Finally, some lucid thoughts on health care here and especially abroad

[Harrison]

That's a good point, but as we've seen, that's why federal employees get preferential treatment. For those of us that pay big bucks to HMOs et al, we do not get that preferred treatment. Hence, the disparity.

Perhaps Abby Block (in the document you provided) can shed some light on this huge chasm between federally-funded insurance, and those of "outside the moat?" Read the last paragraph, where "CYA" applies nicely to cover her opposing parties -- the rich and powerful insurance lobbies.

[LBP]

Whose post and document are you referring to Harrison?
I am not following you at all.

I am not "Amy Block" and I don't know who that is in any of the above posts?

I was suggesting using language that is already in place is helpful...rather than starting from scratch, because existing language has already been tested and interpreted.

It's my understanding that there are different kinds of plans. Some just for major medical emergencies vs. more typical comprehensive coverage.

If my existing insurance covers fusion for my situation but denies ADR because it's experimental and/or investigational...this new policy would mandate coverage because it's FDA approved. What situations are you concerned about?

[jeffdanto]

Harrison and LBP, you both alluded to two of the major problems/discrepancies in how the majority of us receive health insurance.

LBP mentioned "Basically, If any drug, medical device, or biological product is FDA approved it can no longer be deemed "investigational" and/or "experimental" and should (must) be covered by one's health insurance plan if (1) it is being used for it's intended purpose and (2) it is deemed medically necessary and appropriate for the patient as determined by their treating medical professionals."

They key here is that insurance agencies are given the ability to determine what is and what isn't medically necessary. That's the loophole right there! What gives them this ability to determine an ailing patient's fate? ERISA!

Harrison noted that "federal employees get preferential treatment." The reason for this is because Federal employees that receive their health insurance from the Federal agency they work for are not covered under the laws of ERISA. As a result, these insurance agencies MUST cover all FDA-approved devices and drugs.

Let's not also forget... Artificial Disc Replacement surgery is not the only device that faces these problems. MANY devices are not covered by employer-based health insurance agencies.

[LBP]

Maybe I wasn't clear...I am stating that we should be proposing that the federal policy be extended to all private insureds. Use the language of the FEHB policy and tweak it a little so that it's treating physicians determining medical necessity, not the insurance company. The FEHB policy applies to all drugs, medical devices, and biological products. Starting with something familiar and extending it to more people, keeping things consistent is an easier sell than trying something new, unclear how to implement and too specific to one ailment. Congress would have to specifically state that this new legislation would superseed current interpretations of ERISA laws, thereby limiting and in part eliminating the power of insurance companies to dictate what's "investigational and experimental" and what's medically necessary. It would be nice to add a clause with bite that allows patients to sue for pain and suffering and attorneys fees for a bad faith insurance lawsuit, if the patient is denied coverage for an FDA approved drug, medical device or biological product when prescribed for it's intended use.

[jeffdanto]

I'm with you LBP! By extending FEHB, wouldn't you allow customers to sue insurance agencies? At the same time, though, why would you need to sue if everything approved by the FDA is covered?!

[LBP]

Hopefully we wouldn't need to sue...but the ability to, keeps everything in balance.

[CindyLou]

LBP, I'm with you 100%. You nailed it. Use the existing document (has stood the test of time and argument) and tweak it where needed. It is an abomination that some Joe Blow inside a privately owned company holds the keys to my and everyone else's health dictates.

[Harrison]

Do you think that the extension of FEHB is possible in our lobby-entrenched system? It may be the “better” choice for all, but if we could simply “move the needle” by getting all approved surgical procedures and devices “covered,” that may be more feasible. But I confess I am not familiar with the lobbying environment, but I will learn.

Just to comment on my June 23 post, this article appeared today, illustrating my concerns about throwing the baby out with the bathwater:

Plenty Of Patients, But Enough Doctors?

"...With the average new patient already waiting more than a month, 33 days on average, to see their doctor, no one wants to wait to find out what the influx of new patients will do to the health care system..."

[Abbe]

I also agree with LBP 100%! Using the FEHB lingo and letter by Abby Block should be the way to go if lobbying the government. It drives the point that coverage should be consistent with the FDA rulings that a device or drug are deemed acceptable for it's intended purpose and must be covered and not considered "Investigational or Experimental" if already approved by the FDA.

I have heard no strong argument from my insurance Co. as stated in the ERISA bill "The regulation protects you providing for a fair process by describing the standards for a decision, by describing the standards for a decision, and providing for a meaningful disclosure by describing the notice and disclosure that you are entitled to receive from your plan. My plan is a bit difficult to interpret due to it being Motion Picture Industry Pension & Health Plans. Seemingly Blue Shield, which is the hospitalization portion of the plan, dictated their decision and because Blue Shield just says No the "Plan" says no without any regard to all the documentation I sent them.

[Abbe]

Here is a site I have found which may be a great way of joining up in the Lobbying Washington. It also has links to your own Senators and Congressmen. http://capwiz.com/spine/home/

The National Association of Spine Specialists (NASS6) LEGISLATIVE ACTION CENTER is an online tool designed to help NASS6 members and their patients keep up to date on key health care issues and make their voice heard by their elected officials. You can use this site to track legislation, view your legislators’ voting records and take action on issues that impact health care access, quality and safety. It’s simple and fast because we provide you with sample text and tips on effective ways to communicate with your elected officials. Please take the time to let your representatives know how you feel.

I just sent a letter to Barbara Boxer and Diane Finestein.