During the health care reform debate, we wrote that most people’s attitudes to it were “confused, conflicted, clueless and cranky.” A major reason was that the American health care “system” is fiendishly complicated and few people really understand it. As a result hardly anyone knows much about what is actually in the reform bill (but that does not prevent them from having strong opinions about it). Sadly, the reforms, whatever their merits, will make the system even more complicated, the administration more Byzantine and the regulatory burden more onerous.
System complexity.
The American healthcare system is already by far the most complex and bureaucratic in the world. We were once asked to spend ninety minutes explaining American health care to a group of foreign health care executives. Ninety minutes? We probably needed a few weeks. Most other countries have relatively simple systems, whether insurance coverage is provided by a government plan or by private insurance or some combination of these. But in the United States insurance coverage, for those who have it, may be provided by Medicare Parts A, B, C, and D, 50 different state Medicaid programs (or MediCal in California), Medicare Advantage, Medigap plans, the Children’s Health Insurance Plan, the Women, Infants and Children Program, the Veterans Administration, the Federal Employees Health Benefits Program, the military, the hundreds of thousands of employer-provided plans and their insurance companies, or by the individual insurance market. This insurance may be paid for by the federal or state governments, by employers, labor unions or individuals. Some employers’ plans cover retirees, others do not. The result is that the system is pluralistic, mysterious, capricious and impossible for most patients and providers to understand.
Administrative complexity
The administrative complexity is amplified by the multiplicity of insurance plans. About half of all Americans with private health insurance are covered by self-insured plans, each with its own plan design. Employers customize their plan documents, led by consultants who make a good living designing their plans and tailoring their contracts. As one prominent consultant told us recently, if all the self-insured plan documents were piled on a table they would not just exceed the 2,700 pages of Obamacare, they would probably reach the moon. For the rest of the commercially insured population, health plans may be traditional indemnity plans, Preferred Provider Organizations or Health Maintenance Organizations.
The coverage provided by different plans varies dramatically. They may or may not include large or small deductibles, co-pays or co-insurance. Beneficiaries may pay a large, small or no part of their health insurance premiums. Some plans cover dependent family members and children, others do not. The Medicare Part D pharmaceutical benefit plan involves a “doughnut hole,” which will disappear as health reforms are implemented. Surveys have found that few people fully understand their own insurance plans let alone the bigger picture. While health reform takes some steps toward standardization of insurance offerings and improving transparency, overall it is likely to increase complexity.
Physicians may be paid by salary, fee-for-service, or capitation, with “pay for performance” bonuses based on complicated metrics. In order to get paid, most doctors and hospitals have to use many thousands of codes to describe the care they have delivered. Doctors can spend hours a day doing this; hospitals employ tens of thousands of coders; insurance companies and government programs spend a small fortune entering and checking this coding. A substantial proportion of payment claims are disputed, further increasing administrative costs and the “hassle factor.”
Some insurance companies are for-profit, some are not-for-profit. Hospitals may be for-profit, not-for-profit charities or be run by federal government agencies such as the VA or the DOD or by cities.
The administrative complexity exists in the private and public sectors and in both for-profit and non-profit organizations. Medicare is relatively efficient because it has a simple criterion for eligibility – your age (although it also covers people with disabilities). But for many of us administrative complexity is rampant because health insurance is a function of our jobs or our income (or lack of it). Our insurance changes often (because our employers change their plans, because we change jobs or because our income changes), far more often than it does in other countries. As a result we have armies of people who sell insurance, keep track of who is eligible for what, chase, authorize or deny payments, and lob faxes, emails and assorted missives at us and each other. In Los Angeles County, 1,900 people work on nothing but MediCal eligibility with a union-mandated productivity target of completing two forms a day. There are an estimated 150,000 such eligibility workers across the country. The health reform bill proposes to expand Medicaid by 16 million so the number and cost of these workers will surely increase.
Regulatory complexity
Different parts of the health care system are managed or regulated by dozens of Federal government and state agencies, including the Department of Health and Human Services, the Center for Medicare and Medicaid Services, the Centers for Disease Control, the Veterans Administration, the Food and Drug Administration, and the Agency for Healthcare Research and Quality. One report claims that the health care reform bill will create 183 new agencies, including state insurance exchanges and a Medicare Independent Payment Advisory Board (IPAB) and the Center for Medicare and Medicaid Innovation.
And then there are the acronyms. If you don’t know them you will not understand much of the health policy debate: PPACA, DHSS, FDA, CMS, VA, CDC, AHRQ, SRG, MLR, HMO, PPO, PBM, COBRA, P4P, CER, EMR, HIT, DRG, FEHBP, WIC, CHIP, DSH, MMA, and many more.
We believe that this complexity is a major reason why we have (and this is very well documented) the most expensive, inequitable, inefficient and unpopular health care system of any developed country, with poor to mediocre outcomes. The problem is not the doctors or the hospitals but the system. Reimbursement, with its many thousands of points of public and private sector payment and the mindboggling payment rules, creates a bow wave of administrative costs and many perverse incentives. And these costs are the incomes of powerful interests who fight to preserve them.
The American “system” is exponentially more complicated than the systems in other countries – and the reforms will make it even more complicated. Unfortunately reform that would simplify the system is probably not politically feasible. A benign dictator might scrap the system and start over with a much simpler system. But in a democracy, with powerful interests and 17% of our economy involved, “you can’t get there from here.” We have to build on what we have, heaping complexity on complexity.
It is therefore no wonder that surveys find most people (including, it would appear, many members of Congress) understand very little about the health care system let alone health care reform. A recent Harris poll asked people which of 18 items are or are not in the reform bill. Modest majorities were able to give the right answer for only 4 of the items. And pluralities got the answer wrong on nine of the items. For example pluralities believed that the bill includes higher income taxes for the middle class, new ways to ration care, a new government run health plan, cuts in Medicare benefits, increased payroll taxes and “death panels”.
Of course, many millions of people followed the reform debate with interest and passion, but because the issues were so complicated, very few of them understood them. Which is why rhetoric often trumped substance, and misinformation often fuelled strong opinions. And why American health care is likely to be extraordinarily inefficient and expensive far into the future.
Humphrey Taylor is Chairman of the Harris Poll.
Ian Morrison is a healthcare consultant in Menlo Park, California.
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http://synerchiflow.blogspot.com/2012/04/us-health-care-is-disaster-infogram.html
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I am running for President in the 2012 elections as an Independent candidate.
These are my health care policies:
He says Obama Care does not go far enough, and proposes a completely new healthcare plan he calls “Americare,” which will provide government healthcare for everyone from cradle to grave.
“Americare will pay for the needs of all United States citizens and allow healthcare providers to be compensated according to their skill set. It will replace Medicare, Medicaid, and all private insurance. I believe that all private insurance companies are criminal organizations, because they make profits by delaying and denying care which could in many instances cause unnecessary deaths and suffering to people who rely on private insurance,” explained Abramson.
Abramson wants the liquidation of all private insurance companies, moving their administrative workers into Americare jobs. He wants to offer forgiveness of all medical indebtedness for anyone with debts resulting from the previous healthcare system. He said the cost of Americare will be paid from the savings obtained through military budget cuts.
Insurance was never meant to cure anyone. Before being bastardized it was meant to mitigate the risk of a large unforseen illness or accident. When it was reappropiated as a social tool and funding mechanism is when things started going wrong. Insurance actually started hundreds of years ago well before the idea of America even existed. Insurance has always been in america.
Insurance at first didn’t cover doctors visits then it only reimbursed a set amount, back when an office visit was just an office visit, they didn’t measure it 10 ways and then some. The go betweens got involved when government got involved. The government promised far more in benefits then they could afford, once they had to start cutting cost without admiting they couldn’t live up their promise they had to start measuring everything so they could slice and dice. That is how we got CPTs DRG RBRVS and everything else. The more government needs to manage the more complex it gets. Gary or one of the other doctors correct me but the government is taking us from 10,000 CPT codes to 40,000+? Now it is going to take even more middle people to figure out this even more complex system.
Nate Ogden is right on. The immediacy of a check and balance by the patient is a powerful audit and control mechanism. No one knows better than the patient when he is charged $100 for an aspirin
Yes, Nate it would be nice to have a clearer idea of what is charged and who is paying for it. I hate it when Dr. ‘s suggest a procedure and when asked how much would this cost they say they have no idea. But one thing is sure, insurance never cured anyone.
I think the industry started in Tx. because people couldn’t afford Dr. visits. Exactly how does hiring hundreds of thousands of people to be “go-betweens” for patients and Dr.’s decrease fees ?
What about the rest of the equation chuck? What other parts of our lives do we walk in, expect to spend as much as we want, and have someone else pay the bill and not question our decision? In cases like this you need to look at the history. When insurance started you went to the doctor, received care, paid the bill, then submitted it yourself to insurance to get reimbursed. This worked pretty good for everyone, providers got paid right away, people knew what they were buying and exercised care, and insurance was protected from excessive treatment and wasteful spending.
If you want to see the bill the same day your treated don’t assign your benefits. That simple. Oddly all the people complaining about the system don’t want to take the easy step of solving it.
What other parts of our lives must you do, or have done (for basically fear of death) than “go to the doctor” ? And once there have a service preformed and then leave. 30 days later you get a bill/statement with the price. Basically, most of us go to the doctor and get services we need and find out 30 days later what it costs. Is there any other “industry” that works this way ?
Would you buy a car (which you actually have a choice, not a fear of death) and take it home and wait to get the bill 30 days later ? Would you buy a house only to find out later that the bank thinks 10% is a good rate ?
The system has built in enough time to guarentee a nice profit margin for all envolved.
Time to change. . . please
Here in Europe, Portugal, in the last few years the government made some reforms in the Public portuguese Healtcare system aiming to develop it.
We spend a lot of money on it, but everybody, also turists and foreigns, have the right to Health!
I hope this financial crise won´t destroy it.
All the governments should provide Free Health treatments for their citizens! That is one of the reasons taxes exist for.
http://hubpages.com/profile/JustaMendes
Oh after reading the Wall Street Journal, just lying about attempting to limit diabetic testing from twice a day to 8 times a day.
Last Word: Either Pay the High Prices for Sub Standard Care and Greedy Insurance underwriters or Go Without and Die Quickly.
This is the real choices of the Elitist Point of view. Either way Insurance and/or Provider can not be Held Accountable for any Negative Event . However, This does not apply to the intended target of their preditory and exploitive measures. Dead , Mangled,crippled, Medical Errors , Hospital Acquired Infections and longer stays from preventable events and gross negelgence. The Patient is expected to be accountable for services that end in their death.
Sadly, their is no Honor in this industry that only views consumers as a profit margin. A statistic or a number without as much showing a frailities of being Human. The Industry has saturated their belief system through out Government. Acting as lobbiest and Legislators to protect their profit making enterprises.
The industry has no shame in becoming 38th in Health Care among 40 industrialized Nations! Why? Profits are their primary focus and delivering statisfactory care has become a lesson of self protection;due to cuts in care givers and the absence of funds. Patients Suffer!
Although, Hospitals shed much of their responsibilities for providing proper care measures in order to satisfy investors. Hospitals expect full assurances from the State Legislature. Holding them Harmless, No Matter what the outcomes of Gross negelgence,Medical Error, and Preventable Staph Infection and death.
I do not know of any industry that has Mobb like Protections by our State Legislatures. The argument for greater and greater Profits have voices unmatched to the loss of Human Life. Which means our values have drifted away from core values of our founders. So , In order to keep these parisites from using you and charging your survivors . Is to die at home and overdose on drugs. If you find that objectionable ; Then you must realize what hospital staff are doing the same thing with Morphine. The hospitals are putting down people and Dieing quickly has nothing to do with the industry profiting from it. Save a survivor from Bankcruptcy:Die at Home!!!!!!!!!!!!!!!!
Some states have a plan u can buy into…which isn’t cheap, but isn’t expensive either. For example, I had insurance through my employer. Got laid off, insurance ran out. Had to buy private insurance ar 112 bucks a month…not an option for just anyone but since I was insured before, I didn’t have to disclose pre existing conditions. Chiropractor Dunwoody GA
Easily the best book on how to reform the health care system is by Harvard Business School Professor Clay Christensen – The Innovator’s Prescription. http://davisliumd.blogspot.com/2010/12/best-book-on-healthcare-reform-or.html
Despite the complexity and challenges of the US health care system, Professor Christensen illustrates examples of why we should be optimistic that transformational change can occur and yet rightly cautions that too much regulation will stifle innovation and maintain the status quo. Let’s hope for the former and less of the latter.
Grow up.
This a response from someone who alleges to work with physicians and claims to be interested in the welfare of the public, who only defends in the end the agenda of PPACA and attacks anyone who deters from his agenda.
Yes, I am a physician, and I think you suck! Gee, you think doctors can’t have harsh feelings about those who are focused on ruining health care?
That is how you come across to me. Your retort, sir?
Aren’t insurers required by law to pay claims within 45 days? Frankly, it usually takes me longer to pay bills from my “providers” for what the insurance doesn’t cover than it takes the insurance to pay for what it covers. And in this I don’t seem to be much different than everyone I know.
I suppose if the bill was only 2 pages long because it didn’t spell anything out, then there would be no complaints that there was so much “hidden agenda” or that “nobody knows what was in it”. The CBO managed to publish plenty of analyses on the various iterations of the Bill between fall of 2009 and March of 2010 when it was passed.
” I didn’t have time to do my homework, therefore I feel it shouldn’t count” never went very far when/where I went to school.
“There will be no efficacious resolution to this crisis that is health care and it’s real puny efforts for relief and control of costs ,as offered by corrupt and uncaring politicians, as long as the current leadership and extremist followers, or more realistically the covert operatives who control the alleged leadership of both parties, just pontificate and gesticulate away.”
Actually, there will be no efficacious resolution to the crisis in health care costs as long as
1) the average age of the population continues to rise
2) older people have more ailments than younger people
3) medicine continues to make advances converting quickly fatal diseases to chronic ones (e.g. diabetes, HIV infection, etc.)
4) people who have such diseases prefer to survive rather than die
5) big mutual funds etc. who invest in drug companies and medical equipment companies demand a healthy profit every quarter
6) people who have their retirement money in big mutual funds demand a healthy profit every quarter
Margalit –
I think we’re talking past each other. The point of QALY is NOT to determine who gets what. It’s to determine what we cover and pay for and what we don’t cover and pay for. This is what the UK’s NICE attempts to do. If they decide to cover a service test, procedure or drug based on QALY metrics, they don’t care if the particular patient who gets it is young or old, rich or poor, disabled or healthy. Of course, they may also ration certain procedures like organ transplants based on age, among other factors, as well. We do that for organ transplants too. If insurers want to cover services for a higher price that adequately compensates them for the estimated additional cost that the basic plan doesn’t, they can. Anyone who wants to and can afford to buy such polices, they can. Or, they can self-pay.
The end of life care issue is a whole separate discussion. With appropriate tort reform, the default protocol in the absence of a living will or advance directive could change from “do everything” to apply common sense depending on circumstances. If we paid for palliative care and hospice counseling so patients and their families understood the options available to them, they could make informed choices regarding their end of life treatment preferences. Those preferences could then be stored on a registry so they are available to providers anywhere when needed. Right now, far too many patients have not indicated such preferences, so their families often don’t know what they would have wanted because the patient can no longer communicate at all or is not mentally competent. Doctors then feel that they have no choice but to do everything unless the healthcare proxy, if any, agrees on his or her own to do less than everything. This is an area where the conservative death panel crap does a disservice to us all.
I totally agree with your conclusions that transparency in reimbursement (“disclosure of actual contract reimbursement rates”), tort reform and “more high deductible plans” are the way forward. As deductibles rise, primary care is leaving the domain of insurance. When deductibles are commonly $1,500 or higher, most of primary care will be in cash medicine. This more direct relationship between patients and physicians can help reduce unnecessary costs and will reduce the complexity of the primary care portion of healthcare.
So you attach some sort of average utility measure to a therapy and decide how to tier it based on that. It could be QALY, but I am not sure that QALY is really, relevant since I thought the entire point of QALY was to prioritize who gets what. So for that statin example, a previously healthy 40 year old would get 1 QALY for the $50K, but a disabled person with other ailments would get maybe 0.5 QALY out of the same investment. I guess that is why, when you got to the terminally ill person, or very old person, the formula stopped working, because the real QALY math needs to be applied there (in lieu of common sense, which we seem to lack).
So now, I have another question. Regardless on how you make the tier decisions, how is this different than Nate’s lifetime maximum? And how do we apply a true lifetime maximum when we don’t have one payer, or a universal accounting, solution?
Margalit –
Let me try again using a specific example. Suppose the lowest tier (cheapest) insurance policy under my scenario would cover every service, test, procedure or drug that the experts determine would cost less than $150K per QALY when given to a population with the condition or the risk profile that the treatment is appropriate for. Specifically, let’s say a statin drug like the generic, Simvistatin, would cost $50K per QALY when given to people with CAD, high cholesterol or other appropriate risk factors. The drug is covered under this policy tier whether the individual patient is a billionaire or a poor person and the price that a given insurer negotiated for the drug is the same for every patient covered by the plan. At the same time, if the patient is dying of late stage cancer, advanced Alzheimer’s or dementia, or ESRD, etc. it probably would not make sense to prescribe the drug under those circumstances and the patient or the family may not even want it even though it’s deemed cost effective at the population level. By the way, a $150K per QALY threshold, combined with life expectancy of roundly 80 years, implicitly values a life at $12 million (80 years x $150K) which I think is more than reasonable in a real world of finite resources.
I apologize for the misquote, Barry. But if we make tiers based on QALY, the question becomes whose QALY are we talking about.
For example, if treatment Z is shown to provide 2 QALY for person A, but only 0.5 QALY for person B, would it be priced at X based on a person A profile, or at 3X based on a person B profile, or tiered based on the person?
Barry-
“The administrative complexity of our system is not entirely a bad thing because it gives people choices as opposed to what they would have under a monolithic one size fits all system.”
I agree , the prospect of a one-size fits all approach is frightening. However, the choices that do exist are not true to free market system that allows for the principles of competition to regulate both quality and cost. As I typically identify with libertarian ideals, I am starting to think these ideal cannot apply to healthcare. This massive industry is, one the one hand, a business. On the other hand, however, it is an need that must be met. Toying with cost and availability of services in this industry has far greater implications than in, say, the auto industry. People’s lives are literally at stake. What is so sad is you all who are so concerned with when you will get paid. Is that why you selected medicine as your profession? Isn’t the propose of this blog not to whine over dollars and cents, but to seek out solutions to these complex issues?
“If we’re really interested in bending the medical cost growth curve, we would have payers stop paying for services, tests, procedures and drugs that are not cost-effective or are no better than less expensive alternatives. Disclosure of actual contract reimbursement rates, substantive tort reform and more high deductible plans would also be helpful.”
Thank you, Barry. I agree with this.
Nate I agree with your comment and was trying to cover that by suggesting we need much more oversight on what we are doing presently. That would involve proving you have better control when you test more than for instance 4 times a day, a distinct minority. So you are supporting the Washington State attempts to control costs, I applaud you.
Margalit –
I think you know better. First, I didn’t say “One size fits all.” I said “One size fits all Medicare probably couldn’t and wouldn’t do that” – offer policies with different QALY limits at different prices.
Second, if coverage decisions were ever based on QALY metrics or some other cost vs. benefits criteria, the judgment would be based on a population of people. So, if, say, a new cancer treatment were deemed cost-effective by Medicare and/or Medicaid, it would be available to you, We wouldn’t say to a poor, disabled alcoholic, your remaining life years are only worth 0.5 QALY each so you don’t get the treatment. On the other hand, many people facing end of life situations, if they had all of their options honestly explained to them, may not want the treatment anyway.
Obviously, the wealthy person could afford a policy with the higher limits and a poor person couldn’t. As long as the coverage available to the broad population is widely perceived as good enough, it doesn’t matter. You’re never going to achieve perfect equality as the wealthy will always be able to buy up. In Germany, for example, about 10% of the population opts out of the public health insurance system and nobody has a problem with it.
“Or, we might see insurance offerings that cover services, tests, procedures and drugs that cost up to X per QALY at one price, 2X per QALY at a higher price, and 3X per QALY for a still higher price. One size fits all ”
Does it? If you are poor, disabled and addicted to alcohol, your QALY is going to plummet through the floor. How is this particular form of discrimination any better than the current forms of care denial experienced by Medicaid “beneficiaries”?
Steve –
I don’t think it’s easy for Medicare to alter the status quo except when faced with a crisis. The program was around for 41 years before it even offered a prescription drug benefit which private insurers had for decades. Private insurers developed tiered formularies which encouraged the use of lower cost generics. Private insurers are now experimenting with tiered networks to encourage patients and referring doctors to use the most cost-effective providers. There has been tremendous pressure from those who benefit from the status quo to preclude Medicare from using competitive bidding for durable medical equipment. Doctors resist allowing NP’s to practice at the top of their license including letting them write prescriptions without supervision. Radiologists were OK with remote reading of images during hard to staff nights and weekends but, somehow, to allow the same thing during the weekday risks compromising patient safety. A single payer system would make it easier to preserve the status quo for established interests and resist disruptive innovation that could reduce costs for the system and for payers. There is also far more fraud in the Medicare and Medicaid systems than private insurance.
Regarding new treatments, I’m quite confident they would have developed at a similar pace without Medicare. Currently, however, Congress specifically prohibits Medicare from taking cost into account in making its coverage and payment decisions. If a drug or device wins FDA approval, it’s generally covered no matter how much it costs even if the benefits are only marginal at best. I don’t think that’s a good thing. We might see private insurers start to push back on this before Medicare does. Or, we might see insurance offerings that cover services, tests, procedures and drugs that cost up to X per QALY at one price, 2X per QALY at a higher price, and 3X per QALY for a still higher price. One size fits all Medicare couldn’t and wouldn’t do that in all likelihood.
For an excellent and thorough review of this general topic, I recommend the 2009 book titled “The Innovator’s Prescription” by Clayton Christensen of Harvard Business School.
“More importantly, it leaves room for innovation in both new medical therapies and in payment approaches that would be largely stifled under a single payer system.”
I believe that was the McArdle argument a while back, but I dont see it. Innovators dont care who pays them, just that they get paid. Maybe it is just a coincidence, but we have had our big increase in medical advances since Medicare came along. Was it financially feasible to develop therapies like CABG procedures, stentings, etc. because people knew that they would actually get paid?
Steve
Berkshire Hathaway’s decision to buy stock in UnitedHealth Group and Wellpoint during 2009-2010 may have been made by Lou Simpson and not Buffett. However, even if Buffett made the decision, his intent was to make money in the stock, not to invest float. By contrast, when he made the decision to acquire General Re, the rest of GEICO that he didn’t already own and, much earlier, National Indemnity, he viewed them as fundamentally decent businesses where his people could control the premium setting process and he could personally make the capital allocation decisions that determined how to invest the insurance float.
In the health insurance business, individuals and small groups with full risk coverage probably pay their premiums either monthly or quarterly and thevast majority of premiums are paid out within the year they are earned. Moreover, more than half of people with employer provided health insurance are in self-insured plans. The employer controls the float on those, not the insurer. The insurer is paid a fee to administer the plan under an ASO contract.
The administrative complexity of our system is not entirely a bad thing because it gives people choices as opposed to what they would have under a monolithic one size fits all system. More importantly, it leaves room for innovation in both new medical therapies and in payment approaches that would be largely stifled under a single payer system. If we’re really interested in bending the medical cost growth curve, we would have payers stop paying for services, tests, procedures and drugs that are not cost-effective or are no better than less expensive alternatives. Disclosure of actual contract reimbursement rates, substantive tort reform and more high deductible plans would also be helpful.
It is disappointing that a blog discussing the shortfalls of a complex and inefficient health delivery system leads to argument of third party payment/ float.
Perhaps an examination of conscience and motivation may be in order here. Are you all providers to receive the 0.02 percent interest the insurance company may make off of your delayed payment or are you a provider that seeks to serve your patients?
Did you know that Berkshire Hathaway invested its float capital in millions of shares of the common stocks of United Healthcare and Wellpoint up until around 2009-2010 when Mr. Buffet unloaded his stake? http://buswk.co/cOcDCC
I think that Mr. Buffett saw that healthcare reform bill provisions would crunch float profitability and sold the shares. But nonetheless, the master of float investing was definitively invested in healthcare insurers.
“Claims are paid in 7-14 days by most major insurers and most pay electronically now so you lose the float from the mailman. Lets be generous, and keep the math simple, and say they get 30 days float.”
B*llsh*t! I wish that were true. As president of our corporation for many years and looking at bills for many years this may be a goal, but it is categorically untrue in Pennsylvania. Clean claims are denied less frequently, that has improved markedly.
Steve
Hu,
“. I would support letting someone test as often as they feel necessary ”
This is the problem with people that don’t understand the system and how things actually work. You naively support providing people all the testing supplies they want unaware of all the fraud that is already going on. If you open a weekly or other small newspapers you will see adds from companies paying cash for diabetic supplies. So the insured fills orders for more then they need, pay nothing or next to nothing then sell the excess for cash.
Oh after reading