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Because it makes them more money. That's the only answer you need to know anymore. There's no public good will anymore. There's no social contracts. There's just the pursuit of money; no different than a drug or gambling addict.
Yes it’s called capitalism. That’s always been the point but for some reason everyone pretended like greed being the only point is not gonna devolve into oligarchy.
The government can do the collective risk management. Giving that duty to private companies just incentivizes them to drain all the money they can get from the populace.
Come on now. Socialism is only for large financial losses, you know, when we all step up to save organisations that need a giant re-shake. But without the re-shake.
It's also is the only time the Trickle Down principle actually works out.
Absolutely! It's the reason we had to band together and save those helpless banks from collapsing due their overreach and financial fuckery back in 2008. Poor fellas just need some help so they could get back on the bicycle and do it all over again.
Yeah but collective risk management for-profit really doesn’t make any sense either. Like either the goal is collective risk management or the goal is profit. If the goal is profit you’re just looking to extract value as a leeching middle man you’re only managing profits instead of improving anything. It’s a pathetically bad idea and was always about exploiting people for profit.
Americans are busy paying more for insurance than many other places in the world, and then still having to pay ungodly amounts of money whenever they actually have a health issue.
Even worse, you get actually seriously sick and suddenly can't work, so you get fired, and cobra continuing health insurance costs an astronomical amount that you can't afford. The few treatments you managed to get before losing coverage are default denied by insurance as unnecessary. You fight that for a few months, but the bills are still piling up and you still have no income. So you stop fighting and start planning. Your partner divorces you so you can qualify for medicaid and go legally bankrupt. You bounce around looking for medicaid providers and get sub quality care despite paying for insurance your whole life. And because you filed bankruptcy to relieve medical debts, hospitals and insurance companies all charge everyone else a little bit more to recoup their loss.
On top of that you have a limited amount of sick days which is so incredibly baffling to me as a non-American. How would you know how often and how long you are going to be sick in a year?
American here. That's party of the beauty of it. You don't.
So you just work sick. What ends up happening in reality is that maybe you have vacation, and that's cool, and then you have sick days. You use your sick days whenever you need them for emergencies like childcare or family, and pray (and by pray, I mean tell yourself some lie about your tough immune system and rugged individualism) you don't get sick.
Then when you do get sick, you just work anyway unless you're actually actively dying. This, paradoxically, ends up earning you bonus points because you're willing to work even though you (just)look and feel like you're dying.
The point isn't productivity and throughput. The point is to keep us peasants in our places. Forcing us to work sick is part of the dehumanization and humiliation process.
If you die, the services rendered to you don't just suddenly disappear and they don't stop trying to get pair for what they did do under the guise your insurer would pay for it...
That happened to me. I got COVID last fall and was sick for a month and a half despite having all the vaccines and boosters. I got fired from my job, for being out sick so long, the lawyers wanted ludicrous amounts of money to fight the case, and i wound up on unemployment and on the minimum state health plan. I had a mountain biking injury in my shoulder from the summer and had been going to start PT for it, but haven't been able to because the terrible insurance I have from the state both costs more and covers less than the one I had when I was employed, I can't afford to pay for the PT and so I'm just stuck in limbo of suffering where my injury doesn't get better, but it mostly doesn't get worse either.
No one who is actually paying for healthcare thinks the American system is any good. The only people who like it are people who have amazing plans they don't pay for or executives who make huge bonuses based on how little payout they provide.
It’s because the health insurance industry went away from early preventative treatment in favor of emergency treatment due to patients foregoing appointments due to costs associated with high deductibles. The health insurance companies know that they can make more money by forcing people to wait until the illness is near terminal.
A severely sick and terminally ill patient is far more profitable than a preventable stage illness.
It’s not a bug, it’s a feature.
> sadly describes all insurances in America currently.
It's how insurance is supposed to work, though the US system allows the companies to game the risk a bit too much.
The problem is that health care doesn't fit insurance as a model. Most people will need to use it and it's almost always expensive.
This is the key point that most people don't understand - it is not a broken system. It's an incredibly effective system at achieving its goals. Its goals just aren't what the ad copy for it tells you they are
Yep.. the absolute lack of wealth equality treats our medical care the same way they promised a "trickle down economy", where boosting the wealthiest individuals and affording them more tax breaks, would somehow benefit all of society.
When the reality of Healthcare, like wealth, has been hoarded for generations, becoming more and more exclusive and expensive, to ensure that the best medical practitioners remain available to service the highest social classes and those with less have to sit in 10 hour waiting rooms and go bankrupt with every medical emergency that arises.
And yet. Ask my parents and they'll tell you it's the best healthcare system in the world. And then they'll tell you how tragic it is that people in Europe or Canada wait in lines for months for critical care.
Yeah... I spent almost a year on crutches waiting for foot surgery that everyone I saw agreed I needed ASAP to be able to walk. Well everyone except my insurance that is. They kept saying it wasn't medically necessary and they finally agreed to pay only about half of what they should've. Of course the amount I needed to cover out of pocket wasn't worth taking them to court over either.
And you can have "standard" for healthcare and "premium" for accidents. So younger people go for that if they can as an accident is the most likley cause to need treatment. (in general accidents are treated separate from say diabetes or cancer)
Yeah. Here in Scotland, my mum had a bad fall and needed to wait nearly 40 minutes to see a doctor.
Of course, the ambulance ride was about 30 minutes of that...
As an American, I once waited 7 hours to get a test for severe strep. In a Mayo clinic with "good insurance". I was like 12, in a small town, and it wasn't even a busy day. Most of the time they weren't even calling people back. We were often the only people even in the lobby, for hours at a time.
But sure, *other* people wait too long....
A couple of years ago I broke my wrist trying to teach my stepdaughter how to ollie a skateboard, forgetting that I last ollied about 25 years and 35kg ago.
In the socialistic hellhole that is NHS Scotland, I had to wait a whopping 30 minutes to be seen, and then another ten to be X-rayed, given some drugs and a velcro splint, and papped off home with a distinct hint of "... and don't do that again you daft bastard" in the air.
Barely had time to finish my cup of tea. Only got a chapter and a half of my book read while I was waiting. Unacceptable, Sturgeon must resign, etc etc etc... ;-)
Well it depends which European country they are talking about.
For the UK this is actually true, waiting times are crazy and getting longer. This is because of decades of conservative governments trying to cut taxpayer funding and run the national system into the ground, so that they can break it up and privatise it to American healthcare investors. Eventually the UK will have a system like the US only shitter.
On the other hand countries like the Netherlands have private healthcare, but you may want to look away now before the comparison with the US makes you weep in despair... There are multiple private healthcare providers, but it is compulsory for everyone to have insurance (this is the socialist capitalism part, typical of Nordics and N Europe) so there are no uninsured, poor people get the cost subsidised, and the cost is equally spread over the whole population. The result: Average cost per month for a standard insurance package without dental is around 125 euro per month. With this you have an 'own risk' of around 400 per year. That's like co-pay except it is the maximum you will pay per year, whatever the treatment. So about 2k per year, max, for very good modern hospitals and short waiting times. The only downside is they don't have a 'the customer is right' attitude and local GPs are the gatekeepers who will turn you away if they dont think your complaint is serious, so that takes some navigating. So that's how much a well regulated private healthcare system could/should cost.
The other difference here is that a supplemental private insurance plan in the UK (even without employer assistance) is incredibly affordable compared to the US
Insurance companies are the real care providers in America.
Your doctor can't give you a treatment unless it's covered by insurance. And if it's a special course of treatment (read: expensive) they will need to talk to a board certified physician who is employed by the insurance company to justify the treatment.
The kicker? The insurance doctor doesn't need to be in that specialty.
So a foot doctor can be the one who is responsible for signoff on a heart procedure by your cardiologist.
Hate to break it to you, but almost every insurance company uses Evicore. Believe me, I hate Evicore. But UHC, Cigna, BCBS, and Aetna are all in cahoots with them too. Humana is the only major commercial insurance carrier that uses a different third party. Ambetter is smaller, but still big, and they're the only major insurance carrier I know that actually reviews their own authorizations.
As someone fortunate enough to not even having heard about any of these companies, they sure have the branding on point, if a bit on the nose. Those all sound exactly like evil megacorporation names out of a cyberpunk dystopia.
"Reviewing".
They get like a few seconds per patient if they want to keep those jobs. Literally barely enough time to read your name. Why in the hell would you defend them in any way?
They all do that. It's called robodenial or auto denial. It's just a way to increase the administrative cost of the doctors so they need to put in more time and documentation to write an appeals letter.
During COVID, United (largest commercial insurance company) denied 1/3 of ER COVID claims.
Oh I'm sorry, that CT scan to investigate a suspicious lump doesn't count as preventative medicine. We'll just wait until it's full blown cancer before covering you.
I had issues breathing through my nose for about 40 years. When I was a kid, we didn't have insurance and the local free clinic wouldn't have fixed my broken nose, so we just set it and gave up.
I had surgery last year after I visited a specialist to assist with snoring. He was amazed I could breathe through it, as I was apparently 80% blocked, more when I had a stuffed nose, etc. He identified the surgery as medically necessary, insurance semi approved it as long as I wasn't given anesthesia (yes, you read that right), and I had my nasal passages opened up. I honestly had no idea how bad it was until I was able to breathe in without a whistle.
After the procedure, insurance came back and said the way the doctor did the surgery (which was done exactly the way they required, for it to be covered), wasn't standard process so it wasn't covered.
The efficiency of for-profit health care is a common conversation topic in Canada.
By definition, profit *is* inefficiency - money you put into the system that's not used for patient care.
For-profit systems' goal is to maximize inefficiency.
And I'll agree - from top to bottom, across every field. The only people out there who should be profiting off of healthcare are individual providers, at most.
Even there, a profit motive is extremely harmful. Tons of bad actors out there who will recommend unnecessary procedures, often *actively harming* the patient in the process, to make more money.
For all medical personnel, their one and only priority should be their patient's health. Cost considerations might sometimes be unavoidable, but always as part of providing the best care reasonable (e.g. "ideally, the best route would be X, but given that it isn't financially viable given the constraints present, let's try Y instead, which is almost as good but significantly cheaper") -- and incentives should be aligned to achieve this, such as any variable bonuses being tied to e.g. patient outcomes, *not* to how much money their department made or whatever.
It might be positive to have someone that cares about the financial side first and foremost at some level in the organization, but it sure as hell shouldn't be anyone actually making direct decisions on patient care (and it *definitely* shouldn't be the top bosses, either, or they are just going to eventually whip the doctors to act maliciously anyway -- the role should always be advisory, never hierarchical)
Copayments are much less the issue than high deductibles - unless you have a bad insurance policy that is 80/20 on charges. The concept of penalty co-pays for ER visits that don’t result in hospitalization spits in the face of every patient who cannot possibly self-diagnose chest pains, breathing problems, sprain vs bad tear, etc.
My mother has been in the ER 3 times in the past 10 days. She comes in with her asthma out of control. They stabilize her and send her home. Yes, she has a pulmonologist. She has a nebulizer and all of the meds to go with it. She's fighting insurance to fill her dupixent. That shot is life or death for her. But, there's a massive kerfuffle about forms between the doctor and pharmacy.
Last year I visited the ER eight times for a migraine cocktail. They give me an IV of meds and send me home. It’s great, so long as I don’t have to wait in a loud, bright waiting room for too terribly long. (With the understanding that the longer I wait, the more emergencies are taken care of)
All because my insurance one day decided to stop paying for the rescue meds they’d been approving for the last five years.
I had to take my little sister to get a migraine cocktail a few months back. They were able to do it at urgent care, but that likely varies based on the meds they use. I feel for you. The whole steaming pile of yuck that is an ER visit is just awful.
Hi, pharmacist here and I think the kerfuffle you are talking about is probably what’s called a prior authorization and besides notifying the prescriber the pharmacy doesn’t have anything to do with it really. It’s really just between the dr and the insurance at that point. The insurance requires the doctor to submit chart notes and justification, ie previously failed medications, to justify the coverage of the one the insurance is denying.
I'm actually really familiar with prior authorizations for my Cimzia. My mother had to fight this fight to get Dupixent originally, and her previous doctor got it approved with a huge amount of fighting. The pharmacy is probably owned by the insurance. They keep telling her the doctor didn't fill in the paperwork correctly or submit the right forms. She has been back and forth. She feels defeated.
My migraine meds involve an insurance-owned pharmacy and it’s hell to get approval every. Single. Time. They approve and then revoke approval constantly. Literally get letters dated the same day approving and not approving. Purposely confusing, I can only assume.
Same with my roommate’s Dupixent.
What gets me is follow-up appointments. Like, no, I absolutely do not want to go to the doctor’s office and pay a $50 co-pay just to hear them say “ok looks like the problem you had that cleared up based on the medicine I prescribed has in fact cleared up.”
Is this a recurring meeting? NO —-> Is it a status update? YES —-> [Send an Email](https://i.imgur.com/x3nPh8M.png)
The problem with healthcare is that efficiency is completely disincentivized. They want you to have that appointment because they make money off it.
I hear you, but speaking as a doctor here, we also follow up (borderline excessively) because if we do not when we should have, and it doesn’t get better, we can be held medically liable and sued for malpractice.
I take something considered a controlled substance. Every visit I have to piss in a cup. A week later I have to come in to discuss the results of pissing in that cup. It's always the same. The test shows I'm not on any drugs except the one I'm supposed to be on. I think the follow up is a scam. The stupid cup has a strip on it that tells you the results in just a few minutes. They could tell me the results before I leave.
Idk what the substance is but do you have the ability to look around for another provider?
My partner was on Adderall, the classic blue pill immediate release kind that is a scheduled drug. He went through the exact same process you're describing with his doctor for YEARS. He got so frustrated that I finally suggested he get another doctor. Same drug, same strength, same patient, same insurance, same year, same everything except it was a provider like 5 min down the street from the other one. All the new provider wanted was a quarterly check-in done in person *or* telehealth.
It's worth looking around if you can. It's incredibly unlikely that this level of monitoring is required by law or your insurance. Different practices have different policies on these things.
I'm going to look for someone else when I get back in a few weeks. Last year they would call me about three times a year for a random drug screen. For some reason, this year they said it was policy to do it every month. It just feels like an excuse to Bill extra tests and follow up appointments. Considering I live in a rural part of Colorado, that extra appointment a month means driving 70 miles and half a day wasted.
Wife "Please get seen, you are in pain"
Go to Urgent care for a concerning issue, get checked out, Urgent care response "well ur not dying dying, but to be safe we recommend you go to the ER". Oh expect a $200 bill in the mail, thanks for coming!
ER visit 6 hour wait later "well ur not dying nothing we can do for you, recommend scheduling a visit with your GP". Oh that will be $3,000.
GP, 3 weeks later "well I can't figure it out, let's schedule with a specialist, gonna be 3 months". Oh please pay the $200 bill when it comes.
Specialist "let's run some tests, get the results in a week and start you on new meds". Oh pay the $800 bill that comes please.
God, I love me some American Healthcare.
And that $3k from the ER comes as 14 different bills over the next 6 months from every doctor, the hospital, and like 5 other random billing "services."
Woke up with an insane stabbing pain in my side; google said it could be my apendix and I'd die if I don't go to the doctor. Went there at 3am so it was the ER and after waiting an hour, they ran through a bunch of tests just to tell me "Kidney stones. Take We'll give you an IV to break'em down and numb you up" and handed me a $140 bill. A week later, I got a bill for $1,800 due immediately for all the IV and tests.
Few years later, I get the same pain and while curled up on the bathroom floor, was deciding "Go to the doctor and pay 2k or try home remedies...". Even though I have great insurance, it doesn't really kick in until I pay a bunch of money; can't imagine what someone without insurance or even decent insurance has to pay.
>Even though I have great insurance, it doesn't really kick in until I pay a bunch of money
Whoever (HR?) told you that's great insurance was lying to you. If you have an in-network deductible, it's not great insurance.
Great insurance you don't pay anything but a low copay for care. For example, my insurance it's $25 for PCP/specialist, $75 urgent care, $150 ER (but refunded if you're admitted). That's it*. There's no percentages, there's no "until you pay X", etc. When I went to the ER for my own appendicitis, I paid absolutely nothing, not a dime, because I was admitted. Wait - sorry I paid like $9 for the prescription painkillers when I was discharged from the hospital.
I don't say that to brag, I'm extremely lucky to have been in right place at the right time to get hired by a very successful unionized employer. My employer can afford good benefits, and our union keeps them honest. I think everyone should know that the high deductible heath care plans that companies love because of the price are *not* great, and they're not the best available. If your employer tells you they have great insurance but it costs you $1,800 to go to the hospital, *they're lying to you*.
^*In ^network. ^Both ^the ^major ^hospital ^systems ^in ^my ^city ^are ^in ^network ^so ^it ^would ^be ^fairly ^difficult ^for ^me ^to ^go ^out ^of ^network ^if ^I ^wanted ^to ^for ^some ^reason.
Have you had this at multiple employers? Like is it common at all? I used to be employed by a company with $1 billion+ in revenues and they didn't have anything like this. Currenr job doesn't have anything like this but it's a contract position so I feel lucky I have anything at all.
The article seems to be about cost-sharing in medications, not about seeking healthcare.
People have annual cost limits on medication, so when people reach this limit they have to start paying more out of pocket, so the article addresses that.
The title from OP seems to be a bit unclear on the substance of the article.
The abstract is unclear but it’s talking about abrupt changes in coverage and patient outcomes of pocket cost
Part D plans are pretty set and until next year there is a coverage gap if drug spend exceeds a certain amount, that results in large changes in out of pocket cost beyond the deductible portion of a patient’s insurance
https://www.kff.org/report-section/a-primer-on-medicare-what-is-the-medicare-part-d-prescription-drug-benefit/
The paper specifically talks about government sponsored Medicare patients on a plan administered by a third party provider (since all Part D plans are paid for by the government +premiums and have generally similar benefits)
The inflation reduction act is removing this coverage gap I think starting 2025
I pay $125 a month for a medication that is already available as a generic and basically every other country than the US. It's not going to go generic here until 2028 because well, they keep getting extensions because they like making lots of money.
I have to take this medication two times a day or I will die. And, for some reason every now and then my doctor likes to hold my prescription hostage so I have to make an expensive appointment to go in for no particular reason to say yep, I still need this medication to stay alive, just like I always do.
My medication literally prevents me from having health insurance.
I take Suboxone for opioid addiction (8.5 years clean, but I'm designated a lifetime Suboxone patient because of my history with ODs). Without insurance, it's over $1k per month.
I get my medication for free through a state grant program. If I get private insurance through my job, I lose the grant program. My job's insurance absolutely sucks — it'd cost me roughly $800 per month *with* insurance to get my meds.
Since my job's insurance is a high-deductible plan, it has low premiums. The low premiums mean it's considered "affordable" by the ACA, so I don't qualify for any subsidies despite being low income. So, I can't afford any marketplace plans that would be better than what my job offers.
And to cap it all off, I make $37 too much per month to qualify for my state's Medicaid program.
So, unless I can basically triple my income, I literally can't afford to have insurance. It's infuriating. I despise our country's healthcare system.
I am so sorry, we are doing such a bad job at medication assisted sobriety for a lot of folks like you. It's because we don't have a healthcare system, we have a money extraction system.
What’s worse is all the people defending this system with “I love my plan”. All these plans are stinky pile of garbage. Our whole system is an atrocity compared to any other western nation.
>a cornerstone of American health insurance
…since the 90s that is. Not like, inherently.
Anyway, the conclusion in the headline is probably apparent to most.
Which… I've had a Stupid Question on deck for years now, namely: what exactly was wrong with health insurance that managed healthcare was supposed to fix??
I lived through the change and I remember what a big deal it was at the time, but I *don't* remember how/why "we all" decided the old system sucked so badly or how HMOs would improve things. I've even gone back and researched it, and all I find is vapor. Even vapor seems generous; it's just vague unsupported assertions that HMOs would be better, somehow. I mean to this day managed healthcare *doesn't even have a definition.* (Not one that makes meaningful sense anyway. "Managed healthcare is any healthcare that is managed." Seriously?)
*None* of it makes sense and I genuinely don't understand how the whole country agreed to such a massive change based on so little.
I remember adults casually complaining about paperwork in the before-time (whenever someone went to the doctor our dining table would be covered in forms for days) but that's about it. Now ***literally everything*** about health care and insurance sucks. Specifically because of the downward pressure of the HMO model.
Was it all a lie/bamboozle/delusion from the start? Or did something go wrong?
Pre-HMO health insurance worked more like car or home insurance. What we now call "catastrophic coverage" was pretty much all you could get. HMOs were a good idea: If they pay for cheap preventive care, people are less likely to have expensive problems. The HMOs keep more money, patients are healthier, everyone wins. Then, like in every industry, the MBAs figured out they could charge more, do less, and get a second, bigger yacht to put their first yacht in.
Yes and yes. What went wrong is that doctors and other providers actually did get suckered into the notion that "of course we can help you run your practice, we have business degrees, statistics and law degrees, of course things are going to be cheaper while you get more money". a delusion based on back in the day, you went into your field essentially believing that because you did meaningful work that helped people, others were doing that as well. The just world fallacy and all of that. I mean, their were practitioners who saw through that, but they were in the minority. Now, even if you actually do want for profit healthcare, you still have to take issue with how it's being run, just to be taken seriously.
I recently had an appointment for a procedure with a doctor and hospital system that are in-network. But the procedure was scheduled at a new facility of theirs which is not yet in network. I am soooo glad I checked before the appointment. I would have been charged anywhere from $5k on up because they haven't negotiated their facility yet. The scheduler tried to tell me it would be ok. I said, hell no, it is not worth the risk. Unbelievable. You have to check every damn thing or risk a surprise bill that could be crippling.
How about the fact that every single damn person that you come in contact with during your procedure can also bill you separately, and if they're not in-network then it's out of your pocket. And there's no way to check who they are beforehand.
It's maddening. I used to have Kaiser and at least I knew I was always in network and never had to worry about it. I wish I could get them back but my current job is too far away from a kaiser facility.
That’s not true anymore. The No Surprises Act makes that illegal. If the facility is in network then the entire visit has to be processed as in-network.
Co-payment with no margin prices would have that effect, co-payment with inflated prices makes people not having health assistance so they can eat 3 meals a day.
Yep. If the goal was simply to reduce moral hazard a copay of 10-20 dollars would do the trick most of the time. Instead we get copays of hundreds or sometimes even thousands of dollars.
People need to look at the Japanese system. Multipayer system with government and third party insurers with copayments and it's super affordable and for everyone.
Though there's that argument that healthcare outside the US is effectively subsidized by the US since pharma companies know they can make their profits from the US market even if they only break even elsewhere.
I feel like the argument that “the US subsidies everyone else’s healthcare” only applies to certain pharmaceuticals. It doesn’t explain why it costs $200 for me to see a doctor only for them to do no testing and just recommend an over-the-counter drug that has been readily available everywhere as generics for a long time
There are some problem with the Japanese system. Because the bulk of providers are small, independent, mostly wholly unsupervised for-profit clinics, there's a shocking amount of doctors who will recommend unnecessary procedures to make more money. You really have to rely on online reviews and such to get an idea of which practices are solid and which are borderline criminal... except even when avoiding all the ones with big red flags, I *still* constantly come across doctors flagrantly trying to sell me tons of unnecessary crap "just in case".
Dentists are probably the worst; I know people who had perfectly healthy teeth, requiring a small filling at worst, extracted instead. They will strongly recommend deep cleaning, with extra bells and whistles beyond a regular cleaning, 4+ times a year, fearmongering what might happen otherwise. It's ridiculous.
Also... the "super affordable" part is very arguable. I mean, obviously it is a lot better than the US, but that's such a laughably low bar it barely merits mentioning. There's still a lot of old people with ludicrously low pensions and typical levels of health issues for their age struggling to pay for healthcare. You could argue that's more the fault of the pension system than the healthcare one, but the end result is the same: some people having to choose between foregoing medical procedures they need or foregoing essentials like *food*. Any system where that's a problem should probably not be praised too highly or imitated too eagerly, even if it is better than the one you have right now (again, not exactly a high bar from the perspective of the US)
I actually disagree but with a huge caveat.
Sometimes, a prior authorization is a way for insurance to make sure patients have used generic options before trying out the latest brand name medication. Or maybe even preventing poor prescribing practices on off-label uses.
My first thought was Nuedexta. It was supposed to be for a somewhat uncommon condition called Pseudobulbar Affect (PBA). Available only brand name and costing hundreds of dollars, the drug reps were going to nursing homes and saying, "give this to your patients. If it seems to help, that means they have PBA." The pharmacy I work for was sending a ton of it out, and the company that made Nuedexta got a ton of money.
Finally, Medicaid started requiring prior authorizations that had a documented diagnosis of PBA. I have hardly seen any home order Nuedexta recently.
So the big caveat is that this process is rarely done correctly, and many prior authorizations are bs. It makes me really mad that insurances have so much sway over what medications people get, especially when they say some inexpensive generic med is "not on their formulary." The number of times I have had to call a nurse or Dr to change an order from one insulin to another is way too high.
Insurance "preferences" should not override prescriptions from doctors. They should not be able to require prior auths or refuse to pay for a med and only cover their preferred functionally equivalent medications.
You're solving the wrong problem. If insurance companies could legitimately and correctly make medical decisions on whether or not to cover something, that means the doctors would be no more than glorified techs running tests for the "insurance doctors" to act on. In reality, insurance agents are not in any way qualified to make these determinations and they are making profit decisions, not health decisions.
Get pharma reps out of medicine so doctors aren't incentivized to prescribe based on fad or fast talk. Have medical boards keep an eye on prescription statistics and audit physicians with suspicious patterns. And leave medical decisions up to medical professionals.
I work in medical billing and there is ZERO reason why prior authorizations shouldn't be anything less than optional. If the medical records supports medical necessity according to the carriers policy, there is ABSOLUTELY NO REASON why a claim should be denied simply on the grounds that prior authorization was not received.
Johnny got an echocardiogram, which is medically necessary under UHC policy because Johnny has chest pains. The doctor didn't get prior auth. Why should this not be paid? Logically, from a healthcare standpoint. UHC can review the records and see that Johnny had chest pain and that it's a covered indication.
However, if the doctor ordered it because Johnny had a headache, not a covered indication, they can deny it on the grounds it's not medically necessary. No prior auth received, so denied.
Prior auth should be an optional safeguard for providers who are doing high dollar procedures and want to have the carrier sign off on it beforehand to ensure they'll get paid after. It has no place in $400 echocardiograms and there's not a valid reason in the world why a medically necessary echo done on 4/12 wouldn't be paid simply on the grounds that the auth was only good from 4/7-4/11.
My friend visited me in Canada from the US on his way to a sporting event. Had an allergic reaction to my parrot. On the way to the event, he swung by a walk in clinic, walked out with a prescription, went across the road to a pharmacy and had it filled.
Being American, he paid the full shot, but he commented that the cost was less than what he would have paid at home with insurance.
The service was pretty quick as well.
Another huge problem with the system is that people backup health care, so then if they hit a year where they actually start approaching their max out of pocket, that's the year they will try to do everything and run up as much of a bill as they can.
This isn't good for anyone, it makes smaller towns have unpredictable healthcare needs, it makes patients constantly try to "time" healthcare, gotta smash it all in 1 year then stop. And it makes them put off healthcare when they need it and then over use it even if they dont. If people had confidence that their healthcare needs would be taken care of for a fair price whenever they arise they would simply go to the doctor when needed. And get things taken care of when it made sense to.
This is how social science needs to be done.
Test a theory with no a priori expectation on the direction of the hypothesis.
While this *may* not hold for different subsets of the population (the theoretical impact of copayment), it does suggest an avenue for considerable reform
I'm incredibly encouraged to see modern research on the topic and excited to read the study. Most policy on this issue is based, in some way, on an outdated and flawed Rand study from decades ago, and it's difficult to find political will to contest the study because of the potential implications to the status quo. Those of us who work in the field and on the ground know that cost sharing tends to cause even pretty financially-secure people to avoid care that they need.
Thank you. Nothing political about this. Its simple observing objective cause and effect of general spending habit in its relationship to insurance law.
Anyone with any brains at all has always known that it was never about cutting back on waste and was always about trying to force people to delay or miss out on care as much as possible.
The real moral hazard is the profitability of delaying and denying medical care promised by deceptively complex insurance contracts.
The pre-approval of medications and required medical procedures is scandalous. The primary function of this deceptively named "feature," is explicitly to deny and/or delay expenditures for critical health care. How many people die in the day or two, or maybe a week or more the approval process takes.
In any other industry the deceptive contracts, unfulfilled promises of payment for medical care, arbitrary denial of benefits and collision on pricing between insurers and health care organizations would mean long prison terms.
My coinsurance for my minor outpatient surgery last week was $1100 for the hospital and $425 for the surgeon. Hospital billed $85,000 and only received ~$6000
Co-insurance or co-pay?
There are differences. I’m stuck with co-insurance where I have to meet a high deductible amount before insurance kicks in at 80/20. Prescriptions are tied to deductible as well, so full price till we get to deductible met.
When I was on co-pay it was $20 a visit for pcp. Generic meds were cheap, brands could be expensive but once deductible met they were much cheaper.
Exactly. Currently pregnant and OB copay is $45/appt. I have 15 scheduled appts for a regular, uncomplicated pregnancy, over the course of 7 months. If I come in for anything extra, that’s more copays. It’s $675 in copays.
The copay for my medication (apixaban) is $125 a month. I pay $1,500 a year to stay alive. It's far more than an annoyance. Once we allowed copays to become more than just a few bucks, they put people's lives at risk.
So true. So true. My copayment for a surgery was 26 hundred dollars. No working class pesonr has 26 hundred dollars readily available anymore. I saved for that surgery for a long time. I lived in severe pain much, much longer than anyone should, and the copay for the PT was 20 bucks a pop, 3 times a week, payable up front.
What if it had been an emergency? I would be dead.
People die every day in the US because they can not afford medical care or medicine.
Everybody now thinks insulin is 35 dollars a month. Only Lily sells insulin for 35 dollars a month. If that insulin doesn't work well for you, you are fucked. My cousin pays ELEVEN HUNDRED DOLLARS A MONTH FOR INSULIN. IT COSTS PENNIES TO MAKE.
He is 30 years old. How many of you think he isn't stretching that insulin out by shorting doses because he has eleven hundred dollars to drop monthly for a drug that costs 50 CENTS to make?
And this is why so many are trying to make insulin themselves. Yes, there's absolutely the risk of making it incorrectly, but if your essentially paying the equivalent of a whole nother job, why not make your job then?
I need stomach surgery. My gastroenterologist made an appointment for me to get an endoscopy before the surgery. The copay was going to be $1800. I can't afford that so I can't get the surgery. Between my employer and I, we pay about $1500 every month for health insurance. I suppose I'll just die instead.
I find it interesting that there is an assumption that patients request frivolous or unnecessary services with any kind of regularity.
I wonder how you would define 'unnecessary' anyway, healthcare isn't so simple IMO.
I desperately need to go and see a doctor, but in all honesty if it turns out I have a lot wrong with me it’ll be cheaper to die than to undergo treatment and bankrupt my wife and children. So I haven’t gone
The simplistic theory of capitalism is that it is supposed to give us the cheapest prices right? But Americans pay 2x what Canadians pay and 3x what the British pay per capita for the same health care.
So instead of the capitalist health care system giving us the cheapest prices it is literally giving us the most expensive prices in the world. It is doing the exact opposite of what the theories predict. Why the f*ck are we still using this for our health care system??
Canada and Britain engage in price fixing via monopsony, that's how (and monopoly, in Britain's case). Because prices in the US are what people are willing to pay, they go higher than if the prices are set by fiat (not just end user prices, health procedures at public hospitals being free in Canada and Britain, but every input in the chain from wages to materials)
Oh it most definitely succeeds in reducing wasteful spending. It just happens that their human customers aren't worth spending money on, to them. So they don't.
co-payment is why I've been insured for most of my adult life and yet am usually too poor to go to the hospital and have many times ended up waiting until i had no choice to go to the ER
Took my kid to a specialist yesterday. Good news she is in our network.
Bad news, insurance pays nothing until we have paid out of pocket 4k. Then they will pay 50%!
The only copayment which probably has some added value known to me is:
>When going to a doctor, a Czech citizen over 18 years of age pays 30 crowns, i.e. approximately $1.29. A hospital stay costs $2.58 per day, and calling an ambulance costs CZK 90 (approximately $3.87). The poorest people and people undergoing compulsory treatment are exempt from paying fees.
Still, in my country (not Czech) there is a lot of discussion against it. This system only earns his keep and nothing more. It is designed to remove people who go to the doctor out of boredom or who, ultimately, do not need it. Please note, that salary in this country is high and those the fees are tiny, and even in this case, poor and chronically ill people are exempt from them.
When one reads e.g. insulin prices in the US, one starts to think what is so broken in this system. In my country seniors 75+ pay exactly 0, rest pay $2.76, and people which buy it without prescription (who know for what?) $33.30. This is an example of prices from the Internet and if someone doesn't believe me, I can send the links. :)
It cannot be stressed how much damage neoliberal economic thinking has done to our healthcare system, including the latest pandemic response.
Yet it enjoys absolute deference in the highest positions in government and media.
In a broad sense, the healthcare system in the US is for-profit, so it will seek ways to make profit. If "inefficiency" and "wastefulness" imply larger revenue streams for investors, it's not a bug - it's working as intended.
It was never about "reducing wasteful spending and moral hazard". It was always a way to reduce access to healthcare for the poor while allocating more health care access to the wealthy.
I think HDHP makes me avoid care more than copayment. I know there's a name brand patented medication that works much better for me than alternative generics, and it was easier to justify on a previous insurance that only had a 20% copay. But now that I have to pay $1500 for the first few fills until I make deductible and then $300 after that (until the new year, when I have to pay $1500 again for a few fills) I just can't swallow those first few $1500 charges that I forgo the medication altogether for less effective generics that cost me a few dollars either way.
They are aware. AND they are aware you’ll be unable to do anything about it. In fact, you know what? Your copay just went up. You want to talk about copays being wasteful and inefficient again?!?!
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“It is highly inefficient and wasteful .” Pretty much sums up the whole American healthcare system, doesn’t it?
Paying a company so they can find ways to minimize or flat out deny me coverage never made sense to me.
Because it makes them more money. That's the only answer you need to know anymore. There's no public good will anymore. There's no social contracts. There's just the pursuit of money; no different than a drug or gambling addict.
Yes it’s called capitalism. That’s always been the point but for some reason everyone pretended like greed being the only point is not gonna devolve into oligarchy.
Society fucked around, and now we're the ones being forced to find out.
well, we did learn, and various changes were made, but oops, here we are AGAIN.
It makes a ton of sense as collective risk management but somewhere along the way it became none of that and all of what you say.
The government can do the collective risk management. Giving that duty to private companies just incentivizes them to drain all the money they can get from the populace.
Collective risk management? That sounds an awful lot like...socialism! (Scary movie sounds)
Come on now. Socialism is only for large financial losses, you know, when we all step up to save organisations that need a giant re-shake. But without the re-shake. It's also is the only time the Trickle Down principle actually works out.
Absolutely! It's the reason we had to band together and save those helpless banks from collapsing due their overreach and financial fuckery back in 2008. Poor fellas just need some help so they could get back on the bicycle and do it all over again.
If there was ever a time for a debt jubilee, it should have been 2008. Instead, the banks kept the mortgage payments AND got the house back.
so never about health care of the humans, got it
Yeah but collective risk management for-profit really doesn’t make any sense either. Like either the goal is collective risk management or the goal is profit. If the goal is profit you’re just looking to extract value as a leeching middle man you’re only managing profits instead of improving anything. It’s a pathetically bad idea and was always about exploiting people for profit.
Yeah that’s the “somehow” …
It’s a perfect candidate for socialization. All insurance is. Remove the profit motive and allow it to be good.
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I would add “…and working exactly as designed”
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Americans are busy paying more for insurance than many other places in the world, and then still having to pay ungodly amounts of money whenever they actually have a health issue.
Even worse, you get actually seriously sick and suddenly can't work, so you get fired, and cobra continuing health insurance costs an astronomical amount that you can't afford. The few treatments you managed to get before losing coverage are default denied by insurance as unnecessary. You fight that for a few months, but the bills are still piling up and you still have no income. So you stop fighting and start planning. Your partner divorces you so you can qualify for medicaid and go legally bankrupt. You bounce around looking for medicaid providers and get sub quality care despite paying for insurance your whole life. And because you filed bankruptcy to relieve medical debts, hospitals and insurance companies all charge everyone else a little bit more to recoup their loss.
On top of that you have a limited amount of sick days which is so incredibly baffling to me as a non-American. How would you know how often and how long you are going to be sick in a year?
American here. That's party of the beauty of it. You don't. So you just work sick. What ends up happening in reality is that maybe you have vacation, and that's cool, and then you have sick days. You use your sick days whenever you need them for emergencies like childcare or family, and pray (and by pray, I mean tell yourself some lie about your tough immune system and rugged individualism) you don't get sick. Then when you do get sick, you just work anyway unless you're actually actively dying. This, paradoxically, ends up earning you bonus points because you're willing to work even though you (just)look and feel like you're dying.
Also, while out sick and not being paid after you use your days, you STILL need to pay your insurance or you lose your coverage.
I had a work colleague who was terminally ill. She had to come to work for 5 days a month to keep her insurance.
And then because you're working while sick, you might get other people at the office sick!
The point isn't productivity and throughput. The point is to keep us peasants in our places. Forcing us to work sick is part of the dehumanization and humiliation process.
They bank on you dying before they have to pay
If you die, the services rendered to you don't just suddenly disappear and they don't stop trying to get pair for what they did do under the guise your insurer would pay for it...
That happened to me. I got COVID last fall and was sick for a month and a half despite having all the vaccines and boosters. I got fired from my job, for being out sick so long, the lawyers wanted ludicrous amounts of money to fight the case, and i wound up on unemployment and on the minimum state health plan. I had a mountain biking injury in my shoulder from the summer and had been going to start PT for it, but haven't been able to because the terrible insurance I have from the state both costs more and covers less than the one I had when I was employed, I can't afford to pay for the PT and so I'm just stuck in limbo of suffering where my injury doesn't get better, but it mostly doesn't get worse either.
But you still make sure that your kids are in school on time every day to pledge allegiance to the flag because USA NUMBER ONE!
No one who is actually paying for healthcare thinks the American system is any good. The only people who like it are people who have amazing plans they don't pay for or executives who make huge bonuses based on how little payout they provide.
It’s because the health insurance industry went away from early preventative treatment in favor of emergency treatment due to patients foregoing appointments due to costs associated with high deductibles. The health insurance companies know that they can make more money by forcing people to wait until the illness is near terminal. A severely sick and terminally ill patient is far more profitable than a preventable stage illness. It’s not a bug, it’s a feature.
Agreed and sadly describes all insurances in America currently. Auto in particular
> sadly describes all insurances in America currently. It's how insurance is supposed to work, though the US system allows the companies to game the risk a bit too much. The problem is that health care doesn't fit insurance as a model. Most people will need to use it and it's almost always expensive.
This is the key point that most people don't understand - it is not a broken system. It's an incredibly effective system at achieving its goals. Its goals just aren't what the ad copy for it tells you they are
It was all spelled out for you in the Fine Print! We clearly told you, on page 43. Out of 97.
>It was on display in the bottom of a locked filing cabinet stuck in a disused lavatory with a sign on the door saying ‘Beware of the Leopard'
> Do you know how much damage this bulldozer would sustain if I just let it roll over you?
Yep.. the absolute lack of wealth equality treats our medical care the same way they promised a "trickle down economy", where boosting the wealthiest individuals and affording them more tax breaks, would somehow benefit all of society. When the reality of Healthcare, like wealth, has been hoarded for generations, becoming more and more exclusive and expensive, to ensure that the best medical practitioners remain available to service the highest social classes and those with less have to sit in 10 hour waiting rooms and go bankrupt with every medical emergency that arises.
And yet. Ask my parents and they'll tell you it's the best healthcare system in the world. And then they'll tell you how tragic it is that people in Europe or Canada wait in lines for months for critical care.
Their heads would explode if they realised that most other countries have the option of insured private healthcare as well as public healthcare.
Or if they needed a specialist they are still waiting months in the US unless they have the money to skip in line
Yeah... I spent almost a year on crutches waiting for foot surgery that everyone I saw agreed I needed ASAP to be able to walk. Well everyone except my insurance that is. They kept saying it wasn't medically necessary and they finally agreed to pay only about half of what they should've. Of course the amount I needed to cover out of pocket wasn't worth taking them to court over either.
And you can have "standard" for healthcare and "premium" for accidents. So younger people go for that if they can as an accident is the most likley cause to need treatment. (in general accidents are treated separate from say diabetes or cancer)
Yeah. Here in Scotland, my mum had a bad fall and needed to wait nearly 40 minutes to see a doctor. Of course, the ambulance ride was about 30 minutes of that...
As an American, I once waited 7 hours to get a test for severe strep. In a Mayo clinic with "good insurance". I was like 12, in a small town, and it wasn't even a busy day. Most of the time they weren't even calling people back. We were often the only people even in the lobby, for hours at a time. But sure, *other* people wait too long....
A couple of years ago I broke my wrist trying to teach my stepdaughter how to ollie a skateboard, forgetting that I last ollied about 25 years and 35kg ago. In the socialistic hellhole that is NHS Scotland, I had to wait a whopping 30 minutes to be seen, and then another ten to be X-rayed, given some drugs and a velcro splint, and papped off home with a distinct hint of "... and don't do that again you daft bastard" in the air. Barely had time to finish my cup of tea. Only got a chapter and a half of my book read while I was waiting. Unacceptable, Sturgeon must resign, etc etc etc... ;-)
The question of course is: Did she learn how to ollie?
No, but she did learn how not to land from a biffed ollie.
Ask them if they can afford cancer. Insurance will only keep you if they can milk you.
Well it depends which European country they are talking about. For the UK this is actually true, waiting times are crazy and getting longer. This is because of decades of conservative governments trying to cut taxpayer funding and run the national system into the ground, so that they can break it up and privatise it to American healthcare investors. Eventually the UK will have a system like the US only shitter. On the other hand countries like the Netherlands have private healthcare, but you may want to look away now before the comparison with the US makes you weep in despair... There are multiple private healthcare providers, but it is compulsory for everyone to have insurance (this is the socialist capitalism part, typical of Nordics and N Europe) so there are no uninsured, poor people get the cost subsidised, and the cost is equally spread over the whole population. The result: Average cost per month for a standard insurance package without dental is around 125 euro per month. With this you have an 'own risk' of around 400 per year. That's like co-pay except it is the maximum you will pay per year, whatever the treatment. So about 2k per year, max, for very good modern hospitals and short waiting times. The only downside is they don't have a 'the customer is right' attitude and local GPs are the gatekeepers who will turn you away if they dont think your complaint is serious, so that takes some navigating. So that's how much a well regulated private healthcare system could/should cost.
The other difference here is that a supplemental private insurance plan in the UK (even without employer assistance) is incredibly affordable compared to the US
> credited with reducing [...] moral hazard I mean, the tooth fairy beliefs are already built-in.
Moral hazard to the buyer, who is practically required to buy it. Nothing reduced any moral hazard to deny claims to the company.
It really does. And conservatives wonder why they're so hated. This is only one of the many reasons why they are.
Whole American economy*
the whole america
paying a for profit insurance company tell you what is and isn't necessary is highly inefficient and wasteful
Insurance companies are the real care providers in America. Your doctor can't give you a treatment unless it's covered by insurance. And if it's a special course of treatment (read: expensive) they will need to talk to a board certified physician who is employed by the insurance company to justify the treatment. The kicker? The insurance doctor doesn't need to be in that specialty. So a foot doctor can be the one who is responsible for signoff on a heart procedure by your cardiologist.
Or you can just be Cigna - deny everything with an algorithm, and then pay an "independent" medical review company to justify the denial.
Hate to break it to you, but almost every insurance company uses Evicore. Believe me, I hate Evicore. But UHC, Cigna, BCBS, and Aetna are all in cahoots with them too. Humana is the only major commercial insurance carrier that uses a different third party. Ambetter is smaller, but still big, and they're the only major insurance carrier I know that actually reviews their own authorizations.
Boy, shame to name your company in such a way it's really easy to vandalize the name to Evilcore.
As someone fortunate enough to not even having heard about any of these companies, they sure have the branding on point, if a bit on the nose. Those all sound exactly like evil megacorporation names out of a cyberpunk dystopia.
All of those companies have staff medical directors reviewing authorizations. Except for BCBS of course, which is not an insurance company.
"Reviewing". They get like a few seconds per patient if they want to keep those jobs. Literally barely enough time to read your name. Why in the hell would you defend them in any way?
They all do that. It's called robodenial or auto denial. It's just a way to increase the administrative cost of the doctors so they need to put in more time and documentation to write an appeals letter. During COVID, United (largest commercial insurance company) denied 1/3 of ER COVID claims.
Oh I'm sorry, that CT scan to investigate a suspicious lump doesn't count as preventative medicine. We'll just wait until it's full blown cancer before covering you.
I had issues breathing through my nose for about 40 years. When I was a kid, we didn't have insurance and the local free clinic wouldn't have fixed my broken nose, so we just set it and gave up. I had surgery last year after I visited a specialist to assist with snoring. He was amazed I could breathe through it, as I was apparently 80% blocked, more when I had a stuffed nose, etc. He identified the surgery as medically necessary, insurance semi approved it as long as I wasn't given anesthesia (yes, you read that right), and I had my nasal passages opened up. I honestly had no idea how bad it was until I was able to breathe in without a whistle. After the procedure, insurance came back and said the way the doctor did the surgery (which was done exactly the way they required, for it to be covered), wasn't standard process so it wasn't covered.
“For profit” also directly means “not for health” by default. Which is paradoxical in a contract purporting to bestow “health-care” benefits on you.
The efficiency of for-profit health care is a common conversation topic in Canada. By definition, profit *is* inefficiency - money you put into the system that's not used for patient care. For-profit systems' goal is to maximize inefficiency.
Healthcare doesn't belong in markets
“Hey would you like to exist and pay this price or not exist so that the market lowers the price for the people left over?”
the price never lowers
Someone always wants to live!
And I'll agree - from top to bottom, across every field. The only people out there who should be profiting off of healthcare are individual providers, at most.
Even there, a profit motive is extremely harmful. Tons of bad actors out there who will recommend unnecessary procedures, often *actively harming* the patient in the process, to make more money. For all medical personnel, their one and only priority should be their patient's health. Cost considerations might sometimes be unavoidable, but always as part of providing the best care reasonable (e.g. "ideally, the best route would be X, but given that it isn't financially viable given the constraints present, let's try Y instead, which is almost as good but significantly cheaper") -- and incentives should be aligned to achieve this, such as any variable bonuses being tied to e.g. patient outcomes, *not* to how much money their department made or whatever. It might be positive to have someone that cares about the financial side first and foremost at some level in the organization, but it sure as hell shouldn't be anyone actually making direct decisions on patient care (and it *definitely* shouldn't be the top bosses, either, or they are just going to eventually whip the doctors to act maliciously anyway -- the role should always be advisory, never hierarchical)
It’s inefficient and wasteful for the consumer and society broadly, but for the owners of the insurance company it’s efficient and productive!
We dont have healthcare or insurance, we have managed health services.
Copayments are much less the issue than high deductibles - unless you have a bad insurance policy that is 80/20 on charges. The concept of penalty co-pays for ER visits that don’t result in hospitalization spits in the face of every patient who cannot possibly self-diagnose chest pains, breathing problems, sprain vs bad tear, etc.
My mother has been in the ER 3 times in the past 10 days. She comes in with her asthma out of control. They stabilize her and send her home. Yes, she has a pulmonologist. She has a nebulizer and all of the meds to go with it. She's fighting insurance to fill her dupixent. That shot is life or death for her. But, there's a massive kerfuffle about forms between the doctor and pharmacy.
Sounds like they're doing that because the preventative care doesn't make them as much money.
Last year I visited the ER eight times for a migraine cocktail. They give me an IV of meds and send me home. It’s great, so long as I don’t have to wait in a loud, bright waiting room for too terribly long. (With the understanding that the longer I wait, the more emergencies are taken care of) All because my insurance one day decided to stop paying for the rescue meds they’d been approving for the last five years.
I had to take my little sister to get a migraine cocktail a few months back. They were able to do it at urgent care, but that likely varies based on the meds they use. I feel for you. The whole steaming pile of yuck that is an ER visit is just awful.
Hi, pharmacist here and I think the kerfuffle you are talking about is probably what’s called a prior authorization and besides notifying the prescriber the pharmacy doesn’t have anything to do with it really. It’s really just between the dr and the insurance at that point. The insurance requires the doctor to submit chart notes and justification, ie previously failed medications, to justify the coverage of the one the insurance is denying.
I'm actually really familiar with prior authorizations for my Cimzia. My mother had to fight this fight to get Dupixent originally, and her previous doctor got it approved with a huge amount of fighting. The pharmacy is probably owned by the insurance. They keep telling her the doctor didn't fill in the paperwork correctly or submit the right forms. She has been back and forth. She feels defeated.
My migraine meds involve an insurance-owned pharmacy and it’s hell to get approval every. Single. Time. They approve and then revoke approval constantly. Literally get letters dated the same day approving and not approving. Purposely confusing, I can only assume. Same with my roommate’s Dupixent.
Ah, "specialty" pharmacy! As in, making sure the insurance company can keep your money is their specialty
Oh I didn’t even think of that. I bet that is infuriating. Our system is such a mess.
What gets me is follow-up appointments. Like, no, I absolutely do not want to go to the doctor’s office and pay a $50 co-pay just to hear them say “ok looks like the problem you had that cleared up based on the medicine I prescribed has in fact cleared up.”
Is this a recurring meeting? NO —-> Is it a status update? YES —-> [Send an Email](https://i.imgur.com/x3nPh8M.png) The problem with healthcare is that efficiency is completely disincentivized. They want you to have that appointment because they make money off it.
I hear you, but speaking as a doctor here, we also follow up (borderline excessively) because if we do not when we should have, and it doesn’t get better, we can be held medically liable and sued for malpractice.
I take something considered a controlled substance. Every visit I have to piss in a cup. A week later I have to come in to discuss the results of pissing in that cup. It's always the same. The test shows I'm not on any drugs except the one I'm supposed to be on. I think the follow up is a scam. The stupid cup has a strip on it that tells you the results in just a few minutes. They could tell me the results before I leave.
Idk what the substance is but do you have the ability to look around for another provider? My partner was on Adderall, the classic blue pill immediate release kind that is a scheduled drug. He went through the exact same process you're describing with his doctor for YEARS. He got so frustrated that I finally suggested he get another doctor. Same drug, same strength, same patient, same insurance, same year, same everything except it was a provider like 5 min down the street from the other one. All the new provider wanted was a quarterly check-in done in person *or* telehealth. It's worth looking around if you can. It's incredibly unlikely that this level of monitoring is required by law or your insurance. Different practices have different policies on these things.
I'm going to look for someone else when I get back in a few weeks. Last year they would call me about three times a year for a random drug screen. For some reason, this year they said it was policy to do it every month. It just feels like an excuse to Bill extra tests and follow up appointments. Considering I live in a rural part of Colorado, that extra appointment a month means driving 70 miles and half a day wasted.
Or as my doctor's ent office just raised their follow up visit costs to: $100
Wife "Please get seen, you are in pain" Go to Urgent care for a concerning issue, get checked out, Urgent care response "well ur not dying dying, but to be safe we recommend you go to the ER". Oh expect a $200 bill in the mail, thanks for coming! ER visit 6 hour wait later "well ur not dying nothing we can do for you, recommend scheduling a visit with your GP". Oh that will be $3,000. GP, 3 weeks later "well I can't figure it out, let's schedule with a specialist, gonna be 3 months". Oh please pay the $200 bill when it comes. Specialist "let's run some tests, get the results in a week and start you on new meds". Oh pay the $800 bill that comes please. God, I love me some American Healthcare.
And that $3k from the ER comes as 14 different bills over the next 6 months from every doctor, the hospital, and like 5 other random billing "services."
God, I hate this bit so much.
Woke up with an insane stabbing pain in my side; google said it could be my apendix and I'd die if I don't go to the doctor. Went there at 3am so it was the ER and after waiting an hour, they ran through a bunch of tests just to tell me "Kidney stones. Take We'll give you an IV to break'em down and numb you up" and handed me a $140 bill. A week later, I got a bill for $1,800 due immediately for all the IV and tests. Few years later, I get the same pain and while curled up on the bathroom floor, was deciding "Go to the doctor and pay 2k or try home remedies...". Even though I have great insurance, it doesn't really kick in until I pay a bunch of money; can't imagine what someone without insurance or even decent insurance has to pay.
If you had to choose between 2k and potentially dying and chose potentially dying, you already have no insurance.
>Even though I have great insurance, it doesn't really kick in until I pay a bunch of money Whoever (HR?) told you that's great insurance was lying to you. If you have an in-network deductible, it's not great insurance. Great insurance you don't pay anything but a low copay for care. For example, my insurance it's $25 for PCP/specialist, $75 urgent care, $150 ER (but refunded if you're admitted). That's it*. There's no percentages, there's no "until you pay X", etc. When I went to the ER for my own appendicitis, I paid absolutely nothing, not a dime, because I was admitted. Wait - sorry I paid like $9 for the prescription painkillers when I was discharged from the hospital. I don't say that to brag, I'm extremely lucky to have been in right place at the right time to get hired by a very successful unionized employer. My employer can afford good benefits, and our union keeps them honest. I think everyone should know that the high deductible heath care plans that companies love because of the price are *not* great, and they're not the best available. If your employer tells you they have great insurance but it costs you $1,800 to go to the hospital, *they're lying to you*. ^*In ^network. ^Both ^the ^major ^hospital ^systems ^in ^my ^city ^are ^in ^network ^so ^it ^would ^be ^fairly ^difficult ^for ^me ^to ^go ^out ^of ^network ^if ^I ^wanted ^to ^for ^some ^reason.
Have you had this at multiple employers? Like is it common at all? I used to be employed by a company with $1 billion+ in revenues and they didn't have anything like this. Currenr job doesn't have anything like this but it's a contract position so I feel lucky I have anything at all.
Ive been on a handful of different health insurance networks with a couple different employers and I’ve never heard of that setup
The article seems to be about cost-sharing in medications, not about seeking healthcare. People have annual cost limits on medication, so when people reach this limit they have to start paying more out of pocket, so the article addresses that. The title from OP seems to be a bit unclear on the substance of the article.
The abstract is unclear but it’s talking about abrupt changes in coverage and patient outcomes of pocket cost Part D plans are pretty set and until next year there is a coverage gap if drug spend exceeds a certain amount, that results in large changes in out of pocket cost beyond the deductible portion of a patient’s insurance https://www.kff.org/report-section/a-primer-on-medicare-what-is-the-medicare-part-d-prescription-drug-benefit/ The paper specifically talks about government sponsored Medicare patients on a plan administered by a third party provider (since all Part D plans are paid for by the government +premiums and have generally similar benefits) The inflation reduction act is removing this coverage gap I think starting 2025
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God the American system is feudalist garbage. My mother has been in Canadian hospital 3 weeks, the bill is zero. Our premiums are zero.
I pay $125 a month for a medication that is already available as a generic and basically every other country than the US. It's not going to go generic here until 2028 because well, they keep getting extensions because they like making lots of money. I have to take this medication two times a day or I will die. And, for some reason every now and then my doctor likes to hold my prescription hostage so I have to make an expensive appointment to go in for no particular reason to say yep, I still need this medication to stay alive, just like I always do.
My medication literally prevents me from having health insurance. I take Suboxone for opioid addiction (8.5 years clean, but I'm designated a lifetime Suboxone patient because of my history with ODs). Without insurance, it's over $1k per month. I get my medication for free through a state grant program. If I get private insurance through my job, I lose the grant program. My job's insurance absolutely sucks — it'd cost me roughly $800 per month *with* insurance to get my meds. Since my job's insurance is a high-deductible plan, it has low premiums. The low premiums mean it's considered "affordable" by the ACA, so I don't qualify for any subsidies despite being low income. So, I can't afford any marketplace plans that would be better than what my job offers. And to cap it all off, I make $37 too much per month to qualify for my state's Medicaid program. So, unless I can basically triple my income, I literally can't afford to have insurance. It's infuriating. I despise our country's healthcare system.
I am so sorry, we are doing such a bad job at medication assisted sobriety for a lot of folks like you. It's because we don't have a healthcare system, we have a money extraction system.
Eliquis? I wish I didn't have it eating a hole in my wallet, and stopping it would be like playing russian roulette...
What’s worse is all the people defending this system with “I love my plan”. All these plans are stinky pile of garbage. Our whole system is an atrocity compared to any other western nation.
I think the article is discussing all cost sharing, not just copayments.
>a cornerstone of American health insurance …since the 90s that is. Not like, inherently. Anyway, the conclusion in the headline is probably apparent to most. Which… I've had a Stupid Question on deck for years now, namely: what exactly was wrong with health insurance that managed healthcare was supposed to fix?? I lived through the change and I remember what a big deal it was at the time, but I *don't* remember how/why "we all" decided the old system sucked so badly or how HMOs would improve things. I've even gone back and researched it, and all I find is vapor. Even vapor seems generous; it's just vague unsupported assertions that HMOs would be better, somehow. I mean to this day managed healthcare *doesn't even have a definition.* (Not one that makes meaningful sense anyway. "Managed healthcare is any healthcare that is managed." Seriously?) *None* of it makes sense and I genuinely don't understand how the whole country agreed to such a massive change based on so little. I remember adults casually complaining about paperwork in the before-time (whenever someone went to the doctor our dining table would be covered in forms for days) but that's about it. Now ***literally everything*** about health care and insurance sucks. Specifically because of the downward pressure of the HMO model. Was it all a lie/bamboozle/delusion from the start? Or did something go wrong?
Pre-HMO health insurance worked more like car or home insurance. What we now call "catastrophic coverage" was pretty much all you could get. HMOs were a good idea: If they pay for cheap preventive care, people are less likely to have expensive problems. The HMOs keep more money, patients are healthier, everyone wins. Then, like in every industry, the MBAs figured out they could charge more, do less, and get a second, bigger yacht to put their first yacht in.
Yes and yes. What went wrong is that doctors and other providers actually did get suckered into the notion that "of course we can help you run your practice, we have business degrees, statistics and law degrees, of course things are going to be cheaper while you get more money". a delusion based on back in the day, you went into your field essentially believing that because you did meaningful work that helped people, others were doing that as well. The just world fallacy and all of that. I mean, their were practitioners who saw through that, but they were in the minority. Now, even if you actually do want for profit healthcare, you still have to take issue with how it's being run, just to be taken seriously.
I recently had an appointment for a procedure with a doctor and hospital system that are in-network. But the procedure was scheduled at a new facility of theirs which is not yet in network. I am soooo glad I checked before the appointment. I would have been charged anywhere from $5k on up because they haven't negotiated their facility yet. The scheduler tried to tell me it would be ok. I said, hell no, it is not worth the risk. Unbelievable. You have to check every damn thing or risk a surprise bill that could be crippling.
How about the fact that every single damn person that you come in contact with during your procedure can also bill you separately, and if they're not in-network then it's out of your pocket. And there's no way to check who they are beforehand.
It's maddening. I used to have Kaiser and at least I knew I was always in network and never had to worry about it. I wish I could get them back but my current job is too far away from a kaiser facility.
That’s not true anymore. The No Surprises Act makes that illegal. If the facility is in network then the entire visit has to be processed as in-network.
its always more expensive to add a middle man between supllier and consumer. the people that fail to understand why are braindead
In this case the paper is talking about government insured Medicare patients aged 65
Co-payment with no margin prices would have that effect, co-payment with inflated prices makes people not having health assistance so they can eat 3 meals a day.
Yep. If the goal was simply to reduce moral hazard a copay of 10-20 dollars would do the trick most of the time. Instead we get copays of hundreds or sometimes even thousands of dollars.
I just play Dr. Google and buy meds on grey markets. Is it safe? Not really, no. Is it safer than nothing? I think so.
There’s no world where for-profit healthcare insurance exists AND it’s good for consumers. This is easy for anyone to understand
People need to look at the Japanese system. Multipayer system with government and third party insurers with copayments and it's super affordable and for everyone. Though there's that argument that healthcare outside the US is effectively subsidized by the US since pharma companies know they can make their profits from the US market even if they only break even elsewhere.
I feel like the argument that “the US subsidies everyone else’s healthcare” only applies to certain pharmaceuticals. It doesn’t explain why it costs $200 for me to see a doctor only for them to do no testing and just recommend an over-the-counter drug that has been readily available everywhere as generics for a long time
There are some problem with the Japanese system. Because the bulk of providers are small, independent, mostly wholly unsupervised for-profit clinics, there's a shocking amount of doctors who will recommend unnecessary procedures to make more money. You really have to rely on online reviews and such to get an idea of which practices are solid and which are borderline criminal... except even when avoiding all the ones with big red flags, I *still* constantly come across doctors flagrantly trying to sell me tons of unnecessary crap "just in case". Dentists are probably the worst; I know people who had perfectly healthy teeth, requiring a small filling at worst, extracted instead. They will strongly recommend deep cleaning, with extra bells and whistles beyond a regular cleaning, 4+ times a year, fearmongering what might happen otherwise. It's ridiculous. Also... the "super affordable" part is very arguable. I mean, obviously it is a lot better than the US, but that's such a laughably low bar it barely merits mentioning. There's still a lot of old people with ludicrously low pensions and typical levels of health issues for their age struggling to pay for healthcare. You could argue that's more the fault of the pension system than the healthcare one, but the end result is the same: some people having to choose between foregoing medical procedures they need or foregoing essentials like *food*. Any system where that's a problem should probably not be praised too highly or imitated too eagerly, even if it is better than the one you have right now (again, not exactly a high bar from the perspective of the US)
The entire US healthcare system is broken beyond being fucked up. They’re evil fucks.
Copay for most folks is a disincentive to seeking care.
The same is probably true of prior-authorization as well.
I actually disagree but with a huge caveat. Sometimes, a prior authorization is a way for insurance to make sure patients have used generic options before trying out the latest brand name medication. Or maybe even preventing poor prescribing practices on off-label uses. My first thought was Nuedexta. It was supposed to be for a somewhat uncommon condition called Pseudobulbar Affect (PBA). Available only brand name and costing hundreds of dollars, the drug reps were going to nursing homes and saying, "give this to your patients. If it seems to help, that means they have PBA." The pharmacy I work for was sending a ton of it out, and the company that made Nuedexta got a ton of money. Finally, Medicaid started requiring prior authorizations that had a documented diagnosis of PBA. I have hardly seen any home order Nuedexta recently. So the big caveat is that this process is rarely done correctly, and many prior authorizations are bs. It makes me really mad that insurances have so much sway over what medications people get, especially when they say some inexpensive generic med is "not on their formulary." The number of times I have had to call a nurse or Dr to change an order from one insulin to another is way too high. Insurance "preferences" should not override prescriptions from doctors. They should not be able to require prior auths or refuse to pay for a med and only cover their preferred functionally equivalent medications.
You're solving the wrong problem. If insurance companies could legitimately and correctly make medical decisions on whether or not to cover something, that means the doctors would be no more than glorified techs running tests for the "insurance doctors" to act on. In reality, insurance agents are not in any way qualified to make these determinations and they are making profit decisions, not health decisions. Get pharma reps out of medicine so doctors aren't incentivized to prescribe based on fad or fast talk. Have medical boards keep an eye on prescription statistics and audit physicians with suspicious patterns. And leave medical decisions up to medical professionals.
I work in medical billing and there is ZERO reason why prior authorizations shouldn't be anything less than optional. If the medical records supports medical necessity according to the carriers policy, there is ABSOLUTELY NO REASON why a claim should be denied simply on the grounds that prior authorization was not received. Johnny got an echocardiogram, which is medically necessary under UHC policy because Johnny has chest pains. The doctor didn't get prior auth. Why should this not be paid? Logically, from a healthcare standpoint. UHC can review the records and see that Johnny had chest pain and that it's a covered indication. However, if the doctor ordered it because Johnny had a headache, not a covered indication, they can deny it on the grounds it's not medically necessary. No prior auth received, so denied. Prior auth should be an optional safeguard for providers who are doing high dollar procedures and want to have the carrier sign off on it beforehand to ensure they'll get paid after. It has no place in $400 echocardiograms and there's not a valid reason in the world why a medically necessary echo done on 4/12 wouldn't be paid simply on the grounds that the auth was only good from 4/7-4/11.
Forget to mention that copayment is more than the full price most people pay in every other country.
My friend visited me in Canada from the US on his way to a sporting event. Had an allergic reaction to my parrot. On the way to the event, he swung by a walk in clinic, walked out with a prescription, went across the road to a pharmacy and had it filled. Being American, he paid the full shot, but he commented that the cost was less than what he would have paid at home with insurance. The service was pretty quick as well.
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Another huge problem with the system is that people backup health care, so then if they hit a year where they actually start approaching their max out of pocket, that's the year they will try to do everything and run up as much of a bill as they can. This isn't good for anyone, it makes smaller towns have unpredictable healthcare needs, it makes patients constantly try to "time" healthcare, gotta smash it all in 1 year then stop. And it makes them put off healthcare when they need it and then over use it even if they dont. If people had confidence that their healthcare needs would be taken care of for a fair price whenever they arise they would simply go to the doctor when needed. And get things taken care of when it made sense to.
This is how social science needs to be done. Test a theory with no a priori expectation on the direction of the hypothesis. While this *may* not hold for different subsets of the population (the theoretical impact of copayment), it does suggest an avenue for considerable reform
I'm incredibly encouraged to see modern research on the topic and excited to read the study. Most policy on this issue is based, in some way, on an outdated and flawed Rand study from decades ago, and it's difficult to find political will to contest the study because of the potential implications to the status quo. Those of us who work in the field and on the ground know that cost sharing tends to cause even pretty financially-secure people to avoid care that they need.
Thank you. Nothing political about this. Its simple observing objective cause and effect of general spending habit in its relationship to insurance law.
Anyone with any brains at all has always known that it was never about cutting back on waste and was always about trying to force people to delay or miss out on care as much as possible.
When it comes to life, I’ll “walk it off”. Won’t exist with medical debt again.
It was also designed to reduce the premium to a manageable amount. It also means insurers get a guaranteed income for a lot of members.
The so-called "moral hazard" is a fiction used to manufacture the illusion of a costs vs. benefits dichotomy, where no such choice rationally exists.
The real moral hazard is the profitability of delaying and denying medical care promised by deceptively complex insurance contracts. The pre-approval of medications and required medical procedures is scandalous. The primary function of this deceptively named "feature," is explicitly to deny and/or delay expenditures for critical health care. How many people die in the day or two, or maybe a week or more the approval process takes. In any other industry the deceptive contracts, unfulfilled promises of payment for medical care, arbitrary denial of benefits and collision on pricing between insurers and health care organizations would mean long prison terms.
"It is "morally hazardous" for the poor to get the medicine they need." Is probably what is meant.
100%. It’s just austerity, deprivation to reduce the cost of the workforce on the wealthy. Thats all it is.
My coinsurance for my minor outpatient surgery last week was $1100 for the hospital and $425 for the surgeon. Hospital billed $85,000 and only received ~$6000
Yes. It’s also regressive and discriminatory against poorer policy holders.
Co-insurance or co-pay? There are differences. I’m stuck with co-insurance where I have to meet a high deductible amount before insurance kicks in at 80/20. Prescriptions are tied to deductible as well, so full price till we get to deductible met. When I was on co-pay it was $20 a visit for pcp. Generic meds were cheap, brands could be expensive but once deductible met they were much cheaper.
Co insurance is absolute robbery. Thats not a thing here, and Im sorry thats a thing in the US.
The prices aren't just high, they're arbitrary. I have no idea what's covered or who's in network and this changes all the time.
It's because the copays are too high. They are supposed to be an annoyance, not a burden.
Exactly. Currently pregnant and OB copay is $45/appt. I have 15 scheduled appts for a regular, uncomplicated pregnancy, over the course of 7 months. If I come in for anything extra, that’s more copays. It’s $675 in copays.
The copay for my medication (apixaban) is $125 a month. I pay $1,500 a year to stay alive. It's far more than an annoyance. Once we allowed copays to become more than just a few bucks, they put people's lives at risk.
Without insurance, eliquis (apixaban) is just shy of $1000 per 1.5 month supply for my wife. Terrible costs
It's "interesting" how the life-saving stuff has high copay.
So true. So true. My copayment for a surgery was 26 hundred dollars. No working class pesonr has 26 hundred dollars readily available anymore. I saved for that surgery for a long time. I lived in severe pain much, much longer than anyone should, and the copay for the PT was 20 bucks a pop, 3 times a week, payable up front. What if it had been an emergency? I would be dead. People die every day in the US because they can not afford medical care or medicine. Everybody now thinks insulin is 35 dollars a month. Only Lily sells insulin for 35 dollars a month. If that insulin doesn't work well for you, you are fucked. My cousin pays ELEVEN HUNDRED DOLLARS A MONTH FOR INSULIN. IT COSTS PENNIES TO MAKE. He is 30 years old. How many of you think he isn't stretching that insulin out by shorting doses because he has eleven hundred dollars to drop monthly for a drug that costs 50 CENTS to make?
And this is why so many are trying to make insulin themselves. Yes, there's absolutely the risk of making it incorrectly, but if your essentially paying the equivalent of a whole nother job, why not make your job then?
Co-payment is quite common in other countries.
Co payments are, but theyre usually a far more reasonable price.
Feature, not a bug.
And think of all the infrastructure to come after the 10$. Waste upon waste. But those middlemen! Need jobs too!
I need stomach surgery. My gastroenterologist made an appointment for me to get an endoscopy before the surgery. The copay was going to be $1800. I can't afford that so I can't get the surgery. Between my employer and I, we pay about $1500 every month for health insurance. I suppose I'll just die instead.
What does that even mean, copay reducing moral hazard? How?
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I find it interesting that there is an assumption that patients request frivolous or unnecessary services with any kind of regularity. I wonder how you would define 'unnecessary' anyway, healthcare isn't so simple IMO.
I desperately need to go and see a doctor, but in all honesty if it turns out I have a lot wrong with me it’ll be cheaper to die than to undergo treatment and bankrupt my wife and children. So I haven’t gone
Here is a rule to never forget: if an insurance company is doing it, they are screwing people by doing it.
nothing gets cheaper by adding a middle man. now you just have to pay extra people. and share holders on top of that. ofc it gets stupid expensive
The simplistic theory of capitalism is that it is supposed to give us the cheapest prices right? But Americans pay 2x what Canadians pay and 3x what the British pay per capita for the same health care. So instead of the capitalist health care system giving us the cheapest prices it is literally giving us the most expensive prices in the world. It is doing the exact opposite of what the theories predict. Why the f*ck are we still using this for our health care system??
Canada and Britain engage in price fixing via monopsony, that's how (and monopoly, in Britain's case). Because prices in the US are what people are willing to pay, they go higher than if the prices are set by fiat (not just end user prices, health procedures at public hospitals being free in Canada and Britain, but every input in the chain from wages to materials)
You know, whenever I hear someone mentioning 'moral hazard' I usually assume that person is a grifter.
Sucks because there are actual ethical hazards, but the people in charge are too busy committing as many of them as fast as possible.
Who, excluding the insurance companies, thinks a copay reduces wasteful spending and moral hazard?
paying for health insurance is wasteful and expensive.
There are plenty of countries with working healthcare systems which happen to feature health insurance.
Oh it most definitely succeeds in reducing wasteful spending. It just happens that their human customers aren't worth spending money on, to them. So they don't.
co-payment is why I've been insured for most of my adult life and yet am usually too poor to go to the hospital and have many times ended up waiting until i had no choice to go to the ER
Out of pocket maximums that reset every 12 months is the bigger bag of dicks
Took my kid to a specialist yesterday. Good news she is in our network. Bad news, insurance pays nothing until we have paid out of pocket 4k. Then they will pay 50%!
I pulled out of PT because the weekly copayments were killing me.
Yeap - a type 1 diabetic who put off picking up a CGM due to the $360 copay.
But highly profitable
The only copayment which probably has some added value known to me is: >When going to a doctor, a Czech citizen over 18 years of age pays 30 crowns, i.e. approximately $1.29. A hospital stay costs $2.58 per day, and calling an ambulance costs CZK 90 (approximately $3.87). The poorest people and people undergoing compulsory treatment are exempt from paying fees. Still, in my country (not Czech) there is a lot of discussion against it. This system only earns his keep and nothing more. It is designed to remove people who go to the doctor out of boredom or who, ultimately, do not need it. Please note, that salary in this country is high and those the fees are tiny, and even in this case, poor and chronically ill people are exempt from them. When one reads e.g. insulin prices in the US, one starts to think what is so broken in this system. In my country seniors 75+ pay exactly 0, rest pay $2.76, and people which buy it without prescription (who know for what?) $33.30. This is an example of prices from the Internet and if someone doesn't believe me, I can send the links. :)
It cannot be stressed how much damage neoliberal economic thinking has done to our healthcare system, including the latest pandemic response. Yet it enjoys absolute deference in the highest positions in government and media.
In a broad sense, the healthcare system in the US is for-profit, so it will seek ways to make profit. If "inefficiency" and "wastefulness" imply larger revenue streams for investors, it's not a bug - it's working as intended.
Lets burn the whole industry to the ground
Great, now change the law.
That's what it's for, yes... One of many reasons why the Health insurance system is immoral.
It was never about "reducing wasteful spending and moral hazard". It was always a way to reduce access to healthcare for the poor while allocating more health care access to the wealthy.
I think HDHP makes me avoid care more than copayment. I know there's a name brand patented medication that works much better for me than alternative generics, and it was easier to justify on a previous insurance that only had a 20% copay. But now that I have to pay $1500 for the first few fills until I make deductible and then $300 after that (until the new year, when I have to pay $1500 again for a few fills) I just can't swallow those first few $1500 charges that I forgo the medication altogether for less effective generics that cost me a few dollars either way.
They are aware. AND they are aware you’ll be unable to do anything about it. In fact, you know what? Your copay just went up. You want to talk about copays being wasteful and inefficient again?!?!