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Old 09-10-2008, 06:53 PM
 
Location: Northglenn, Colorado
3,689 posts, read 9,250,335 times
Reputation: 944

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This is an item that strikes at home with me. I have Multiple Sclerosis. This disease is not deadly, but progresses and can lead to permanent and severe disability. The cause is not known, and there is NO cure. Up until 15 years ago there were no treatments for MS. People were Diagnosed with it, and told to go home, or find a nursing home to move into. The new drugs they have available have helped greatly in making sure patients with MS are able to keep working, and slow the progression of the disease. The drugs themselves are all injectable with one being an IV infusion. Copaxone, Betaseron, Avonex, Rebif, and Tysabri. Two pharma companies make these drugs, and well you pay handsomely for the treatments. The injectable are roughly 2100.00 per month, and tysabri is 12,000.00 per month. Here is where the Health insurance comes into my story. My wife is the person that has our HS, we have wonderful coverage and I only have to pay 75.00 per month for my treatment. Others are not so fortunate. Medicare is a government run health care. The treatments under Medicare are considered "Orphan drug" which means that there is not a considerable amount of people with MS to call the drug main stream. (the last study they did on patients with MS was done in 1976, which is where they are basing the numbers on currently) When a drug is called an "orphan drug" they move it into a Tier 4 part of the coverage, this allows them to charge a percentage of the total cost. Where does this play in in terms of UHC and private insurance? Most private health insurance companies have the MS drugs listed under Tier2 (name brand) status, allowing for a normal co-pay. Medicare has it listed under Tier 4 status requiring a 30% copay for the treatment. Many people with MS end up retiring early due to the chronic fatigue that is associated with this disease, they end up using SSDI (social security disability) The amount they get from the SSDI is not enough to cover the Medicare co-pay for the treatment, so... The person has to make a decision, do we eat? or do I go with a treatment. I do not want the government to have control over my health care, I would end up paying a percentage for my treatment in which I cannot afford, a percentage that is derived of a 30 year old count of people with MS. Government works too slow for this disease that can move very quickly, and lead to permanent disability. The other reason is wait lists. With the attacks that come with the MS, i have maybe 24-48 hours to get in to see my Neurologist and get on IV steroids or the attack can permanently disable me. Time is of the essence, and getting into see a doctor on a list that is maybe 2-6 months out is NOT good for my health, nor is it good for anyones health. I did see that Nightline show, and there were some things that were quite compelling. The UK system is moving more and more to a private type system due to the cost that is having to be spent by the government. The swiss system (if i remember correctly) was having similar problems as well as Taiwan's system. Japan's system was failing the other way. Doctors are hard to find due to the price caps that the government has on them, they just cant live on the wages. The only system that seemed to be "working" albeit slowly going broke was Germany's system, which has a mix of private and government coverage.
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Old 09-10-2008, 07:30 PM
 
Location: State of Being
35,885 posts, read 65,253,264 times
Reputation: 22270
Quote:
Originally Posted by TristansMommy View Post
Now why can't coverage like that be opened to all!! That would be acceptable!
I totally agree. And it could be! It really could be! It is all a matter of the contracts. I know it sounds too simple, LOL, but honestly - I work w/ proposals for behavior healthcare (third party administrators) as part of my work and it really could be done - that we ALL had a policy similar to this.

I know I would be thrilled!
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Old 09-10-2008, 07:34 PM
 
Location: State of Being
35,885 posts, read 65,253,264 times
Reputation: 22270
Quote:
Originally Posted by Noahma View Post
This is an item that strikes at home with me. I have Multiple Sclerosis. This disease is not deadly, but progresses and can lead to permanent and severe disability. The cause is not known, and there is NO cure. Up until 15 years ago there were no treatments for MS. People were Diagnosed with it, and told to go home, or find a nursing home to move into. The new drugs they have available have helped greatly in making sure patients with MS are able to keep working, and slow the progression of the disease. The drugs themselves are all injectable with one being an IV infusion. Copaxone, Betaseron, Avonex, Rebif, and Tysabri. Two pharma companies make these drugs, and well you pay handsomely for the treatments. The injectable are roughly 2100.00 per month, and tysabri is 12,000.00 per month. Here is where the Health insurance comes into my story. My wife is the person that has our HS, we have wonderful coverage and I only have to pay 75.00 per month for my treatment. Others are not so fortunate. Medicare is a government run health care. The treatments under Medicare are considered "Orphan drug" which means that there is not a considerable amount of people with MS to call the drug main stream. (the last study they did on patients with MS was done in 1976, which is where they are basing the numbers on currently) When a drug is called an "orphan drug" they move it into a Tier 4 part of the coverage, this allows them to charge a percentage of the total cost. Where does this play in in terms of UHC and private insurance? Most private health insurance companies have the MS drugs listed under Tier2 (name brand) status, allowing for a normal co-pay. Medicare has it listed under Tier 4 status requiring a 30% copay for the treatment. Many people with MS end up retiring early due to the chronic fatigue that is associated with this disease, they end up using SSDI (social security disability) The amount they get from the SSDI is not enough to cover the Medicare co-pay for the treatment, so... The person has to make a decision, do we eat? or do I go with a treatment. I do not want the government to have control over my health care, I would end up paying a percentage for my treatment in which I cannot afford, a percentage that is derived of a 30 year old count of people with MS. Government works too slow for this disease that can move very quickly, and lead to permanent disability. The other reason is wait lists. With the attacks that come with the MS, i have maybe 24-48 hours to get in to see my Neurologist and get on IV steroids or the attack can permanently disable me. Time is of the essence, and getting into see a doctor on a list that is maybe 2-6 months out is NOT good for my health, nor is it good for anyones health. I did see that Nightline show, and there were some things that were quite compelling. The UK system is moving more and more to a private type system due to the cost that is having to be spent by the government. The swiss system (if i remember correctly) was having similar problems as well as Taiwan's system. Japan's system was failing the other way. Doctors are hard to find due to the price caps that the government has on them, they just cant live on the wages. The only system that seemed to be "working" albeit slowly going broke was Germany's system, which has a mix of private and government coverage.
This is an excellent post! You hit on so many important areas, such as pharma costs and orphan drugs . . .

Also, healthcare access. I don't think most Americans realize the wait times other countries w/ UHC have built into their system. Here, you can get an MRI in a matter of days. Your wait in Canada, for ex., may be months. Not picking on Canada - just saw a report lately that mentioned the wait times for MRI there.

THank you for sharing your info. It hits home when someone can relay their own personal experiences, especially in dealing w/ a progressive illness such as MS. I hope your regimen continues to work for you.
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Old 09-10-2008, 07:39 PM
 
Location: State of Being
35,885 posts, read 65,253,264 times
Reputation: 22270
Quote:
Originally Posted by bibit612 View Post
I am sorry that you had cancer. I did too, just last December. Inspite of that, I believe that insurance companies, like any company in business, has to make a profit. And by its very nature, insurance companies provide the safety net for misfortunes of everybody. Just because the health insurance companies are in the limelight lately, it does not mean that companies like State Farm, Allstate, or life insurance companies don't make a profit. One catastrophe is enough to wipe the solvency of insurance companies leaving many more uninsured people who can't get coverage. Imagine just a few companies who operate in rural New Mexico for example. If insurance companies shut down because they can't make a profit, how will claims be paid. One has to understand how insurance works in the first place...that premiums are created to make reserves in anticipation of future claims. The fact that the claims cannot be predicted with any accuracy, premiums become an estimate. In good times, what has been collected is invested in the open market, to take care of large claims when they come, because the cash inflow may be exceeded by an outflow. It is a very very complex system and solutions are not easy. Throw the Feds in there and taxation turns it into a nightmare. Do we need it to be affordable? YES! Do we need it to be accessible? YES! I am just getting a little weary of reading the "bad insurance company" as the source of evil in all this.
Actually, insurance companies are no more to blame than pharmaceutical companies and - the government itself (whether feds or state gov't) Policies can be fashioned that would cover more lives and spread the risk if states would insist on it. And pharma costs definitely affect insurance costs.

Also, the expense of high tech equipment - that drives up healthcare costs, as well. What is an insurance company to do? If your doc orders an MR or a PET, for ex., SOMEONE has to pay for that!!!! Is the hospital supposed to absorb it (and go bankrupt?) Is the insurance company supposed to absorb it? Is the manufacturer supposed to sell the equipment at cost?

It is a complicated system and no easy answer when it comes to containing healthcare costs. And no one entity or segment of the system is "to blame."
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Old 09-10-2008, 08:04 PM
 
Location: Tolland County- Northeastern CT
4,459 posts, read 6,091,541 times
Reputation: 1237
Connecticut has made a step toward affordable health care for all

Since this forum is for 'debate'- I hope providing this link is appropriate- 'The Charter Oak Health Plan'.

Community Health Network of CT
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Old 09-10-2008, 08:06 PM
 
Location: Pennsylvania, USA
5,217 posts, read 4,111,192 times
Reputation: 908
Quote:
Originally Posted by Noahma View Post
This is an item that strikes at home with me. I have Multiple Sclerosis. This disease is not deadly, but progresses and can lead to permanent and severe disability. The cause is not known, and there is NO cure. Up until 15 years ago there were no treatments for MS. People were Diagnosed with it, and told to go home, or find a nursing home to move into. The new drugs they have available have helped greatly in making sure patients with MS are able to keep working, and slow the progression of the disease. The drugs themselves are all injectable with one being an IV infusion. Copaxone, Betaseron, Avonex, Rebif, and Tysabri. Two pharma companies make these drugs, and well you pay handsomely for the treatments. The injectable are roughly 2100.00 per month, and tysabri is 12,000.00 per month. Here is where the Health insurance comes into my story. My wife is the person that has our HS, we have wonderful coverage and I only have to pay 75.00 per month for my treatment. Others are not so fortunate. Medicare is a government run health care. The treatments under Medicare are considered "Orphan drug" which means that there is not a considerable amount of people with MS to call the drug main stream. (the last study they did on patients with MS was done in 1976, which is where they are basing the numbers on currently) When a drug is called an "orphan drug" they move it into a Tier 4 part of the coverage, this allows them to charge a percentage of the total cost. Where does this play in in terms of UHC and private insurance? Most private health insurance companies have the MS drugs listed under Tier2 (name brand) status, allowing for a normal co-pay. Medicare has it listed under Tier 4 status requiring a 30% copay for the treatment. Many people with MS end up retiring early due to the chronic fatigue that is associated with this disease, they end up using SSDI (social security disability) The amount they get from the SSDI is not enough to cover the Medicare co-pay for the treatment, so... The person has to make a decision, do we eat? or do I go with a treatment. I do not want the government to have control over my health care, I would end up paying a percentage for my treatment in which I cannot afford, a percentage that is derived of a 30 year old count of people with MS. Government works too slow for this disease that can move very quickly, and lead to permanent disability. The other reason is wait lists. With the attacks that come with the MS, i have maybe 24-48 hours to get in to see my Neurologist and get on IV steroids or the attack can permanently disable me. Time is of the essence, and getting into see a doctor on a list that is maybe 2-6 months out is NOT good for my health, nor is it good for anyones health. I did see that Nightline show, and there were some things that were quite compelling. The UK system is moving more and more to a private type system due to the cost that is having to be spent by the government. The swiss system (if i remember correctly) was having similar problems as well as Taiwan's system. Japan's system was failing the other way. Doctors are hard to find due to the price caps that the government has on them, they just cant live on the wages. The only system that seemed to be "working" albeit slowly going broke was Germany's system, which has a mix of private and government coverage.
Sorry to hear about your situation.

I wanted to address the tier system you mentioned.. that Medicare categorizes it as an "orphan drug" while other insurance companies do not and categorize it as a Tier 2.

The difference may very well be in your statement in which you say that Medicare doesn't see enough patients in their system and therefore it is an "orphan drug".

If you had a UHC system you would probably find a higher percentage of patients that do have that disease and do require that drug, which could very well move that drug up to the Tier 2 category.

It is the same reasoning behind why other countries that have socialized medicine are allowed to buy U.S drugs at a much bigger discount than an American Citizen would pay for the drug and that is because they buy in bulk.

Of course, all of this is a hypothetical and of course we don't have all the answers. I don't think a full hypothetical that addresses the issue and lays out a thorough and definitive plan has ever been addressed. There is still more opposition than acceptance of a potential UHC for it to even be worked up.

But.. what if in a worked up scenario of health care, the decisions were actually made by the physicians and NOT administrators in either a private health insurance company and/or a government entity.

And what if you have a UHC but could purchase additional private insurance to supplement a UHC.. and of course the private insurance plan would be far cheaper as it's not as in demand, that would pick up where the UHC left off (similar to the British system?). And all of it would still be very affordable AND accesable?
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Old 09-10-2008, 08:07 PM
 
Location: Pennsylvania, USA
5,217 posts, read 4,111,192 times
Reputation: 908
Quote:
Originally Posted by anifani821 View Post
I totally agree. And it could be! It really could be! It is all a matter of the contracts. I know it sounds too simple, LOL, but honestly - I work w/ proposals for behavior healthcare (third party administrators) as part of my work and it really could be done - that we ALL had a policy similar to this.

I know I would be thrilled!

I too would be thrilled if it were...
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Old 09-10-2008, 08:11 PM
 
Location: Pennsylvania, USA
5,217 posts, read 4,111,192 times
Reputation: 908
Quote:
Originally Posted by anifani821 View Post
Actually, insurance companies are no more to blame than pharmaceutical companies and - the government itself (whether feds or state gov't) Policies can be fashioned that would cover more lives and spread the risk if states would insist on it. And pharma costs definitely affect insurance costs.

Also, the expense of high tech equipment - that drives up healthcare costs, as well. What is an insurance company to do? If your doc orders an MR or a PET, for ex., SOMEONE has to pay for that!!!! Is the hospital supposed to absorb it (and go bankrupt?) Is the insurance company supposed to absorb it? Is the manufacturer supposed to sell the equipment at cost?

It is a complicated system and no easy answer when it comes to containing healthcare costs. And no one entity or segment of the system is "to blame."

Here is something that I'm a little perplexed about on the pharma side. My mom needed a sleeping pill..I can't recall the name. She had insurance but had to meet her deductable and was getting her prescription filled at Walmart. She didn't give her insurance card because, I believe she said, she didn't have drug coverage. So she paid $80 for the pills.

Then something came up and they ended up with her insurance card. Suddenly the price dropped to $20 because even though it wasn't covered, they must have had some kind of contract you mentioned.

However, my mom found in town a Pharmacy that sells drugs to those that do not have any insurance and those same pills that were once $80 without her card and became $20 with her card she was suddenly able to buy for $9!!! The SAME pills....

She doesn't know how or why? It is quite a head scratcher.
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Old 09-10-2008, 08:19 PM
 
12,607 posts, read 14,605,815 times
Reputation: 14096
I don't believe universal health care is the answer. We see what has happened in other countries that have it - people who have cancer have to wait too long to have a CT scan or surgery or whatever. There are long waiting lists to see a doctor. What if the government started to think if they were paying your doctor bills, they had a right to tell you how much you could weigh, how often you have to exercise, what you can eat, whether you can smoke and how much alcohol you can drink, who you can have sex with - the list could potentially be endless. If nothing else, they could tell you if you don't fit their profiles for good health, you won't be covered. What if you had to pay more if you lived in an area where you were more likely to be a victim of violent crime? What if you had a family history of cancer? Would they start checking your driving record and deny you coverage if you are a risky driver? Or make you pay more?

We are already paying for healthcare and education for illegal immigrants. I think we need to put an end to that. Why should illegal immigrants get free health care when our own citizens don't?

For my own experience, we have always had health insurance either through me or my husband. When I carried the insurance and was quitting my job to start a business, my husband found a job with insurance that would cover us. I didn't leave my job until we were covered under his plan.

Almost 2 years ago I started going to a new doctor. I have always thought that doctors cared first and foremost about the patient. But this new doctor ordered all kinds of tests and I went along with it, thinking she was just being thorough. But after a while I decided NO MORE because I started to think she was on one hand doing tests, giving shots, etc. to rack up more revenue for her own office, and also referring me to her doctor friends for consultations and more testing to increase their revenue. I definitely think she does whatever she can to make the bill higher, since I have insurance that will cover it. I was supposed to go back to her a year ago and haven't been back. I'm going to look for a new doctor.

I think we have to be active participants in our health care. If I think there is a valid reason for testing, I will do it and pay out of pocket for expenses not covered by my insurance. But I'm not trusting doctors to be only looking out for my health anymore because now some of them are more concerned about profit.

Actually, I like the quote by Thomas Edison - The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease.

I think some doctors now are thinking more in terms of wellness and staying healthy, eating right and exercising, and concerned about the whole patient, including their physical, mental, emotional and spiritual health. I need to find one of those doctors.
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Old 09-10-2008, 08:33 PM
 
Location: Northglenn, Colorado
3,689 posts, read 9,250,335 times
Reputation: 944
Quote:
Originally Posted by anifani821 View Post
This is an excellent post! You hit on so many important areas, such as pharma costs and orphan drugs . . .

Also, healthcare access. I don't think most Americans realize the wait times other countries w/ UHC have built into their system. Here, you can get an MRI in a matter of days. Your wait in Canada, for ex., may be months. Not picking on Canada - just saw a report lately that mentioned the wait times for MRI there.

THank you for sharing your info. It hits home when someone can relay their own personal experiences, especially in dealing w/ a progressive illness such as MS. I hope your regimen continues to work for you.
the MRI with my current coverage is not just in a matter of days, it is literally in a matter of hours. I have been on Copaxone for 7 months now, so far it is working very well for me. When I started it the total monthly cost was 1400, within seven months it jumped to 2100. There are no Generics for these meds due to patents and another reason. 4 of the most common treatments (DMD injectable) which include Copaxone, Rebif, Betaseron, and Avonex, three fall under the type of drug called a Biologic drug. These are drugs derived from biological substances IE an enzyme pulled from gerbil livers, or modified bacteria that are used to "trick" your immune system. Well our government and FDA right now has NO way to test or approve these drugs for generic use. Therefore there will never, or in any good time frame be a generic form (lower cost) of these drugs, so us MS patients must always rely on Name brand drugs for our treatment. In the case of Copaxone, it is a mix of different Amino acids, there currently is no way to approve this type of drug as well, although there is one being brought up in court cases at the moment. They would have to run the full clinical trials to get the generic form approved, which would cost the same as the name brand due to the testing they are required.
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