The Deer Hunter

It’s hunting season again.

Deer hunters in Day-Glo Orange junp suits have been sighted at WaWa, sipping coffee in the dark-early, fortifying themselves for a day sitting up a tree on an uncomfortable piece of metal.




Turkey hunters are practicing their calls, hoping to entice some fat Tom into shotgun range.

Slick, fast-talking pitchmen are reaching out to senior citizens, imploring them to enroll in their Medicare programs.



Just like that 5 point buck or Tom Turkey, those poor seniors who answer their call are in for a nasty surprise.

Believe it or not, Medicare is great health insurance. It covers almost every medical procedure a person may need. Plus, the US Government puts a strict limit on what providers can charge Medicare patients, and this fee is much less then the going rate. If a procedure is denied by Medicare (unless the patient agreed to it up front) the provider cannot balance bill the patient.

Medicare is not free, of course. The patient is responsible for a co=payment that amounts to 20% of the government mandated rate, Fortunately, there is supplemental insurance that can cover even this expense.

Medicare is not perfect, however. There are things that is basic Medicare does not cover at all, like prescription medications. However, there are supplemental insurance plans that cover these expenses.

Most seniors these days can afford the out of pocket expenses from traditional Medicare. Unfortunately, some cannot. These poor souls are the ones targeted by the TV pitchmen.

For several years now, the government has allowed ‘private’ health insurance carriers to operate their own form of Medicare. Patients who opt for this coverage lose their traditional coverage and receive their coverage through one of these alternate plans, which are, in effect, a HMO.



Seniors are enticed by promises of lower co-pays, free gym memberships, and prescription coverage, but they usually don’t realize what they lose – great, cover-all health insurance. Once they sigh on the bottom line, for the next year at least, they are subject to greatly reduced coverage under the HMO plan. What sounded great on TV often becomes a sad story of seniors being denied access to health care that was covered by traditional Medicare.

I pity these hapless souls, just like I pity that beautiful Buck tied to the hood of that Chevy pickup in the Wal-Mart parking lot.


Like Joni said, “don’t is always seem to go….”

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Who’s the Boss

Was it Tony or Angela? That was the ongoing question in the long running sitcom. Personally, I never really gave a damn. It was never one of my favorite TV shows. I always preferred Tony Danza’s character in Taxi – now that was a sitcom!


OK, so if we don’t really care “Who’s the Boss?”, let us ask instead, “Who’s the Doctor?”

I spoke before on how PhD’s in medicine are the only people who are routinely given the social title of ‘Doctor”. Right or wrong, it is the social norm. But now we are being faced with a new dilemma.

There are people who are getting PhD’s in medical fields who are not normally addressed as ‘Doctor’, and they’re out to change the social norm.


A person who has their PhD in Nursing or Physical Therapy are by definition Doctors – but in the past they would never dream of being referred to as such. This is no longer the case. Many such health care providers are asking to be referred to as ‘Doctor’ – which in a professional environment will surely lead to vast confusion.

Traditionally, in health care, Only persons with degrees of “MD”, “DO”, “DC”, “OD” and “DPM” were addressed as ‘Doctor’, as were those who had their PhD in Psychology. Now, if this trend continues, we may be looking at nurses and physical therapists claiming this coveted title.

This trend, if it is allowed to get traction, will surely lead to great confusion amongst health care consumers.

I am sure that it is already being exploited by the health insurance industry.

Right now, some poor sod is surely getting a call from their health insurance carrier saying something like “I’m sorry Mr. Jones, but our Medical Director, Dr. Smith, has reviewed your file and determined that surgery to remove your brain tumor is not medically necessary”. Too bad no one bothers to explain to Mr. Jones that “Dr. Smith” is a retired pediatric nurse with flat feet and a PhD in nursing.




So don’t be surprised when your prescription carrier won’t pay for your ED meds because Gene Simmons says that “Real Men don’t need Viagra”.

After all, Gene has long ago claimed the title of “Dr. Love”.






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Hit Me With Your Best Shot

It’s that time of year again.

The beaches are closed. The leaves are falling. There’s a definite chill in the air.

….and, oh right – it’s time for my annual flu shot.

Like most people north of 50, I’ve been getting a flu shot every fall. So far, it seems to be working for me, as I haven’t had a real bad flu since I started getting the shots. The older we get, the less our bodies can fight off a flu infection.

Thanks to modern medicine, the flu is a lot less dangerous than it was 90 years ago, when it killed millions world wide. And while it is less dangerous, the flu can still be fatal to the elderly and those with compromised immune systems. Not that I’m elderly, mind you, but I’ve been getting my vaccine every year for the past ten years ago.



My experience with this important vaccination every year has proven two things:

First, the shots do work – I haven’t had a serious flu since I’ve started getting my annual vaccine.

Second, it warms my heart that at least SOMEONE in the healthcare field is finding a way to make the system more affordable and better.

Here’s what I mean. When I first got my flu shot, I got it at my doctor’s office. This meant making an appointment, waiting in line, and paying for an office visit.

Over the years, the routine has been changed. I started going to my local pharmacy for the shot. At an appointed time, a nurse would be available to jab me in the arm with the anointed needle. Not only was this more convenient, it saved me money, as I didn’t need to pay for a separate office visit. (even if the visit was covered, remember, always, Star Trek Economics).

This newer approach even saved me some pain – nurses are always better at giving injections than a MD is.

My health insurance company also got it right – in order to encourage me to use this more economical method of vaccination, the waived my co-pay, so I paid nothing out of pocket for my date with the hypodermic devil.

This year, there was a even a newer twist – I could now walk into my pharmacy at any time and get my flu shot. Plus, the deadly deed was dealth by a pharmacisit (who was working there anyway). This is an even less expensive way of delivering the vaccine. Face it, jabbing a needle into someone’s muscle ain’t rocket science. It makes sense that the most convenient – and cost effective – method be used to deliver the vaccine.



As an added bonus, by making the vaccine easy and cheap, more people will be encouraged to get it on an annual basis. This will, in term, same many of us from the prolonged illness, lost wages, or even more dreadful consequences of a nasty flu.

Everybody wins.




Wow, a move to more effective, convenient, and affordable health care in the United States. I’d never thought I’d see the day.


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Consumer Reports

Consumer Reports has been saving America money for over 50 years. Many thrifty Americans have grown to depend on heir sage advice, unbiased product reviews, and money saving tips. Many of us won’t make a major purchase until we consult Consumer Reports.

I only wish I did before I bought that Yugo.



Recently, however, Consumer Reports gave some advice on how to save money at the doctor’s office. Unfortunately, uncharacteristically, this piece of advice was bad. It could get your doctor into big trouble. Yikes!

Consumer Reports recently suggested that you negotiate with your physician in order to get a lower price on your medical care. So your doctor wants $800 to remove that mole? “Tell you what, Doc – let’s just make it $400 bucks and we’ll call it square. There is a doctor down in Tijuana that’ll lop that sucker off for $25, but I’d rather give the business to you….”



On the surface, this seems to make sense. After all, most of us are inclined to negotiate other professional services, like having our house painted or our tax forms completed. So, why shouldn’t we try to negotiate with our doctors as well?

The primary reason why this is a very bad idea is that the doctors can get into trouble for foing this. A lot of trouble.

You see, around 95% of all doctors ‘participate’ with at least one health insurance carrier. This means that they have a contract with that carrier, where the carrier will allow their subscribers to treat with that provider under their health plan and, in return, the doctor will agree to a lower (then their ‘normal’) fee for the services that they provide.

These contracts are very specific how they constrain the doctors, and in almost every case they place severe penalties on the doctor if they were to provide discounts to non-contracted parties.



In other words, let’s say that Dr. Jones has negotiated a contract with Blue Cross to be in their network. Dr. Jones, who normally charges $100 for an office visit, agrees that she will accept only $60 from Blue Cross for the same service – a 40% discount. In return, Blue Cross will provide Doctor Jones with a steady stream of patients. Now, Blue Cross won’t be very happy if they discover that another patient has negotiated a fee of $50 for the same office visit. That patient doesn’t have insurance, and therefore doesn’t have a contract that entitles them to the discount. This means that the $50 charges for the visit is really the ‘normal’ fee, and Blue Cross really should have a 40% discount off of that figure. They should only be paying Dr. Jones $30 for an office visit. They may demand (and are contractually entitles to) a refund from the doctor of $30 for each office visit they paid for under the contract. Ouch.

By the way, Blue Cross doesn’t care if the doctor gives carriers a discount, so long as they too have a contract with the doctor. There is honor amongst thieves, after all.

You might ask “So what if I got a discount – who’s to know?” Well, it turns out that the Health Insurance companies are very good at finding this information out. Usually, what happens is that the patient who received the discount turns around and submits the claim for the discounted visit to their insurance carrier. Once they do this, the cat is out of the bag, and the doctor is in big trouble.

There are ways around this, of course. A clever provider will code the discounted office visit differently then their normal visits – clling it a ‘consultation’ or a ‘brief office visit’. So long as they never use these billing codes for insurance visits, they should be covered, but since they really don’t benefit from giving their patient’s discounts, why should they take the risk of being discovered and persecuted? After all, the repercussions are great, financially and otherwise.



The clever solution to this dilemma are ‘health discount plans’. These plans are sold everywhere, including Costco. For a small annual fee, you get a card and a list of providers who are contracted to give discounts to plan members. Because the providers are under contract, they are immune to the pitfalls of of the cuff discounting. These plans are not health insurance – the’re more of a buying club. However, they can save you a lot of money, and save the doctor a lot of aggravation. And they can help cut the health insurance carriers out of everyone’s’ finances.

They’re a Win-Win-Win solution.

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Extreme Couponing

If horse racing is the sport of Kings (and Drag racing the sport of Queens), it’s apparent that Extreme Couponing is the sport of bored housewives. The hit TLC show documents the sport’s many participants - people compete by combining manufacturer’s coupons, double coupon policies, and in store specials to acquire unneeded groceries for little or no money. They proudly display their at-home basement stock rooms, where rows of shelves display their caches of peanut butter, energy bars, and laundry detergent.



Food hoarding like this hasn’t been seen since the Y2K crisis.

You can’t ask these people a logical question, like “why does a post-menopausal woman like you need 98 boxes of Tampax”? It isn’t usually about needs. For these people, it’s a form of sport. From where I stand, it’s a sign of mental illness.

With the emerging formulary battle between health insurers and Big Pharm, I can foresee that we soon will see ‘Extreme Couponing – Pharmacy Edition” where desperate housewives will double their discounts on their favorite pharmaceuticals, acquiring a at-home stash of drugs that would make Owsley jealous. They’ll be adding new racks in their basement stockrooms just to store their discount collections of Lipitor, nexium, and other prescriptions that offer discount coupons….



On a more serious note, people are asking me about my take on the formulary wars. Like watching your Mother-In-Law drive off a cliff in your new BMW, my feelings on this subject are mixed.



On the positive side, Big Health formulary policies are helping guide patients to more affordable drugs that they might otherwise have been unaware of. Big Pharm’s coupons also significantly lower the out of pocket expense for many patient’s prescriptions.

On the negative side, formularies are almost allowing Big Health to make medical decisions and exercise their medical opinion – something that they have no right to do. And Big Pharm’s coupons are really just a band-aid fix that only serves to mask the real issue – the way over-priced prescription medicine.

All in all, the whole formulary battle is really something akin to “Spy vs. Spy” – in other words, the battle will vacillate back and forth month to month with no clear long term victor. The only certain outcome will continue to be the long term loser – the American health care consumer – who will continue to face ever-escalating costs for their health insurance premiums and prescription medications.




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Don’t Give Me No Lip

We’ve all seen advertisements for prescription drugs on Television. Well, maybe there are a few exceptions.




Perhaps you’ve just emerged from a 40 year coma (like in that Robin William’s movie).




Or, like Tommy, you’re blind, deaf and dumb (speechless, that is, not imbecilic)




Or perhaps you’re Amish.



(Hell, scratch that example. Even the Amish must have seen a prescription drug commercial, even in a fleeting glance through a window as they drove by their English neighbor’s farm in that covered surrey).

Yep, chances are extremely good that, as an American, you’ve seen at least ONE television commercial for a prescription drug. Most of us have seen thousands.

Today, I saw something completely different. I saw a commercial that instead of imploring us to take a drug, it begged us NOT TO STOP taking one.



If you haven’t seen it yet – be patient – you will. It stars a middle aged fellow sitting on his road bike on the side of the road. It seems that someone must have tried to convince him to stop taking Lipitor – and he wasn’t having any part of it.

This is serious business – Lipitor is one of the best selling drug in America. Who would want you to stop taking it?

Well, your health insurance company for one.



There is a Battle Royale being fought between the Pharmaceutical Companies and the Health Insurance carriers. The pissing match has been taking place pretty much behind the scenes, but recently the general public has been allowed to glimpse behind the curtain – and it ain’t a pretty sight.

The pharmaceutical companies have been reaping in huge profits for many years now on their overpriced wares. The Health Insurance companies have capitalized on this red hot market by offering prescription drug coverage – something that you wouldn’t need if the drugs were realistically priced. These two parties are basically a pair of symbiotic leeches living off the lifeblood of our healthcare dollars. Both leeches got fat and bloated on this blood - until the blood supply started to diminish. Now these two bloodsuckers are turning on one another.



Faced with increased government pressure to control costs, the health insurance carriers are targeting Big Pharm and their ridiculously overpriced chemicals. Big Health has a new superweapon that it is using to great effectiveness against Big Pharm – the Formulary.

In effect, your Health Insurance carrier’s Formulary is a Naughty and Nice list of prescription drugs. It consists of different tiers of prescription drugs, and the tiers are differentiated by increasing copayment amounts. If a pharmaceutical refuses to give a Health Insurance Carrier a price break on one of their meds. That drug gets pushed up to a higher tier. So, if you get a prescription to a high tier drug, your copayment might be as high as $100. A similar drug for the same condition (whos manufacturer plays nice with Big Health) might only carry a $10 copayment. By penalizing their subscribers, Big Health is banking on them to reject the higher copayment drugs and ask their physicians to prescribe a lower tier – land lower co-payment – alternative medication. In fact, if you call your Health Insurance Carrier to complain about a high copayment, they will gladly tell you what lower tier drugs are available, and suggest that you ask you doctor for a new prescription.

This is a economic blackmail. It is also very effective. As a result of this formulary favoritism, many patients are seeking out less expensive prescription medicines, and pressuring their doctors to prescribe them.

The Formulary battle lines have been being drawn for years, but Big Health went too far recently. They’ve bumped Lipitor, one of Big Pharm’s Superstar medications, up to the highest formulary tier. Faced with huge monthly copayments, many patients are flocking to low tier alternatives like Simvastatin, which works almost identically to Lipitor but costs only a tenth of the price.



So Big Pharm is fighting back. Witness, if you will, the latest Lipitor commercial.
And since television is only so influential, Big Pharm has deployed their own superweapon – the prescription card. You can now get a free prescription card that will lower your Lipitor copayment to only 4 bucks a month – much less than Simvastatin - thereby cutting the legs off of Big Health.

And this little border skirmish between Big Pharm and Big Health is rapidly escalating into World War III.





Tee hee. I love the smell of Napalm in the morning.

More on this subject in my next post….

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