7 ms·

Another common misconception about medicare is that they won't deny tests or procedures that your physician deems medically necessary. Medicare can and does is

by nugget 7y ago

Another common misconception about medicare is that they won't deny tests or procedures that your physician deems medically necessary. Medicare can and does issue such denials. I worked next to a family medicine MD with a primarily medicare/medicaid patient panel and he would spend at least two hours per clinic day on the phone arguing with various counter parties about the medical necessity of certain orders he had submitted. He said it was by far the most frustrating part of his job. If you look at where CMS policy is headed, I would expect more care dictated by flow charts and algorithms and less autonomy in the hands of physicians.

disabled 7y ago
Yeah, if the Americans on here were smart, they would investigate things about their healthcare system further, especially when it comes to being on Medicare and retired. For that they should study the Kaiser Family Foundation's Website, backwards and forwards. One can end up in a situation where they need an extremely expensive, lifesaving medication, that subjects them to Medicare Part D catastrophic coverage levels. I have Medicare and if I lose my employer based insurance coverage through a family member, I will have to pay $50,000/year to stay alive. This is something I cannot afford as I am disabled. Not to mention, the third leading cause of death in the United States is preventable medical errors. If you do not believe me, then Google it. You can go to the absolute best institutions, hospitals, and doctors, but you cannot evade a statistic like that. It is way to pervasive. Our healthcare system, along with is quality, are absolutely deplorable. But the good news is, most people on here are educated and are skilled workers. They can emigrate to other countries. I would recommend the European Union countries in general, but obviously Western Europe and Northern Europe are better. But, anywhere in the European Union really is a step up from American-style care. I am a European Union citizen. I am Croatian, besides being American. I am leaving the United States soon. I cannot wait to start a new life and adventure. I am tired of living in fear about my healthcare.
- nugget 7y ago
  In many areas of practice the US provides some of the best care in the world. Places like MD Anderson in Houston and Sloan in NYC attract sick people from all over the world for a reason. It's fair to credit these institutions for what they do well. >you cannot evade a statistic like that The best advice I tell people is to make sure you have a patient advocate (family member or friend) with you 24/7 when you are hospitalized aka "in the system". I stayed with a friend for a one week hospitalization and witnessed multiple preventable medical errors that could have resulted in intubation and admission to the ICU (and perhaps death). I had to physically intervene to prevent the administration of a contraindicated drug which my friend had explicitly declined. I had to diagnose and fix faulty bedside telemetry myself. I had to retrain the CNAs on how to accurately collect sublingual temperature readings. The entire experience was quite eye opening. I've never spent time in a hospital in Europe but I would be surprised if the benefit of an advocate was not somewhat universal.
  - disabled 7y ago
    I agree with you on this 100%. You do absolutely need somebody with you in the hospital 24/7, as a lot of things happen that should not. This is unquestionably true in the United States. However, everybody should have a friend or family member with them at the hospital 24/7, anywhere in the world. While what you said is absolutely true, there are serious breaks in continuity of care that allow for these things to happen too. Not having a true standardized health record (versus something that is effectively a billing machine) that can be accessed anywhere, by healthcare professionals, and without obstacles is extremely disastrous. This needs to be studied more. What I am trying to say is that staying in the hospital 24/7 as an advocate may be a necessary and needed remedy, besides being something that should be necessary in general. But only works as a remedy in the most basic sense.
    - sizzle 7y ago
      I wish there was a tech solution to having oversight on the mistakes of the hospital care team. Maybe the patient can wear a sort of body cam over the bed to police the care team staff and have some machine learning algorithm develop a confidence score on their technique in administering correct medications (or catching incorrect medication or dosage pre-administration), verifying time spent since last time patient was checked and quality of care spent when they did check on patient (if they need to be changed, are they comfortable, do they need to be adjusted to avoid pressure sores, etc), policing them when not sanitizing hands or covering face to avoid infecting immunocompromised patient, policing physicians to see if they actually checked on patients and if they are charting procedures to bill insurance that they never performed or "upcoding" to extract more insurance $$$ etc etc. I have a background in the sciences and was premed myself, so I am familiar with the medical field (completed premed coursework to attend medical school + know the process for becoming a board certified and practicing physician) and am passionate about healthcare and human centered design (have years of doing great UX work in tech and pharmaceutical companies). Contact info is in bio. Would love to talk to anyone else interested in this to get something going and working on solving these problems. My dad had a hemorrhagic stroke and I'm bedside every night and passionate about making sure his care team does their job and prolongs his life so we can get out of the hospital and on he road to recovery. I would love to scale this up to patients in hospital beds globally and save lives from avoidable medical care mistakes and oversight!!
- refurb 7y ago
  The EU countries are generally much less likely to pay for a new, expensive drug than the US is. And even if they do, it typically takes 1-2 years after it’s approved before they’ll pay. Yes the US system is terrible and expensive, but one reason it’s expensive is because it’s rare for them to say “no”.
  - disabled 7y ago
    > The EU countries are generally much less likely to pay for a new, expensive drug than the US is. > And even if they do, it typically takes 1-2 years after it’s approved before they’ll pay. This statement is very untrue for Germany. Germany brings medications to market typically very quickly after approval. This is especially true in the realm of rare diseases (which are common: 6-8% of the general population has one) where access to these medications is often a life or death matter. There has been research on stuff like this. I would look in to it if I were you before making assumptions. There are also other countries in the EU that do well with this.
    - refurb 7y ago
      The GBA in Germany does an assessment before making a reimbursement decision. That process takes 6-24 months after approval. In the US, drugs are typically reimbursed the day after approval (though it can take a few weeks for manual approval). And because the process is so onerous and the GBA fights on price, some drug companies are choosing not to launch in Germany.[1] [1] http://www.pharmafile.com/news/166284/boehringer-lilly-wont-launch-trajenta-germany http://www.pharmafile.com/news/166284/boehringer-lilly-wont-...
      - disabled 7y ago
        Wrong. This is unbelievably wrong. Please stop spreading false information. Also, check your sources. A "brought to you by big pharma" article, from a website about big pharma news, let alone about an isolated case, is likely to be extremely biased. First, these medications are absolutely never reimbursed the day after approval in the United States. If you get a prescription for a medication the day after approval from your doctor, the insurance company will almost certainly (practically a 99% chance) call the medication "experimental" and "not medically necessary", and deny all coverage of the medication. You will have to appeal the denial, and you will be extremely lucky if you do get approval to take this medicine. To do so, you have to write an extremely detailed letter, very cohesive and without any sort of mistakes that give it any uncertainty. You basically have to tell them that you will either cost more to them than the cost of the drug, if it is not approved by them, or die. If you are "extremely lucky" your insurance is (almost) guaranteed to send your doctor a prior authorization request. This takes weeks to resolve, if not months. This is basically a request so that a a bureaucrat from an insurance company can "give you permission" to take this medicine. If you are "lucky" it gets approved. There are people who are denied approval just because they have another condition (that is off-label) in addition to the FDA-approved condition that the drug was approved for, just because this was affirmed in a check box in the prior authorization. It is straight up incompetency. Also, doctors reviewing any sort of appeal or prior authorization are practically guaranteed to be practicing medicine in a board-certified field that is completely irrelevant to the condition you have. They can also deny you the recently approved medicine because they require you to do step-therapy first, and sequestering this medication as not being an option for a very long time. This means that you must try a cheaper and less-effective medicine first, putting you at risk of having your condition worsen in potentially devastating and irreversible ways, before being able to try more effective medicines. So, patients with devastating conditions like multiple sclerosis will often have to go through a series of trials of less effective medications, often with their conditions worsening in an irreversible way, just because their insurance says so. There is no way to legally get around this in the United States as a patient. To top this off, more than likely, the medication will not be put on the formulary. Pretty much all insurance companies in the US subject their subscribers to a formulary. A formulary means that you cannot take certain medications under any conditions, and the health insurance company will not cover the medication under any conditions whatsoever. It will absolutely be denied, no matter what. There are tons of medications that have legitimate medical uses, that are excluded from insurance plan coverage, even in the case when there is no alternative for it. Between automatic denials, prior authorizations, step therapy, and formulary exclusions, which are standard practice in the United States, it is guaranteed that one will not get the needed, recently FDA-approved medication, for months at best, but in reality, it could be several years, or even never. They do let people die in life or death situations all the time. Regarding Germany: By the way, orphan drugs (rare disease drugs) dominate current regulatory approvals, being the vast majority of current drug approvals. These medications typically cost hundreds of thousands of dollars per year, if not millions per year, now in the United States. This is not the list price of the medication or the amount that was billed to insurance either. This is the reimbursement rate by insurance, that is paid under contract. Countries like Germany have no issue paying for them, and they are reimbursed much quickly than you claim. https://www.sciencedirect.com/science/article/pii/S109830151830189X https://www.sciencedirect.com/science/article/pii/S109830151...
mnm1 7y ago
So exactly like private insurance but without a profit motive.

by nugget 7y ago

disabled 7y ago

Yeah, if the Americans on here were smart, they would investigate things about their healthcare system further, especially when it comes to being on Medicare and retired. For that they should study the Kaiser Family Foundation's Website, backwards and forwards. One can end up in a situation where they need an extremely expensive, lifesaving medication, that subjects them to Medicare Part D catastrophic coverage levels. I have Medicare and if I lose my employer based insurance coverage through a family member, I will have to pay $50,000/year to stay alive. This is something I cannot afford as I am disabled. Not to mention, the third leading cause of death in the United States is preventable medical errors. If you do not believe me, then Google it. You can go to the absolute best institutions, hospitals, and doctors, but you cannot evade a statistic like that. It is way to pervasive. Our healthcare system, along with is quality, are absolutely deplorable. But the good news is, most people on here are educated and are skilled workers. They can emigrate to other countries. I would recommend the European Union countries in general, but obviously Western Europe and Northern Europe are better. But, anywhere in the European Union really is a step up from American-style care. I am a European Union citizen. I am Croatian, besides being American. I am leaving the United States soon. I cannot wait to start a new life and adventure. I am tired of living in fear about my healthcare.

nugget 7y ago
In many areas of practice the US provides some of the best care in the world. Places like MD Anderson in Houston and Sloan in NYC attract sick people from all over the world for a reason. It's fair to credit these institutions for what they do well. >you cannot evade a statistic like that The best advice I tell people is to make sure you have a patient advocate (family member or friend) with you 24/7 when you are hospitalized aka "in the system". I stayed with a friend for a one week hospitalization and witnessed multiple preventable medical errors that could have resulted in intubation and admission to the ICU (and perhaps death). I had to physically intervene to prevent the administration of a contraindicated drug which my friend had explicitly declined. I had to diagnose and fix faulty bedside telemetry myself. I had to retrain the CNAs on how to accurately collect sublingual temperature readings. The entire experience was quite eye opening. I've never spent time in a hospital in Europe but I would be surprised if the benefit of an advocate was not somewhat universal.
- disabled 7y ago
  I agree with you on this 100%. You do absolutely need somebody with you in the hospital 24/7, as a lot of things happen that should not. This is unquestionably true in the United States. However, everybody should have a friend or family member with them at the hospital 24/7, anywhere in the world. While what you said is absolutely true, there are serious breaks in continuity of care that allow for these things to happen too. Not having a true standardized health record (versus something that is effectively a billing machine) that can be accessed anywhere, by healthcare professionals, and without obstacles is extremely disastrous. This needs to be studied more. What I am trying to say is that staying in the hospital 24/7 as an advocate may be a necessary and needed remedy, besides being something that should be necessary in general. But only works as a remedy in the most basic sense.
  - sizzle 7y ago
    I wish there was a tech solution to having oversight on the mistakes of the hospital care team. Maybe the patient can wear a sort of body cam over the bed to police the care team staff and have some machine learning algorithm develop a confidence score on their technique in administering correct medications (or catching incorrect medication or dosage pre-administration), verifying time spent since last time patient was checked and quality of care spent when they did check on patient (if they need to be changed, are they comfortable, do they need to be adjusted to avoid pressure sores, etc), policing them when not sanitizing hands or covering face to avoid infecting immunocompromised patient, policing physicians to see if they actually checked on patients and if they are charting procedures to bill insurance that they never performed or "upcoding" to extract more insurance $$$ etc etc. I have a background in the sciences and was premed myself, so I am familiar with the medical field (completed premed coursework to attend medical school + know the process for becoming a board certified and practicing physician) and am passionate about healthcare and human centered design (have years of doing great UX work in tech and pharmaceutical companies). Contact info is in bio. Would love to talk to anyone else interested in this to get something going and working on solving these problems. My dad had a hemorrhagic stroke and I'm bedside every night and passionate about making sure his care team does their job and prolongs his life so we can get out of the hospital and on he road to recovery. I would love to scale this up to patients in hospital beds globally and save lives from avoidable medical care mistakes and oversight!!
refurb 7y ago
The EU countries are generally much less likely to pay for a new, expensive drug than the US is. And even if they do, it typically takes 1-2 years after it’s approved before they’ll pay. Yes the US system is terrible and expensive, but one reason it’s expensive is because it’s rare for them to say “no”.
- disabled 7y ago
  > The EU countries are generally much less likely to pay for a new, expensive drug than the US is. > And even if they do, it typically takes 1-2 years after it’s approved before they’ll pay. This statement is very untrue for Germany. Germany brings medications to market typically very quickly after approval. This is especially true in the realm of rare diseases (which are common: 6-8% of the general population has one) where access to these medications is often a life or death matter. There has been research on stuff like this. I would look in to it if I were you before making assumptions. There are also other countries in the EU that do well with this.
  - refurb 7y ago
    The GBA in Germany does an assessment before making a reimbursement decision. That process takes 6-24 months after approval. In the US, drugs are typically reimbursed the day after approval (though it can take a few weeks for manual approval). And because the process is so onerous and the GBA fights on price, some drug companies are choosing not to launch in Germany.[1] [1] http://www.pharmafile.com/news/166284/boehringer-lilly-wont-launch-trajenta-germany http://www.pharmafile.com/news/166284/boehringer-lilly-wont-...
    - disabled 7y ago
      Wrong. This is unbelievably wrong. Please stop spreading false information. Also, check your sources. A "brought to you by big pharma" article, from a website about big pharma news, let alone about an isolated case, is likely to be extremely biased. First, these medications are absolutely never reimbursed the day after approval in the United States. If you get a prescription for a medication the day after approval from your doctor, the insurance company will almost certainly (practically a 99% chance) call the medication "experimental" and "not medically necessary", and deny all coverage of the medication. You will have to appeal the denial, and you will be extremely lucky if you do get approval to take this medicine. To do so, you have to write an extremely detailed letter, very cohesive and without any sort of mistakes that give it any uncertainty. You basically have to tell them that you will either cost more to them than the cost of the drug, if it is not approved by them, or die. If you are "extremely lucky" your insurance is (almost) guaranteed to send your doctor a prior authorization request. This takes weeks to resolve, if not months. This is basically a request so that a a bureaucrat from an insurance company can "give you permission" to take this medicine. If you are "lucky" it gets approved. There are people who are denied approval just because they have another condition (that is off-label) in addition to the FDA-approved condition that the drug was approved for, just because this was affirmed in a check box in the prior authorization. It is straight up incompetency. Also, doctors reviewing any sort of appeal or prior authorization are practically guaranteed to be practicing medicine in a board-certified field that is completely irrelevant to the condition you have. They can also deny you the recently approved medicine because they require you to do step-therapy first, and sequestering this medication as not being an option for a very long time. This means that you must try a cheaper and less-effective medicine first, putting you at risk of having your condition worsen in potentially devastating and irreversible ways, before being able to try more effective medicines. So, patients with devastating conditions like multiple sclerosis will often have to go through a series of trials of less effective medications, often with their conditions worsening in an irreversible way, just because their insurance says so. There is no way to legally get around this in the United States as a patient. To top this off, more than likely, the medication will not be put on the formulary. Pretty much all insurance companies in the US subject their subscribers to a formulary. A formulary means that you cannot take certain medications under any conditions, and the health insurance company will not cover the medication under any conditions whatsoever. It will absolutely be denied, no matter what. There are tons of medications that have legitimate medical uses, that are excluded from insurance plan coverage, even in the case when there is no alternative for it. Between automatic denials, prior authorizations, step therapy, and formulary exclusions, which are standard practice in the United States, it is guaranteed that one will not get the needed, recently FDA-approved medication, for months at best, but in reality, it could be several years, or even never. They do let people die in life or death situations all the time. Regarding Germany: By the way, orphan drugs (rare disease drugs) dominate current regulatory approvals, being the vast majority of current drug approvals. These medications typically cost hundreds of thousands of dollars per year, if not millions per year, now in the United States. This is not the list price of the medication or the amount that was billed to insurance either. This is the reimbursement rate by insurance, that is paid under contract. Countries like Germany have no issue paying for them, and they are reimbursed much quickly than you claim. https://www.sciencedirect.com/science/article/pii/S109830151830189X https://www.sciencedirect.com/science/article/pii/S109830151...

mnm1 7y ago

So exactly like private insurance but without a profit motive.