Thanks, heebie! This is not my area of expertise so I'm hoping someone who knows more about it will point me in the right direction.
To answer 2., Medicare Advantage was being subsidized, and those subsidies are being phased out, so the business is less desirable.
Can she get by with medigap coverage and pay for dental and eye care out of pocket?
I have no idea why the problem would be county specific unless, possibly, the cost of medical care there was very high.
I'll take a look; I don't really know details here. In general, Advantage plans' rates are set administratively by a complex formula, with geographic adjustments, so theoretically something could have happened that affected Atlantic County disproportionately.
It wouldn't be the end of the world to be on traditional Medicare for a year, right? Has she figured out if her regular doctor would keep her as a patient on that basis?
Also, are we talking about Advantage alone (hospital and professional services), or is there also a Medigap or Part D component?
Dumb question, why isn't ordinary Medicare an option?
Unfortunately it does not appear that her regular doctor will keep her on that basis.
I know for sure there is a Part D component but I don't know about Medigap.
"I grow old ... I grow old ...
I shall face trouble staying Medicare enrolled."
2: I don't think those changes are driving plans out of the market in any general way, though. There are other ways plans make money through MA- rates are administratively risk-adjusted, and they're skilled at working out where the adjustment is excessive and targeting those populations. Also the risk factors are determined based on ongoing coding by providers, so upcoding pays off.
that her regular doctor will keep her on that basis
Deeply personally insensitive policy question here -- how big a deal is this, really, as long as she can see some doctor? Having to go to a non-preferred provider is something that comes up a lot in discussions of lousy insurance, and as a problem because insurance companies are going to shrink networks as a cost-cutting measure in response to Obamacare. People clearly care about this a great deal, or talk about it as if they did.
But is there much evidence that restricting doctor choices results in worse medical outcomes? Maybe there is, but it seems kind of unlikely, given that the vast majority of doctors are acceptably competent and the vast majority of patients wouldn't be able to tell if they weren't.
CHANGEBAD!
the vast majority of doctors are acceptably competent
This is so far removed from my experience that I don't have a response!
(my experience is probably not representative, I know)
9: This is an on and off discussion in our household because we will be in the position of "needing"* to change some doctors if the UPMC-Highmark battles ever get to where they are threatening to go. I stand accused by my wife as not giving a sufficent shit. In part because I don't think our current providers are all that great. To be fair, she is mostly pissed at 1) the hassle of changing, and 2) UPMC engaging in this behavior while being tax-exempt.
*In quotes because we could still see them at out-of-network rates.
Somebody is missing a real opportunity to move public opinion toward single payer by not running ads about how fucked up is it that two non-profits are fighting a TV ad war because one of them is trying to become a regional monopoly in health care.
"If UPMC isn't allowed to take over the Sudetenland, you won't be able to keep your current doctor."
This Medicare site seems pretty good at running down a list of options. It shows three medical+drug plans offering in Atlantic County: AmeriHealth, Horizon Medicare Blue Choice, and Aetna. All HMOs, so probably they mean a new doctor unless Horizon is some variant of BC/BS with the same network.
Count me as one who doesn't give a shit if I see a different doctor every time. Maybe if I was using a doctor to manage my chronic illness, I would care, but I actually prefer to manage my chronic illness without one.
15: Yes. And Horizon Blue does show (pdf) that what is almost surely the plan the person was in has been cancelled (Horizon Medicare Blue Access w/Rx Enhanced (HMO‐POS based on the 2013 price). The key change is that it does not look like they will offer any POS plan in New Jersey in 2014.
"Due to increasing health care costs and continued federal government cuts to Medicare Advantage, Horizon BCBSNJ had to discontinue certain MA plans, create new plans, and increase premiums, in order to continue to be the only carrier offering MA plans in all 21 counties of New Jersey," Vincz said. "We are working with all impacted MA members to help them understand their options, which include new Horizon MA plans, traditional Medicare paired with one of our Medicare Supplemental plans, or even other carriers' plans."
Thank you, Obamacare...
the vast majority of doctors are acceptably competent
I think this may be more true in a big city, and less true elsewhere.
17.last is somewhat facetious of course, but it is all part and parcel of the ACA becoming the overall framework of health insurance in the country. All of the pre-existing conditions become part of the ACA narrative.
... how fucked up is it that two non-profits are fighting a TV ad war ...
When I worked for a Blue Cross/Blue Shield affiliate, the party line was pretty adamant that we were a "not-for-profit", not a "non-profit". I was never clear on what the difference was.
To be fair, this was in defense of the tendency of local politicians to see the company's reserve fund as source of funding for their pet projects. Shakedowns for various "charitable donations" were a regular occurrence.
The whole system is rotten to the core.
"the vast majority of doctors are acceptably competent"
Yeah, it's not true here in Fuck Smith. We've found one doctor who is really competent, and she left the free clinic we (well, I) like to go to (because it's free, duh).
She's now at a clinic we can go to, but it costs us a $30 co-pay. Dr. Skull insists on going, because she is so much better than the incompetent hacks who stay at the free clinic.
I'm fine with the hacks, because I go in there know what I need and tell them to do it. But what if I didn't know?
I'm just being nosy here, but what makes you think they're meaningfully incompetent (rather than interpersonally annoying)? They've misdiagnosed or mistreated you or someone you know?
Even competent doctors are going to misdiagnose a great number of people.
I'm thinking back to my midwifery practice, which had five midwives, and I thought one of them was a clown. I got a test result back that meant a 1/66 chance of some birth defect, and she reported it to me as 1/6, and didn't seem to understand the difference when I finally saw the results on paper. That sort of thing?
IME there are three types of bad doctoring:
1 (most common): Bad fit. Doctor isn't responsive in seeing you, doesn't read/listen when they do, is judgmental or dismissive of your health concerns, or otherwise just doesn't have moderately decent interpersonal chemistry such that you have a baseline level of trust.
2. (less common): Special situation making change of doctors especially burdensome and dangerous. E.g. long and complex medical history; need for seamless communication between specialists in the same practice; extremely challenging situation requiring trustbuilding (eg person with severe developmental disabilities who took 3 years of visits to be comfortable with a Pap; abused child who is terrified of dentists).
3. (even less common): Outright bias or abuse by doctor toward "people like you".
I'm fortunate to have had relatively rare interactions with medical professionals, and I've witnessed all of the above -- the difference being that I am an UMC white native English speaker who has had uninterrupted private health insurance her whole life, in a major metro US area with some of the best healthcare in the world, so it hasn't affected me personally as much.
I care a lot about having to change doctors. I had a really hard time finding an OB who didn't promote liposuction and labiaplasty in their office. There are not many options in this town, and I can't drive into Austin or San Antonio easily on a weekday.
With the kids' check-ups, I wouldn't care as much - they're mostly on the vaccination schedule and wellness visits, and I assume that would be pretty consistent anywhere. We use walk-in med clinics a lot for everything else, (ie they get sent home from daycare with a rash or teary eye, and if we can get them into a med clinic that night, we can send them back the next day on ointment or eye drops.)
I was in a position to see traditional Medicare and a generous supplemental plan in action for an elderly person in the mid-oughts. It worked really well. In a New York City, all of this person's doctors took Medicare and it was not hard to find such a doctor.
Aside from the fact that the doctor of the person in the original post doesn't participate, what are the specific drawbacks now of traditional Medicare, compared to Medicare Advantage? Why not switch to what is essentially an indemnity plan? It seemed to give greater flexibility. Do NJ doctors not commonly take traditional Medicare?
26: I choose drs by seeing which of them was an undergrad humanities major. For real. Current OB/Gyn was a phil major at -- what does alameida call it? -- the University of Ravenclaw.
The insurance co. has a page with everyone's mini-cv! Like, "Speaks limited French and enjoys college hockey" or whatever.
3. (even less common): Outright bias or abuse by doctor toward "people like you".
Not that uncommon, I suspect. This American Prospect article includes the statistics that 13% of LGBT retirees have, "been denied healthcare or received inferior care because of their sexual orientation" and 20%, "do not disclose their sexual orientation to a physician for fear of discrimination."
The source cited is this report (pdf), which I haven't read.
My doctor sucks, his common diagnostic technique is to ask me what I think he should do about whatever problem I've come in for. But then it's also impossible to get an appointment with him and I haven't actually seen him in a few years, I get shunted to RNs or other more junior MDs at his practice. Maybe he's playing hard to get.
Aside from the fact that the doctor of the person in the original post doesn't participate, what are the specific drawbacks now of traditional Medicare, compared to Medicare Advantage? Why not switch to what is essentially an indemnity plan? It seemed to give greater flexibility. Do NJ doctors not commonly take traditional Medicare?
First, Advantage plans can make things more convenient by bundling together Plan D or Medigap.
Second, due to the subsidies, plans have often offered extra perks on top of regular benefits, like gym memberships. That may be on the way out.
Third, since there is someone there to coordinate, people with complex medical conditions could at least theoretically get better overall care by signing up with a plan that has all the specialists and PCPs communicating with each other. I think this occasionally happens in reality.
I was trying not to be a downer, Nick, but since you brought it up...yeah. "Even less common" sadly IME just means "less common than having bad chemistry with your doctor," not objectively uncommon overall.
I actually think it's weirdly like sexual harassment, in that IME the same doctor can behave utterly differently depending on the social class/background of the person s/he's treating. So just like the male co-worker who innocently (and truthfully!) says, "Tom is a great guy, I've never seen him harass anyone," you can have someone say "Dr. Jackson is terrific, he spent so much time and listened to everything I said," while meanwhile another patient he palpates an obvious abdominal tumor, looks contemptuously at her, and tells her to go home and stop eating so much.
I have a not-great fit with the doctor I see, but refuse to see the one in the practice who told me I'd be a better foster parent if I were Christian or at least had a religion. There's a fantastic doctor who saw me once at the after-hours clinic but he's not taking new patients while he focuses on addressing the local heroin problem, which is great in the big picture but disappointing for me. I like the girls' doctor and nurse practitioners very much.
meaningfully incompetent (rather than interpersonally annoying)
Misreading lab results, losing lab results, refusing to forward medical records to other doctors, refusing to provide interpreters, refusing to see me without an interpreter (that they failed to provide), making diagnoses without any testing and then overmedicating in dangerous ways, accidentally writing the wrong dosage on prescriptions, ignoring calls from pharmacists who are concerned about the abnormally high dosage on a prescription, etc.
I have the standard mathematician problem that I arrogantly assume I know more about other people's fields than the experts. This is a problem with doctors, as most doctors I meet with I feel like do a worse job than me+google. My rate of correct diagnosis is as good overall as doctors (e.g. there have been times when I was right the primary care doctor was wrong as later determined by a specialist). The few doctors where I've actually been impressed by their intelligence has made a difference for me. I really like doctors who say "Well, I don't think you have a brain tumor because x, y, z" and where I can see that they're really thinking rather than just jumping to the most common boring conclusion.
22: Basically what Witt said. The doctors at the free clinic are baseline okay, in that I doubt they've killed anyone with their incompetence.
But Dr. Skull (for instance) is Type II diabetic, and all they did was tell him to exercise and lose weight. (O rly? B/c we never thought of that!) Whereas super competent doctor who we have to pay for did research and found a medical regime that has helped him (Byetta) which has helped him lose weight, along with the exercise and diet.
And the kid has anxiety issues. All free clinic doc did -- after talking to her for literally two minutes -- was want to put her on anti-depression drugs. Super competent doctor interviewed her at length, and recommended diet changes, exercise, and meditation techniques, with a follow-up in a couple of months if that didn't help.
Free clinic doctors also tend to be way behind the curve on any medical research and kind of judgmental toward poor patients.
But yeah, as long as I go in there knowing what the problem is and don't expect them to have to think, they're fine.
Minivet, can you give more information about the kind of free/near-free clinic I take my girls to? Our experience is totally different from delagar's, and I'm actually sort of an evangelist to other foster parents because the people working there all understand issues that are common in poor families and I think the diagnoses and health planning are better because of that than what they got from the suburban practices that their previous foster families took them to. (In almost all cases, the practice we use is also where the parents or relatives took the children before they went into care, so we're even able to get continuity of medical records and in some cases have been able to talk to a doctor or nurse who remembered the child from before, which is hugely helpful information.)
I believe ours is a federally qualified health center but I honestly don't know a ton about what that entails. Our local org has a specific clinic for homeless people and doesn't process private insurance, so essentially everyone who goes is either uninsured with free/sliding-scale rates or on Medicaid or sometimes Medicare. I have no idea how that will change once the ACA rolls out, actually, and should probably look into that even though it doesn't impact us.
Oh, and each time a child has a doctor's visit, the child is allowed to select a new book to take home, which is great. We've had some beloved favorites we found there.
So a couple of years ago I went to my doctor's office and saw her RNP for a minor thing that had been bothering me (excercise-induced breathing trouble). She hmm'd a bit, sent me for a lung function test and prescribed an inhaler to try out. She might or might not have left me a message when the test results arrived; I never called back to find out what happened. How crazy is it to call them and say "so, that thing we were looking at two years ago? Still exists. Did we learn anything?"
They're legally obligated to keep your records around for much longer than two years. No reason not to call.
I forgot also to mention that there are some programs that help low-income seniors with Medicare cost-sharing, even if they aren't low-income enough to qualify for Medicaid. Those are described here but administered by the states rather than CMS.
It might be worth your friend looking into it even if it seems at a glance that she'd be above the income limit, because I'm not sure if SSI income is counted toward the limit.
I don't know enough about free clinics or FQHCs to bridge the gap between your and delagar's experience, Thorn, but I suspect the experience is going to vary a lot - being a free clinic does not per se make it bad. In some cases they'll have cultural and linguistic competence working with low-income people that the average doctor's office wouldn't.
One of the systematic problems I do know about is that FQs get specially high rates in Medicare and Medicaid as a quasi-subsidy, but those rates are per visit and it has to be a face-to-face visit, so they're incentivized to get through as many visits as possible (in some cases literally, via bonus structures for doctors and midlevels), and it doesn't pay to try to move to better modes like telephone or email consultations for simple stuff.
told me I'd be a better foster parent if I were Christian or at least had a religion
Oh my god, would a doctor regret telling me that. I wouldn't have to refuse to see him; I'd pretty sure he'd refuse to deal with me.
(And I'd only be confirming his prejudices, of course, but nevertheless.)
My parents have had some experiences similar to delagar's 38: sloppy doctors who would make a quick diagnosis without gathering all the relevant information. In those cases, competent doctoring would have simply meant putting in more time and effort.
This is all anecdotal, but I get the impression that a general practitioner (or a general surgeon) has a wide range of skills, but is likely to do any given thing about 70% right. Which is in fact good enough most of the time, but not always. If you have a complicated case, or some kind of chronic illness, then you probably need it done 90% right, and for that you need to see a specialist.
Speaking of Healthcare, Rude Pundit has the most essential read on the rollout. And not even rude or profane so you can use it on skeptics you know (it's constructed quite well for that very purpose).
48: Her, actually, and she's a Pakistani immigrant, so it was really not the response I expexted.
My secondhand experience with free/FQHC doctors is all over the map. Some are great, some are terrible, and some are probably middling doctors if you tested them in isolation, but better than average at treating/recognizing certain issues because they see them so much more often than a fancy doctor would.
I appreciate the ideas and links from Minivet and everyone!
Even just conceptually, it's hard to diagnoses a diagnostician.
My PCP is kick ass. I chose her, because she had training in integrative/alternative stuff, but is totally science-based and had good published articles. Also, she's totally respectful and recognizes the need for an advocate in an ER and treats me well despite a history of mental health issues.
I used to see supervised med students a lot for my physicals. Some were great, others not so much, but I always saw her in the end. If I need to go in on a day that she's not in the clinic, I'll see someone else--maybe one of her fellows or an NP who works with her or maybe just whatever random doctor is there. They aren't usually as willing to tell me why they recommend something. Luckily, the hospital I go to is mid-tier in price and not likely to be dropped by my insurance.
On the I think I'd have a nervous breakdown if I lost my psychiatrist. He doesn't take my insurance, and I'm not sure what and where he does, i.e. if he takes it at a clinic (probably--cause I think he sees some people in a state clinic). Most of his income must come from his research activities, and, even though I pay him out-of-pocket, he's essentially seeing me pro bono.
7 years of history means a lot.
My parents had to change to become part of a coordinated care team, but it's been awesome for them--even if they grumble, and some of the new ICOs and SCOs with contracted providers and their own NPs for home visits are totally fabulous even though they restrict doctors, i.e. to ones who keep records of things like A1Cs and are willing to spend time coordinating care, for which they pay.
On the other hand, the community health clinic which has traditionally served the LGBT community is excellent and gets a lot of money from well-off people. Worth going to even if you're not LGBT. They stopped doing free flu clinics though when almost everyone got insurance and the DPH started focusing their vaccination efforts (i.e. free vaccine) on children.
50: That is a good read, but it's still kind of disappointing. The roll-out of the original Medicare was, apparently, quite smooth.
56.last: Well it was much more phased and slow. Was also viewed as rocky at the time and included many hospitals not participating in the usual suspect areas because it would require treating blacks.
Much of the discussion in this thread (as well as the larger "discussion" going in the country) is really about the degree of tiering within the current medial delivery system, and to what the deisrable target should be. "Good" health care is viewed (probably appropriately) as a scarce resource and want to be able to use their personal monetary and social capital resources to obtain their "due". It is not an easy problem, and to some extents we are all bozos on this bus (see also education).
And then I found a $5,000 list price medical procedure.
Overheard on Metro: "My parents worked SO hard to find jobs with health insurance. And it annoys me that now, like, anyone can get it."
Our insurance costs are rising dramatically this year, and being passed onto employees at Heebie U. I can't really figure out what the hell is going on. Our co-pays and deductibles are going up several times over.
That's floating in the air as an unspoken ominous cause, but I can't nail down the mechanism. I did off-blog ask Kermie about it, and he said there's nothing obvious that would be driving up our rates.
Your employer is probably cutting their contribution figuring people will blame Obamacare.
Our impact was mostly changes in deductibles and co-pays as well, rather than the top-line contribution. But not that dramatic. The long-term trend of the "Basic" becoming more attractive than the "Comprehensive" that we generally get also continued. In fact this year we probably should have switched to the Basic--it definitely wins for us for a completely unexceptional health year.
I don't think 63 is quite it. My two explanations are either:
1. the self-funded group we're in just coincidentally ran up really high health care costs last year, and is having to pay it down this year, or:
2. someone in the administration is projecting that ACA will make rates skyrocket, and everyone genuinely believes these predictions, and is responding accordingly.
Our president is constantly reminding us at faculty meetings that NO increases in health care costs are being passed on to ANY employees and we should all be a lot more thankful for that than we seem. (usually he brings this up in the context of how critically underpaid so many staff are, and how they are getting all kinds of secret hidden prizes that they don't remember to think about. I guess it might be true, but we should probably be paying the secretaries more than $18,000/year anyway).
65: Right, it is tempting to ascribe these things directly to immediate things like the ACA, but we, for instance, have had much more significant increases in the past. Usually do to changes in underlying contracts, demographics and recent performance etc. (as well as conscious attempts to move compensation percentiles, or change who you are benchmarking against.) It's all just one more arrow in the management quiver.
Can I blame Obamacare for the British energy companies putting their prices up by 10%? It makes as much sense as the rest of this shit.
Gas is under $3 here. I guess that's good?
68: but you're getting a new nuclear power station, so it'll all be good in the long run!
Gallon. It's like $3.50 here, but PA's oil is long gone.
A gallon is like four liters, but different in some way I can't remember.
£5.00 an American gallon here and it's just come down to that. The people who are adding 10% are the electricity and heating gas thieves.
Per American gallon. In UK terms, I understand that's eight firkins and a gill.
Dead thread, but this is too perfect:
The House Energy and Commerce Committee asked John McAfee, the tech security guru who went on the lam in Central America last year under suspicion of murder, to examine the troubled rollout of Obamacare's online insurance website, according to CNBC.
77: that's the stupidest thing ever, as a matter of fact.
That fucker cost me a hard drive, indirectly.
GPs are often hopeless in the UK, too. I think the issue is that it's a speciality for mediocrities that still attracts the authority of Doctor. I'd reduce the numerus clausus and replace them with decent, competent nurses, incidentally stripping the anomaly of GPs being private contractors to the NHS.
Lot of stupid going around today. Like this tweet from conservative (I think?) writer Justin Green defending the hysterical media pile on:
Laying a marker: if/when they fix Healthcare.gov, will be in no small part because liberal writers were truthful in their reporting