Healthcare has become a game with few winners

 I am about to dip my toe into some very murky water indeed. It is deeply influenced by the government and manipulated by major corporations.  It is required by virtually every person (citizen or not) in the country. The dangerous water is “healthcare,” and it is profoundly troubling.

By and large, received excellent care over my lifetime. I have gotten it from the gamut of providers: large socialized systems (the Army and the VA), private and not-for-profit (a term I choke on) hospital systems, large and small medical practices, and even individuals. In general, the practitioners have been wonderful: knowledgeable, caring people.

However, the process of acquiring care, receiving it, and paying for its use has become less a service, and more a game. It is a game in which the government sets incomprehensible rules, insurance companies manipulate things to make money, and institutions often treat the public like pawns or cattle. Within this system, the practitioners try mightily to do what they swore to do, preserve life and mitigate suffering, fundamentally disconnected from the process in which they toil.

The problem starts with us, “we the people.” American consumers want it all, the best of everything, without limits.  If grandmother is 80 years old, she should still get a new heart. If I have a pain or a temperature, I want a magic elixir to make it disappear. If your “parts” don’t work so well, you want a little “blue pill.” For all of this, we expect Walmart prices, or better yet, it given to us without charge. It starts here; it is our “entitlement.”

Then, other players get in the game. The government can’t afford the price tag, so they simply pretend it doesn’t cost what it costs. Through laws, like Obama Care, it dictates what is covered and how much it will pay. It is a fantasy world, but our elected officials are cowards, collectively afraid to tell us the truth and fix it for fear they won’t get re-elected.

Next, the insurance companies use this system to generate record profits. They create an arcane system by which they “negotiate” charges for services that are simply detached from reality and require the public to pay exorbitant prices for service they often don’t even use (and we wonder why young healthy people opt out of coverage).

Hospitals, networks, and practitioners who actually provide the care, operate within a system not of their own making. They try, like any business (yes, healthcare is a business), to make a profit (or “not-for-profit” profit).

Here the fun really starts. Multitudes are hired to figure out how to “game” the system. One “code” describing a service may not pay much, so they search for another that might be used to describe that very same service and has a higher reimbursement. Unfortunately, the insurers look at the diagnosis and often determine that the “code” isn’t appropriate. (when did they become doctors?) Coverage denied. The practice wants its money, so they send the patient a bill, not for the discounted rate they agreed with the insurance company/government, but for the “full price.”

It is like going to the store to buy something you absolutely need and not knowing what the price will be until you get to checkout. But, once it is swiped, you have to pay the price, whatever that may be. Sheer insanity.

Some personal examples are illustrative, if anecdotal.

My wife had shoulder surgery (everyone was informed that it was not work-related). Great care, but when the bill for Physical Therapy came in, it was “coded” Occupational Therapy. Apparently, that reimbursement rate is higher, so we were stuck fighting everyone (see above), to get the charge corrected (how many man/woman-hours were wasted on that endeavor?)

Another time, I was admitted to the hospital overnight for what turned out to be a minor, but potentially serious, incident. Again, the care was great. Afterwards, I received a bill for many thousands of dollars…many.

OK, they must not have gotten reimbursement from the insurance company. Another (less friendly) letter arrives, reminding me to pay. I check the EOB (explanation of benefits) from the insurance company (this is clear as mud). They have paid, and I owe a much less onerous sum. I haven’t gotten a bill for that, only the many thousands of dollars.

OK, they’ll figure this out and send me the corrected bill. The next bill threatens to send me to collections. I blow a gasket and call the number on the bill…lengthy wait listening to bad music…a nice lady answers and I explain my problem. She says, “Yes, that is correct. We will send you a bill for that amount.” Click.

What? They understood all along, I only owed the lesser amount! They knowingly sent me incorrect statements and threatened to ruin my credit. If I had been some little old man on a pension who didn’t understand the system, I would have paid the whole amount Or, I would have ended up in court and had a garnishment mandated by the judge. No one questions it. Incompetence? Negligence? Or worse?

I go to an appointment only to be greeted with a notification that if I am 15 minutes late, I will have an additional charge. What about the hour I wait, after arriving 10 minutes early? Do patients get reimbursed for the time they wasted because the practice deliberately overbooked appointments?

Everyone with whom I speak has had similar experiences. How did we screw this up so badly?

Healthcare has become a game with many losers and few winners. The problems are intractable. Too much money. Too much momentum. Too little honesty. Too little courage.




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