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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by fachad on July 15, 2002, at 11:08:36
I saw some posts over at social babble on some insurance not covering Ambien, and I just felt the need to enlighten the board to the awful truth about health insurance, especially as it relates to employer provided group plans. There is a lot more to this story than I could post on PSB, but here are the highlights.
Your employer may provide health insurance for employees. In order for them to get quotes for this, you have to have each person that wants to be on the group plan fill out a questionnaire with their health problems, any regular meds, etc.
There are so many things wrong with this I can't believe it really happens. First, are you pleased that the HR staff of your employer knows your medical history, and your medications? That seems like an invasion of privacy.
Also, it means that if you have a "sickly" person on your staff, everyone has to pay more out of each paycheck for their health insurance. I joked to my business partner that we should hire only very healthy athletes until after we get a good quote for cheap insurance. I was only kidding, but an unethical company could (secretly, of course) terminate employees if their medical problems were jacking up the health insurance rates.
But that would only work for one year, because the insurance companies do "utilization reviews" to determine the next year's premiums. They look to see how many claims were made, and how much it cost them. Then they adjust the rates for that group to be high enough for them to make money the next year. They actually look at how much each person cost.
If an employer asks, why have our rates for our health insurance increased 200% since last year, they (some insurance agent) can actually point out that Joe's wife is on Zyprexa, and that s*** costs big $$$. And Jane's husband needed back surgery, and god knows back patients are second only to psych patients for needing ongoing expensive care...
It's the same as auto insurance - if you get tickets and have wrecks, your rates go up. But in the case of an employer provided group health plan, if any one person gets sick or needs meds, EVERYONES costs go up. If the guy in the next cube is a smoker, and gets cancer, next year you won't be able to afford your company health insurance.
Your employer can dodge this practice, called "profiling", by switching health insurance companies each year, but that's a huge hassle to people.
Because the cost of the company provided plan was so high a few years ago, we almost decided we could no longer afford it.
So my wife and I tried to get self pay health insurance. First they told us $600 per month per person, but only if we "got off" certain meds. Then they came back and said that due to our medical history, they could not offer us health insurance, at any price, as private individuals. The only chance of us getting insurance was through a group plan, where our high utilization could be offset by someone else's low utilization.
But the group health insurance costs so much that the business can barely afford to pay its part, and the employees can barely afford to pay their part.
So I am now in a position where I may end up on the street corner holding a cardboard sign that says “Will Work for Health Insurance”.
Posted by judy1 on July 15, 2002, at 11:58:22
In reply to Insurance, Profitability, Utilization, Profiling, posted by fachad on July 15, 2002, at 11:08:36
That was very frightening and unfortunately true. My husband keeps a certain amount of money (pre-tax) for health reimbursements and they refused to reimburse my therapist charges because there was no diagnosis(s) put down. Since my husband is a VP in a very large company, I'm terrified this will have consequences on his career- I don't know, the guy with the crazy wife. So I think it's even more far-reaching then you propose. Take care, judy
Posted by fachad on July 15, 2002, at 12:22:23
In reply to Re: Insurance, Profitability, Utilization, Profiling » fachad, posted by judy1 on July 15, 2002, at 11:58:22
judy1,
Here are a few things that may provide some small comfort to you in your situation.
>Since my husband is a VP in a very large company
The larger the company, the less this whole utilization thing is a factor. This is a statistical method, and the larger the group, the less effect any one high utilizer has on the total average utilization of the group.
Also, this type of information is supposed to be somewhat confidential, and larger companies usually have better procedures to protect confidential material.
Finally, even if you are being stigmatized, it is for costing the insurance company a lot of money, not for being "crazy".
They don't really care if you have paranoid schizophrenia or seasonal allergies or cancer. All they really care about is how much money your treatment is costing...
> That was very frightening and unfortunately true. My husband keeps a certain amount of money (pre-tax) for health reimbursements and they refused to reimburse my therapist charges because there was no diagnosis(s) put down. Since my husband is a VP in a very large company, I'm terrified this will have consequences on his career- I don't know, the guy with the crazy wife. So I think it's even more far-reaching then you propose. Take care, judy
Posted by fachad on July 15, 2002, at 12:23:51
In reply to Insurance, Profitability, Utilization, Profiling, posted by fachad on July 15, 2002, at 11:08:36
Here's a little sarcastic version of the story from the perspective of the insurance company...
Anyone who takes psych meds needs to add "High Utilization" to their list of diagnosis.
High Utilization is that horrible condition where someone actually uses their health insurance, and gets benefits. In severe cases, the benefits they claim exceed the premiums they've paid, resulting in losses at the bottom line.
There are several approaches to treatment.
The best treatment is prevention. Try not to insure high utilizers if at all possible. You can discourage them by setting their premiums ridiculously high.
If you find yourself insuring high utilizers, there are still a few things you can do to protect your bottom line.
Try to exclude their conditions from coverage.
Put a cap on their coverage.
Put a "gatekeeper" in place to keep them from getting quick access to expensive treatments. If you can stall long enough, they may die or switch insurance companies - either way your bottom line is protected.
Exclude high cost medications from coverage and demand they use low cost generic meds instead. A one-time open heart surgery can cost less than a lifetime supply of daily expensive meds.
And keep your eyes open for high utilizers. Do your "Utilization Review" homework and regularly update the data in your "Group Profiles". Don't let sick people ruin the profitability of your health insurance business!
Posted by judy1 on July 15, 2002, at 12:53:45
In reply to Re: Insurance, etc. - Some Small Comforts » judy1, posted by fachad on July 15, 2002, at 12:22:23
It was a comfort- thank you so much. You're so knowledgeable about all of this, is that because of all the negative experiences or is this your field? Take care, judy
Posted by mist on July 15, 2002, at 13:35:48
In reply to Insurance, Profitability, Utilization, Profiling, posted by fachad on July 15, 2002, at 11:08:36
Fachad,
I appreciate your posting what you did. The more awareness there is about the profit before people practices of insurance companies the better.
I'm curious to know what doctors think about this state of affairs? I know they aren't happy with the insurance companies but don't know their exact position on issues like this, or what they're doing about it.
I believe tax money should pay for health care. A lot of tax money is wasted anyway. It's not a matter of more taxes but spending the money the right way.
Posted by Shawn. T. on July 15, 2002, at 20:24:49
In reply to Curious what doctors think about this?, posted by mist on July 15, 2002, at 13:35:48
If I ever receive any national attention because of my research, I will beat this issue to the death.
Shawn
Posted by fachad on July 15, 2002, at 21:23:38
In reply to Re: Insurance, etc. - Some Small Comforts » fachad, posted by judy1 on July 15, 2002, at 12:53:45
I came to know about this stuff from negative experiences in both personal and professional areas.
On the level of personal experience, my wife has had a lot of medical problems, and we found out about the whole "utilization" thing when her company plan became so expensive that we tried to get self-paid insurance.
That's when they told us to that due to her medical history, she was "uninsurable" as a private person and we need to pursue an employer group plan.
She works for a family business with her parents, so she was given the task of finding affordable health insurance for their company. That's when we found out about the "profiling", and how the insurance companies keep stats on employer groups to identify high utilization and increase premiums for those groups.
I don't think they are supposed to release such detailed information, but the insurance agent actually told her which people were to blame for the rate increases.
Also, I started a business that year, and wanted to get health insurance benefits for my employees. That's when I had to gather medical history questionnaires from each employee to turn in to these prospective insurance companies so they could give us quotes. It felt so weird to look at everyone’s medical history, and knowing what meds they were on, like I shouldn’t be seeing this stuff, but insurance companies want that info before they will give small groups quotes for benefit packages.
With both our small businesses, it is a big stress every year about how much the premiums are going to go up, and if the company will still be able to afford to provide health benefits, or if it will just cost too much. It is a very serious business issue - the costs are really high even with employees paying part, it puts a huge strain on a small company. Many companies cannot afford to provided health benefits and remain in business.
And knowing that every time I see a doctor for anything, and every time I fill a script, it is being monitored and used as a basis to increase our premiums...it is very upsetting, but that's just how it works in the real world.
It really is an awful situation.
> It was a comfort- thank you so much. You're so knowledgeable about all of this, is that because of all the negative experiences or is this your field? Take care, judy
Posted by fachad on July 15, 2002, at 22:07:04
In reply to Re: Curious what doctors think about this?, posted by Shawn. T. on July 15, 2002, at 20:24:49
Shawn,
Please take a look at these two posts. They are related to this one in that they implicate pharmaceutical companies in the same way this post implicates insurance companies.
The unfortunate thing about the profit motive in drug companies is that the study data that folks like you and I devour is "prepared" with marketing objectives in mind.
Something that is very important to keep in mind as we try to understand these medications is that this industry (psychopharmacology/psychiatry) is not just about the science of brain chemistry and the improving of mental health.
There are two other major factors that go into it: economics and legislation. And I've described what I've found out about how those factors drive our care in these posts.
Ritalin is not marketed as ADhttp://www.dr-bob.org/babble/20020307/msgs/97442.html
Re: Why isnt Moclobemide available in the USA?
http://www.dr-bob.org/babble/20020215/msgs/94775.html
I think those three: insurance, drug company marketing, and government legislation are the major non-medical items that factor into our care.
> If I ever receive any national attention because of my research, I will beat this issue to the death.
>
> Shawn
Posted by Ritch on July 15, 2002, at 23:28:29
In reply to Insurance, Profitability, Utilization, Profiling, posted by fachad on July 15, 2002, at 11:08:36
> Your employer may provide health insurance for employees. In order for them to get quotes for this, you have to have each person that wants to be on the group plan fill out a questionnaire with their health problems, any regular meds, etc.I had a former small employer who changed insurance companies every year on purpose to get the cheapest quote.
> There are so many things wrong with this I can't believe it really happens. First, are you pleased that the HR staff of your employer knows your medical history, and your medications? That seems like an invasion of privacy.All I can say is (from what I understand to be true-anyhow), is that Clinton made only *written* documentation of insurance transactions potentially available to the employer. *Digital* filings between your doctor/pharmacist and your insurance company are supposed to not be disseminated information that your employer can be privy to. The "Flexible Spending Accounts" of late rely on a lot of *written* information, however....
I do know for sure that employers can get a breakdown from the insurance company of the *total* $$$ claims for specific meds. They were listed on the bulletin board where I work. I don't think the insurance co. can provide really employee specific info., but they *can* tell the employer everything about what drugs the *group* is taking and at what cost, etc.
Interestingly, generic hydrocodone and alprazolam (at very low cost) was high on the list (but not pricey). Patent antidepressants were also high on the list, but also had the highest cost factors. It seems they (the insurance co's.) are targeting patent AD's as their biggest cost factor.>
> Also, it means that if you have a "sickly" person on your staff, everyone has to pay more out of each paycheck for their health insurance. I joked to my business partner that we should hire only very healthy athletes until after we get a good quote for cheap insurance. I was only kidding, but an unethical company could (secretly, of course) terminate employees if their medical problems were jacking up the health insurance rates.Most new companies that start up want to do just exactly that (hire healthy young athletes). I have worked with "sickly" coworkers who have been terminated primarily due to their health problems. Of course the "objective criteria" used to terminate them was associated with the general need for them to use "medical leave"-which involves a higher statistical (objective) rate of absenteeism, etc. I am not talking depression here, but primarily "physical" chronic illnesses.
>
> But that would only work for one year, because the insurance companies do "utilization reviews" to determine the next year's premiums. They look to see how many claims were made, and how much it cost them. Then they adjust the rates for that group to be high enough for them to make money the next year. They actually look at how much each person cost.That doesn't surprise me. They *may* not know the *details*, but they DO know the $$$. They probably have a *ratio* of how much is paid out for each employee vis a vis the premiums paid in. Your privacy may be protected (as far as dx-specific meds, i.e.), but not your cost to the company.
>
> So I am now in a position where I may end up on the street corner holding a cardboard sign that says “Will Work for Health Insurance”.
My take on that is similar to my position about the draft-If you don't tax, draft, or kill people in America nobody will give a damn about any policy consequences (thanks-John Irving). Fine and dandy if you have good private insurance-but what if YOU lose your job and have a health problem? The baby boomers are getting older and not as healthy as they used to be, but they aren't stupid and can VOTE. George W.'s prospects in 2004 seem to be getting a litt more distant...........
Mitch
Posted by Dr. Bob on July 16, 2002, at 11:02:34
In reply to Insurance, Profitability, Utilization, Profiling, posted by fachad on July 15, 2002, at 11:08:36
> I saw some posts over at social babble on some insurance not covering Ambien, and I just felt the need to enlighten the board to the awful truth about health insurance...
A little enlightenment is fine, but I'd rather have discussion about insurance, etc., take place at Psycho-Social-Babble. Here's a link:
http://www.dr-bob.org/babble/social/20020714/msgs/26545.html
That way, this board can focus more on the medications themselves. Thanks,
Bob
PS: Follow-ups regarding posting policies should be redirected to Psycho-Babble Administration.
This is the end of the thread.
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