Americans want universal health coverage

[ladelfina]

Cool Dood: if Canada bans private doctors and private education, that is wrong, wrong, wrong! I'm sorry that's the case. If that makes me a 'libertarian Democrat', then I guess that's what I am.

lets-retire: I don't see the big difference between the gov't. regulating some payments versus Wal*Mart beating down their suppliers. Is Wal*Mart more virtuous just because it's private? 

We shouldn't "force" people to go to medical school any more than we should "force" people to become astronauts. But in one case we found the will to produce astronauts.

Right now, it may not be the government that "runs" the doctors' offices, but it is sure as hell IS the private insurance companies!! Either way, health care professionals have to deal with someone who says they won't pay more than 'x' for a particular service. If that ends up being the case, in the public example you have 10%-25% off the top extra to spend, minimum. And the doctor and his/her staff have to deal with one set of regs and forms, not 30 different ones requiring several members of staff to sort out.

Paul Krugman of the NYT (bolding mine):

A little background: conservatives have never mounted an attack on Medicare as systematic as their effort to bully the public into privatizing Social Security. They do, however, often talk about Medicare "reform." What this amounts to, in practice, is a drive to replace the traditional system, in which Medicare pays doctors and hospitals directly, with a system in which Medicare subcontracts that role to private H.M.O.'s.

In 1997 Congress tried to take a big step in that direction, requiring Medicare to pay per-person fees to private health plans that accepted Medicare recipients. There was much talk about the magic of the marketplace: private plans, so the theory went, would be far more efficient than government bureaucrats, offering better health care at lower cost.

What actually happened was that private plans skimmed the cream, accepting only relatively healthy retirees. Yet Medicare paid them slightly more per retiree than it spent on traditional benefits. In other words, instead of saving money by subcontracting its role to private plans, Medicare was in effect required to pay H.M.O.'s a hefty subsidy.

The only thing that kept this "reform" from being a fiscal disaster was the fact that after an initial rush into the Medicare business, many H.M.O.'s pulled out again. It turns out that private plans are much less efficient than the government at providing health insurance because they have much higher overhead. Even with a heavy subsidy, they can't compete with traditional Medicare.

http://www.pkarchive.org/column/032604.html

I haven't investigated this yet personally; I am taking him at his word. (plus, it's the cocktail hour!) But I don't see how the government, as an insurer of first resort, rather than an insurer of last resort, can be any worse than the situation we have now. The government, as lets-retire says, has not "figured out" a whole heckuva lot.. The insurance lobbyists dole out big bucks, and that money talks... loudly. My dad, a surgeon, spent several hours each night dealing with BC/BS paperwork, and that was just the predominant insurer of the day in our area. That talent could have been better spent elsewhere. Now it's worse: the last time I saw a PCP in the US, she indicated at least 30 different companies' regulations that she had to contend with before conceding or denying this or that form of treatment. How is that better/desireable? Does it help the patient, or just help employ bean-counters?

It's just like the new Medicare plan D "reform".. how can you choose the plan that will cover your meds based on a private "plan" that can change at any time without informing you (but you have the chance to switch only once a year, during the "open enrollment" conceded by the insurance companies?). I hope Rich can chime in again with his current, real-life, experiences vis-à-vis Medicare and other insurance providers and their relative performance.

 

[Eagle43]

Many years ago, I had a professor criticize the AMA.  He said they specifically did not want universal health care and that they limited the number of doctors graduating with medical certifications.  Do they, can they still do that?  I mean, half the docs in town here are from India, and they are good.  Best heart surgeon in town is from India.  One of the given reasons for AMA's actions was that it took so long and so much money to get through medical school.  Would that not be a way to increase care.  Just pay for their medical schooling, internship, etc. and churn out the doctors.  Just trying to think outside the box, and for all I know somebody has already proposed this. 

 

[Rich_by_the_Bay]

Many years ago, I had a professor criticize the AMA. He said they specifically did not want universal health care and that they limited the number of doctors graduating with medical certifications. Do they, can they still do that? I mean, half the docs in town here are from India, and they are good. Best heart surgeon in town is from India. One of the given reasons for AMA's actions was that it took so long and so much money to get through medical school. Would that not be a way to increase care. Just pay for their medical schooling, internship, etc. and churn out the doctors. Just trying to think outside the box, and for all I know somebody has already proposed this.

Contrary to popular belief, the AMA is, well, irrelevant. No one I know used them for anything but their journal JAMA, and for group insurance for members. The don't set policy, they don't really speak for any identifiable constituency, and are a dinosaur in many ways. They have no control over medical school size or specialty selection. I have not belonged in decades. Maybe through the early 1970s it was a different story.

To be fair, they are a great source of manpower surveys and physician demographic analysis and do lots of good things regarding voluntarism, etc. But as far as the political landscape, nada. Specialty societies have largely replaced them, IMHO.

 

[cute fuzzy bunny]

Back a bazillion years ago when the govt first wanted to implement DUI laws, they went to the AMA for guidelines. The laws being kicked around proposed a .14 BAC as the point where an average driver would become impaired. After presumably extensive analysis the AMA came back and...surprise...found that .14 was where a driver in fact became impaired.

A few years later, the newer laws called for .10 as the limit. The AMA was consulted and...wow...in just a few short years american drivers lost some of their ability to hold their liquor and were now impaired at .10.

Guess what happened when MADD pushed new legislation for .08 and the AMA was consulted...

 

[Rich_by_the_Bay]

I hope Rich can chime in again with his current, real-life, experiences vis-à-vis Medicare and other insurance providers and their relative performance.

Happily, someone else does my billing for me these days, but here is a quick primer:

1. MD has to choose whether to be a "participating provider" or not. No, means that you bill the patient and the patient pays you, then the patient tries to get reimbursed from MC. Yes means that you agree to accept as payment in full anything MC decides is OK for your services, i.e. a humungous discount approaching your actual costs in some ways. Then you have to separately bill the patient for the 20% usual copay up to the "allowable" amount.

2. If you do NOT participate you can accept assignment (i.e. MC's approved rates) on a case by case basis. You get paid slower and...

Medicare automatically takes 5% off their approved amount for NON-participators when you do accept assignment, so you take another hit. It is routine for MC to deny claims with messages to your patient that MC has determined that the test you just had is "medically unnecessary." Imagine the calls this generates, with patients very unwilling to pay their copay in this instance. So you appeal, resubmit with more or different information. 90-120 days later you may get your $20 for a $50 office visit for which MC "approved" $20.

Then you get to bill the Medigap carrier.

There's more, but you get the idea.

Kafka, anyone?

 

[ladelfina]

Urgh! Sorry, Rich.. that sounds like a total drag. You would be tempting me to rethink my position, but I've also had surprise bills show up from my HMO for things that, six or eight months after the fact, they decided not to cover.

How can we, either as doctors or as patients, prevent being blindsided by rejected claims?

What would your vision be of how we could improve the system?

Thanks for taking the time to share your expertise with us!

 

[lets-retire]

lets-retire: I don't see the big difference between the gov't. regulating some payments versus Wal*Mart beating down their suppliers. Is Wal*Mart more virtuous just because it's private? 

Right now, it may not be the government that "runs" the doctors' offices, but it is sure as hell IS the private insurance companies!! Either way, health care professionals have to deal with someone who says they won't pay more than 'x' for a particular service. If that ends up being the case, in the public example you have 10%-25% off the top extra to spend, minimum. And the doctor and his/her staff have to deal with one set of regs and forms, not 30 different ones requiring several members of staff to sort out.

You got the Walmart reference correct in your first sentence, so I won't address your second. Heck they ever were able to force concessions from Coke, a major company. Would you as a business owner like to have one major company (being the gov't in this case) giving you money or several smaller ones (being several insurance companies). Yes it is a pain that you have to know each comapnies policies, but I'm sure each one has a different payment amount. Some you make from others not so much. Personally I'd rather have 100 different income sources than just one (wasn't that idea in the Millionaire Next Door?).

On a related note I just saw this want ad: F/T MEDICAID/ MEDICARE Representative needed. Must have minimum 2 yrs. experience in followup of denials and aging reports. So the feds still have denial of payments just like the private companies.

 

[larry]

Thought this might be fitting under this category, it's an e-mail that's being passed around.

American Health Care

Two patients limp into two different American Medical clinics with the same complaint. Both have trouble walking and appear to require a hip replacement.

The first patient is examined within the hour, is x-rayed the same day and has a time booked for surgery the following week.

The second sees the family doctor after waiting a week for an appointment,
then waits eighteen weeks to see a specialist, then gets an x-ray, which isn't reviewed for another month and finally has his surgery scheduled for 6 months from then.

Why the different treatment for the two patients?

The first is a Golden Retriever.....

The second is a Senior Citizen.

 

[free4now]

How can we, either as doctors or as patients, prevent being blindsided by rejected claims?

It seems to me this is a problem that has to be solved by legislation and enforcement. There needs to be "safe harbors" where if a certain set of conditions have been demonstrably met, then the claim cannot be rejected. And for situations where the "safe harbors" don't apply, the insurance companies need to be held responsible for evaluating the evidence in a timely fashion and coming to a decision before the procedure happens.

The absolute worst part is the way doctors require patients to sign a statement saying if the insurance company rejects a claim the patient has to pay. Even if the doctor is "in network" for their insurance company.

If the doctor and insurance company have established a contract for working together to decide what procedures are covered, why should the patient bear the fallout when they can't agree? It's really extortion on the doctor's part... they are saying "we won't give you the covered treatments we've agreed to provide to your insurance company, unless you agree to pay if we disagree with your insurance company." They can get away with it simply because the healthcare industry isn't sufficiently competitive. No matter whether you think it should or shouldn't be more competitive, the fact is that right now it's not competitive and legislation needs to address the tyranny of the weak (consumer) by the strong (insurance and medical establishment).

 

[OldAgePensioner]

I just received two pieces of mail illustrating the exact point here.

BlueCrossBlueShieldIL sent me a statement of what they paid to Northwestern. For services that have been under review since Oct1, 2005.

Couple of days later Northwestern (which has 3 divisions that charge seperately) sent me something saying BCBSIL paid $3400ish, and they discounted $$2,500ish and some of the total of $9500 is still under review.

I looked it over and have no idea what either is talking about, they use different dates of treatment, different #s. Absolutely no way to know what's going on.

Something is very wrong with healthcare vs insurance.

 

[Rich_by_the_Bay]

The absolute worst part is the way doctors require patients to sign a statement saying if the insurance company rejects a claim the patient has to pay. Even if the doctor is "in network" for their insurance company.

If the doctor and insurance company have established a contract for working together to decide what procedures are covered, why should the patient bear the fallout when they can't agree?

A. If a doctor and patient decide a service is needed, the doctor provides that service, and the insurance company rejects it, you feel the doctor should pay for it? Think we have a doctor shortage now?

B. Now the "the doctor and insurance company have established a contract for working together to decide what procedures are covered." That's almost as common as the misbelief that doctors get paid by the prescription, or that the AMA runs medical practice in this country.

In fact, if the doctor signs a participation agreement with an insurance company, she generally agrees in advance to accept whatever they deem the "proper" fee to be. For  noncovered services, it is between you and the patient; better to tell them in advance if a recommended service is not covered by insurance - unless you'd rather be surprised. Insurance companies often do not play nice with doctors; it is not a collusion, but rather an objectionable, reluctant and tense tug of war.

I used to make house calls to needy and elderly patients. The trip charge (about an hour round trip) was not covered by Medicare. I billed the patient a small amount for that (not nearly enough to cover the 3 additional patients I didn't see that day due to lost travel time). They were uniformly grateful, often not only paid the bill but threw in a batch of cookies. I always told them in advance that a travel fee was necessary or else I simply could not take the time to make house calls.

In fact, most doctors spend hours of time and money fighting insurance companies who on their own decide that particular services are "not medically necessary" or are "not covered." The only doctors who work with insurance companies to determine one-sided policies are the ones who work for the insurance companies (i.e. on their payroll).

So, feel free to rant at the system (I do it all the time )  -- I strongly support universal health care for reasons such as yours. Just wanted to clarify the misunderstandings.

 

[free4now]

For noncovered services, it is between you and the patient; better to tell them in advance if a recommended service is not covered by insurance - unless you'd rather be surprised.

Right on. If the doctor looks up the procedure and says insurance won't cover it but it's a good idea, then the patient is empowered to decide to go ahead, decline, or shop around for a better deal (in terms of quality, price, or both).

In contrast, the bad situation is when the doctor thinks something is covered, performs the procedure without telling the patient it's not covered, and then goes after the patient for the the fee because they can't get it out of the insurance company. It sounds like you don't do this Rich, but I betcha your office makes patients sign something that puts them on the hook for such cases.

 

[free4now]

I live near San Francisco and have been considering moving to the city. Maybe this will hasten my plans:

Mayor Gavin Newsom unveiled a proposal today that would make San Francisco the first city in the country to provide health care for all of its uninsured residents through a plan that covers everything from patient doctor visits and surgeries to prescription drugs.

http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2006/06/20/MNG3OJHDTV5.DTL