United wouldnt cover my refill my script for antibiotics because they said I didnt need it yet despite the fact that the very same Doctor gave it to me because the original amount wasnt enough.

True it only cost me $15 but what the hell am I paying $80 a month for if they wont cover me on the rare chance I actually use my insurance?

Consumerist said:

If you're going to switch providers, shouldn't you find out whether they cover the medicine you'll be needing?

Well, sure, if she made the decision. But most people don't get to actually make that decision - it's made by their employer to save money. And the insurance company covers their lower price to the company by cutting corners whenever they can - like denying coverage for a legitimate prescription.

K

I ran into the same problem with ExpressScripts and Wellbutrin XL. After 6 months, they said I was "ineligible" for my prescription to continue unless I switched to a (nonexistent) generic. After a couple of months of talking to my doctor, my insurance provider and the pharmacist, I gave up. Needless to say, thanks to ExpressScripts, I've been off my meds for a year and a half.

I think the insurance companies are hoping to eventually cut out the middleman and simply run their own clinics and pharmacies. "I'm sorry, sir, we're unable to set your broken leg because we've deemed it a non- life threatening affliction. Here, we have prescribed you a 30-day supply of ibuprofen. Do you need someone to help you out to your car?"

Isn't it pretty safe to say that you could easily substitute United Healthcare in this example for just about any other insurance company?
I mean, the only reason you're not writing this about everyone else is because you haven't gotten letters about it, but they all pretty much suck equally.

They're equal suckertunity providers.

I've been battling Empire Blue Cross/Blue Shield for the same reason. Two weeks ago I went to the pharmacy to have my Lexapro RX filled and was told that Empire only pays for 1 pill a day. My dosage is 15mg so my doctor writes out the RX for 45 10mg pills and I have to cut them (it's a pain).

After my doctor repeatedly faxed and called them my RX was finally approved...Of course this was after they tried to switch me to another cheaper drug. During this 2 week long process I was told it would take 72 hours for Caremark to receive a fax (that's one slow fax machine) So I requested a supervisor...Two days later received a phone call from a customer service supervisor informing me everything was all set with my authorization. So you can imagine my surprise when I went back to the pharmacy and my RX was denied again for lack of pre-authorization. After about 6 phone calls between the pharmacy and Caremark my RX was finally filled. But I went a week without my meds...I basically told Empire and Caremark if I didn't get my meds I was going to go to the ER.

The best part is all the gory details ..like the representative at Caremark's Emergency hotline telling me she couldn't give me advice because I might sue them. The customer service hotline that gives out false operating hours and being hung up on.

I'm lucky considering I have half my wits about me but I feel bad for the people that can't navigate these systems and just have to take it from these insurance companies. I don't know why I'm paying for insurance and the worst part is they treat you like a criminal when you try to file a claim.

I've said it before -- there is a special little corner of hell reserved for these "utilization reviewers."

Ugh, don't even get me started on health insurance. Every month I send off a monstrous check for my individual health insurance (not provided by work) but every time I need ANY medical care, it somehow isn't covered.

In my opinion, the absolute worst is that they refuse to cover my annual "Well Woman" exam (for those of you non-women, that's the yearly trip to the gyno for the fun pap smear). It's abhorrent that they would prefer to take their chances on me getting cervical cancer than pay $120 once a year to prevent it. As it turns out, my ins company offers coverage for that ONE exam for an increased rate, which works out to cost me about $200 a year. Obviously it's more cost efficient for me to just pay for my own, apparently unnecessary, pap smear.

And I'm not even going to get started on the many insurance companies that have no problem shelling out for a horny old man's Viagra scrip, but deny coverage for birth control pills.

I am a pharmacist and I often get caught up in United Healthcare's crap. I think that they are hands down THE WORST insurance company that I have to deal with.

I had a guy come in a few weeks ago and they would not pay for hemorrhoid suppositories for a poor guy. I called the doctor to get him to switch it to a hemorrhoid cream (which was about half the price) and they would not pay for that either. The doctor then called United to get them to cover either the cream or the suppositories. After the doctor called and explained the obvious necessity, they still refused to pay for either. What a pain in the ass.. literally.

Homerjay is right though. Most of these companies have their own fair share of nonsense. United just happens to be the worst of them all.

I have Medco. My employer recently switched to them promising they covered the same drugs at the same cost as our previous company. I looked at the fine print and it has a list of drugs that they say they can limit to certain quantities a month. My main drug of choice, Imitrex, is on that list. If I go over this secret number, they too say it will require a review between them and my doctor.

Imitrex is a life-saver for me, but it costs $20 a pill. If I don't pop a pill in early stages of a migraine, I'm in for 24 hours of horrible pain where I can't even function enough to stand up. Not even a shot of Demerol will save me at that point.

So far I haven't hit this secret amount. I'm going to be in deep trouble if I do. I'll find myself wondering whether or not to take each pill and if I make a wrong choice, I'll be in bad shape for a day. :(

This is becoming a problem here in Canada too. I have Blue Cross through work. I was given a Rx for an Asthma inhaler by my doctor because I'd had a really nasty chest infection, and my doctor said it would help me breathe.

I'm glad I don't have Asthma or any other condition requiring an inhaler on a regular basis. My pharmasist told me that Blue Cross will only cover the first Rx for inhalers. Then, if you need a refill, you have to apply to see if they'll fill it. She also told me that unless you need it to survive, they'll deny you the refill forcing you to pay over $100 per refill.

This is America. Let me give you a hint... Tort reform is a bad idea. You know why? Because then you can't SUE!!!

Let me see... failing to cover a doctor written prescription, a bad result, and a jury. I am sure not covering 15 pills is really going to sit good with a jury...

These lying insurance companies promise their "clients" the moon and deliver feces. The lies they tell patients easily qualifies as the 21st century equivalent of carney schuckterism. They tell these poor people they'll pay for their medical needs then deny the charges, they lie and tell them a call from your doctor will get them their meds - those "calls" take 2 hours with the phone tree from hell and then the doctor gets an automated fax denying the need for the medicine. I've seen medicines disapproved for "equivalents", even though the request stated clearly the patient was allergic to the medicine UHC recommended. Upon calling the allergy to the attention of the reviewer at UHC, a second fax was received recommending the medicine the patient was allergic to again. I've seen the company deny necessary medicines and blame the doctor for "failing to request" the medicine from UHC, fortunately the doctor had all the faxes and phone calls to th company well documented.

I recently had the same problem with a prescription for my son. The prescription was for 1 1/2 pill a day of a 50mg dose (75mg total). The insurance refused to cover the 1/2 pill portion. The solution (at my pharmacist's suggestion) was to have the doctor write a separate prescription for 25mg of the drug. Yes, the insurance company honored (and continue to honor) both prescriptions.
Do I understand this? No. Am I going to argue with them about it? Not while they continue to pay.

All of the stories above my post happened because back in the Reagan era, the U.S. passed a federal law called ERISA. Basically, ERISA says that the only thing you can sue an employee benefit plan (be it insurance, 401(k), etc) for is the amount of money that they owe you.

No punitive damages are available under ERISA. Thus, while you can sue your car insurance company for punitive damages if they don't fix your car, you cannot sue your health insurance company for punitive damages if they refuse to pay for necessary health care or meds. This applies even if you die because they refused to pay.

Since the insurance companies have no risk, other than the risk that they might actually have to pay your claim later, they have no incentive to pay your claims now.

If you want the law changed, vote Democrat and call your Senator/Congressman to complain.

We've had similar problems with Medco, though they've never stopped paying for a prescription once they started. If there's a problem we pretty much find out the first time the scrip is filled, and a letter faxed from the doctor's office to Medco fixes the issue (we know the system pretty well at this point).

I do have a problem with the formulary of approved drugs and their approach to it, as it really second-guesses the doctor's judgement. For example, for stomach issues I had been on Prevacid. When I changed jobs and got Medco, Prevacid wasn't on their forumulary but Nexium was. That was okay, they were equivalent proton pump inhibitors. But they would not approve a scrip for Nexium until I tried a less expensive acid reducer (Zantac) first. I had tried that before under my previous plan, but since they had no record of it under their plan, no go. My doctor ended up writing a scrip for Zantac, giving me enough samples of Nexium to tide me over, then gave me a Nexium scrip a month later (which I then had no problem filling). Silly.

A new thing this year was actual copay penalities if you have an ongoing scrip that you don't fill through their mailorder system. So, the first three months your copay may be 20%, but if you continue to go month to month your copay goes up.

Percentage-based copays are another way they are trying to steer our decsions on prescriptions. No more flat $20 or even $30 copays for us (remember the days of $15 copays?). Now a scrip can run us $70 or $80 a month if it's a newer drug with no generic.

Smashville, what's the difference between Wellbutrin and Wellbutrin XL? I ask because there is a generic for plain Wellbutrin.

Drugs are frequently used for more than one purpose, and insurance companies won't pay for some of those uses. That's why they want to talk to the Dr -- the prescription doesn't specify why the drug is being prescribed.

For instance, Retin-A is used for acne, but it's also used to reduce wrinkles. Acne is (usually? sometimes?) considered an eligible medical problem, while wrinkles are purely cosmetic.

Similarly, Wellbutrin is used as an anti-depressant and also to help people stop smoking. The latter use is strictly short-term, so if you've been on it for a while they'll want to make sure that's not what they're paying for.

One major difference is that XL is only one dose per day...I honestly don't know...maybe my doctor had a deal with the company.

I do know that one part I don't miss about it is that Wellbutrin XL gave me the worst shits of my life...I felt like a panda bear...sitting there talking to folks and then...oh...there I go...

My employer switched to United this year, from Cigna. I've payed 20% higher premiums this year, and United has weasled out of paying most of my claims except the most clear-cut ones. I have nothing but bad things to say about United Health Care. Next year I'm changing jobs to an employer with Cigna, and I can't wait.

I wonder if Cinga prescription coverage is relatively good, because I have Cigna for my general medical coverage but my company went with Medco instead. How do they compare? Not that I have a choice, mind you. It's Medco or nothing.

A new thing this year was actual copay penalities if you have an ongoing scrip that you don't fill through their mailorder system. So, the first three months your copay may be 20%, but if you continue to go month to month your copay goes up.

I went through that a few years ago when I was still covered by my father's insurance. They messed up my first order by filling it for the wrong dosage and insisted that the doctor wrote it that way on the perscription.

Smashville - The XL messed with my stomach too, and was actually the reason I switched back to the SR. I've had very good luck with the SR formula. I have to take it twice a day, but depending on your dose, you still may only need to take it once. It's definitely worth revisiting with your doc if you feel like the meds would be helpful.

I make this argument day after day to people that believe it is axiomatic that the private sector can provide any service better than the public sector. Privatized healthcare is a bad idea. It is not a consumer good. The end user does not have a real choice in allocating its purchasing power, some dork in HR does that for you.

A national provision of some base level of healthcare would prevent (or lessen) the instances of large companies (I'm looking at you Wal-Mart) massaging people's hours to avoid offering them benefits. It would also enhance labor mobility as employees wouldn't have to worry about losing coverage when switching jobs. Health insurance companies have zero incentive to actually perform for the end user, they just have to keep the benefits buyers at companies happy. This is easy to do, a slinky with a BC/BS logo might do the trick.

End of the day, with some base national coverage, the higher end private supplementals would have to compete on actual service. Right now there's a fixed pot of consumers who pretty much have the binary choice of A) being uninsured or B) being insured. There's not really a way to increase market share through services, it's just a matter of controling costs. For those playing at home, controling costs is a euphamism for denying coverage.

The US spends 15% of GDP on healthcare, other developed nations generally spend 7-11% of GDP on healthcare. By every objective measure (infant mortality, life expectancy, etc.) the US is below average compared to other highly developed countries. It's a disgrace and it should change, but it won't because healthcare is a business not a right. Ask Bill Frist.

"She also told me that unless you need it to survive, they'll deny you the refill forcing you to pay over $100 per refill."

Geez, what kind of asthma inhaler is that?

We currently have fairly decent insurance (knock on wood) that just costs an arm and a leg. We pay substantially more than we ever get out in benefits, but being uninsured is a bad option.

My sister, however, had the insurance company try to deny her lifesaving medicine after she was on the insurance for 16 years with no problems; the minute she ACTUALLY GOT SICK they told her she was too expensive to cover and tried to drop her and/or deny care.

Our last insurance plan was actually excellent - inexpensive and anything in-network was covered, no questions asked - except for their pregnancy policy, which was uproariously funny and moronic. In order to have the pregnancy covered (all prenatal and birth costs), they demanded you inform them BEFORE you get pregnant that you are attempting to get pregnant so they can pre-approve the pregnancy insurance costs. However, such pre-approval was only good for 30 days. So apparently as soon as you started trying to get pregnant, you were meant to call them every month and say "still trying!"

I know they were trying to deny lots and lots of pregnancy coverage on the technicality of "oh, hey, you didn't tell us BEFORE you got pregnant so we don't have to cover it!" I'm sure 90% of people just lied to them, though. Personally I'd have waited until the EPT test said I was knocked up, then call and say "I'm going to try to get pregnant!" and then call two days later and say "I'm pregnant!"

I'm with Roddy; these companies should be illegal. They're inefficient and they don't do what it should be their core mandate to do -- help people get and stay healthy. They're almost completely concerned with their bottom line (which is not the same thing as being smart about money -- it means that they see a 1% gain in money as worth giving up any amount of service, as long as they can't "get caught" for it) and the government has done a dismal job of forcing them to fulfill their purpose (outside of making rich executives). The fact that they inflate prescription drug prices so unbelievably much (to the tune of hundreds of thousands percent profit), and are allowed to claim that it's to cover R&D without ever providing the numbers to prove it is disgusting. We all know that money's going to fancy marketing and bribing doctors, and they're allowed to get away with that and so much more. I'm utterly disgusted in our society for blatantly valuing money-for-the-rich over basic health for everyone.

The last straw for me was the Oct. 2005 bankruptcy rules changes, which made it impossible to discharge medical debts by declaring bankruptcy. So now that I'm one of the millions of uninsured, working in Michigan which has the highest rate of people *with jobs* who aren't offered insurance (and a Republican gubernatorial candidate whose answer to lack of insurance was "get a job"), if something happens and I get stuck with a huge bill, I can just pay it off forever. There's "western civilization" for ya.

-PD

Eyebrows McGee -- that's insane about the pregnancy policy -- *lots* of women get pregnant without trying. I also think these companies that have refused to pay for birth control are really short-sighted -- it costs a lot more to pay for prenatal care, childbirth, and health care for a new child. Fortunately, some states are now mandating b.c. coverage. My BC/BS policy covers b.c. pills -- they certainly should if they're going to cover boner pills. And doesn't it make sense to cover smoking cessation and other substance abuse issues, rather than pay for treatment of lung cancer, cirrhosis, etc. down the road?

It also gets me how companies discriminate against people with mental illnesses -- if the criterion is "does the patient need the drug to survive?", they could rule out quite a few psychotropic drugs (God help us if the Scientologists get control of the health insurance industry!). While someone might not drop dead if they don't get their Paxil or Lexapro, it can have a tremendous impact on quality of life. And if you want to quantify the impact in terms of business, there are plenty of numbers available about how depression costs so much in lost productivity, sick days, etc. And it's hard enough battling the nickel-and-diming insurance companies -- try doing it when in the throes of a major depression.

acambras -- Exactly. And who decides what drugs are "necessary for survival"? One could theoretically make the argument that psychotropic drugs *are* life-saving for people with certain mental illnesses, if only that they're now much less likely to attempt to drive their cars off a bridge. With the stigma placed on mental illness in this country, its hard enough for people to get up the nerve to ask for help. Denying coverage as medically unnecessary just reinforces the mistaken concept that they aren't real problems at all.

Smashville, it sounds like the XL is just a double-dose of Wellbutrin SR -- which *just* went generic about a year ago. My Dr said a while ago that I could take the whole dose at once, so now I'm just paying the generic copay.

Though he also said that less than half his patients moved to the generic with no problem, so your mileage may vary.

I wonder why health insurance can't be a co-op, like credit unions are. It seems that would work a lot better.

If you want the law changed, vote Democrat and call your Senator/Congressman to complain.
This is not-- as so many other issues raised on this fine are not-- a political issue. If your theory on changing this situation is to vote for one party, then why didn't the Clinton administration and the Democratic Congress "solve" this back in '92-94?

acambras- My state mandated birth control pill coverage several years back, and my insurance company co-pay promptly jumped from $10 to $25 relatively shortly thereafter. I'm pretty sure it's no coincidence that the average price for birth control pills without insurance is right about $25... So I went from being excited and saving money for two months, to being right back where I started...

formergr -- I've said it a million times -- insurance companies are EVIL. It sucks but it doesn't shock. I don't know what state you live in or what insurance you deal with, but some are less sucky than others, I guess. :-(

The thing is, health insurance companies don't necessarily WANT to pay for smoking cessation and other preventative measures because they (or someone else in the backslapping industry) PROFITS off the treatments given when the disease/pregnancy/crisis reaches a critical point. It's an inherent conflict of interest.

Unfortunately this problem is not as simple as sucky insurance companies. As RowdyRoddyPiper said, healthcare consumes 15% of our GDP and is over a trillion-dollar industry in the US alone. A lot of the cost increases are actually being driven by the government cutting Medicare payments, shifting the cost to those of us insured by private carriers. And now they are planning to cut payments again! Soon doctors will stop taking Medicare patients all together.

Statistics also show that as much as 80% (give or take) of our medical expenses are driven by lifestyle choices (smoking, fast food, obesity, etc). So take a look in the mirror before you blame everyone else.

A third issue is that many, many, many of these types of problems are driven by an industry that is afraid to embrace technology and create more efficient ways to work. Such as creating medical databases that allow access to patient histories on demand (no more fed ex-ing records, etc.). Coding errors and overly complex administration systems both raise costs and make efficient care impossible on all sides.

The cost of new technology is also driving the need to recover R&D costs. For example, it can cost $500M to $1B to bring a new drug to market. Anyone ready to give up their Zithromax for old school penicillin?

As someone working in the insurance industry (but not for one of the big companies), United Health Care does have some customer service issues that need to be fixed. However, all insurance companies are just trying to run a business, they don't set out to screw consumers - but that just seems to happen. So make use of your insurance agent, a good one can be your advocate and cut through some of the crap.

The rising cost of healthcare has too many players (consumers, the gov't, insurance, hospitals & doctors, Rx companies, etc) to have an easy fix. The healthcare industry must embrace a consumer-oriented system - including transparency and a simplified pricing system- before it collapses in on itself. If it does not change, the government will take over. To get a sample of that just think about dealing with the BMV, the IRS, and the Post Office all wrapped up in one institution deciding who gets treatment and who does not.

For those of you who like a good academic debate, economist Michael Porter has a great article entitled "Redefining Competition in Health Care" from Harvard Business School Publishing.

I've said it here before and I'll say it again - health insurance companies are the worst plague on America today, for all the reasons above and more.

And to add on the bandwagon, I've had the exact problem the submitter has, twice. It's nothing new, and it's so rampant it's disgusting.

Then again, my insurance company (Aetna) hates me. As an asthmatic bipolar pregnant woman, I cost too damned much to be treated like a valued customer. My monthly out-of-pocket medical expense is usually in the range of $200, not including premiums. And I consider myself lucky that it's so "low."

If the Wellbutrin is anything like Effexor, your XL will be equivalent to my XR (extended release). Basically, because of the length of time it takes a drug company to get a drug approved for market (often 10-15 years), they only have a relatively short amount of time while it's still on patent & protected from generics.

So what they do is then patent variations of the drug that are under patent for the full 25 years and market those. Effexor has a generic equiv, but Effoxor XR doesn't. In my case, my doctor has seen bad experiences with the generic form, so he writes the XR prescription so that I (and others) get the branded version. The provincial government (and most extended health plans) will cover a branded version if there's no generic.

Your doctor may be doing the same thing.

Media-Matt, it sounds like you've been reading (or writing) too much health insurance industry propaganda lately.

Weave -- re: Imitrex:
Our ins co only covers 8 pills / month, regardless of the size of the pill. Our doc prescribed the larger pills and we cut them in half. Instantly twice as many doses.

Refills can be gotten a little over ever 3 weeks. Use them and refill often enough so you have enough pills to keep yourself properly supplied.

If you need a pill but have run out of refills, your pharmacist may be able to "front" you one or two doses while you're waiting for the doc to refill or for the next monthly refill cycle to roll around. Our local CVS sometimes does this for us. It's also good to use a national chain when travelling in case you need something refilled while on the road.

"Statistics also show that as much as 80% (give or take) of our medical expenses are driven by lifestyle choices (smoking, fast food, obesity, etc). So take a look in the mirror before you blame everyone else."

That's fine and dandy, and I'd actually save a LOT OF MONEY by paying for my own health care rather than paying for insurance. I take two monthly Rxs, see the doctor for a physical yearly and probably two or three times when I get acute sinusitis. I'm not the cheapest patient, but I pay WAY MORE for insurance than my non-insurance health care costs are.

So why am I not dropping my insurance? Because if I got in a car accident, or needed to be hospitalized for a serious illness, or had a heart attack, I could never afford to be uninsured. It would ruin my life, and my family's. (Also, pregnancy and birth is totally unaffordable without insurance, but that's a slightly different problem.)

Why isn't my health insurance more like my car insurance? Why don't I pay for routine maintenance myself, and then pay much LESS to have coverage for the catastrophic events? (Heck, divert 1/10 of the resources freed up by not having to screw with copayments on yearly physicals and you could track the data and give people a discount for GETTING yearly physicals and taking reccommended meds!)

"Statistics also show that as much as 80% (give or take) of our medical expenses are driven by lifestyle choices (smoking, fast food, obesity, etc). So take a look in the mirror before you blame everyone else."

This is a good point. The fact that health insurance is gene

"Statistics also show that as much as 80% (give or take) of our medical expenses are driven by lifestyle choices (smoking, fast food, obesity, etc). So take a look in the mirror before you blame everyone else."

This is a good point, and the fact that group health insurance is generally not permitted to be risk priced tends to put the burden of paying for poor lifestyle choices onto those that do not engage in such activity. It's generally thought to be okay to charge someone more because they are a poor driver, but a taboo to do so because they have a two whopper lunch. Maybe the only way to solve this is to allow health insurance companies to risk price insurance.

Another commenter had pointed out that the only reason they carry insurance is that the downside on catastrophic illness/injury is way too much. This is a case of making sure that you can withstand the odds beating you before you try and beat the odds and it is totally apropriate behaviour. This is precisely the reason that a federally funded backstop could really improve consumption patterns in offered healthcare. If someone knows that they are on the hook up to the first $50,000 but they can live with that, it could encourage people to really weigh the costs of going to see a doctor about every little thing. As it sits right now, only the aggrivation of doing the paperwork or the risk of something not being covered is able to deter me from seeing the doctor anytime anything is wrong (well that and the whole missing work thing), but this hardly seems like the right way to encourage responsible consumption of healthcare resources.

But Roddy, are you saying that wellness-type appointments aren't responsible consumption of healthcare resources? Because if you talk about setting a $50K deductible (which is basically what you seem to suggest in your post above), many people aren't going to get preventative care.

Doesn't it make more sense for conditions like diabetes and hypertension to be diagnosed and managed early, rather than waiting for a stroke, heart attack, blindness or amputation down the road? Doesn't it make sense for women to get annual gynecological exams to ensure early diagnosis of cervical, ovarian, and breast cancers (same with men getting exams for early diagnosis of prostate and testicular cancer?) Doesn't it make sense for pregnant women to get proper prenatal care, to lessen the risk of premature birth and other complications that could negatively impact the child's health for years?

Like I said before, many health insurance companies are breathtakingly short-sighted when it comes to supporting wellness programs. If we focused a little more on the prevention (or at least early diagnosis) of illness, we could actually lower the number and duration of doctor and hospital visits, thereby aiding in the "responsible consumption of healthcare resources."

I asked my doctor why the health insurance companies are so short-sighted as to refuse to cover my birth control prescription. Don't they realize that it costs them a lot more to pay for me to have a baby than it would for them to just shell out for the pill? The doctor pointed out that the insurance company is betting that b.c. is so important to me that I will find the money to pay for it myself rather than risk getting pregnant when I don't want to. And guess what? They're right. I think this is emblematic of their philosophy on a lot of non-life-saving and preventive-type stuff: they are betting that that medication or annual physical or whatever is important enough to you that you will find a way to pay for it yourself.

Roddy and MediaMatt - I disagree strongly with your statement. While there are indeed cases of people going to a doctor because they got a scrape, there are a lot of cases involving people who had serious problems but don't get it checked out because they can't afford an extra 100 - 200 dollars for a doctor's visit. That's a pretty hefty chunk of change for people my age, especially ones who don't want to get into credit card debt for things they can "live with". Lifestyle choices do indeed affect people's health, But how many doctor's have lamented "if they'd only come in sooner we could have treated this so much quicker and cheaper"?

My Situation: I am a 23 year old male, I don't smoke, I don't drink, I don't do drugs. I live a pretty mild life by most standards. My girlfriend and I live together in an apartment in VA. I am soon to be paying 200ish a month for coverage on both myself and my girlfriend through my employer with United Health Care.

With that coverage, I intend to take my girlfriend and I in to meet a mew primary care physician who works in that network, get a prescription for my asthma as it has started getting worse again (I was on ventolin/albuterol in the past, but it went away for a few years and has returned) I would like to meet with an allergist to see if I can find a set of pills like Allegra and Singulair which would allow me to sleep through the night. At current I wake up twice a night regurally unable to breathe and need to take what's left of my old prescription for Albuterol.

The costs of doing the above tasks for me out of pocket far exceed what I can reasonably spend while still having money to pay for school / bills. Health Insurance from my perspective is here to cover exactly this type of situation. Yes, it's also great if I get into a car accident, But I need daily doses of medicines for things that are well beyond my control. My asthma has been with me since birth.

Most insurance companies (well, at least the better ones) are beginning to recognize it is better to catch a potential problem early rather than wait for a huge problem to pop-up later. Wellness is now a huge buzzword for the insurance/benefits industry. Gotta love those buzzwords!
They are now beginning to offer a lot more in the way of finding risks early. Things like diabetes, heart conditions, and even smoking can be dealt with a lot cheaper and in the early stages. Unfortunately it has taken many years and billions of dollars to recognize this.
Just like all of us, it has taken a hit to the wallet to motivate both insurance carriers and employers to take action.

Many of the new Health Savings Accounts and other Consumer Directed Health Plans are going away from PPO/HMO type programs. The individual is responsible for most of the smaller costs (dr visits, prescription drugs) until they meet a high dedcutible (anywhere from $2,000 to $10,000 for an individual, double that for a family)to get back to more of a catastrophic type of plan structure. The plan is then paired with some sort of savings plan (similar to a medical 401(k) or IRA) to help cover the deductible and coinsurance amounts. (Also many dr.s may give a discount if you pay cash so they can avoid billing headaches)
This shifts the costs more fairly to those who use a lot of resources but still protects them in case of a crisis.

FYI - many studies show the average American uses less the $500 in medical services in a year, and the old 80/20 rule (20% of the people use 80% of the resources) can swing to even more of a 90/10 situation.

As far as reading/writing too much propaganda - sorry just finished my MBA and it included a couple of Health industry classes.
In my opinion this is much like the Great Left Wing/Right Wing Media Conspiracies - if you really believe the Insurance & Health Care Industries are working together to screw the little guy you are giving them too much credit. They are two parts of a lumbering behemoth that rolls on out of control and to anyone who gets squashed, sorry it is not personal.

I don't necessarily think the insurance and health care industries are working together -- the insurance industry alone is evil enough to screw with people's lives. Full disclosure -- I have a very deep, personal contempt for the health insurance industry, based on my own experiences and the experiences of so many others. Somehow I can shake off troubles with retailers, utility companies, etc., but when the health insurance industry screws with me, I do take it very personally. It really gets me riled up.

The other reason I don't think the insurance and health care industries are in collusion is because almost every doctor I've ever talked to hates the insurance industry with a passion. Usually it seems to be over paperwork, getting nickeled and dimed at every turn, and having their education and judgement questioned by non-doctors.

Maybe the only way to solve this is to allow health insurance companies to risk price insurance.

Do we really expect health insurance companies to be able to do this properly? OK, you could assume that everyone at least 20 pounds overweight is eating junkfood and is therefore a risk but what about the skinny people who's eating habits are just as bad? Are we going to have to get our arteries checked for buildup every year?

What about adrenaline junkies? How are they supposed to know you make a habit out of putting yourself in harms way? What if you live in a bad neighborhood?

RP -- I did actually have to fill out a BC/BS underwriting form about 10 years ago. It asked if I was involved in "high-risk sports" like hanggliding or skydiving.

And I swear to you that it asked if there was any history of "female problems." And they put "female problems" in quotes.

Yes, I have a "female problem" -- stupid-ass male bureaucrats who write stupid-ass underwriting forms. Much more painful than cramps.

"But Roddy, are you saying that wellness-type appointments aren't responsible consumption of healthcare resources?"

Not at all. I think that preventative medicine is absolutely something that is overlooked by insurance companies. My point is in fact the opposite. If someone has a high deductible (that is basically going to cover them only if something really really bad happens) then they have an incentive to expend that ounce of prevention now, to avoid the pound of cure later. The fact that my insurance costs me the same regardless of my undertaking steps to prevent illness or not (through regular screenings, not smoking, not drinking to excess, etc.) is what distorts the price of healthcare in general.

I'm not saying that people should only have high deductible insurance. What I am saying is that the high deductible backstop would allow people greater flexibility in chosing to insure every little thing, or not. I can imagine there are many families that would rather have the backstop in place and use the cash that they save to manage their own preventative care by paying for it out of pocket rather than insuring against everything under the sun. Some years they win, some years they lose, but they get the level of care (and can manage their healthcare costs on their own) rather than subsidizing a bunch of people that wash down their morning bag of chips with a 64oz mountain dew.

"Maybe the only way to solve this is to allow health insurance companies to risk price insurance.

Do we really expect health insurance companies to be able to do this properly? OK, you could assume that everyone at least 20 pounds overweight is eating junkfood and is therefore a risk but what about the skinny people who's eating habits are just as bad? Are we going to have to get our arteries checked for buildup every year?"

Oddly enough yes. Most other forms of insurance (home owner's, auto, life) are priced individually based on empirical evidence. The insurer doesn't have to catch every single one of your behaviours to price you apropriately, just enough of the ones that will determine if you are likely file a claim or not. The point of risk management in insurance is that having a large enough book of exposures will tend to have the outliers wash out and the portfolio should conform to some fairly straightforward statistical model. Not to say it conforms exactly, but it's close enough that you don't have to scalp people to insulate yourself against bad underwriting. Now arguably the human body consequently the things that can go wrong are much more complex than driving a car or insuring a house, but it might not be a bad idea to give it a shot.

You do of course bring up the ethical questions (do I have to get my palque levels checked each year, adrenilin junkies getting priced more, etc.) that make health insurance a much more touchy subject than other forms of insurance, but if people want efficient allocation of healthcare dollars maybe some sacrifices have to be made.

When I was in grad school, I did have "major medical" insurance. The premium was about $500 a year and it was really meant to cover catastrophic injuries or illnesses -- nothing else (e.g., no prescription coverage). I referred to it as "hit by a bus" insurance. I never had to use it -- I wonder if it would have been worth the paper it was printed on if I'd needed it. But like other posters have said -- it's too risky to go without.

It was interesting -- the "card" they gave you was actually a piece of paper (like you might have for proof of insurance for your car), but I had to WRITE in my name, address, and social security number on the card myself. Yeah, that wouldn't raise ANY eyebrows in the ER.