The End Is Nigh!!!

[Guest MormonGator]

2 hours ago, Just_A_Guy said:

 

I’m sorry, brother, but this “Children are dying and we’ve got to Do Something™!” schtick has lost its potency with me. 

It's lost it's effect on me too @Just_A_Guy. When progressives say "We need gun control in order to save our kids!" it's total garbage. And when the right says "We need to censor heavy metal lyrics in order to save our kids!" It's also total garbage. 

Edited April 13, 2019 by MormonGator

[pwrfrk]

If you want to do something positive for the kids' sake, then I suggest you tackle dealing with helicopter parents.  These kids don't even know how to live because their parents are so afraid their kids are going to have the horrible childhoods they had, failing to realize THAT is exactly what helps kids learn and grow is to have horrible events, unplanned of course, happen in their youth.  That is the only way to learn and to grow into a better person.

[anatess2]

On 4/12/2019 at 9:59 PM, Scott said:

I agree with you.

So what's the solution?   Obviously what we have been doing hasn't been working.

Treat medicine the same way you treat any other capitalist endeavor in the USA.  Take government out of it except for FDA-type regulations and other regulations such as anti-monopoly, etc.  Healthcare is not the responsibility of employers - healthcare should go back as simply enticements for employment.  Therefore, any person should be able to create their own group that negotiates coverage and prices with insurance companies outside of their employment.   Government should NOT dictate what is covered and what is not covered, and that includes pre-existing conditions.  Insurance companies should compete like any other company in the USA including having to account for inter-state commerce.  Health Savings Accounts can be encouraged through Federal tax exemptions.  If a State wants to provide healthcare as part of their welfare system, then the State can provide for HSA-type accounts (same concept as an EBT card) that people can use to pay doctors/pharmacies or purchase insurance with or the State can purchase a State-group Catastrophic insurance coverage.  This is just a start.  

 

[unixknight]

On ‎4‎/‎12‎/‎2019 at 10:26 PM, Scott said:

I'm listening, but what is your solution?  

I don't have all the answers, but a really great start would be to start getting Government out of healthcare, as @anatess2 suggests.

On ‎4‎/‎12‎/‎2019 at 10:26 PM, Scott said:

As said before, because it's for sale.  A few of the rich (and I have no problem for them doing this) can afford a specialized doctors and facilities that are here.

The US isn't the only place the rich are going for healthcare.  They are also going to Japan, Singapore, South Korea, etc.

And that tells you nothing about the state of healthcare where they're coming from?  We already discussed why people would go from the U.S. to other places, which you used to defend the idea that the U.S. has a problem that single payer healthcare would fix.  Yet we still see people going out of the country from places where there already is a single payer system.  So why is that?  "It's for sale" isn't an answer.  I work next door to a shopping mall with hundreds of thousands of items for sale.  That alone doesn't make me want to go buy even one.

On ‎4‎/‎12‎/‎2019 at 10:26 PM, Scott said:

I understood you, but I was pointing out that most of those countries' governments also spend less on healthcare per capita than our government does.  Their high taxes aren't due to more government health spending; they are for other reasons.

 Such as?

On ‎4‎/‎12‎/‎2019 at 10:26 PM, Scott said:

Here the insurance company make the decision for the child's care.   

Incorrect.  While the insurance companies may have a lot of influence over the medical options they'll cover, that doesn't outright force the parents into any particular treatment, or into no treatment at all.  

On ‎4‎/‎12‎/‎2019 at 10:26 PM, Scott said:

I don't know the answer to this. 

Don't you think you should, if you're going to defend the system that made that call?

On ‎4‎/‎12‎/‎2019 at 10:26 PM, Scott said:

Here, why do insurance companies get to say no? 

They can only say no to what they'll pay for, not to what the parents can do given other options.  See above.

On ‎4‎/‎12‎/‎2019 at 10:26 PM, Scott said:

Let me use a personal example.  My jawbones are decaying and I will die if I can't don't get them fixed.   The medical insurance won't cover the cost, so I'm leaving the country to get it fixed.  Why do insurance companies have so much power?   

I'm going to assume you've explored other options so I won't insult your intelligence by suggesting a few, but I find it hard to believe that an insurance company can legally withhold coverage for a condition that is life threatening.

Still, it's a symptom of our public perception of what insurance companies do that this is viewed as them having power.

On ‎4‎/‎12‎/‎2019 at 10:26 PM, Scott said:

Yes people do die here from lack of medical care.  A lot of them do.  The law you are referring to only applies to what is considered to be an immediate emergency.  It doesn't apply to things that don't kill you immediately.

Are you aware of state funded healthcare options that provide for those who can't afford it on their own?  Since we're using personal experiences, when I was a young man with a new, pregnant wife, I wasn't working at the kind of job that offered health insurance.  So, we went through the state, which funded an HMO plan for those who were unable to pay for their healthcare.  Thus,  the birth of my first child was covered, as was all the prenatal care and postnatal care for both mother and child.  Not even a life threatening situation, and still all was covered.  

Later, when I was able to cover health insurance through my job, I was able to take over.

On ‎4‎/‎12‎/‎2019 at 10:26 PM, Scott said:

I'm listening.  What would you say is the best solution?  

Start by pulling the Government out.

[Vort]

2 minutes ago, unixknight said:

On 4/12/2019 at 7:26 PM, Scott said:

I understood you, but I was pointing out that most of those countries' governments also spend less on healthcare per capita than our government does.  Their high taxes aren't due to more government health spending; they are for other reasons.

 Such as?

Defense!

Just kidding.

[anatess2]

On 4/12/2019 at 10:26 PM, Scott said:

Let me use a personal example.  My jawbones are decaying and I will die if I can't don't get them fixed.   The medical insurance won't cover the cost, so I'm leaving the country to get it fixed.  Why do insurance companies have so much power?   

Let me get this straight.  You have medical insurance that doesn't cover fixing your decaying jawbone?  Did you know this before you purchased the insurance?

An insurance company is supposed to have zero power over you.  It gets power over you when you are prevented from shopping health insurance, like the stupid Obamacare mandate that forces you to get insurance from your employer or from some heavily-government-regulated entity.  When shopping for health insurance is deregulated, then health insurance has the same power over you as... your neighborhood Walmart.

[Guest Scott]

3 hours ago, anatess2 said:

Let me get this straight.  You have medical insurance that doesn't cover fixing your decaying jawbone? 

Yes anatess; that's exactly what I am saying.  No medical insurance I can find covers jaw necrosis and I have been fighting with the insurance companies for a few years now.

Medical insurance companies will say that it is dental since it involves oral surgery.    The thing is that while the necrosis itself may not be life threatening, it gets infected and then results in a hospital stay and only then will the hospital pay that part (for the infection).   They will not fix the decaying jaw.

Here is a photo of my face from my last hospital visit. 

  I will not show a photo of the inside of the mouth because people will be grossed out.   Just google "jaw necrosis" if you really do want to see photos of what jaw necrosis looks like.

 

Quote

Did you know this before you purchased the insurance?

Not at first, but I do now.   There are no medical insurance companies I can find that will cover it.  I have checked.  If you find one, let me know and I will be eternal grateful.

Here's the thing.  If I don't get it fixed, I could die.  The last infection (February) cut off my breathing and I was set to the emergency room.  I almost died.  Medical insurance will pay for this part.

They won't pay for the surgeries to fix the jaw in the first place so it doesn't get infected.  The case is to small for the lawyers to what to take on contingency and they keep putting us off.

The medical insurance says that fixing the jaw is oral surgery, but dental insurance only pays up to a few thousand dollars.   We have already spent tens of thousands of dollars trying to get it fixed and will need tens of thousands of dollars to get it fixed.

Between my son and I, we spent $110,000 on out of pocket medical expenses last year alone.  We did manage to fight the insurance company on my son's side and did recover $30,000, but that's it.  (The owner of the engineering firm helped us out by getting involved with the insurance company; he was infuriated that they weren't paying more).  

If anyone is interested in how the problem came about in the first place, it was because a kid on a snow tube (accidentally) hit me while I was walking on the sidewalk and he was sliding down the hill.   My jaw was broken, but my family was not well off financially and I didn't get medical care (I was 7-8 years old at the time).   The broken jaw healed, but left behind cracks that decades later harbor bacteria that cut off blood supply and eat the bone away.

Now I make a really good wage, but even so, $110,000 a year out of pocket medical expenses is a lot of money.  (I think the year before that our out of pocket expenses were around $60,000.   Unless you are ultra rich, that's a lot of money for anyone.   (if we weren't able to come up with the money, I don't know what we would have done). 

Medical insurance companies always find loop holes when it comes to paying for unusual problems.   They are pretty good with paying for "normal"  problems because they are forced to.  If you have an unusual medical problem, you are often out of luck with the insurance companies and have to fight them. 

Between us and my employer, our medical insurance is ~$2300 a month, so it isn't exactly a cheap plan. 

Anway, I screen shot our medical expenses so far this year: 

Daughter:

Son:

Wife:

Me:

They aren't that high except for my son, but I don't have my big medical expense until May 20, when I have some more jaw work done.  That won't show up the medical statements though.   My son's medical expenses are still in dispute, so we're hoping to get at least some of the below payed.  Right now they have only paid $143.13 out of $24,299.35.  

Not including dental (which is the big cost for me), our out of pocket so far this year (as of 4/15/2019) is $27,256.84.  The year isn't even 1/3 over yet.  This doesn't include the $1000 out of pocket we pay for medical insurance premiums and an even greater amount that my employer pays.

As said, "normal" problems are not a problem with medical insurance.   My wife, me, and son (but luckily not our daughter) all have "unusual" medical problems though no fault of our own.  It was and still is a fight to try and get the medical insurance to pay, even for necessary procedures. 

I won't say what my son's treatment is since he is a minor and doesn't want to be in the public spotlight, but our big medical expenses for me is getting my jaw fixed.  For my wife, it was her heart.

My wife was born with a defective heart valve.  She is very athletic, has never smoked, or drank, and we live a healthy lifestyle.   We only heard about her life threating heart condition when we were getting a physical for a mountaineering expedition.   Obviously she was in good shape.

Anyway, we found out her aeortic heart valve had a diameter of 0.77 cm.  For a "normal" adult it is 3-5 cm.  She got her heart surgery in January 2017 where they replaced her heart valves and ~1/4 of her heart with titanium and carbon parts.   Obviously it was very expensive.  Our out of pocket expenses were about $60,000 and we were thought that we were done with anything major medical.  Then 2018 hit and my son and me had other problems and we were out of pocket $110,000.   This year might end up somewhere in the $50,000 to $100,000 range.

What is weird is that before 2017, none of us, other than childbirth, every had any major medical expenses.  Then within two years 3 out of 4 of us had some major problems.  They weren't "normal" medical problems either, but were highly unusual, every one of them.   Hopefully by next year, the nightmare will be over.  

I must say though that it is no surprise to me that people go bankrupt in this country due to medical expenses.   We got close, but were able to squeak by because I have a high paying jobs, had a house that was almost paid for, had savings and 401K's.  They're all gone now, but at least we were able to make it through.   No one can ever accuse us of not being wise with money.   

Average or above average income people can easily go bankrupt due to medical expenses, even if they are wise with money.

Also, I feel most for children that don't receive enough medical care.   It does happen in this country, no matter what others are claiming.  

Quote

An insurance company is supposed to have zero power over you. 

I agree that they shouldn't, but they do.  They have a lot of power over all of us, whether or not we want them too or not.  Just wait until you have an unusual medical condition and you will see. (Actually I hope that you or anyone else never has to find out and I wish you all good health). 

Edited April 15, 2019 by Scott

[Just_A_Guy]

@Scott, I’m sorry to hear about all you e been going through.  Out of curiosity, have you tried one of those “Christian healthcare ministries” that are basically non-profit HMOs?  Anecdotally, I hear they are much better to work with as long as you aren’t dealing with a “vice-related” medical condition.

[Guest Scott]

23 minutes ago, Just_A_Guy said:

Out of curiosity, have you tried one of those “Christian healthcare ministries” that are basically non-profit HMOs?  Anecdotally, I hear they are much better to work with as long as you aren’t dealing with a “vice-related” medical condition.

Yes, we are looking into that too.   My only fear is that they also will consider my jaw work to be dental (they don't cover dental), even though it could kill me if I don't get it fixed.   I am still waiting to hear back from them, but it has been a few months now.  

[Vort]

56 minutes ago, Just_A_Guy said:

Out of curiosity, have you tried one of those “Christian healthcare ministries” that are basically non-profit HMOs?  Anecdotally, I hear they are much better to work with as long as you aren’t dealing with a “vice-related” medical condition.

Without going into too much detail: My family has used Liberty HealthShare. We are very happy with the results, inevitable red tape notwithstanding. Despite a couple of serious and unanticipated medical emergencies, we have been treated very well. Liberty HealthShare has both my gratitude and my recommendation. In our current screwed-up health care system, this seems like a very reasonable alternative, maybe the most reasonable. (Fair warning: They won't cover pre-existing conditions for some initial period, maybe years long. I'm not sure.)

I would point out to my lawyer friend that health share organizations are most definitely not HMOs in any legal sense. My understanding is that they are essentially unregulated, and at least in principle can deny health care payments for any reason they might choose. In my family's experience, Liberty HealthShare has been extremely honest and shown nothing but integrity (again, red tape notwithstanding, and there's a bunch of red tape). But there are few legal guarantees, so choose wisely and keep your eyes wide open.

[Vort]

40 minutes ago, Scott said:

Yes, we are looking into that too.   My only fear is that they also will consider my jaw work to be dental (they don't cover dental), even though it could kill me if I don't get it fixed.   I am still waiting to hear back from them, but it has been a few months now.  

Please be sure to ask specifically about pre-existing conditions, what the wait is, whether they will even accept you with such a condition, etc.

[anatess2]

4 hours ago, Scott said:

Yes anatess; that's exactly what I am saying.  No medical insurance I can find covers jaw necrosis and I have been fighting with the insurance companies for a few years now. 

<snip>

Not at first, but I do now.   There are no medical insurance companies I can find that will cover it.  I have checked.  If you find one, let me know and I will be eternal grateful.

Okay, my heart goes to you and your family for all the medical troubles you have.

I used to work for Blue Cross and Blue Shield back in the 90's.  Back then, we receive Oral & Maxo claims a lot.  There are procedures that BCBS PPO/et. al. covers and there are procedures that the Dental insurance covers.  I know BCBS covered sleep apnea related jaw surgery.  So I'm gonna say it is safe to assume that they covered jaw necropsy.  I don't know what changed from the 90's to today.  (Obamacare maybe?).  Anyway, how that usually worked was that the O&M surgeon's office run the codes through both Medical and Dental insurance plans (BCBS carries both) and the things that the dental plan covers gets rejected by the medical plan and vice versa.

Where we usually get rejected claims that cause a huge headache for everybody is when the O&M surgery is a result of a car accident.  This one gets pingpong'd between BCBS and the car insurance.  Another headache is when there are 2 insurance plans one of which is not BCBS (e.g. both husband and wife have a family plan) - it gets pingpong'd then too.

 

Quote

Between my son and I, we spent $110,000 on out of pocket medical expenses last year alone.  We did manage to fight the insurance company on my son's side and did recover $30,000, but that's it.  (The owner of the engineering firm helped us out by getting involved with the insurance company; he was infuriated that they weren't paying more).  

$2300 per month with $110,000 out of pocket is TERRIBLE insurance!  

Before Obamacare, I had Hospital and Surgical Only insurance (BCBS).  I paid $120 per month for a family of 4 non-smoking non-drinking no-chronic-illness and no-pregnancy-coverage plan.  No copays, no deductibles.  Your jaw surgery and your hospitalization would have been covered 100% no out of pocket expenses.  Obamacare made that insurance plan illegal so I lost the plan.  I put $380 per month on an HSA which I used to pay for well-check visits, non-hospitalization-or-surgery-related meds, etc.  That HSA got eliminated too because our new insurance plan didn't qualify for HSA.

 

Quote

What is weird is that before 2017, none of us, other than childbirth, every had any major medical expenses.  Then within two years 3 out of 4 of us had some major problems.  They weren't "normal" medical problems either, but were highly unusual, every one of them.   Hopefully by next year, the nightmare will be over.  

I must say though that it is no surprise to me that people go bankrupt in this country due to medical expenses.   We got close, but were able to squeak by because I have a high paying jobs, had a house that was almost paid for, had savings and 401K's.  They're all gone now, but at least we were able to make it through.   No one can ever accuse us of not being wise with money.   

Average or above average income people can easily go bankrupt due to medical expenses, even if they are wise with money.

Also, I feel most for children that don't receive enough medical care.   It does happen in this country, no matter what others are claiming.  

This is the MAIN PURPOSE for insurance.  FOR CATASTROPHIC events.  An insurance plan that covers well-checks and ear infections but doesn't cover catastrophic care or has an unaffordable deductible/copay is a useless plan.

 

Quote

I agree that they shouldn't, but they do.  They have a lot of power over all of us, whether or not we want them too or not.  Just wait until you have an unusual medical condition and you will see. (Actually I hope that you or anyone else never has to find out and I wish you all good health). 

THAT is the problem.  IT SHOULDN'T.  Obamacare MADE THAT WORSE.  Now, you put medical care in the hands of inefficient government and you'll have... the VA.  Where the insurance company doesn't have power over you anymore, the government does instead.

My father survived lung cancer for 4 years.  He did not carry insurance.  He got treatment from a clinical trial and the rest all his children and his brothers and sisters helped pay for.  Other than his doctors in the trials, he had my brother as his primary care doctor, and my sister his primary care and home health nurse.  So we didn't have to pay for doctors/nurses.  He could have survived a lot longer than 4 years but he was tired and left the clinical trials and refused medication after that.  My father's brother had colon cancer, my aunt had ovarian cancer, my other aunt breast cancer (yes, it runs in the family) - all without insurance.  My uncle passed away after over 20 years of the cancer.  Both my aunts are still alive and in remission.  They all stayed in the Philippines and the family helped pay for their treatments.  In the Philippines, if your family is a specialty doctor (my brother and my uncle are specialty doctors), you can do a service exchange with other specialty doctors and their family.  And because my brother is affiliated with several hospitals, we get massive hospital discounts.  So our big ticket was the infusions and meds.  None of us have gone bankrupt with all those cancer patients in the family.  Yet. 

I'm going to say this again - insurance that covers ear infections but not catastrophic care is a useless insurance.

 

Edited April 16, 2019 by anatess2

[Guest Mores]

On 4/12/2019 at 9:42 PM, Scott said:

I don't know, but for sure a lot of it can be attributed to lack of care.  While the things you mention may contribute, preventative care is very expensive for children.

While I currently make a high wage (engineering), I grew up in a household that did not.  I can guarantee you that we went without medical care a lot as children, and I can also guarantee that we were not alone.   I can also guarantee that it still happens today.

I currently make a high wage and I CHOOSE to not have medical insurance.  All my children are well taken care of and healthy.  This is not because I can afford doctor visits.  It's because I know good health habits by eating right and exercising.  I also know first aid, so I'm not paying through the nose at the ER because my kid scraped his knee.

A doctor once applauded me for this because with the years he'd been in the ER, he found that a great majority (he didn't give me an actual percentage) of cases in the ER are things that could have been taken care of with simple first aid.  Wanna know why hospital care is so costly?  It's crap like that.

Why are YOU having such problems with the insurance companies? Because they're too busy trying to cover "healthcare" rather than reserving their funds for REAL problems like your jaw.  The whole industry would be better served if we only had catastrophic coverage for everyone and left preventive care to families and charities.

Edited April 16, 2019 by Mores

[unixknight]

16 hours ago, Scott said:

Medical insurance companies will say that it is dental since it involves oral surgery.    The thing is that while the necrosis itself may not be life threatening, it gets infected and then results in a hospital stay and only then will the hospital pay that part (for the infection).   They will not fix the decaying jaw.

Brother, I feel for you, just as we all do.

You make a very convincing case for why our system needs a ton of work.  Other have mentioned parts of what's causing the problems and I agree with them.  

Nobody's saying the system here is perfect.  In fact I don't know anyone who says it is.  What I'm saying (and I believe what others here are saying also) is that we believe the remedy for the problems is NOT to hand everything over to the Government.  Doing so would only be trading one set of problems for another, and the set we'd be getting are worse than what we have already.

I'm glad you have the option to get what you need elsewhere.  I think that's a good example of the kind of freedom we want to maintain.  It's a shame it's too expensive here and that's a problem we need to address.  I have my own ideas on why prices for medical care in this country are so high and I've seen some movement in the Government to address that.  (Transparency in cost being one example.)  

[anatess2]

1 hour ago, unixknight said:

(Transparency in cost being one example.)  

THIS.

When I had insurance that only covered hospital and surgical without pregnancy, I got pregnant.  I ended up with this one OB that delivered my kid because his office worked with me on pricing.  He ended up leaving that OB group to become independent when I was 5 months along and I followed him to his new office who kept the pricing plan that we agreed on.  He put a big self-pay mark on my folder because I had a difficult pregnancy and so we decided what to do tailor-made specifically to my symptoms and what the OB thinks needs to be done instead of what the insurance protocol says should be done, so I got lab work that the insurance wouldn't have covered unless some other test is done first, and that kind of thing.

[unixknight]

What people don't understand about Obamacare is that it was designed to fail.

Remember how Obama coined the phrase "obscene profits" when referring to insurance companies?  And that was the moral imperative that drove people to support and defend it  even without knowing what it entailed?  Remember all that?  

Well I looked up the average profit margin that insurance companies were operating at.  At that time, health insurance companies were getting a profit margin of just 2.5%.  That profit margin ranked health insurance as something like 35th in the list of most profitable industries.  Want to know what #1 was?  Beer.

So one of the features of Obamacare was the idea that insurance companies had to cover pre-existing conditions. So that 2.5% would rapidly  go negative.  So what did insurance companies do, just to stay alive?  They jacked up premiums and deductibles, of course.  Suddenly Obamacare, which promised that every single American would get health insurance and it would be cheaper, AND it would allow you to keep your current doctor, turned out to be a hat trick of lies.  My health insurance costs more than doubled for my family.  Many people lost access to the doctor they were used to, and suddenly EVERYBODY had to buy it whether you could afford it or not.  Sustainable?  Nope.  Those who passed it did so knowing it would fail, and then the plan was to swoop in with a single payer system that would save the day.  

Obamacare was always designed to maneuver us into a single payer system.

By dismantling it, Republicans have been ruining that plan.

[anatess2]

4 hours ago, unixknight said:

By dismantling it, Republicans have been ruining that plan.

I wish that was true.

 

[Guest Scott]

14 hours ago, Mores said:

All my children are well taken care of and healthy.  This is not because I can afford doctor visits.  It's because I know good health habits by eating right and exercising.  I also know first aid, so I'm not paying through the nose at the ER because my kid scraped his knee.

We also excersize a lot.

Last year, I went hiking or climbing on 198 days (which includes after work climbs) and climbed 113 mountains.  That was last year alone.  So far this year I haven't done as well, but have hiked or climbed on 48 days (since January 1) and climbed 20 mountains.

We are a very active family and we also know first aid.   Unfortunately though, we can't do our own heart surgeries or bone surgeries.  Unfortunately a healthy lifestyle can't fix everthing.  

Luckily since I have a good job, we were wise with money, and we had a lot saved up, we were able to get by.

[Guest Scott]

On 4/15/2019 at 9:09 PM, anatess2 said:

$2300 per month with $110,000 out of pocket is TERRIBLE insurance!  

Most expensive insurance plans are good on paper.  Most (other than extremely high cost) are good at covering "normal" or "common" problems because they have to be.

If anyone has an "unusual" medical problem in this country though, you are basically hosed due to loopholes with insurance and medical care.  

Unluckily all three of us (me, my wife, and son) all had unsual problems.  (I hope at least) that doesn't happen to most people.   I explained what happened with my jaw and how they are consider it deltal and why that was a problem.

My wife's heart was also highly unusual.    There were only two surgeons we could find that even wanted to touch it.  One was at the Cleveland Clinic in Ohio and one was at the Heart Center of the Rockies in Loveland Colorado.

Here's where the insurance companies get you if you have an unusual problem.

With our ~$2300 a month medical insurance , there is supposed to be a $6250 out of pocket max for in network and $12,500 out of pocket max for out of network.  This looks good on paper.  However, the first catch is that neither deductable or out of pocket max counts towards each other.  The second catch is thatif you go out of network, the facilities, doctors, and surgeons are allowed to bill patients for the difference in cost for what the insurance pays vs the billings.   (I'd suggest that everyone here check their own insurance policy fine prints).

In my wife's case, her cardiologist and the hospital were both in network, but the surgeon was not.  Neither deductable counted towards the other and we got a huge bill from the surgery from the out of network surgery.

I don't think the surgeon was trying to cheat us though (I didn't feel the same way towards the insurance company),  He basically had commissioned someone to build 1/4 of a human heart out of titanium and carbon allow and build her a new artificial heart valve as well.   

The insurance paid somewhere around $350,000 (?) (plus after care, etc.) and we were responsible for somewhere around $60,000 (including all tests, etc.).

If there are no in network facilities, doctors, surgeons, etc. insurance companies are in theory at least,  supposed to do what is called a single case agreement where major medical expenses can be considered to be in network when it comes to cost to the patient.  To do this though, you have to prove that there are no in network doctors or facilities available. 

This isn't as easy at it seems.  We would tell the insurance company that we can find no in network surgeon who will do the surgery and they would just respond by sending a generic list of a bunch of surgeons that were in network.  They didn't bother seeing if the surgeons would do the surgery and every one we contacted would not.   X rays, ultrasounds, etc. of my wife's heart were sent all over the country (heart surgeons would even comment that they had never seen a heart like hers and they were interested in finding solutions).   Doctors couldn't even fathom that my wife was even alive or her heart was even functioning with the shape of her aortic valve and chambers and with the amount that everything was leaking.   Although a lot of surgeons were interested in the phenomenon, we could only find two that were willing to perform the operation.  The insurance company still didn't accept this though and just kept giving us generic lists of various in network surgeons, first in Colorado and then other states.    They were just pencil pushers and really didn't know what the situation was no matter how many times it was explained to them.   We called time and time again (hours upon hours) and would get someone different every time.

Anyway, the insurance did end up paying a lot for my wife's surgery, but I still felt cheated on our out of pocket costs.  We have been paying into insurance for decades in case anything catastrophic ever did happen.    The insurance company wasn't there for us even after we had been loyal customers for many, many years.   

We didn't know any of it was coming.  It was a complete shock.   Though my wife had a heart murmur, we thought we were both in perfect health.   The only way we found out was from a physical that we were supposed to take for a mountain climbing trip.  If anyone is interested in a little background about how we found out about the heart condition, here is a story about it:

https://www.summitpost.org/love-bombshells-heartbreak-and-mount-shasta/698612

The doesn't continue past the initial phase of finding out though.   The surgery wasn't actually performed until eight years after the above was written.   It wasn't performed sooner since there was a good chance that the surgery itself could have been fatal, so it was decided by the doctors that the surgery should be postponed until her heart deteriorated.     The doctors (understandably) didn't want to risk doing the surgery while she was still healthy because if the surgery turned out to be fatal (there was a pretty high change of this), it would have shortened her life for nothing, so they (intentionally and with our blessing) waited until the heart deteriorated.    Although it was "only" aortic stenosis, it was a very unusual case of the disease.

Edited April 17, 2019 by Scott

[Guest Mores]

8 hours ago, Scott said:

We also excersize a lot.

Last year, I went hiking or climbing on 198 days (which includes after work climbs) and climbed 113 mountains.  That was last year alone.  So far this year I haven't done as well, but have hiked or climbed on 48 days (since January 1) and climbed 20 mountains.

We are a very active family and we also know first aid.   Unfortunately though, we can't do our own heart surgeries or bone surgeries.  Unfortunately a healthy lifestyle can't fix everthing.  

Luckily since I have a good job, we were wise with money, and we had a lot saved up, we were able to get by.

Missed my point entirely.  I'll repeat.

• You have a serious condition.
• You're having trouble with medical expenses.
• OTHER PEOPLE ruin things for you because they use serious services like ER and other hospital services for minor issues.

It's almost like you're so stuck on the idea that socialised medicine will solve everything that you're not even hearing the argument.  I can even predict what you're going to say next:

"No, I heard you.  But I'm arguing..." and then proceed to make another argument that ignores the point I just made so that you can support socialized medicine.

[unixknight]

8 hours ago, Scott said:

If anyone has an "unusual" medical problem in this country though, you are basically hosed due to loopholes with insurance and medical care.  

Indeed.  This is definitely a problem.  We agree completely on that, but it's not clear to me why the only solution must be socialized healthcare.

[anatess2]

8 hours ago, Scott said:

Most expensive insurance plans are good on paper.  Most (other than extremely high cost) are good at covering "normal" or "common" problems because they have to be.

If anyone has an "unusual" medical problem in this country though, you are basically hosed due to loopholes with insurance and medical care.  

Unluckily all three of us (me, my wife, and son) all had unsual problems.  (I hope at least) that doesn't happen to most people.   I explained what happened with my jaw and how they are consider it deltal and why that was a problem.

My wife's heart was also highly unusual.    There were only two surgeons we could find that even wanted to touch it.  One was at the Cleveland Clinic in Ohio and one was at the Heart Center of the Rockies in Loveland Colorado.

Here's where the insurance companies get you if you have an unusual problem.

With our ~$2300 a month medical insurance , there is supposed to be a $6250 out of pocket max for in network and $12,500 out of pocket max for out of network.  This looks good on paper.  However, the first catch is that neither deductable or out of pocket max counts towards each other.  The second catch is thatif you go out of network, the facilities, doctors, and surgeons are allowed to bill patients for the difference in cost for what the insurance pays vs the billings.   (I'd suggest that everyone here check their own insurance policy fine prints).

In my wife's case, her cardiologist and the hospital were both in network, but the surgeon was not.  Neither deductable counted towards the other and we got a huge bill from the surgery from the out of network surgery.

I don't think the surgeon was trying to cheat us though (I didn't feel the same way towards the insurance company),  He basically had commissioned someone to build 1/4 of a human heart out of titanium and carbon allow and build her a new artificial heart valve as well.   

The insurance paid somewhere around $350,000 (?) (plus after care, etc.) and we were responsible for somewhere around $60,000 (including all tests, etc.).

If there are no in network facilities, doctors, surgeons, etc. insurance companies are in theory at least,  supposed to do what is called a single case agreement where major medical expenses can be considered to be in network when it comes to cost to the patient.  To do this though, you have to prove that there are no in network doctors or facilities available. 

This isn't as easy at it seems.  We would tell the insurance company that we can find no in network surgeon who will do the surgery and they would just respond by sending a generic list of a bunch of surgeons that were in network.  They didn't bother seeing if the surgeons would do the surgery and every one we contacted would not.   X rays, ultrasounds, etc. of my wife's heart were sent all over the country (heart surgeons would even comment that they had never seen a heart like hers and they were interested in finding solutions).   Doctors couldn't even fathom that my wife was even alive or her heart was even functioning with the shape of her aortic valve and chambers and with the amount that everything was leaking.   Although a lot of surgeons were interested in the phenomenon, we could only find two that were willing to perform the operation.  The insurance company still didn't accept this though and just kept giving us generic lists of various in network surgeons, first in Colorado and then other states.    They were just pencil pushers and really didn't know what the situation was no matter how many times it was explained to them.   We called time and time again (hours upon hours) and would get someone different every time.

Anyway, the insurance did end up paying a lot for my wife's surgery, but I still felt cheated on our out of pocket costs.  We have been paying into insurance for decades in case anything catastrophic ever did happen.    The insurance company wasn't there for us even after we had been loyal customers for many, many years.   

We didn't know any of it was coming.  It was a complete shock.   Though my wife had a heart murmur, we thought we were both in perfect health.   The only way we found out was from a physical that we were supposed to take for a mountain climbing trip.  If anyone is interested in a little background about how we found out about the heart condition, here is a story about it:

https://www.summitpost.org/love-bombshells-heartbreak-and-mount-shasta/698612

The doesn't continue past the initial phase of finding out though.   The surgery wasn't actually performed until eight years after the above was written.   It wasn't performed sooner since there was a good chance that the surgery itself could have been fatal, so it was decided by the doctors that the surgery should be postponed until her heart deteriorated.     The doctors (understandably) didn't want to risk doing the surgery while she was still healthy because if the surgery turned out to be fatal (there was a pretty high change of this), it would have shortened her life for nothing, so they (intentionally and with our blessing) waited until the heart deteriorated.    Although it was "only" aortic stenosis, it was a very unusual case of the disease.

This is the perfect case for crowd funding and/or charity organizations.  It won't just be those doctors interested in finding out about your wife's problem.  There would be other people interested too.  The doctors refuse to do the surgery because they don't want to be sued if it doesn't work out. 

And I agree completely with @unixknight.  You had a Rare problem.  It is illogical to hook the entire country's economy to solve a Rare problem.  A Rare problem requires a Rare solution... that's why places like St. Jude's Hospital exists.

[unixknight]

3 minutes ago, anatess2 said:

And I agree completely with @unixknight.  You had a Rare problem.  It is illogical to hook the entire country's economy to solve a Rare problem.  A Rare problem requires a Rare solution... that's why places like St. Jude's Hospital exists.

Even if this were a common problem, our healthcare system does need a LOT of work.  It's too expensive, people are overly reliant on insurance (because of the expense) and there isn't enough transparency.  Solve those problems and the rest will attend to itself.

[anatess2]

2 minutes ago, unixknight said:

Even if this were a common problem, our healthcare system does need a LOT of work.  It's too expensive, people are overly reliant on insurance (because of the expense) and there isn't enough transparency.  Solve those problems and the rest will attend to itself.

Just a minor correction:  People are overly reliant on insurance because of CULTURE.

Why do people expect to have insurance pay for anti-biotics but not replacement car brakes?  Because insurance paying for anti-biotics has become a Cultural Standard.

[unixknight]

5 minutes ago, anatess2 said:

Just a minor correction:  People are overly reliant on insurance because of CULTURE.

Why do people expect to have insurance pay for anti-biotics but not replacement car brakes?  Because insurance paying for anti-biotics has become a Cultural Standard.

True, but I put the blame on the insurance companies themselves.

Go back to the '50s, and insurance was only for huge problems.  Regular doctor visits and stuff were inexpensive and easy to afford out of pocket.  

One day, the insurance companies got the bright idea to reduce their expenditures on emergencies by encouraging people to go to their regular doctor more often.  The incentive:  Insurance would pay for it!  Let that go on for a generation or two and now we have an entire culture that find the notion of simply paying for a doctor visit to be alien to us.

Edited April 17, 2019 by unixknight