whole. private insurance companies are holding up the process on purpose. there is no excuse for the amount of time they garnish reimbursement.

another shady thing that we have seen over the past year regarding the private carriers revolves around short paying their fee schedules on drug and administration payments to physicians. we had to build an enhancement to our reimbursement software that identifies variants and short pays from payors so clinics can easily identify issues and go back to the appeals process to be made whole. almost every short pay is less than what Medicare is paying. this is not a small isolated problem and is becoming more and more rampant. the private carriers simply do not care and do not even wish to pay their contracted rates. its despicable. this has been talked to so many times, but they simply do not care to change as they don't have to.

lets take it a bit further and look at the esa guideline that was changed last year to prohibit reimbursement on ESA (Epo, Procrit, Aranesp - These products are for anemia and help establish a level of activity, like being able to eat while on treatment, to any chemo patient) for anything above a 9 hgb (you and i have a 12+hgb) level that was pushed down by Medicare. the insurance companies followed suit and decided to take it even further by denying every claim for an esa on its first submission and requiring documentation on each case before it will pay a claim. since only around 20-25% clinics have an EMR the denial process adds weeks to each clinic's A/R. Also not all insurance carriers are on electronic remittance/ electronic claims so a lot of times you are sending and receiving snailmail to work through the process. Medicare actually is on both e-835/837 and e-payment so the speed at which the physician population is reimbursed is a lot more favorable in the govt scenario as well.

however, all of this is a moot point due to the fact that no one wants to take anyone without secondary insurance to cover the copays which are astronomical at times. as a result people are sent to the hospital and denied treatment in the clinic and the system carries the burden yet again.

anyways, so what im trying to say is that each patient is being treated as a single patient (at least in the wonderful world of oncology). how could you spread the wealth on a 4% margin? If the patients scenario does not fit then they are sent to the hospital. if it does fit then they are looking at various regimens in a regimen analyzer at options with the same efficacy to see what the most profitable regimen available is to treat that patient.

our care is not based on what we need or what is best for us. it is being handled by bean counters trying to make the system work so they are not underwater on the treatment they would like to give. a lot of the time they can not give them mos effective treatment based on insurance, copay, and/or reimbursement factors and must choose a similar treatment with similar efficacy that will keep them above water regarding reimbursement from private or govt parties.

lotsa text

[matt]

Originally Posted by vinnie97

this is the last time i'll ever respond to one of your posts.

yay!

[tricky]

Originally Posted by matt

okeydokey - done with my meetings today so here we go.

i find your comment to be factual only before the MMA was signed into law. as we all know the MMA changed the way reimbursement was paid out on drugs and administration codes within the clinical world. it took the reimbursement from AWP to ASP(Average Sales Price) +6% (well actually ASP +4% because the 2% prompt pay discount that we receive, the distributor, for paying our bill in 2 days instead of 30 is factored into the price as well - We currently have legislature that is in the house to correct this flaw). So in effect these clinics and their physicians are now working on a 4% margin which is dramatically different from the prior AWP system. this is a factor because of what you mentioned before. pre-MMA there was a lot more money to shift around to help take and cover those indigent patients, patients that could not pay their copay, and or charity cases. since the inception of ASP+6% there is certainly no way to help those in need of financial assistance around copays or charity cases, etc so off to the hospital they go to pay a higher fee schedule and burden the system.

another reason i disagree with your statement revolves around Medicare and its reimbursement rates being copied by every major insurance carrier. once ASP numbers are released quarterly the commercial payors (UHC, BCBS, Cigna, Aetna, etc) copy those numbers to lower the reimbursement they are to pay as quickly as possible. they see Medicare as the measuring stick when deciding what to reimburse regarding drug expenditures. one interesting thing to note is that the usual turnaround for a claim to be processed and paid is 14-30 days with Medicare. almost every private insurance company is running in the 60-90 day turnaround area. i shouldn't have to explain the cost of capital to show you that there is a benefit in going with a govt program like Medicare to be made whole. private insurance companies are holding up the process on purpose. there is no excuse for the amount of time they garnish reimbursement.

another shady thing that we have seen over the past year regarding the private carriers revolves around short paying their fee schedules on drug and administration payments to physicians. we had to build an enhancement to our reimbursement software that identifies variants and short pays from payors so clinics can easily identify issues and go back to the appeals process to be made whole. almost every short pay is less than what Medicare is paying. this is not a small isolated problem and is becoming more and more rampant. the private carriers simply do not care and do not even wish to pay their contracted rates. its despicable. this has been talked to so many times, but they simply do not care to change as they don't have to.

lets take it a bit further and look at the esa guideline that was changed last year to prohibit reimbursement on ESA (Epo, Procrit, Aranesp - These products are for anemia and help establish a level of activity, like being able to eat while on treatment, to any chemo patient) for anything above a 9 hgb (you and i have a 12+hgb) level that was pushed down by Medicare. the insurance companies followed suit and decided to take it even further by denying every claim for an esa on its first submission and requiring documentation on each case before it will pay a claim. since only around 20-25% clinics have an EMR the denial process adds weeks to each clinic's A/R. Also not all insurance carriers are on electronic remittance/ electronic claims so a lot of times you are sending and receiving snailmail to work through the process. Medicare actually is on both e-835/837 and e-payment so the speed at which the physician population is reimbursed is a lot more favorable in the govt scenario as well.

however, all of this is a moot point due to the fact that no one wants to take anyone without secondary insurance to cover the copays which are astronomical at times. as a result people are sent to the hospital and denied treatment in the clinic and the system carries the burden yet again.

anyways, so what im trying to say is that each patient is being treated as a single patient (at least in the wonderful world of oncology). how could you spread the wealth on a 4% margin? If the patients scenario does not fit then they are sent to the hospital. if it does fit then they are looking at various regimens in a regimen analyzer at options with the same efficacy to see what the most profitable regimen available is to treat that patient.

our care is not based on what we need or what is best for us. it is being handled by bean counters trying to make the system work so they are not underwater on the treatment they would like to give. a lot of the time they can not give them mos effective treatment based on insurance, copay, and/or reimbursement factors and must choose a similar treatment with similar efficacy that will keep them above water regarding reimbursement from private or govt parties.

lotsa text

thanks for the info

[tricky]

Originally Posted by vinnie97

Oh, and using public money to pay for the cost of irresponsibility and casual banging doesn't sit well with me. It's just another slap in the face of self-restraint.

abortions are cheaper than welfare, juvenile justice, public housing....all that stuff that can happen from unplanned pregnancies.

buy hey....god wants us all to have babies and we'll prosper. just like bristol.

[PETA]

Originally Posted by Ash

What about covering the cost of birth control and not abortions?

That issue is plan to plan. Most cover it for any purpose, some for purposes not relating to birth control (regulating periods, endomitriosis, etc etc) and some (few) don't cover it at all. I don't think that covering birth control pills would raise many political red flags but you never know. Personally I'd be all for it being covered.

Raises and interesting question though and it intersects with Matts comments on the MMA... would the plan have a national formulary? Would there be multiple plans w/multiple formularies? What kind of exception, override, appeal process etc.

[PETA]

Originally Posted by matt

okeydokey - done with my meetings today so here we go.

i find your comment to be factual only before the MMA was signed into law. as we all know the MMA changed the way reimbursement was paid out on drugs and administration codes within the clinical world. it took the reimbursement from AWP to ASP(Average Sales Price) +6% (well actually ASP +4% because the 2% prompt pay discount that we receive, the distributor, for paying our bill in 2 days instead of 30 is factored into the price as well - We currently have legislature that is in the house to correct this flaw). So in effect these clinics and their physicians are now working on a 4% margin which is dramatically different from the prior AWP system. this is a factor because of what you mentioned before. pre-MMA there was a lot more money to shift around to help take and cover those indigent patients, patients that could not pay their copay, and or charity cases. since the inception of ASP+6% there is certainly no way to help those in need of financial assistance around copays or charity cases, etc so off to the hospital they go to pay a higher fee schedule and burden the system.

And this highlights an important problem. Gov't plans wether drug or care will set their rates where they set them. Will those rates be so law as to make private insurance so expensive that very few can afford it? Will it further raise the cash payers threshhold?

Originally Posted by matt

another reason i disagree with your statement revolves around Medicare and its reimbursement rates being copied by every major insurance carrier. once ASP numbers are released quarterly the commercial payors (UHC, BCBS, Cigna, Aetna, etc) copy those numbers to lower the reimbursement they are to pay as quickly as possible. they see Medicare as the measuring stick when deciding what to reimburse regarding drug expenditures. one interesting thing to note is that the usual turnaround for a claim to be processed and paid is 14-30 days with Medicare. almost every private insurance company is running in the 60-90 day turnaround area. i shouldn't have to explain the cost of capital to show you that there is a benefit in going with a govt program like Medicare to be made whole. private insurance companies are holding up the process on purpose. there is no excuse for the amount of time they garnish reimbursement.

Private insurers do hold up payment and I agree that's crap. I have no illusions about them being the "good guys." But, the gov't reimburses at a lower rate than private insurance which pays less than cash payers. That strata of price differences is the "problem" in the sense that it illustrates the rising costs and the growing gaps in those "tiers" (for lack of a better word.

Originally Posted by matt

another shady thing that we have seen over the past year regarding the private carriers revolves around short paying their fee schedules on drug and administration payments to physicians. we had to build an enhancement to our reimbursement software that identifies variants and short pays from payors so clinics can easily identify issues and go back to the appeals process to be made whole. almost every short pay is less than what Medicare is paying. this is not a small isolated problem and is becoming more and more rampant. the private carriers simply do not care and do not even wish to pay their contracted rates. its despicable. this has been talked to so many times, but they simply do not care to change as they don't have to.

This is an issue of insurance companies being "bad actors." I have no issue with slappiong thewm hard on this point.

Originally Posted by matt

lets take it a bit further and look at the esa guideline that was changed last year to prohibit reimbursement on ESA (Epo, Procrit, Aranesp - These products are for anemia and help establish a level of activity, like being able to eat while on treatment, to any chemo patient) for anything above a 9 hgb (you and i have a 12+hgb) level that was pushed down by Medicare. the insurance companies followed suit and decided to take it even further by denying every claim for an esa on its first submission and requiring documentation on each case before it will pay a claim. since only around 20-25% clinics have an EMR the denial process adds weeks to each clinic's A/R. Also not all insurance carriers are on electronic remittance/ electronic claims so a lot of times you are sending and receiving snailmail to work through the process. Medicare actually is on both e-835/837 and e-payment so the speed at which the physician population is reimbursed is a lot more favorable in the govt scenario as well.

Again, bad actor. We don't disagree. I worked for an insurance company doing drug benefits adminstration and their appeals process was designed to do exactly what you mentioned above. It put in delays and in many cases the insured simply did not know he could appeal. So, here we agree - that crap gotta go.

Originally Posted by matt

however, all of this is a moot point due to the fact that no one wants to take anyone without secondary insurance to cover the copays which are astronomical at times. as a result people are sent to the hospital and denied treatment in the clinic and the system carries the burden yet again.

anyways, so what im trying to say is that each patient is being treated as a single patient (at least in the wonderful world of oncology). how could you spread the wealth on a 4% margin? If the patients scenario does not fit then they are sent to the hospital. if it does fit then they are looking at various regimens in a regimen analyzer at options with the same efficacy to see what the most profitable regimen available is to treat that patient.

our care is not based on what we need or what is best for us. it is being handled by bean counters trying to make the system work so they are not underwater on the treatment they would like to give. a lot of the time they can not give them mos effective treatment based on insurance, copay, and/or reimbursement factors and must choose a similar treatment with similar efficacy that will keep them above water regarding reimbursement from private or govt parties.

lotsa text

it is a lot of text might take two posts to get my response in.

oncology (and a few others) are exceptions in the sense that they are extremely expensive... other issues not so much. Stiches, flu shots, anti-biotics for various minor illnesses etc etc can be segregated out.

I mentioned before the idea of disaster insurance. The worry of the insurance issue isn't parents with no insurance and little Billy comes down with tonsilitis... it's daddy coming down with lung cancer. If we're trying to avoid bankrupting Daddy (not an unreasonable thing to want to do) we can quite probably accomplish this through less substantial measures. We can create carve out programs etc etc.

Mostly, I'm worried that the "solutions" will be worse that the problem they intend to fix. I'm also concerned about a large scale program shifting what I consider a fundamental personal responsibility - I mentioned that before (that's mostly a social concern though not a political or economic one even if it impacts them both). The problem is that with some many moving parts we're likely to see unintended and unforseen consequences. That's not an unreasonable thing to be concerned about imo. I think you'd (and everyone) would agree that clear and accurate information would be very useful. I'm fairly confident that both sides have plenty of truthg speakers... and plenty of crap spewers. They're sometimes hard to distinguish.

Anyway - as I said I acknowledge the gov't has every right to step in. Imo, when the free market is not permitted to function properly the gov't may step in and straighten it out. But, like I said, so many moving pieces. Do we address them all at once? Do we address specific issues and keep moving? I could give a whole bunch of ideas about how I think that could be accomplished but that's kinda minutiae at this point.

[PETA]

Originally Posted by tricky

abortions are cheaper than welfare, juvenile justice, public housing....all that stuff that can happen from unplanned pregnancies.

buy hey....god wants us all to have babies and we'll prosper. just like bristol.

well, in that case why don't we simply execute all people in prison, wards of the state and on public assistence if its cheaper than keeping them alive? Hell, add in people with terminal illnesses and those with very low odds of recovery. End of lif care is astronomically expensive so the savings should cover a lot of other things.

[matt]

im hoping they would work with groups like CCE (Cancer Centers of Excellence) who analyze each and every regimen quarterly and decide to move forward with 3-5 standardized regimens on each diagnosis that will best treat the patient without sacrificing efficacy. this translates to lower costs and higher reimbursements for private and govt payors. today there exists ways to lower forecast costs (this is the probably the BIGGEST problem that everyone has these days - how do we really forecast cost when people are being treated in so many various ways!). we have developed these data-sets for both the payor and providers. we are putting the power back in the physician's hands to show cost and to share in that spread with the insurance carriers. this translates to real savings (per patient - not per drug) and has not been achieved on a global scale before. the private sector has ways to fix the high cost of healthcare through standardization right now, but not many are listening. the clinic's that are will be the people to survive this mess.

also, national guidelines are already in place - NCCN, ASCO, NOA, etc. those guidelines are being used for reference to reimbursement and those would more than likely be the basis for "formulary" you are asking about. it would be crazy not to use those - everyone does.

one of my friends here within my organization wrote the first asco guideline. she has so much to say about all of this. really is interesting to have all of these resources around during such an interesting time in our country's journey.

tons of problems though, lol.

[PETA]

Originally Posted by matt

im hoping they would work with groups like CCE (Cancer Centers of Excellence) who analyze each and every regimen quarterly and decide to move forward with 3-5 standardized regimens on each diagnosis that will best treat the patient without sacrificing efficacy. this translates to lower costs and higher reimbursements for private and govt payors. today there exists ways to lower forecast costs (this is the probably the BIGGEST problem that everyone has these days - how do we really forecast cost when people are being treated in so many various ways!). we have developed these data-sets for both the payor and providers. we are putting the power back in the physician's hands to show cost and to share in that spread with the insurance carriers. this translates to real savings (per patient - not per drug) and has not been achieved on a global scale before. the private sector has ways to fix the high cost of healthcare through standardization right now, but not many are listening. the clinic's that are will be the people to survive this mess.

also, national guidelines are already in place - NCCN, ASCO, NOA, etc. those guidelines are being used for reference to reimbursement and those would more than likely be the basis for "formulary" you are asking about. it would be crazy not to use those - everyone does.

one of my friends here within my organization wrote the first asco guideline. she has so much to say about all of this. really is interesting to have all of these resources around during such an interesting time in our country's journey.

tons of problems though, lol.

Yeah, I know everyone uses a formulary but I was curious (its minutiae again) about... well... I said it above.

Another thing.. healthcare facility costs vs revenue vary greatly from institution to institution as well as region to region. The more efficient the facility is at curing the patient - usually the lower the bills (fewer tests, shorter stays etc etc). Which works a perverse outcome - the worst facilities may be the most highly compensated. National standards are nice but one of the proposals I read was to take the lowest cost basis for a procedure (wherever that may be) and insitute it as a national standard. Probably not workable. Again, yes, many many problems.

[matt]

Originally Posted by PETA

And this highlights an important problem. Gov't plans wether drug or care will set their rates where they set them. Will those rates be so law as to make private insurance so expensive that very few can afford it? Will it further raise the cash payers threshhold?

one thing that has been thrown around concerning this is taking the exchange of ownership on drug expenditure from distributor to provider out of the equation and put that on the govt or commercial payor. think drugs on consignment. that way the making money on drug issue is totally out the window and the physician would be able to earn money on administration fees, office visits, and P4P (pay for performance) initiatives like programs like PQRI, etc, which pay a bonus to physicians that report various forms of information as part of their treatment. there was a similar program that was reviewed a few years ago named CAP, but it never got off the ground.