pre-existing conditions exclusions, c-sections, abuse, but not viagra

18 Sep

I came across this post Its worth reading the whole post, albeit its pretty disgusting what insurance companies do in the quest for increased revenue.


When a woman isn’t currently pregnant, she often still cannot get coverage. Many insurers consider a Caesarean-section pregnancy a pre-existing condition and refuse to cover women who have had the procedure. From a 2008 New York Times story about a Colorado woman who had Golden Rule Insurance:

She was turned down because she had given birth by Caesarean section.Having the operation once increases the odds that it will be performed again, and if she became pregnant and needed another Caesarean, Golden Rule did not want to pay for it. A letter from the company explained that if she had been sterilized after the Caesarean, or if she were over 40 and had given birth two or more years before applying, she might have qualified.


Spousal Abuse

Earlier this week, the Huffington Post’s Ryan Grim reported on the fact that in seven states plus the District of Columbia, “getting beaten up by your spouse is a pre-existing condition.” The insurance industry figures that if “you are in a marriage with someone who has beaten you in the past, you’re more likely to get beaten again than the average person and are therefore more expensive to insure,”

An interesting comment

So why do insurance companies pay for Viagra?

I had heard that viagra was commonly covered, and based upon spam, it was not cheap… and yet C-sections are considered pre-existing. Thus I went to do some digging to see what the QALY values were.


The researchers calculated that Viagra costs about $11,290 per QALY that it produces. This amount is less than many other accepted health treatments. Most accepted health treatments cost less than $50,000 to $100,000 per QALY. The researchers also found that Viagra costs less than $50,000 per QALY if 1) fewer than 0.8% of the men who take the drug have a major treatment-related side effect, 2) fewer than 0.55% of the men die as a result of taking Viagra, 3) Viagra costs less than $244 dollars permonth, or 4) successful treatment of impotence improves quality of life by at least.05 on a scale of 0 to 1.


An incremental cost-utility analysis was performed to combine the costs and QALYs of the two delivery approaches. The authors used the widely accepted threshold of $50,000, above which the intervention was not considered cost-effective. The incremental cost per QALY of elective repeat Caesarean delivery relative to VBAC was $112,023, which was well above the threshold. Thus, the cost-effective option was VBAC. This conclusion was sensitive to the probability of successful vaginal birth after VBAC. When such a probability was less than 0.65, elective repeat Caesarean delivery was the dominant option. When the probability was between 0.65 and 0.74, the cost-effectiveness ratio of elective Caesarean was below $50,000. When the probability was between 0.74 and 0.76, the cost-effectiveness ratio of elective Caesarean was above $50,000. The results were also sensitive to the costs associated with neonatal outcomes, while the conclusions of the analysis were robust to variations in the remaining factors.

Pretty much this means women of child bearing age are relegated to large employers, thus taking a huge talent pool out of the picture for startups and small business. Private insurance is really not an option for many based upon the greatly increased usage of C-sections.

The thing is… how long until large employers start removing benefits. They already have increased deductibles, in some cases upwards of $5000. They’ve shifted more and more of the ~$10,000-$20,000 family premium to the employee, some will see a 5-10% takehome paycut come January. Many this fall are deciding they can no longer provide for family coverage. Many have already removed some coverage, more and more is on the way. Do folks really think the status quo is the best way to go?







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