Friday, August 27, 2004

Socialism Saves

from CNN
U.S. drug manufacturers are fighting the reimportation of lower-priced drugs from Canada and Europe back to the U.S. market, trying to cut off the foreign pharmacies that are selling to U.S. customers.

16 comments:

Sheryl said...

I'm surprised that haven't just made all medical drugs illegal, and then the CIA could just protect the illegal sale of prescription drugs at the mostly unreasonable prices imaginable.

8/28/2004 12:53:00 AM
gecko said...

So am I to guess that you believe that buying cheap drugs from Canada would not effect pharmaceutical companies here in the U.S.? I believe that these companies would not be able to afford the research necessary to develop new drugs. Perhaps the government should take over the pharmacuetical industry? Sorry, I got bored reading teeny bopper blogs from Asia...

8/28/2004 09:50:00 PM
Sheryl said...

Gecko,

What good is it developing fancy drugs if no one can afford them?

My ex lives in NZ, where they have socialized medicine. He has poly-arthritis. If he lived in this country, he would never have been able to afford the two hip operations that the NZ government paid for. He'd probably be in constant pain, his familiy would be bankrupt just buying the pain pills, and he'd be completely non-productive (not to mentioned depressed about being a burden on his family.)

Instead, he was working for the NZ railroad when I met him, was completely self sufficient, had considerably less pain with his prosthetic hips, could get around and do whatever he wanted and live a normal life.

Those are the kinds of decisions we're making here. Whether CEOs at Bristol
Myers should be making nearly $6.5 million dollars a year or whether Americans should have access to the kind of health care that other nations take for granted.

It's time to stop protecting the two legged, profiteering cockroaches of this country and started demanding fair access. This is not about R&D. It's about class warfare, where only some people can really really feel secure about their health safety net.

Sheryl

8/29/2004 12:36:00 AM
J.R. Boyd said...

Yeah, I wouldn't worry to much about the pharmaceuticals; we already pay for their R&D. To quote the NYTimes business page, "Basic biomedical research has long been heavily subsidized by United States taxpayers... high-tech pharmaceuticals owe their origin largely to these investments and to Government scientists..." through the National Institute of Health and universities...

8/29/2004 05:48:00 AM
gecko said...

Sheryl, I am being realistic when I say what may work in a small country like New Zealand will not work in the U.S. We are just too large and diverse.

As for govt funding I don't think this is unreasonable and I don't think it is anywhere near the cost to develope and test new drugs.

8/30/2004 08:21:00 PM
Sheryl said...

Gecko,

You are half right. The US situation is extremely complex, but that is exactly why we need socialized medicine.

I've worked in health insurance, and even though there are dangers of explaining some things at this time of night (when my brain is shot), I think I'll take the risk.

A lot of it is the bureaucracy of health insurance ( I believe I have heard something like 80% of the cost of healthcare in this country is administrative.)

Nothing I did in any of my jobs would have been necessary in a single payer/single provider system. I say single provider, because it's not just about who foots the bills. It's also about corporate profiteering.

OK, most claims are filed on what used to be called a HCFA form. (I believe they changed the name recently, as well as the agency to regulate such things. That way some government bureaucrats could pretend they were trying to reform the system.) Unfortunately their campaign coffers are too full with money from big insurance and big medicine, etc.

On these forms you have information about how the doctor has classified the disease in question according to the International Classification of Diseases ICD-10. There are thousands and thousands of diseases.

Every provider will have different deals cut with different insurers. Some accounts are "capitated," meaning that the insurance company pays a fixed amount of money per year and can request as many services as they want relative to the terms of their contract. Then some contracts are based on a pay per service basis, and they too negotiate different deals with each insurance company. Providers will be dealing with hundreds and hundreds of insurers, and each will have an account number in their computer.

Each insurer will have its own set denial codes on their "Explanation of Benefits" or "Remittance Advice;" that's just their paperwork they send with their reasons for rejecting claims. So people will be hired just to convert the denial codes over to something consistent into their computer system. (Ex, one insurance company will use code 031 to mean something like incorrect diagnosis, whereas a different insurance company uses code 1 to mean the same thing. So if you work for some laboratory, you have to enter these paper claims into your computer, and for your system incorrect diagnosis is code 17.) There are usually about 20-30 reasons for rejecting claims, but some companies have more and some have less. And of course, the rejections are also coded by people, so they are not only frequently miscoded but sometimes their computer doesn't really have a code that quite fits their reason for rejecting the claim. In those cases, the person receiving the claim just has to take a guess or call to find out why the claim is being rejected. Chance are if they call, the person they talk to won't know or will tell them the wrong thing.

So then you also get into CPT codes for different procedures. I believe it's HCPCS codes for durable medical equipment. I'm sure there is yet a different coding system for the drugs. Each health care provider has a provider code. The doctors each have UPIN codes. And of course, you don't just have different fee schedules between insurance companies and providers, but also different deadlines for filing claims. And sometimes you don't have the information on hand for all these codes, so you have to call the doctors or the providers or the insurance companies to get their codes from them.

Sometimes doctors will order tests which are not covered by policies. If the patients have government insurance, then the provider will also have to get the patients to sign advance beneficiary notices before providing the service.

Some claims are automated if the provider has a large enough volume to justify it. Otherwise, the provider must submit the HCFA form with also sorts of paperwork proving doctors ordered the services or products.

Then the insurance company will try to find a loophole, so they don't have to pay it.

Things get tricky because the patient gave their doctor info for their AETNA policy, because they don't want to tap into their Medicare policy. Unfornately, they didn't realize that Medicare is always the primary insurance and Aetna knows that they are the secondary policy, so they deny the claim back. Then you have to file a paper claim to Medicare with a copy of the denial from Aetna and a fresh claim form.

They also play ping pong when doctors order the same procedures on different body part of the same day, because it's the same procedure code, so they assume it's a duplicate. They ping pong the claims back when a claim is submitted two days after the patient has died and demand written proof that the tests were ordered BEFORE the patient died. They will deny a claim if the doctor writes the name of the disease out for a test request rather than writing the disease code on the form. (Example: the diagnosis is written out as "hyperplasia of prostate" rather than 600.) They will deny a claim if any of the applicable codes don't match the written explanation of whatever the code is supposed to represent. Any excuse whatsoever to not pay a claim is used.

Sometimes a doctor sends a patient to receive a service which is "out of network," because of some HMO contract.

It's ridiculous--I could go on and on. Some people do nothing for a living other than research the paperwork for rejected claims. It's a very easy to get a job doing that.

All this could be bypassed if we weren't trying to protect corporate profiteering and big medical bureaucracies that just simply aren't necessary.

And there is also truth in what is said about malpractice insurance as well. With socialized medicine patience can't sue. Doctors can have their licenses revoked however, and if they do fuck up the patients still have mostly free healthcare.

But that's where the costs are. And it would mostly be avoidable if we had socialized medicine. It's all completely insane. In fact, I have given myself a headache just thinking about it.

8/31/2004 05:40:00 AM
Sheryl said...

OH, and I forgot about incorrect policy numbers as well. There are a just a million reasons that the system has evolved into a bureacratic nightmare, and most of it is solely to prop up capitalism for a sector of the economy where capitalism is innately inefficient.

By idealogues always put their philosophies of the marketplace above public welfare, and that is why the UN ranks us something like 35th in healthcare worldwide. Because it's gotten where it is just too expensive, and people are sitting back and not getting treated in the early stages of their diseases, because they think they can't afford it. And then suddenly something that could have been nipped in the bud is a matter of life and death, and the costs are astronomical at that point. So much for preventative care, which is always cheaper.

8/31/2004 05:52:00 AM
Anonymous said...

This is why when you meet with your Human Resource Rep for whatever company you work with , they break the explanation of what your insurance covers to basics like copays, and hospital stays, and ask that you read the material included with your packet, or go to the insurance provider's web site for specific questions. And that's why, when you change providers during an open enrollment period you can lose coverage on a medication because the condition was pre-exhisting, and the insurance provider doesn't have to cover it.
Plus, you can't forget that pharicutical companies don't really do much in the line of research and development in older drugs, but they still keep the prices high, meaning that treatment for "cured" illnesses is too costly for an insurance company to agree to the treatment, and beyond the means for the average patient to afford on their own. For example 2nd line MDR-TB treatment was costing $15,000 per patient in Peru before Jim Kim and Dr.Paul Farmer organized and worked with a Dutch company to create generics and lowered the cost $1500 for 4 drug resistant TB. In case your wondering that's a $13,5000.00 differance in cost just because no one noticed that the patents on the drugs expired more then 20 years ago, and they could begin creating generics. (Read "Mountains Beyond Mountains", this example is on page 173)
If the pharmicutical companies cared about research and developement they would have been creating generics or devising new medicne for TB and MDR-TB. Instead they set differant prices according to the "need" and did no new development or research. Paris drugs were cheaper then Peruvian drugs but you couldn't buy the drugs in Paris and ship it to Peru because there was a global shortage due to an emergency need in Peru, so now you're getting into price gauging, and International Trade and all kinds of things...
Ahh!

8/31/2004 03:57:00 PM
gecko said...

Let me hereby give out my first liberal consideration to an issue effecting all people on US Soil; I agree the system is damaged. I agree that a large amount of govt regulation is needed to 1) streamline medical insurance coverage. 2) Bring down the cost of medicines and medical care. 3) Limit the number of frivolous malpractice lawsuits.

I do not want the government to force people to 1) Use this or that doctor or HMO. 2) Be provided health care for free, unless it's provided by their employer.

Take the model of everyone get's free healthcare. Having free health care, I can call up and make an appointment for every little ache or innoxious blemmish that shows up on my body. When I call, I get an appointment which is well past the time/date I desire, however I am at the mercy of the "HMO" and have to get an appointment next week. If I happen to somehow be fifteen minutes or more late, I lose my appointement. If I need medication, which is free, I may have to go all the way accross town to get it. Now, there are only 3000 or so families vying for the same healthcare I have. Welcome to the military. Now, times that by, say 300 million families?

I think heavy govt regulation is the key to keeping costs down. I can compromise that much. Socialized medicine will only over-saturate the system with patients and drive the quality of service to deprivation. We are just too large and too diverse a nation for socialized medicine.

You didn't mention current options for non-insured Americans, such as local community clinics with pay as you go services. I have used this system and it works fine. The care is better quality than the military clinic and is relatively cheap. I can only go by the one visit, though.

9/04/2004 11:18:00 PM
J.R. Boyd said...

I don't know a lot about this; on the other hand, I don't know that you have to. It's ridiculous that people have to go to other countries to be able to afford medication that is produced in this one. Decent societies should provide access to healthcare for their citizens, period. No reason why the wealthiest nation in the world can't swing it; in fact, an efficient system would be cheaper. If we stopped building so many bombs we could probably federally fund education too, and have the best schools in the world. This is not any kind of impossible human quandary, far beyond our limited means. It simply requires some effort to fix what's wrong, and challenge the interests determined to keep it that way.

9/05/2004 12:27:00 AM
gecko said...

It's not so simple as that. You can't just trade bombs for cheap medicine and education.

Also, there is a difference between access to health care and health insurance coverage.

9/06/2004 07:04:00 PM
J.R. Boyd said...

"You can't just trade bombs for cheap medicine and education."

Says who?

9/06/2004 07:14:00 PM
Anonymous said...

I have to agree with gecko on this. It's not as simple as trading bombs for education and health care. That's the equivalent of throwing money at the problem and expecting it to go away.
There needs to be a detailed examination of all parts of the health care industry, along with records of the numbers and cost of legal issues arising from medical malpractice suites etc. If we are examining it as a system, then we need to know where each part of the machine breaks down most often, and only then can we really work to a solution. Maybe the solution is socialized medicine, and maybe it isn't. (Though my Canadian friends seem fairly happy with the inconvenience of a trip across town for meds, and a slightly later doctor’s appointment, and to my knowledge none of them abuse the system for minor ailments like a rash or pimple).
If we use geko’s example of socialized medicine then obviously it won't work for the US. But geko seems to forget that if medicine were socialized nation wide, then all health care providers, all pharmacists, all insurance companies would have to exist under the conditions established. That means that all however many billion people living in the US would not be making appointments to their local vets hospital/clinic.
And if his experience at the clinic was positive, then doesn't that point all the more to creating a more accessible health care system for all? You can't create a system that shuts people out, and continue to expect non-profit agencies like your neighborhood clinic to continue to pick up the slack.

9/07/2004 01:13:00 PM
J.R. Boyd said...

I don't disagree; within a given context things require careful consideration. But what's wrong with healthcare, in a fundamental way, is the framework we have inherited: healthcare policy exists as a dialogue between private entities and the state, to the exclusion of ordinary Americans, who, apart from threatening disruption and creating instability for the former, are not real players in the decision-making process...

That's a long-winded way of saying that people should control the institutions of their society democratically. That means real power is diffused, not concentrated in either the state or corporate structures. If people decide that healthcare, education, and other things that directly enrich their lives are more important than maintaining a permanent war economy for defense contractors who build superfluous weapons systems on our bill, then, as a general rule, they should have the authority to fund what they want, de-fund what they don't want. In theory they do. But that the government is working overtime to frighten the population into supporting more privatization and less reform should shed light on whose interests are consistently taken to heart.

This is all rather abstract, and not geared to the immediate consideration that the current healthcare crisis requires: how best to provide access to the general population right now. (I wouldn't suggest there is a simple answer.) However, American history is filled with reforms that meet the short-term needs of citizens without fundamentally moving power away from the interests who created their plight in the first place; indeed, they often serve to re-establish that power in a more sophisticated way. This is important to bear in mind if what we enjoy as citizens is to be more than a gift from above, and rather something that we choose, implement, and maintain for ourselves.

9/07/2004 05:45:00 PM
Sheryl said...

I love how when we talk about health care or education we're "throwing money at the problem," but while the Pentagon can't account for a trillion dollars in 1999, we need to increase military spending. And our spending has almost doubled since 1999 (they just don't both with the audits anymore.)

But I agree that we should not waste money on bureacracy, which is why I suggested a single payer, single provider system, because that also means a SINGLE ACCOUNTING SYSTEM. Uniformity means efficiency and efficiency saves money. My point was that right now we have thousands of different systems within our healthcare system, because insurance carrier and provider does things their own way in the name of "free enterprise."

The joke goes, the great thing about standards is that there are so many to choose from. Any profesion that requires experts to do a job costs more. And the inefficiencies from lack of expertise costs money. One provider, one insurer, one system.

And for the record, Radical Moderate, I did in fact mention things being rejected for bad diagnosis codes on a claim, which just goes to show that there are so many details involved that it all just gets lost in a sea of information.

9/08/2004 02:41:00 AM
Anonymous said...

Hi. I just want the world to know that the pharmisuticals are not doing enough research on meds. I just resently lost my son to a medicine that was not tested on infants and the result of using this med was death after 19 months. I have tried to reach the company that makes this med and they keep blowing me off. I think that there should be much more testing and even more testing and less approval of meds that aren't. I am a mother that lost her son due to the lack of research and the lack of info on the meds. I am a mother who lost her son to a med that was never supposed to be given to an infant. Please, we should make them hear our voices and see the pictures of those they hurt and make them understand that we expect more from them. We surely pay for it when we buy the meds, we deserve more.

3/01/2005 11:56:00 AM

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