Is Health insurance in the wrong

MaritesaRN · Aug 28, 2009

Most insurances do pay for those things, but it is up to the patient to do those things.
But to play the devil's advocate. It is our duty to ourselves to get preventative care. House insurance pays for major damage in case of an accident. It does not cover routine expected repairs. Life insurance pays if you die, not for your personal upkeep. Auto insurance covers damage from an accident, but does not pay for maintanence.
Why do we expect health insurance to pay for routine care? That should be our responsibility, to provide proper care and maintenance for ourselves.
That said, I really like having them cover my checkups, though I do pay more for my insurance.

:nurse:

A good insurance system needs to cover the people for the preventive--- if you look at it , both will benefit; people get treated before it gets worse, and insurance company benefits by not spending more money in the worse part of the disease. You are a lucky lady that you have insurance either from your husband or from your employer. But what if you do not have a husband or lost your job ....what next? You will have no insurance and will most probably rely on medicaid of which is already beyond it's capacity with all this unemployment. Few to none, can afford the expensive COBRA premiums for a few months until they find work, that is if they can find work.

Routine care is for basic exam and labs to make sure things are in the norms. Of course people should take care of themselves in exercise and diet, etc. Not every one can afford on their own a papsmear lab work for $250.00! ( that was the bill from the laboratory from my preventive papsmear) .

That said , I feel that your response is naive. It is like the story of the French revolution, when the people revolted because they are starving, one of the royalty's response to this was, " if they have no bread, then why not eat cake?" :confused:

husker_rn, RN · Aug 28, 2009

I'm all for healthcare reform. Some detracters say people won't get care in a timely manner.....to that I reply that if you can't afford insurance or have poor coverage you STILL won't get care as quickly as someone with insurance. It's easy to say all is well ....unless you're one of the millions with little or no coverage. Not sure the answer but if there was no profit in healthcare I'm guessing things would be much different.

MaritesaRN · Aug 28, 2009

The whole "health insurance only covers you when you get sick" is not a correct statement. My insurance covers preventative exams such as physicals and pap smears as do most insurance companies...which to me are preventative...It's up to the patient to take the initiative to get these exams.

:coollook:

You are right , most insurance covers preventive measures of which they pay 100%, and person should not pay anything for preventive measures , and they do give you a list of what the preventives are. My insurance from my employer seemed to be getting expensive or higher premiums as the years go by . Before I do not have to worry about paying anything except for the out of pocket of which was very little. anyhow, to make it short, I had a physical and my physician ran a couple of relevant tests . In the lab order he also included a lipid and a metabolic ( really basic labs) . guess what ......the 2 relevant lab test was denied ! Now I will have to spend time arguing w/ them becaseu this is medically necessary...my precious time wasted doing the work of this insurance company , and I will bill them of the time used to correct their mistake ! Then the laboratory sent me a bill , I then spent a time calling the insurance company , only to find out that this laboratory did not submit any claim, but he wants money from me.........then as though not enough , rather insult to injury, the lab sent me a letter threatening to report me to the credit people. :banghead: tha was it ...... I called them and told them to try it , so I can sue your as.. !!! See these are the kind of things that needs to be fixed. There should be no confusion in the process and no denial of a relevant lab tests!!!! --- they simply do not want to pay. I will log in all the time that I dela w/ this insurance and then bill them for my time because of ther mistakes. :nurse:

Yup , I am taking this on !!! I am just so fed up w/ the inefficiency of the current system. Any new health reform will be so welcome.......not for me necessarily but for the uninsured people out there, who must have a health care type of package, specially the children ! Here in California , due to lousy budget , they are taking some fundings from the healthy family funding..... there goes preventative care for some children !!!! Now you tell me ....do we need health reform or not????

caroladybelle, BSN, RN · Aug 29, 2009

A good insurance system needs to cover the people for the preventive--- if you look at it , both will benefit; people get treated before it gets worse, and insurance company benefits by not spending more money in the worse part of the disease. You are a lucky lady that you have insurance either from your husband or from your employer. But what if you do not have a husband or lost your job ....what next? You will have no insurance and will most probably rely on medicaid of which is already beyond it's capacity with all this unemployment. Few to none, can afford the expensive COBRA premiums for a few months until they find work, that is if they can find work.
Routine care is for basic exam and labs to make sure things are in the norms. Of course people should take care of themselves in exercise and diet, etc. Not every one can afford on their own a papsmear lab work for $250.00! ( that was the bill from the laboratory from my preventive papsmear) .
That said , I feel that your response is naive. It is like the story of the French revolution, when the people revolted because they are starving, one of the royalty's response to this was, " if they have no bread, then why not eat cake?"

As I said I was playing the Devil's advocate, but you actually were too "naivie " to read that, nor have you read my post history of supporting universal health care.

Having said that, I have had to go uninsured for quite a few periods of my life including during nursing school. I have also raised a child during time periods when I made "too much" money to qualify for assistance or financial aide, but was barely making over minimum wage. I worked full time through nursing school because I had no other choice. And as a cancer survivor though in remission for over 20 years, I am virtually uninsurable except through an employer.

I still paid for my child and my routine healthcare and for our meds. It meant a great deal of sacrifice and stretching money to the max.

I recently had a physical that I paid the full fees (no insurance) for it. Why???? Because the insurance that I had briefly for one job did not cover my regular MD, and that MD has helped me when I didn't have insurance. It cost me several hundred dollars. I paid it. Ironically, I found out later that the MD would have negotiated a lower fee or comped me, as he is glad that I make sure that I get my care done.

No one can afford a $250 papsmear lab bill...oh, yes they can because I have personally paid those bills.... and more. I can can dig out my bills for endoscopy while I was uninsured. If you think that that a endoscopy is painful, try paying the full bill for one. It is very rude to be dismissive of me - I am hardly Marie Antionette nor royalty and I have lived at the bottom with no safety net to be found (again plenty of posts on this BB).

Quite a few people grip about spending several hundred dollars for their yearly physical, but then pay as much or more for their monthly car payment. Which is more important...keeping your body in good condition or having a bright new shiny car?

I will admit that I gripe as much as the next person about having to fight about getting my mammogram reimbursed (you can reference prior posts on that one), but the fact is a physical (and that mammo) should be considered in my yearly budget, as it is part of maintenence and SHOULD be my responsibility. Insurance should not need to be my "nanny" for routine "life" maintenance.

I currently pay a higher fee to my employer to have slightly better insurance coverage. I do now have very good health insurance through my employer but I also worked very hard to get a job with an employer that offers that benefit. That employer requires extra work on my part to be employed by them and I have sacrificed to earn that. I continue to sacrifice for that.

I do believe in universal coverage and I do believe in reform....mostly because nations with it, without a doubt have better longer lives than we do and someothing has to be done to rein in costs. The current system is badly broken.

PS That "let them eat cake" comment - your use is ironic . It has never been shown that Marie Antoinette (who never wanted to marry into the french royalty) actually uttered that phrase preceding the french revolution. It was a falsehood that was spread to inflame the populace against the french royalty. And it was a very successful lie.

carolinapooh, BSN, RN · Aug 29, 2009

The whole "health insurance only covers you when you get sick" is not a correct statement. My insurance covers preventative exams such as physicals and pap smears as do most insurance companies...which to me are preventative...It's up to the patient to take the initiative to get these exams.

MANY insurance companies (and I'm not talking about big group policies which many of us are very fortunate to have, I'm talking about what Working Average Joe can afford to pay for) DON'T pay for preventative medicine at all. I see it way too much up here on my floor.

carolinapooh, BSN, RN · Aug 29, 2009

As I said I was playing the Devil's advocate, but you actually were too "naivie " to read that, nor have you read my post history of supporting universal health care.
Having said that, I have had to go uninsured for quite a few periods of my life including during nursing school. I have also raised a child during time periods when I made "too much" money to qualify for assistance or financial aide, but was barely making over minimum wage. I worked full time through nursing school because I had no other choice. And as a cancer survivor though in remission for over 20 years, I am virtually uninsurable except through an employer.
I still paid for my child and my routine healthcare and for our meds. It meant a great deal of sacrifice and stretching money to the max.
I recently had a physical that I paid the full fees (no insurance) for it. Why???? Because the insurance that I had briefly for one job did not cover my regular MD, and that MD has helped me when I didn't have insurance. It cost me several hundred dollars. I paid it. Ironically, I found out later that the MD would have negotiated a lower fee or comped me, as he is glad that I make sure that I get my care done.
No one can afford a $250 papsmear lab bill...oh, yes they can because I have personally paid those bills.... and more. I can can dig out my bills for endoscopy while I was uninsured. If you think that that a endoscopy is painful, try paying the full bill for one. It is very rude to be dismissive of me - I am hardly Marie Antionette nor royalty and I have lived at the bottom with no safety net to be found (again plenty of posts on this BB).
Quite a few people grip about spending several hundred dollars for their yearly physical, but then pay as much or more for their monthly car payment. Which is more important...keeping your body in good condition or having a bright new shiny car?
I will admit that I gripe as much as the next person about having to fight about getting my mammogram reimbursed (you can reference prior posts on that one), but the fact is a physical (and that mammo) should be considered in my yearly budget, as it is part of maintenence and SHOULD be my responsibility. Insurance should not need to be my "nanny" for routine "life" maintenance.
I currently pay a higher fee to my employer to have slightly better insurance coverage. I do now have very good health insurance through my employer but I also worked very hard to get a job with an employer that offers that benefit. That employer requires extra work on my part to be employed by them and I have sacrificed to earn that. I continue to sacrifice for that.
I do believe in universal coverage and I do believe in reform....mostly because nations with it, without a doubt have better longer lives than we do and someothing has to be done to rein in costs. The current system is badly broken.
PS That "let them eat cake" comment - your use is ironic . It has never been shown that Marie Antoinette (who never wanted to marry into the french royalty) actually uttered that phrase preceding the french revolution. It was a falsehood that was spread to inflame the populace against the french royalty. And it was a very successful lie.

It's great that you could pay for your own medical care - but the fact remains that there are plenty of people - good, honest, hardworking people - who can't - who are at the end of their means or who have been dealt crappy, crappy hands and simply don't have the ability to pay.

Ask the people who have gone bankrupt because they couldn't pay medical bills because THEY were diagnosed with cancer and lost their jobs - and lost their medical insurance and STILL NEED TREATMENT costing tens of thousands of dollars a pop. (We have two on my floor right now in this mess.) Ask the people who were disabled in car accidents, could no longer work, and lost health insurance but still need thousands of dollars in rehab. They're out there and they're really not hard to find. These folks are not worried about preventative care, because all the preventative care in the world wouldn't have necessarily saved them (try preventing leukemia in a three year old or lung cancer in a nonsmoker - there's no test for lung cancer until you get it).

Forgive me for saying so - but you also sound a bit dismissive over others' plight by saying "oh yes they can" - because sometimes good people can't. I am a huge huge supporter of universal primary care, but God knows we need some sort of safety net for those who need more - and getting sick shouldn't mean you have to fear losing your health coverage.

caroladybelle, BSN, RN · Aug 29, 2009

Sigh....

You are still not reading my post and topic.

The OP was about insurance paying not PAYING FOR ROUTINE YEARLY physicals. And my post had to do with paying for ROUTINE physicals/checkups.

It had nothing to do with covering :leukemia, lung cancer, catastrophic events, major surgeries. as those are not "routine" care and obviously should be covered by insurance.

It also had nothing to do with people that have lost said insurance or being uninsurable. Because presumably they ARE NOT insured, therefore the matter as to whether insurance will pay for preventative care or not is irrelevant as THEY DO NOT HAVE INSURANCE!

I too have pts that have lost jobs and have difficult lives and high expenses from medical care, especially given my specialty. Virtual all of my patients will spend weeks in the hospital and 100s of thousand of dollars. And plenty of them are uninsured/underinsured. Few to none of them have adequate resources to handle these expenses.

This has nothing to do with the topic of insurance covering ROUTINE care...because it is definitely not routine care.

Sure there is no test for lung cancer before getting it , just as there are very few cancers that have tests that will show that you will get ANY cancer before it shows up. This still has nothing to do whether insurance will cover ROUTINE care in those that they insure.

The topic is whether insurance (in regards to those that they insure) should be expected to pay to pay for "routine care".... in addition to catastrophic care, cancer care, major surgery that is clearly nonroutine care, and clearly covered.

And like car maintenence, or house maintenance, those of us that have insurance should expect to pay for "routine" care, though it is nice if insurance does it for us. A case can be made that if I neglect the routine maintenance of my car, I will get into more accidents (bad brakes, car conking out in traffic, skidding from bad tires) that will cost insurance more money. I still don't see car insurance companies ponying up to pay for my ROUTINE tire rotation.

Insurance (again referring only to those insured as that is the TOPIC) was designed for caring for the accidents in life, the leukemias, the car accidents, the major surgeries. While it is nice when it will cover routine care/checkups, that is not its' responsibility, it is ours.

llg, PhD, RN · Aug 29, 2009

I think this thread is bringing out an important distinction that most people usuall miss:

There is a difference between an insurance policy -- that exists to help people spread the financial risk of major events ...

... and a maintanence contract -- that exists to form a buying group that lowers the cost of regular maintenance activities.

Whether we are talking about health, cars, homes, appliances, electronics, etc., that distinction is the same. The fundamental purpose and product of "insurance" is to pool money to share the risk of large losses. The fundamental purpose and product of a maintencance contract is the pooling of resources to form a large buying group that then negotiates lower prices for routine services.

In the US, the HMO and PPO concepts have tried to merge the two -- and insurance companies have offered a few health maintenance benefits as part of their plans. That disguises the fact that there are 2 very different financial goals being addressed. People have come to merge the 2 in their minds. So, the discussion gets convoluted as one person is thinking of one function and the other person is thinking of the other function.

To make sense of it all, we need to clearly differentiate between the 2 functions to avoid mixing up our apples with our oranges. Only then will we be able to design a health system that will address both components appropriately.

We need to think about them more clearly.

carolinapooh, BSN, RN · Aug 29, 2009

Sigh....
You are still not reading my post and topic.
The OP was about insurance paying not PAYING FOR ROUTINE YEARLY physicals. And my post had to do with paying for ROUTINE physicals/checkups.
It had nothing to do with covering :leukemia, lung cancer, catastrophic events, major surgeries. as those are not "routine" care and obviously should be covered by insurance.
It also had nothing to do with people that have lost said insurance or being uninsurable. Because presumably they ARE NOT insured, therefore the matter as to whether insurance will pay for preventative care or not is irrelevant as THEY DO NOT HAVE INSURANCE!
I too have pts that have lost jobs and have difficult lives and high expenses from medical care, especially given my specialty. Virtual all of my patients will spend weeks in the hospital and 100s of thousand of dollars. And plenty of them are uninsured/underinsured. Few to none of them have adequate resources to handle these expenses.
This has nothing to do with the topic of insurance covering ROUTINE care...because it is definitely not routine care.
Sure there is no test for lung cancer before getting it , just as there are very few cancers that have tests that will show that you will get ANY cancer before it shows up. This still has nothing to do whether insurance will cover ROUTINE care in those that they insure.
The topic is whether insurance (in regards to those that they insure) should be expected to pay to pay for "routine care".... in addition to catastrophic care, cancer care, major surgery that is clearly nonroutine care, and clearly covered.
And like car maintenence, or house maintenance, those of us that have insurance should expect to pay for "routine" care, though it is nice if insurance does it for us. A case can be made that if I neglect the routine maintenance of my car, I will get into more accidents (bad brakes, car conking out in traffic, skidding from bad tires) that will cost insurance more money. I still don't see car insurance companies ponying up to pay for my ROUTINE tire rotation.
Insurance (again referring only to those insured as that is the TOPIC) was designed for caring for the accidents in life, the leukemias, the car accidents, the major surgeries. While it is nice when it will cover routine care/checkups, that is not its' responsibility, it is ours.

(I will apologize for this post up front because it's shamefully disorganized and I'm aware of that. But health care is my soapbox and I'm going to get on it.)

Which was what I said in an earlier post - but my point is still relevant. What I was saying is there are folks who cannot afford preventative medicine out of their own pocket - they simply can't. And they're not driving the latest shiny car, they're busting their tails to keep their heads above water.

There are too many insurances that do not pay for routine care because they do not perceive it as routine in the first place. I expect insurance to pay for routine care because that's why I have it - I don't have it as catastrophic coverage, I have it to help out with all medical expenses. At three hundred bucks a month it BETTER pay for some routine care. Routine care can put you out on the streets as quick as a medical catastrophe can.

Why is it that in the US - the wealthiest nation per capita on the planet and the most industrialized nation in the so-called first world - we can't provide basic health care for people? We don't even provide it for our poorest citizens, because the sheer number of Medicaid patients who turn to my hospital's ED for MD care tells me we don't.

Car insurance doesn't buy tires because it's not designed to - it essentially amounts to catastrophic coverage: car gets wrecked, they fix it because you don't have four grand or whatever to repair it, which is not the same as health insurance. Car insurance does not pay for preventative maintenance - although it's interesting that now with the purchase of some new cars you can purchase extended plans that DO cover routine maintenance....to pull your comparison a bit further.

So back to health insurance.

If it were TRULY HEALTH insurance, it would PAY to keep you healthy, no questions asked, and not cover your bill once you're hospitalized (ha ha, or not, as the case may be). And it's not something big insurance wants to do because they're too blind to see prevention as cost effective: I've seen insurance companies say they'll pay for a CT scan but not a PET scan nor an MRI, and they''ll pay for your cancer treatment. Well, here's the problem: accurate diagnosis of the cancer can't be made without the PET scan, so we can't figure out effective treatment. So what good is the insurance? We could prevent a lot of incorrect treatment and possibly cure you - but we can't unless you've got five grand out of your own pocket for this PET scan. We THINK you have Cancer X, but it could be Cancer Y - and we'll only know with a PET, which you can't get b/c you can't afford it. So we'll try treatment for X, and if it doesn't work we'll try Y. The kick is, you might not have either - you could have Cancer C - which the PET would probably also show. Nice, huh?

I just saw that last week. No kidding - I wish to God I was.

The problem in this country is we have no stopgap, nothing to cover people who can't work anymore because they got sick or people who developed X condition and lost their health coverage, so they don't even have primary care anymore which could help prevent even more problems...it's a vicious cycle and it's disgusting that it happens here, of all places.

If you have a chronic disease (and cancer is now considered more a chronic than terminal disease), every specialist visit is routine care - and unless you have a group policy (because we passed a law saying they have to cover you), you probably don't qualify for that routine/preventative care, so when your cancer comes back, you might not find out until it lands you in the ED and it's become acute care. But you have insurance companies saying, no no, you can't go to X physician because you've already been there too many times over the life of your policy...

(And as far as group policies and employers kicking in more for prevention, look up the Cleveland Clinic's successful Lifestyle 180 program and read about the money they've saved due to a SIGNIFICANT DROP in health care dollars fronted by the organization...premiums for employees DROPPED last year because they're saving money by footing the bill and encouraging participation in this program. Kicking in cash for prevention is saving them money - if it didn't, you can bet they'd stop it. Hopefully other companies will learn a lesson and get on the bandwagon.)

Of course the uninsured and underinsured are relevant to the conversation because they stand as grim evidence of the inherent problem: the abominable state of health care in this country, which is what I thought the thread was about - "IS HEALTH INSURANCE IN THE WRONG"? You bet your pants it is.

Yes that was a rant - and disorganized, and I apologize. But I assure you, what I said was completely relevant to the topic and the thread at hand.