I recall warning specifically of this last year, more than once. It's only a matter of time. Back then, the "word on the street" was, just plug in correct code, in correct manner, and your verifiable pathology is covered. True, then, for the most part, but then ominous signs began to appear, in dribs and drabs, and the writing was plainly on the wall, "if you are going to go for it, do it now". If not, just wait and pay cash, your choice. This is big BIG money we are talking about here, and all the comparisons to expensive MS drugs makes for good philosophical arguments, but does nothing to cure the sticker shock insurance companies are facing.
So yeah, some of us were warning, more than once, and it was dismissed as conspiracy theory, or just not getting it or not understanding the ICD codes.
Here's one after another one of Trevor's inflammatory blog postings:
.....And of course, since getting anything treatment-wise now through an IRB is like pulling eye teeth blindfolded, patients could conceivably in the future, be faced with much fewer options, to wit:
1. Fly overseas, mortgage the house, do what you have to do, roll the dice.
2. Hope your insurance doesn't begin to get ahead of this, and force you to choose as nick stated above, or makes a specific exclusion for any type of CCSVI treatment as experimental, IF you are already dx'd with MS. And once one of them does it, finds a way to get those exclusions in there, the rest won't be far behind.
3. Wait on the studies to not only be completed, but accepted in academia, 5-10 years. Not "A" study, but the study(ies), confirming the studies, making CCSVI not just accepted, but embraced and pursued as a viable alternative to MS treatment, either concomitant with the DMD's, or instead of for the earliest dx'd cases.
This is not to fearmong, focus on the negative, roll things up and call it a day, because something somewhere on the internet is amiss.
But, it is something to keep in mind for future reference. I have a sense we may be referencing this more very soon.
Or this one: http://www.thisisms.com/ftopicp-133497-insurance.html+coverage#133497
Posted: Sun Sep 12, 2010 12:47 pm Post subject: Re: Time To Stand Up And Fight
Eventually my surgeon was barred from treating MS patients by his insurance company.
A slightly different angle than what I was alluding to last night in my post about the possibility (despite the accepted treatment of venous occlusions as a known pathology with it's own code) of insurance companies in the future "tightening the belt" so to speak, until as such time that CCSVI gets it's OWN code, or is accepted to be treated industry-wide under the codes already in existence for IJV's.
One person answered that they were given what amounts to an ultimatum by their insurer, drugs, or procedure, but not both.
Now if I gather what you are saying, it was the Dr's own insurance (i.e. malpractice insurance, which is a huge factor in any office) put the kibbosh on him doing any more procedures?
That's yet another angle I had not considered.
Insurance companies are corporations. They aren't there for your health, my health, or any other health besides the bottom line. Think we all get that.
Insurance companies always work off what is best for the bottom line, and I offer for any given quarter.
To have an onslaught of 50-100k operations for (estimated) 2-500,000 patients (assuming a certain % want to get treated, can find treatment, have insurance, and identifiable and treatable conditions), would put a serious cramp on the bottom line, and I understand the logic is, "well DMD's cost x dollars over lifetime". Yes, they do.
Spread out over a lifetime. Palatable. Plus insurance rarely if ever pays the going rate. Bigger the company, better their negotiating power to drive costs down via volume. (This is how Costco strongarms it's suppliers to get the best price).
So let's just go 50k, testing to treatment to follow up, for say half the MS'ers in America only. 250,000 x 50,000= 12.5 BILLION dollars of outlay in a very short period of time. And that's just a thumbnail with round numbers.
Let's say every person in the US with MS, and the count of 500,000 I think to be very outdated and low, but lets just bump the example above up to 75% of the 500,000 = 375,000x50k a pop= 18 billion, 750 million dollars.
That is a substantial, humongous outlay of money in a short period of time, with the presumption that say only 20-40% of those treated will discontinue their meds.
Now this may appear to be mere moaning and groaning and negativity, but for the rest of us in the real world, life is lived by the numbers game. Insurance doesn't lower my rates on my auto because they like me, think I'm cool, or in need, or anything else. I played the numbers game well, didn't have any accidents, or tickets, for x years, and the actuarials are pretty heartless and cruel if one has the opposite.
So, now my question is, besides the insurance company angle, which many will say, including me, "well my insurance covered it, no problem", at what point in the future will they do the simple math I did above and balance out their inclusion/exclusion criteria to effect the best condition for their corporation, OR, attempt to spread out those big numbers over the longest period possible, so the CEO doesn't get canned when the quarterlies (which most corps live and die for) show a substantial drop?
And at what point will insurers for malpractice step in and say, "no vein treatments for any MS patients or you lose coverage?".
Things to keep in mind in the times ahead, just because all seems cut and dried with the 50%+ stenosis treatment paradigm under established codes, doesn't predict the future, it's just a good guess.
I hope so, but if the bean counters I've ever known get their hands on it, there won't be any interviews when the calculators start whirring... This is working off a presumption of where CCSVI research may end up in the future, a seriously big "if". Then furthering that presumption to assume that people would be inclined to discontinue their DMD's, sans any recommendations from the PTB, which we can safely assume is not going to come any time soon.
So what I see happening, is a continuance of the DMD machine, it's not going away any time soon, thereby it's costs will continue unabated, but now we've tacked on an expensive surgery atop that cost. I doubt the insurance companies are going to sit idly by while all that occurs and just keep plunking down big bucks for MS patients who just *happen* to collectively, at the same time, require expensive surgery on the same collection of veins....
I mean I hope it don't go down like that, but that's where I see it is heading very quickly....
Really, I mean I REALLY hope none of that happens. I'd be happy to be wrong about it, but we are seeing little snippets of it here and there, keep a watchful ear...
They are doing pretty much what I expected, and we will continue to get reports like these from across the country, and once that train looks like it's leaving the station, expect an onslaught of other providers to get on board.
Best bet, is for CIS people to NOT get an MS diagnosis until after they are treated, after all, it does nothing to improve your circumstance anyways. (having the dx).
Beyond that, I would expect that the insurers will say, "be more than happy to treat CCSVI, after it's been thoroughly studied". Expect to wait more than a few years for that one, if ever, this is how treating will be delayed, we've already been "actuarial'd" in with our pricey drugs and care, tossing in another experimental, unproven, untested procedure to treat MS patients is something the insurers won't allow. If you think Canada had a "bum rush" on IR's and MRI tubes and ultrasound machines, wait until the media stops kissing pharaceutical big $$ butt and goes nationwide with this on a real news report and not sporadic obscure markets where it has a miniscule impact in comparison. Wait until Montel (if and when of course) get's his limelight on this.
As I've stated before, the above will basically (as happened in Canada), compel insurers, government and private alike, to take a stance on the issue, and fall on one side or the other, more action will likely cement that into place even more, but perhaps not on the side we would prefer.
And once again, the MS patient comes a distant last place in all of this.
That's not negative talk, it's not conspiracy talk, it's real life and it's the truth.
It's not insurmountable, but I think just telling people that "oh, just get the ICD's and boom, you're in" is, and has been, the WRONG THING TO SAY. I'd go so far as to say it's been very bad advice, as it leaves out the above warnings which I copied from my other postings, call this a time sensitive situation.
I'd max out every credit card I have ever had to get what I've got the past 2 years, and would be thankful for only having to do that.