Health Care/Insurance - what do you have

I'm curious about the system in the US. I have heard horrible things about your health insurance system, have heard from members here how they are not allowed certain types of exams, how some have no insurance and I wonder how people do in this case.
The health care system in Europe, in this part where I live, is really good. I may talk about it later, but to give you an idea, if you feel sick, you don't even have to go to the hospital. You call a doctor home, he'll come and see you, give you the medication if he has it, often he does, you do pay a little extra, but most of us are covered by a second insurance and never pay anything.

Btw, the doctor is driven around by a chauffeur at night, can you believe it? :eek:

Wow! Docteurs avec chauffeurs qui visitent la maison! I could get into that.

I belong to Kaiser Permanente, a "health maintenance organization", through my work. I pay no premiums for the insurance for myself and one dependent, which was great when I was raising my son. If I visit the doctor, it costs $10. Generic drugs, most of which I can have mailed to me, cost $5.00. My primary physician changes every few years, but I have kept the same gynecologist and optometrist for years and am very happy with them. Getting "urgent care" appointments the same day is easy, but you have to see whoever is on call. Routine appointments should be made a month or more in advance. The quality of care has been pretty good, but I always back it up with my own research on the internet. Doctors can be wrong.

I had PPO when I worked for the City of New Orleans and they kept changing insurance companies. One company, GIA, took forever to pay my hospital and dental bills and I kept getting tagged for it.

I accidently chose an HMO when I got onto the job that I'm on now. BIG MISTAKE. I went to my dentist only to learn that the most expensive task had to be covered from my pockets. So I changed to PPO again.

Blondie, we had (don't know if we still have) BlueCross in Brazill, I'm pretty sure it was American, and the doctors association led a huge fight against them.

They were greedy, tried to manipulate doctors into not asking expensive exams even when necessary, would pay us very little for each consultation while charging the companies and the employees a lot, they are simply dishonest . I have a very bad image of them, too.

In Brazil we have the national health system which covers a big part of the population, everybody is entitled to it, but some people get free private care from their companies. You pay according to your profession, I remember paying a lot! But the good thing is, there are free hospitals for the homeless, the jobless, the poor people. Everybody gets to be treated.

We also have the right to have a practice where everything is paid privately, we as doctors are not obliged to accept the different insurances. But most of the doctors work with those, all of them company health insurances. The national health insurance only works in their own hospitals or afilliated hospitals (but those are the great majority in the country). Any type of insurance in Brazil covers only consultations and hospital charges, they never cover any prescribed drugs!

In Luxembourg, the national health insurance covers everybody who wants, but it's paid. If you don't pay, you are not covered. You have to pay everything, but poverty is not an issue here. Every doctor in his private practice sees everybody, indenpendently of their type of insurance, national or private. We are covered up to 85%, sometimes 100% of all costs, including prescribed drugs, by the national system, but most of us have a complementary insurance which will pay whatever remains, so in reality we never pay anything. Dentists are a bit different, usually we pay a part of the treatment, and it may be expensive.

And yes, I love the fact that we can call the doctor home. During the day he'll drive, but in the night he has a driver. And you can also have massage and some days in the Luxembourgish spa, if you have back pain, for example. I never used it, but I have friends who have, and they say it's incredible.

The system in Japan was pretty much simple, they cover a percentage of everything, drugs, hospital, consultation, maybe 85%, I don't remember, and the doctors may see you in their practices, too. Private insurance is not common, everybody has the "Kenkou Houken" and everybody has to face long long lines and lots of waiting to get anything. But I remember the hospital of the Tokyo University, wow... it was luxurious! When you have an appointement, you go to the reception, gives your name, and they give you a kind of beeper. You can go and do what you want, and when your time has come, or you are the next, your beeper will tell you. So you don't have to wait in one place, you may walk around and eat, or have a coffee...:)

Insurance, on its face, sounds great. People pool their resources, in the form of premiums (the insurance bill), for 'coverage against some possible future unknown calamity', whether it be health or property.

Modern insurance (as done here in the USA) involves premiums paid to an Insurer from which the pool pays expenses to the extent of the contract. Premiums are set by the insuring company, normally with governmental oversight. These businesses are in it 'for profit'. Thus they use actuarials (sp?) so as to target their risk, and with other data, set premium policy.

Other data includes the fees charged to the insured to repair / replace the injury/property per the insurance contract. Often the insurer pays directly to the 'entity' responsible for the repair / replacement. It is this cost that can potentially corrupt a potentially viable pooling of resources. As the 'pool' picks up the tab for all expenditures of the insurer via premiums, the entity can charge the maximum it can get away with over and above that which the free market would bear if the insured had to pay the bill without the insurance pool. As the premiums are generally so spread over a large pool, the premiums can be maintained within the financial ability of the insured. Thus is perceived 'a good deal', whereas in reality one can be financially raped, and not knowing, be thankful. And it is common practice, here in the USA, for insurance companies to try and not PAY.

This is called a SCAM.

As Maria said: "Blondie, we had (don't know if we still have) BlueCross in Brazill, I'm pretty sure it was American, and the doctors association led a huge fight against them.

They were greedy, tried to manipulate doctors into not asking expensive exams even when necessary, would pay us very little for each consultation while charging the companies and the employees a lot, they are simply dishonest . I have a very bad image of them, too." Good example.

But remember, a national system has its flaws too. It would appear to me that the costs of administering such a system, buried within the national budget and covered by taxation, could just as easily be corrupt, perhaps even more so.

"they are simply dishonest".

Sounds like politics to me.

The problem is when politics enters areas where it shouldn't enter. It's immoral. It's completely immoral that any interest other than the health of patients may govern a health system.

The US health system is far from being an example. It's a corruption of the very concept of national health care. As much capitalist as I can be, and I am in many ways, health should stay away from being a means for profit and should be accessible to any citizen, regardless of their social condition.

I love the example of Europe, because it's succesful, it's established in rich countries, and it proves that we can balance finances with a good care. Except for England, where the system is terrible for most of the population, Western Europe has made health care available to everybody.

Like you Maria...I'm in Healthcare. I'm not a provider, but I am in hospital administration. The US healthcare system sure isn't perfect, much like most industries based in capitalism, there are the extremes at both ends. If you have great resources (financial/insurance), you can take advantage of some of the best medicine, state of the art technology, and pharmocological research in the world. If you have little resources, you must work like a dog to find what is available to you out there and trust me...its not much. The problem with healthcare as an excersize in capitalism is that healthcare is more than a product/service...it really is a mandate...more than right. If I am sick and without resources, I can go on to harm those around me. Contrary to popular knowledge though there are resources available to the un or underinsured. The problem is that it is difficult to find them, they are unknown to most people, and, thanks to our war time efforts and Republican held federal government, chronically underfunded. :(

I don't know if this was true, but I heard about 20 years ago that the USA and South Africa were the only industrialized nations without a national healthcare system (we were in great company, weren't we?). Since South Africa has been liberated, are we now the only industrialized country without a national healthcare system? Does anyone know?

'C' was telling me the other day the in Chile, the government pays all the doctors and nurses, so everyone who needs medical attention gets it. I think that is pretty nice. But when we went to Chile a couple years ago I remember how crazy the hospitals were ('C's father was being treated for diabetes there) and you had to wait in crowds of people just to get up to the elevators. It was definitally nuts...but the idea is a good one. There are so many people here who don't seek medical help because they don't have insurance and don't feel like forking out 800 bucks just to get checked.

Just a note about coverages . . . I hear people all the time say: "I hate, CIGNA, or I hate Blue Cross or I hate whoever" because they didn't cover whatever. If you have group health insurance through your employer, it is your employer who decides what is covered by that policy, not the insurer. Some people have CIGNA where a procedure is covered and some people have CIGNA where that same procedure is not covered. CIGNA did not make that determination, your employer did.

On the matter of slow payment, that is the insurer and sometimes you have to stay on top of them about it. In Texas, the State Insurance Board controls the insurance companies and state law says that a valid claim must be paid within 60 days. I have spoken with them several times about late payment of claims and they always go after the insurance company.

At the present, the City I work for is self insured and then we have an outside company we contract with to administer the claims. I will say that I like this setup much better than what we had.

Patricia, what a beautiful avatar!!! :) I love it!

Merci, ma chere Maria. Actually, Peachy deserves the credit for my avatar. She resized the photo for me with a twinkle of her eye so that it would meet the Ageless avatar specifications.

Originally posted by peachy51
Just a note about coverages . . . I hear people all the time say: "I hate, CIGNA, or I hate Blue Cross or I hate whoever" because they didn't cover whatever. If you have group health insurance through your employer, it is your employer who decides what is covered by that policy, not the insurer.

On the matter of slow payment, that is the insurer and sometimes you have to stay on top of them about it.


You hit the nail on the head about group coverage (through your employer). Many people do not realize that their employer is the one who designs the benefit structure for the employees.

I work for what will soon be the largest BCBS plan in the U.S. I have been there for 12 years. Prior to that I worked as an RN in a hospital in two different capacities. So, I've got a perspective from all kinds of angles.

I have learned so much while working for a health insurance company. Prior to working there, I used to blame all that was wrong with healthcare on the insurance co. I am now able to see a different side of how it all works. Most people in the U.S. have no idea how their health plan operates. It's easy to blame the insurance co., because after all, their physician does. But, people need to educate themselves.

There's more to it than meets the eye. I have seen alot of waste on the part of both the physicians in our network and our members. I mean billing for ALL kinds of things. Physicians double-billing, or upcoding, which increases the amount they are reimbursed (basically lying about the services they provided), performing unnecessary surgery, billing for services they never rendered. Members (customers) billing for spa visits, houseboat items, whirlpool tubs (with no medical reason), and sometimes even filing claims on people they claim to have rights under the policy, but who by law do not. Example: a woman claimed her b/f was her legal husband. That's insurance fraud.

Insurance companies put in measures to monitor what is being paid as a way to control costs, but it's not to save the cost to the insurance co. as most people assume. It's to keep the cost of care down for everyone, to control the cost of the premiums that our members must pay in order to have health insurance. If we did not have some sort of measure of containing costs, then the cost of premiums would rise for everyone and then we'd all be without insurance. That's something alot of people don't realize.

On the issue of insurance co's paying claims untimely, often this is due to waiting for information from the physicians office.

edit: One more thing. I am proud to say that the company I care for has a mission statment that we are there to improve the health of the people we serve. And, we have won many national awards for initiatives aimed at improving health, such as our Hospital Quality Program and Disease Management initiatives aimed at improving chronic diseases such as asthma, copd, diabetes. We also work very hard to ensure that we operate under high standards of quality and we have won excellent ratings by the NCQA, which is the National Center for Quality Assurance. An excellent rating means that our company is focused on providing the best possible care and service for our members.

I am with NASE and have MegaLife, mainly catastrophic insurance with a large deductible (makes monthly payments much less). But have not been happy with the coverage. Will soon be switching over to FirstCare. Anyone know what this one is like? :confused: Always lots of surprises in store with these outfits. :eek:

maria...is that you sweety! Yeehaw! Glad to see you posting.

To answer your question...my health care situation sucks (I'm in the US).

I am a business owner, so I have to pay for my own coverage. I just opened an HSA (Health Savings Account) because my accountant advised me to...the money you put in an HSA is tax deductible, so I save a little that would otherwise go to the IRS (US tax man). BUT...my monthly payment for insurance is $194.00...that's for a policy that only covers major medical stuff with a annual deductible of $2,500 ! So, I have to pay out of pocket (using money that I deposit into my HSA) for all my prescriptions, doctor visits, lab work, etc, up to $2500 a year...then I have to pay 80% of anything above that. It definitely makes me think twice about going to the doctor when I'm sick :( .

All costs added up, I spend about $400 a month for premiums and Rx's. Makes me kinda wish I taught again and received all that great health insurance coverage I once did through the public school system...but then I wouldn't be able to set my own hours, travel the world with my dance company on performance tours, etc.

*weighing the trade-off*

Okay, I'll stop whining.

When I was in Austria last time I heard all about their health care system...and it ROCKED. Every woman got guaranteed 6 months paid leave for giving birth, every one had free, excellent health care, etc. If you ask me, the higher taxes over there are WELL worth it.

maria, do you make house calls?

HUG to you, girl,
Karen

I had Kaiser for a long time. I'm one of those people that rarely gets really sick and the Kaiser system that Patricia described above worked well for me.

But then they couldn't figure out what was wrong with me when I was having serious problems with my girl parts. In fact, what all three of my ob-gyn's at Kaiser told me definitely wasn't the problem is exactly what it turned out to be. Two of them tried to put me on hormones. After months of suffering, when open enrollment came along, I switched to Blue Cross. I went to another doctor, had another ultrasound, was diagnosed, and was fixed up in less than a week.

I had my knee surgery at Kaiser but I added Kaiser because I knew the orthopedist already, and knew he was awesome. I won't go back to Kaiser.

I currently have Blue Cross. I pay more out of pocket but I can pick my doctor.

The only problem with this is that I'm fighting the bill for the anesthesiologist for my surgery on my girl parts. None of them seem to contract with PPOs and the bill is usurious.

actually, marie's post is from 2003, and the poster who revived this is a scammer trying to sell you health insurance.....

Whoops. Thanks, Kat. I didn't notice the date of the original post. Hate when that happens. :)