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Health care changes are coming soon (realize your options & scenarios)

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Posted 10/25/2013 3:46 PM (GMT 0)
Do your  homework since we cannot discuss much herein without thread locks or removed posts.  Change happens.....  (my sympathy for all patients).

 

Posted 10/25/2013 4:22 PM (GMT 0)
Z:

Funny you should post this. I just got an email from my employer, sent to all of us who have healthcare benefits.

It is rather lengthy, but here is one part. I've put XXX in place of the name of the plan.

They have not identified which drugs are specialty drugs and which drugs are biological drugs. I would assume for PC folks, Provenge would be a biological drug. I know I got a big hassle when I first tried to order Casodex (generic). They finally approved it after Dr. Scholz sent in an appeal. Oddly enough, my cost was $10 for a 3-month supply! I suspect many of our drugs are at least specialty drugs. I get a Lupron shot at the doctor's office and apparently that does not come under the prescription drug plan. So far, so good on that. They pay about 80%-90% on that.

I might add that I don't mind the increased cost if it does mean that those who lack insurance can now get insurance. I usually express this sentiment in much stronger language, entailing terms like "national disgrace," but I don't want to get too political here, given our rules. Of course, I have no idea how much is the increased cost! The fact that they are talking about getting help from the drug companies implies that the increased cost will be substantial ("very high," as they say)

>>>>>>>>>>>>>>>>>>>

  • Adding a Prescription Drug CoPay Tier
    A copay tier will be added to the prescription drug plan for biological/specialty medications.
    • The current plan requires pre-authorization for all specialty drugs by XXX  Medical Management prior to being filled at the pharmacy.
    • The copay for biological/specialty medications will vary depending upon the specialty drug and will likely be very high, but Copay Assistance programs are available from drug manufacturers to decrease the true out of pocket cost per 30 day prescription.
    • XXX Pharmacy Management will notify and provide each member currently taking a biological/specialty drug with instructions on how to apply for the Copay Assistance program.

    • >>>>>>>>>>>>>>>>>>>>>>>

    Mel

    Posted 10/26/2013 1:50 AM (GMT 0)
    There are a number of patient care quality provisions in the ACA that I'm excited about.

    It has set up the Patient-Centered Outcomes Research Institute (PCORI). Its goal is to promote comparative effectiveness research through improvements in “healthcare delivery and outcomes, by producing and promoting high-integrity, evidence-based information that comes from research guided by patients, caregivers, and the broader healthcare community.”

    The Patient-Centered Outcomes Research Institute — Promoting Better Information, Decisions, and Health

    It also sets up the National Quality Forum (NQF), whose mission is to improve healthcare quality by generating consensus on national healthcare priorities, advocating performance improvements, creating quality measures, and promoting goals through education and outreach.

    What is exciting about all these new measurements is that patient-centered quality performance by doctors and institutions will become publicly available. They will use the Physician Compare Website to give the public access to this quality performance information, including patient ratings, treatment efficacy, safety, and outcomes.

    For Medicare, the plan is to tie physician incentives and disincentives to performance. The Physician Quality Reporting Initiative (PQRI) gives financial inducements for physicians to report their quality data and penalties for those who do not. In 2016 there will be trial programs that enact strict pay-for-performance measures to specialized, free-standing cancer centers. If these measures prove effective in terms of enhanced quality and economic benefits, pay-for-performance may be rolled out more widely in 2018.

    I think this will change the way we choose our doctors, and encourage all doctors to lift their game.

    - Allen
    Posted 10/26/2013 2:11 AM (GMT 0)
    Or it  may just be a lot of superfluous bureaucracy concealed behind an abundance of inflated rhetoric, replacing time that should be devoted to patient care with more and more layers of paperwork.  OK, so I'm cynical, but I tend to distrust just about anything that can't describe itself in simpler terms.
    Posted 10/26/2013 2:17 AM (GMT 0)
    TA,

    I do not think that the creation of two more government agencies will encourage doctors to "lift their game". I do think if they were offered financial incentives they might consider lifting their game ... I know I would.
    Posted 10/26/2013 2:49 AM (GMT 0)
    That's exactly the point. By creating metrics that any patient can access, good doctors will gain patients, poor doctors will lose patients. There's a lot of financial incentive in that.

    These aren't government agencies. PCORI is a nonprofit, independent entity of 19 stakeholders representing various health care interests. The governors are people like the dean of the UCLA Medical Center, the Chief Medical Officer of Pfizer, the Chair of Health Policy at Harvard, and the NIH Director. NQF is divided into Councils representing consumers, health plans, health professionals, hospitals/providers, community health agencies, suppliers/industry, purchasers,and a quality measurement, research and improvement council.There are about 400 member organizations including the AUA, AMA, Johns Hopkins, Memorial Sloan Kettering, Mayo Clinic, AARP, Blue Cross/Blue Shield, GlaxoSmithKline, VHA, etc. I think that getting all these entities collaborating is a great idea.

    - Allen
    Posted 10/26/2013 3:02 AM (GMT 0)
    Allen, thanks for your view on this, agree with you on this.
    Posted 10/26/2013 4:32 AM (GMT 0)
    Alan,
    Unfortunately most of the good doctors already have all the patients they can handle. We will see a two tier level of service, those who have good insurance and those whose plans have only a select number of doctors who will accept that insurance. We are already seeing that limited choice in Medicaid.
    I agree with Zufus that we will see a lot of unintended consequences and there will be some winners along with a lot of losers that did not expect to lose what they had.
    Posted 10/26/2013 4:51 AM (GMT 0)
    Is this another trick thread that I am not getting? Didn't understand your opening statement, zufus, but wanted to. Can you say it a different way for those of us thick as lead?

    david
    Posted 10/26/2013 4:54 AM (GMT 0)
    I don't post too often, but I have to agree the consequences are just beginning on this. Our insurance has again changed and now my Doctor is no longer in network, which is Dr Lam. Talk about my heart sinking. Plus the prescriptions are changing. The out of pocket for not in network is cost prohibited.
    Posted 10/26/2013 5:11 AM (GMT 0)
    We just had numerous job loss at both local hospitals in my area....and from what I read its because of the new laws.....not to mention ecxcellus just dropped 22,000 patients on their Medicaid program...said they would be operating at a loss under Obamacare.....the childrens hospital was almost closed until the city fought and people stepped up to help with funding.

    the change Im seeing is not a positive one. Im lucky Ive got Tricare being retired military.....because I looked up a plan on the NY health net and the Obama care program would cost me about 800 bucks a month for a silver program....and Id have to pick up the other 30%....Not to mention a $12,000 deductible which Id be maxing out every year with what Im going thru.....so add another 1000 a month for a total of 1800 a month. Im just not seeing how this is so affordable. really don't think the program will work...people are starting to see the sticker shock.
    Posted 10/26/2013 5:23 AM (GMT 0)
    John,

    Unlike Medicaid, which restricts fees, the insurance exchanges only allow one to purchase existing health insurance plans. From the doctor's POV, my Anthem Blue Cross insurance reimburses him at whatever rate they negotiated, irrespective of the way I got into the plan.

    I think you raise a good point, however, about the supply of good doctors relative to the increased demand. I think most of the shift will be from the ER, where the uninsured go now, to primary care physicians, which is more appropriate. I doubt the load on the doctors we most often seek will grow substantially -- most of the newly insured will be younger and less likely to get PC. There may be some greater wait time to get an appointment with my urologist, but I doubt it will be intolerable.

    Those quality metrics will help our doctors get smarter about treatments (e.g., increased shared decision making about AS in appropriate cases, greater use of brachytherapy and hypofractionated radiation protocols, etc.).

    - Allen
    Posted 10/26/2013 6:00 AM (GMT 0)
    We just received our open enrollment for 2014.

    Deductibles up 50%. Employee contribution up 22%. Overall coverage reduced. I also am categorized as a "Luxury" program. So it's taxable.

    Nice.

    This thread won't last. No fault to our mods....

    Tony
    Posted 10/26/2013 6:03 AM (GMT 0)
    I just had to let go a nice lady in my office. Her biggest concern was health coverage for her family of 4. Her husband has been struggling since the economy started tanking in 2007. I just ran the numbers for her and she would need to pay $3000 a year based on what I believe her and her husband will make per year (I'll still send her some consultant work). I'm sure that is a huge relief for her.

    The plan wouldn't make sense for me, in fact, I wouldn't even qualify, but then again it wasn't intended for me. It was a moral obligation to the 40 or so million Americans who needed it.
    Posted 10/26/2013 6:21 AM (GMT 0)
    Tony, that's an assumption at this point, albeit quite a reliable one, and we have some governors to thank for it without getting into further details.

    Tony this was in response to your now deleted post about the 30 million...

    Post Edited (davidg) : 10/26/2013 12:28:23 AM (GMT-6)

    Posted 10/26/2013 11:56 AM (GMT 0)
    TA,

    I agree that good doctors will gain more patients; however, as we are seeing with Medicare and family doctors, the good ones drop out of the system ... they refuse to accept Medicare.

    For example, currently I can not get care from the family care clinic within 1/4 mile from my house, they do not take Medicare. However, because the University of Colorado accepts federal funds, they must take Medicare so I drive across town to see them.

    Another example, many psychiatrists in Colorado are refusing to take any insurance ... they work on a cash only basis.

    I am afraid this trend will only increase. Metrics will have no impact, especially if there is a shortage of doctors and doctors opt out of the systems. It's economics, supply and demand ..... If the demand for doctors exceeds supply the prices (doctors fees) will go up.

    Post Edited (RCS) : 10/26/2013 6:55:43 AM (GMT-6)

    Posted 10/26/2013 12:56 PM (GMT 0)
    Our long time group insurer dropped the state employees (wife is school principal) coverage, so we have to change carriers, and the plans are not the same. Out of pocket upfront went from $1000, to 6,000 per person. Cost of all plans are 38% more than previous year.

    The previous insurance carrier were great after my diagnosis. Patient advocate from them called several times to check on status, she informed me that they would pay for airline tickets, hotel and travel expense to any of the NCI cancer centers, didn't know that until they informed me.

    The state had this new carrier 15 years ago and it was a nightmare.
    Posted 10/26/2013 1:22 PM (GMT 0)
    My R. N. wife works at the county health department's general clinic. For decades, they have been providing routine healthcare to low income families and public aid patients here in the county for just a $10 copay for each visit for most, and for free to the public aid folks. They are a Federally Qualified Health Center (FQHC).

    They also serve our enormous illegal immigrant population, providing essentially free medical care to the "undocumented" at taxpayer expense. Probably 80 percent of their clientele fall into this population, though the number is hard to pin down since they are absolutely prohibited from enquiring about citizen status.

    Now, with the ACA, their funding is to be cut by 70 percent, and it's unclear whether they will be able to treat people enrolled under the ACA. Also, the new director has indicated that he intends to get rid of the doctors, replacing them with PA's, and also get rid of the nurses, replacing them with nursing assistants.

    Meanwhile, if the low income folks enroll in a Bronze plan, they'll be paying deductibles of 6K and copays of 40 percent, if they can find a doctor who will take them on as patients.

    How is this an improvement for these people? More unintended consequences you might say. Better patient care? I'll believe it when I see it.













    More of the "unintended consequences" you might say, and one more sign of the huge quantity of smoke being blown up our a*****.
    Posted 10/26/2013 1:32 PM (GMT 0)
    why would they have to go with the bronze plan? what's wrong with the silver one?

    The plan is designed to help millions upon millions of people in need. The scope is infinitely bigger than the one example you provide.

    as per taxpayer money, everyone was aware of that and voted accordingly not once, but twice.
    Posted 10/26/2013 1:44 PM (GMT 0)
    Davidg....do you truly believe people voted for that?  That most had even the slightest comprehension of what was coming down the pike?  Only now are people learning details about it, and if you were to query the man on the street you still would find widespread ignorance.  I've never bought the argument that the people voted for this.  They voted for a candidate, not a plan.  If you were to take a poll, I think you'd find that many thought they were going to get free health insurance, and free health care.

    Less is wrong with the silver plan, but even with a subsidy that's a significantly greater expense for people who often can't afford to pay the mortgage right now.

    I have six siblings, most of whom live in upper middle class neighborhoods.  Their "take" on social issues is often very different from mine.  I'm pretty sure it's because my wife and I still live in the starter home we bough 35 years ago in a lower income neighborhood with every conceivable ethnic group represented.  It's a different perspective.

     

    Post Edited (clocknut) : 10/26/2013 7:48:45 AM (GMT-6)

    Posted 10/26/2013 1:50 PM (GMT 0)
    I look forward to at least being able to purchase any insurance. When I was employed our insurance premiums went up each year and deductibles increased. None of it due to ACA but to the medical market place. All you need to do is look at the trend in medical costs and it has nothing  to do with insurance or the lack thereof.

    I have been turned down on health insurance for the last six years. One plan was a 40% copay with premium of $10,000 per year and did not cover any pre existing conditions. So far, after the initial outlay of close to $100,000 in failed treatments the yearly costs have been around $6,000. A lot less than insurance.

    Now, access to doctors. I have been turned down by local practice after telling them I was self pay. Asked why my money was less acceptable than insurance. I pay up front when I walk in the door. Med oncologist keeps trying to pass me off to a local cancer clinic and so far has refused to set up an appointment. Reason... self pay. Hospital refused to provide accurate cost data on brochoscopy. Gave me a range of $1500 to $16,000. The lower is pay in advance and take your chances on the higher end. Still waiting on pulmunologist to decide on needle biopsy in lieu of bronchoscopy. He loses out on that option and it is lower cost all around.

    I intend to purchase a gold plan as it closely approximates the plan I had while working. I personally believe this will be a gold mine for the medical profession who claim to lose billions for uncompensated care. The preventive aspects alone should reduce the load on emergency facilities. I see good things coming from this and do not anticipate the collapse of the medical industry in this country.

    Don

    Don

    Posted 10/26/2013 1:53 PM (GMT 0)
    Clock, this is veering on the political. Yes, I voted for this and yes, I think people were fed up with many aspects of our health coverage issues and what a great many people considered an immoral policy towards millions upon millions of poor people and thus voted for a candidate who said he would do something about it. Perhaps my view is conditioned by the fact that the people I talk to are in NYC and its suburbs. There are problems, some technical, some political, but I certainly wasn't expecting it to be a smooth transition.

    I know the woman I had to let go will find great relief in it because Cobra isn't a realistic option.
    Posted 10/26/2013 1:56 PM (GMT 0)
    Thanks Don. I've experienced the same problems you outline while being on the best plan my firm offers (total cost of plan around $27K per year). The system was rancid long before the ACA and that doesn't even include the millions of uninsured.
    Posted 10/26/2013 1:58 PM (GMT 0)
    Davidg, I don't want to see this discussion veer into the political, but we're learning more and more about what healthcare may look like in the future, and I would think we could talk about that without the bitterness and divisiveness that we've seen in Washington.  I hope you're right and that this turns out to be a good thing.  Time will tell, but if it turns out badly, it's going to be hard to put Humpty Dumpty back together again.
    Posted 10/26/2013 2:07 PM (GMT 0)
    Sure, I just wish the professional pundits and the bloggers and some politicians would stop trying to exploit the crisis for their own motives and help give this thing a fair shot.
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