Author Topic: Let's talk about health share  (Read 23976 times)

freya

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Re: Let's talk about health share
« Reply #150 on: May 31, 2019, 06:48:23 AM »
You definitely have to read the fine print.  This is Sedera's prescription coverage (to take an alternative to Liberty which I agree does sound problematic):

Quote
Prescriptions for medication related to a qualifying medical condition are shareable for the
customary cost of the first 120 days. (
Quote
Treatments for cancer and sublingual immunotherapy
—a curative treatment for allergies—are not subject to this limitation
; medications related to
Quote
organ transplants are limited to 12 months duration
) All medication, prescribed or not,
administered during inpatient hospital stays will be shareable. Sedera employs various
mechanisms in order to substantially reduce the cost of maintenance medications, including
the use of a mail-order pharmacy program (buy-up option).

Note: Sedera members do not share the cost of prescriptions for maintenance of chronic or
recurring conditions (e.g. diabetes, eczema, blood pressure control) beyond the initial 120-day
period. Subsequent sharing of a prescription for maintenance of the same condition will
occur only when there is a new need. Sedera members do not share expenses for
psychotropic medications for chemical imbalances that cannot be verified by laboratory
tests.

So, no issues for cancer chemotherapy, but a multiple sclerosis patient is out of luck once they're past the 120 day coverage period.   Also, it's not clear whether a new clinically-evident lesion would be considered a new shareable "need".  They also explicitly exclude long term coverage for diabetes, high blood pressure etc.  And the "chemical imbalances" suggest that they won't cover things like Prozac for depression, Ritalin for ADHD etc.

The overall approach with Sedera is not to cover the routine small potatoes stuff, but to focus on the unexpected.  I like this approach actually, since it incentivizes patients to put some effort into minimizing ongoing costs that won't break the bank for an individual, but that can in aggregate put a large burden on an insurance plan. With traditional insurance, there is no such incentive.

However, their exceptions sound like there hasn't been a lot of thought put into it.  If I were seriously considering Sedera (or other health sharing plan) I'd call and ask some hard questions about expensive long-term conditions like MS.

BeanCounter

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Re: Let's talk about health share
« Reply #151 on: May 31, 2019, 07:26:18 AM »
You definitely have to read the fine print.  This is Sedera's prescription coverage (to take an alternative to Liberty which I agree does sound problematic):

Quote
Prescriptions for medication related to a qualifying medical condition are shareable for the
customary cost of the first 120 days. (
Quote
Treatments for cancer and sublingual immunotherapy
—a curative treatment for allergies—are not subject to this limitation
; medications related to
Quote
organ transplants are limited to 12 months duration
) All medication, prescribed or not,
administered during inpatient hospital stays will be shareable. Sedera employs various
mechanisms in order to substantially reduce the cost of maintenance medications, including
the use of a mail-order pharmacy program (buy-up option).

Note: Sedera members do not share the cost of prescriptions for maintenance of chronic or
recurring conditions (e.g. diabetes, eczema, blood pressure control) beyond the initial 120-day
period. Subsequent sharing of a prescription for maintenance of the same condition will
occur only when there is a new need. Sedera members do not share expenses for
psychotropic medications for chemical imbalances that cannot be verified by laboratory
tests.

So, no issues for cancer chemotherapy, but a multiple sclerosis patient is out of luck once they're past the 120 day coverage period.   Also, it's not clear whether a new clinically-evident lesion would be considered a new shareable "need".  They also explicitly exclude long term coverage for diabetes, high blood pressure etc.  And the "chemical imbalances" suggest that they won't cover things like Prozac for depression, Ritalin for ADHD etc.

The overall approach with Sedera is not to cover the routine small potatoes stuff, but to focus on the unexpected.  I like this approach actually, since it incentivizes patients to put some effort into minimizing ongoing costs that won't break the bank for an individual, but that can in aggregate put a large burden on an insurance plan. With traditional insurance, there is no such incentive.

However, their exceptions sound like there hasn't been a lot of thought put into it.  If I were seriously considering Sedera (or other health sharing plan) I'd call and ask some hard questions about expensive long-term conditions like MS.
This is extremely risky.
Many cancers are now treated with chemotherapy or follow up chemotherapy in pill form. My mother was on one, after her $1M stem cell transplant, for five years. The pill cost $900 per day. Prior to getting a blood cancer she was a fit women who didn't smoke and walked five miles per day with NO family history of cancer.

The idea that one can go on a health share for as long as they are healthy and then move to the ACA when they become sick is exactly why the ACA is struggling. I was a finance director of a plan on the exchange that shut down because we were bleeding money. All our members were sick. And this is also why premiums have gone up so much.

Also, as mentioned previously in this thread Health Shares have extremely high administrative expense. This in conjunction with their very low reserves (if any) really just make them not much better than a pyramid scheme. Or akin to just setting up a GoFundMe once you get sick.

I'm not a fan at all of our current system. I could go on and on for pages on how broken it is. But joining a health share in lieu of commercial insurance is truly putting your assets at risk.

hops

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Re: Let's talk about health share
« Reply #152 on: May 31, 2019, 07:31:00 AM »
This can be difficult to imagine until you've been there, but the last thing I'd want to do when terribly ill is travel, if it could be avoided. (That's assuming you're even fit to travel. Sometimes you aren't.) My chronic illness is unpredictable and disruptive enough to my family without us having to uproot our lives to deal with it in another setting for an unknown period of time, with doctors who may not know as much about it as a subspecialist closer to home.

It's not that I don't have faith in the healthcare systems of other countries, but some diseases and procedures are more common in certain parts of the world than others. Even within states or multi-state regions, there will be hospitals that direct specific patients to other hospitals for proper treatment. There are two sides to traveling for treatment, and people often focus on the more optimistic one, which is finding yourself in a situation so benign that you have the option to shop around and travel to maximize savings. The darker side is having to travel because it's your spouse's or child's only hope for survival.

There's so much variability around what a disease can take from you, how quickly (and painfully, and sometimes permanently) it might happen, and where to receive the best care for your situation. When I first got sick, as a toddler, with a common illness that had nothing to do with neglecting my health or making poor life choices, the bill was $200k, adjusted for inflation. That was several times what my parents' house cost back then. Many more hospitalizations followed. They sometimes had trouble locating doctors and surgeons with the right expertise to treat my level of disease severity. Thirty years later, my dad still gets emotional when he remembers the terror he felt when the bills arrived, and the relief when he saw insurance covered nearly everything.

SimpleCycle

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Re: Let's talk about health share
« Reply #153 on: May 31, 2019, 10:33:34 AM »
@FIREby35, I think you are much more apprised of the true risk profile of these plans than most people and are quite capable of making an informed decision.  You are right about hospital collections and bankruptcy options, but most people would find that to be quite an adverse outcome.

I can see myself traveling to Mexico for treatment in some scenarios and not others.  Certainly a person who is FIRE and retired is much more able to travel for medical care than someone who still relies on their U.S. based income.

My biggest issue is options that make people think they have coverage but have many exclusions that leave them with significant exposure.  It's also my beef with short term health plans.  I actually was on a short term health plan when I first got very ill almost 20 years ago, and nothing was covered because it fell under a plan exclusion.  No healthy person expects to suddenly develop a serious illness, but it happens all the time.  And catastrophic is a matter of degrees.  When I was 22, $2k a month in health care costs and $1800 a month in income was catastrophic.  I literally couldn't pay for medication I needed.

Ultimately, we need to solve health care costs in this country.  I'd prefer a solution that works for everyone, young and old, sick and healthy, rather than a workaround that benefits a few at the expense of others.

FIREby35

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Re: Let's talk about health share
« Reply #154 on: May 31, 2019, 04:19:17 PM »
PS - No, I don't know why I felt compelled to write such a long post on medical bill sharing. My wife made fun of me.

Life is risky. I hope we all make it out alive, but I doubt it :)

freya

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Re: Let's talk about health share
« Reply #155 on: June 01, 2019, 09:32:00 AM »
Sedera's online info made it clear that time limits on prescriptions did not apply to cancer chemotherapy, so the cited example above would not be an issue.  Regarding the 12 month time limit on organ transplantation, that gives you enough time to switch to an ACA plan or go on Medicaid.  The latter being more likely...if you are an organ transplant case you're highly likely to qualify as disabled.  (In NY state the ACA plans are actually Medicaid managed care plans with premiums so this doesn't matter in terms of coverage.)

The problem BeanCounter raises about health shares saving money by skimming off the healthy population is right on target.  Private insurance companies have been doing this too, because the majority of medical costs in the US are actually paid by Medicare and Medicaid (about 2/3).   Basically, the sick population is already mostly on government insurance. The healthshare vs no insurance vs ACA issue is the same phenomenon, just limited to the remaining 1/3 of health costs.  The only way to fix this is to establish a single-payer or single-risk pool scheme.  From an individual's standpoint there's nothing you can personally do about it.  You have to consider what's optimal for you given the structure we have.


FIREby35

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Re: Let's talk about health share
« Reply #156 on: June 02, 2019, 07:27:35 AM »
I was thinking about this a bit more. Does it boil down to two risks? 1) the financial catastrophe part 2) access to medical care?

My message/point on the financial part is that you can do a lot with legal strategies that cost less than the monthly premium and offer the same protection against financial considerations. Non-lawyers don't have to know the details, but if they know not to panic and to seek help if/when the worst happens then they are good (At least, I feel that way and I have coached my wife in case I'm not around). You could go so far as finding a person with experience dealing with hospitals in advance as "insurance."

The access to care part seems like a financially independent person could get access to care with cash. Not everyone can "self-insure" because they don't have savings. But, for me, I have enough cash. I suspect many others here are in that position as well.

Beside financial shock from a big bill and access to care - is there something else important I am missing?

PS I agree about the macro level points that healthy people opting out of the private market isn't good for the entire system. But I also think we all make individual decisions based on the incentives that exist in the current (crazy) system. For me $1,500 to $2,000 per month for a family of five while still paying big deductibles was/is a lot to ask for the benefit of "the system."