Tax Rebates: Maybe Health Insurance Should Pay Attention!

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So hubby and I are excited about this tax rebate thing… looks like we fit in that middle class group that will get $1200 back from the federal government.

We reflected on the rebate for a few moments, and the thoughts by legislators and the president alike — why they voted “yes.” I share their thoughts with you:

1. The economy is a mess. We need to make people spend more money to improve it.
2. If we GIVE them money, they will have more to spend.
3. We want voters to re-elect us in November , and if we give them money, they will like us and vote for us.

So here’s little old me, wondering the following:

1. Mr. President and Ms/Mr Legislator — excuse me — but wasn’t that my money to begin with? I sent you a WHOLE lot more than that last year, and I’ll be sending you a WHOLE lot more this year. I don’t believe you are “giving” me anything!
2. And one other question — where did all this extra money come from that you have to give back to me? All I hear about is the escalating costs of the war in Iraq and the hole that has put in the federal budget. So who exactly are you taking money away from so you can give it back to me?

Those thought processes would be enough to share in today’s post….but…. why stop now?

I got to thinking that health insurers should begin to take a page from the federal government’s book…

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Why Your Doctor Won’t Help You

Notice that the title doesn’t say “can’t Help You.”  It says “won’t.”  There’s a big difference.

CPT codes are the stuff a doctor’s practice is made from.  I know — you thought patients were the basis for a physician practice, but no, CPT codes are more important than patients — even though I can guarantee that most doctors wish that was not true.

CPT Codes, Current Procedural Terminology Codes, are all those little numbers that show up on the bill you are handed as you walk out of the doctor’s office.  They are supposed to represent every type of task performed in medicine — from a basic check-up, to diagnosis, to administering a shot, to giving a medical test, to the levels of that test, to surgeries, to anything at all.  They are developed by the AMA, the American Medical Association,  and are intended to be the standard by which all doctors get paid, and all insurance reimburses.  The codes are revised regularly, and new codes are developed by an editorial board that represents the membership of the AMA.

Among the most frustrated of patients I hear from are those who can’t get diagnosed.  There can be a number of reasons for not getting a diagnosis, but one of the big problems is that patients can’t find one central person to review all the evidence.  They are sent from specialist to specialist, each looks at his own tests and results, but they don’t look at results from other doctors, except maybe the one who referred the patient. 

I call this daisy-chaining.  Each doctor represents a link to the answer.  Each link might look at the information from the link it is connected to.  But none of those links review information from links they are not directly connected to.

So what does that have to do with CPT codes?  Plenty.  Because the reason they won’t look at the other records is because there is no code for doing so — therefore — there is no way they can get paid (reimbursed by Medicare or insurance) to look at the big picture for a patient.

Why not?  I have theories, and they all relate to money, of course.  The AMA represents the doctors.  One would think that if doctors wanted to do this kind of big picture diagnosing, or review of other’s notes and reports, then the AMA would develop a code for it, right?  So theory #1 is that doctors don’t want to be doing so.  They don’t want to be responsible for that particular task. 

Theory #2 is that why would the AMA waste its time if insurance won’t cover the cost anyway?  And that’s actually the root of today’s blog.  A review of the new codes for 2008 shows that codes have now been developed for doctors who take phone calls or email from patients.  However, the report includes a caveat that says Medicare and insurance companies won’t be reimbursing for them anyway.

So that explains why your doctor won’t do what you wish he would do — take a comprehensive look at all your health challenges, and help you get diagnosed even after seeing a slew of specialists.   They wish they could — but they can’t.  If they can’t get paid, they can’t stay in business.  If they aren’t in business, then what good does it do for anyone?

I do give a bit of credit to the AMA for at least giving their new codes a shot — it’s a start.  Many more are needed.

But what’s really needed is someone to kick the payers in the backside.  They work for US, afterall — we pay taxes and we pay premiums.  So why aren’t they held accountable to reimburse for all those codes? 

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Health Insurance = Better Health (No kidding)

A report issued this week by JAMA, the Journal of the American Medical Association, reviews a study done by Harvard about the health of Americans and their access to health insurance.

More than 7,000 people ages 55 to 72 were studied. More than 2,200 of them had no health insurance to begin with, but were able to take advantage of Medicare once they turned 65.

Among those who had been uninsured and had cardiac or diabetes problems pre-Medicare coverage, 10 percent had fewer cardiac problems than would have been expected by age 72.

Bottom line, according to the researchers, is that health improves when we have access to health insurance.

Let’s put this one in the no-brainer category! Or — actually — let’s look at it another way:

Healthcare is way too expensive for too many (47 million Americans) to afford. Once you take away that money barrier, they will seek care — and they will be healthier.

My bottom line: This study wasn’t about insurance coverage’s affect on health. It was about removing a barrier.

Which then, of course, begs the question: If removing the barrier to seniors makes them healthier, what could it possibly do for those of us who are healthy to begin with? Maybe keep us healthier throughout our lives? And maybe cost the system less to keep us healthy?

And — doesn’t this make those who vote against SCHIP even bigger scrooges? What do you think about that, George Bush?

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Doctors Work the System to Increase Income – at the Patient’s Expense

Found an interesting op-ed from the Dallas News online yesterday, written by Dr. Steve Cole entitled, “Biggest factor in rising health costs are the doctors themselves.” Unfortunately, the title doesn’t even begin to touch the content, so many folks will miss this enlightening piece — a piece that should be read by everyone who has an interest in the costs of healthcare.

The article explains many of the reasons healthcare costs go up based on a doctor’s wants and needs and not necessarily on the best interests of the patient. There are a few statements that should make all of us pause — because they speak to the real problems of increased costs. I give Dr. Cole plenty of credit for citing these points — and no doubt he’s taking plenty of flak from his physician-colleagues for raising them.

Find the rest of this post at the new blog location.

Expensive Medical Tests – Who Really Wins?

Here’s one of the best examples I’ve encountered of the dysfunction of American medicine. It will leave you shaking your head. And you might be surprised by my comments about it. Here’s the scenario as described in the Syracuse Post Standard this week:

Recently, Excellus Blue Cross Blue Shield, the largest health insurer in Central and Western New York State, invoked a policy wherein physicians who order MRIs, CT scans, PET scans and other expensive diagnostic tests are required to get permission to perform those tests, or the test won’t be reimbursed — meaning — if the patient has the test, the patient must pay out of her pocket– her insurance won’t cover it. They say they have done this because the number of MRIs have gone up 100 percent in three years and they need to stem the tide of these expensive tests.

A high school girl injured herself, and her orthopedic doctor, Irving Raphael (who also happens to be team physician for Syracuse University), ordered an MRI to look at what he was sure was a stress fracture. But when he tried to get permission from Excellus, he was turned down and told he had to prove the girl had a stress fracture (so he could give her an MRI to prove she had a stress fracture. Seriously.)

So — since he did not get permission to give her the MRI, (and presumably because her parents didn’t want to pay for one themselves, because they are quite expensive – up to $1000) the doctor simply sent the girl home, and told her to stay out of gym class.

I’ve chatted with a number of folks about this, including my editor at the Post Standard. Most are outraged. It makes them mad that something that has become routine in most places is now under scrutiny, and they place the blame squarely on the shoulders of Excellus’ greed — like — what else is new?

So let’s break this down by participant:

From the doctor’s point of view: he feels like he can’t do his job without the right tools. His practice owns some of those tools, although whether he owns the MRI is unclear in the story. That’s really no different from the carpenter who owns his own hammer, or the plumber who owns his own snake, is it? Except that payments for an MRI lease are likely huge (5 figures per month is a guess) — and the more MRIs he does, the more money he makes.

But more important for the doctor is the fact that it’s HIS job to help this girl heal. If he can’t properly diagnose her, he feels as if he can’t properly treat her. Not only does he have the ethical obligation to do so, but he runs the risk of malpractice if he doesn’t.

Now –I’m not a doctor — but I went online to see how a stress fracture is diagnosed and treated. Turns out an x-ray, the “old fashioned” approach to a stress fracture, can rule out anything more damaging than that stress fracture. It does require an MRI to see the stress fracture.

Bottom line? Regardless of how the stress fracture is diagnosed, the treatment is the same, regardless of whether Dr. Raphael does an MRI on it or not. And regardless of whether he charges Excellus $1000 or not.

From the patient’s point of view: She has a stress fracture. She must stay off her injury for six weeks. No matter how she is diagnosed, her circumstance doesn’t change.

From Excellus’s point of view: You know, I rarely have anything positive whatsoever to say about health insurance companies. Their only goal is to take as much money as they can from patients, and pay out as little as they can, and patients die everyday from denied benefits, or too little assistance. It’s a profit model which, while I do understand it, I think has gotten out of hand.

In this circumstance, they identified a major hole in their rules – and wanted to plug the money gush. They are convinced that doctors are ordering tests that are excessive and unneeded. So they set up a new policy requiring permission — which means — they aren’t denying all the MRIs, CTs, etc — just the ones they think aren’t needed.

The question is — who says they aren’t needed? You’ve got a doctor who is trained to do this work, asking a nurse for permission. Does that make sense?

From the consumer’s point of view: This is where I differ from my usual point of view. In this case, I actually support Excellus looking at ways to cut their costs for the expensive tests. The care for this girl didn’t change at all, regardless of the fact that she had no MRI. There are thousands of these unneeded MRIs and other tests being done on a regular basis — and do you know who is paying for them? We are. As consumers of health insurance, all those extras are being subsidized from MY premiums and YOURs.

The bigger problem here is that Excellus really did it wrong. You can read the article to see how they went about putting their policy into place — wrong wrong wrong — and just plain dumb. It wasn’t until after the new policy imploded on them until they went back to correct it. But the damage in the form of distrust, and patients lost to the new policy, can’t be undone.

As patients, we want the best treatment. But we can’t continue to equate the most expensive and extensive tests to the best treatment. Granted, having those capabilities is important — and I want to know they are available — but they just aren’t necessary for every instance. Using them is like taking a limosine to the supermarket…. it might be nice, but it just isn’t necessary! There are even some who believe that some of the tests, used too often, can be dangerous for the patient due to exposure to radiation.

As consumers, we want the lowest cost for the best treatment. Insisting on expensive, yet unnecessary tests, continues to cost us more and more. We need to begin asking questions of our doctors about these kinds of tests, looking them up to learn more about them, and managing parts of our healthcare with the intent of keeping our wallets as healthy as our bodies.

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A Lemon Law for Medical Consumers?

From Hannah Montana to drive-by shootings, there is plenty of interesting news in Cincinnati, Ohio today.  But to me, your friendly patient advocate, an even more fascinating topic was reported in Cincinnati’s news this week:  the possibility of a lemon law for medical consumers.

To me, it’s one of those “now why didn’t I think of that?” ideas!

A woman named Betsey Exline gets the credit here.  Last spring she went for a routine colonoscopy, which was botched, and she ended up with emergency surgery and a stay in the hospital for eight days. 

Nine doctors, the emergency surgeons and the hospital then billed her for the insult.  Can you say “unmitigated gall?”

Should she sue?  She could, although lawsuit cost estimates range into five figures and she’s not getting any younger.

Instead, this very wise woman took a very different approach.  Bless her heart, she’s not looking to make money from this error which she will suffer from for the rest of her life.  She just wants someone to pay her bills.  She just wants someone to recognize that it should not be her responsibility, or her insurance company’s responsibility, to pay for the errors caused by others.

Hello?  Duh!  That just makes so much sense!

So Betsey contacted her local Ohio state representative and is now pursuing the introduction of legislation that would, in effect, force those who caused the errors to pay for the errors — but not through the courts.  Instead the legislation will create a consumer protection process for medical errors. Those who caused the errors will be required to cover the costs that result from their errors.

And if it becomes law?  The doctors win because it will cut down on lawsuits.  The insurance companies win because it will cut down on lawsuits, too.  And the patients win — at least to the extent they won’t have to pay those unfair bills.

(And who will stand in the way?  Of course, those lawyers who handle medical error victim lawsuits.  but that’s another blog post for another day.)

Wish I was in Cincinnati, Betsey.  I’d find you — just to shake your hand.  You’re a fixer of the first order.

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Where Health Insurance Meets You-Tube

Forwarded to me today by my security guru Bob — who understands the power of combining a sense of humor with a pointed message….

If you are a patient, and a health insurance consumer, I hope you can see the humor through your frustration.

If you work in health insurance, and you’re tired of the bashing — well — that’s the way it goes. Your best takeaway will be that it makes no difference whether this video reflects reality — it reflects consumer perception which is far more powerful.

Give it a look-see and form your own opinion:

Go Ahead And Die! (Pirates Of The Health Care-ibean)

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Oprah Takes on Health Insurance

Oprah took on healthcare, insurance and the lack thereof today. While I think she did an astounding job of moving the discussion forward, I think a major point was missed — and needs to be pointed out.

Joining Oprah were Michael Moore, the director and producer of Sicko, Karen Ignagni who is the top lobbyist for the association of health care insurers, and Uwe Reinhardt, a health economist. The debate was heated, hit many of the important points, and during the hour, Oprah asked several times, “What do we believe?”

Believe? Here’s how it was posed: “Do we believe the child of a gas station attendant and the child of a CEO deserve the same access to healthcare?”

How many answers can there be? Of COURSE that child should have the same access!

.. but guess what… they don’t.

This is not new to anyone. And then, of course, the question about the 47 million Americans who don’t have health insurance is imposed…. but then — Joe Average American retreats to this thought process, “well, at least I’m insured and my family is insured, and I’m only one person anyway, and there’s nothing I can do about it, because I am only one person.”

Here’s the point that was missing — The great majority of Americans think like Joe Average American — and that thinking is flawed! Joe Average American — you have missed the point! Joe — you have coverage that isn’t going to cover what you think it is! You have coverage that will pay far less than you think it will, despite the fact that it has already cost you hundreds if not a thousand dollars a month just to have that coverage to begin with!

Yes — Lisa Ling showed the stories of three people who had insurance, yet were denied care. Those are huge, and sad, stories.

But that’s not what I’m talking about. I’m talking about those people who need help with normal, every day care. Their child breaks a leg? It costs them hundreds or thousands of dollars in addition to their insurance coverage. Find out you’ve got allergies? It will be declared a pre-existing condition and it won’t be covered. You’ve got GERD? Even though your health is covered, you prescriptions may not be — it will cost you an additional $300 or $400 per year for the drug you need.

Michael Moore and Oprah reiterated a number of times that they don’t understand why anyone should profit from healthcare. And I do differ with them on that, at least to a degree. I think that profitability is a great motivator for innovation, and it’s profit that drives good research, new discoveries and treatments, and eventually, advanced care.

But I don’t believe that’s true for insurance. Profitability should not be allowed when it comes to human lives.

For those who have insurance and who think they have decent insurance (even though they are usually wrong) …. be advised that you are likely clueless about how little coverage you really have. Be advised that your healthcare dollar won’t go nearly so far as you think it will. And be advised that the health insurance lobby owns too many legislators who will make sure that doesn’t change anytime soon.

I don’t know how Karen Ignagni sleeps at night. Honestly. I’ve seen spin doctors, but hers spins only a much more tangled web.

And those tangles are costing more lives every day.

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Find more commentary on Sicko here.

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Tom: A Progress Report

Last week I told you about my email pal, Tom, who fought valiantly with his health insurance company to get clearance for specialized heart surgery. Tom won permission — and his surgery was performed last Wednesday.

I received an email last night — from the man himself — and he tells me he made it through the surgery and is beginning to get back on his feet. woo hoo!

He promises some details later. He alluded to some snafus and even says he has become familiar with hot flashes! But his short email did sound, well, relieved.

Thanks to those of you who kept Tom in your prayers and thoughts. And yes, I promise to keep you posted.

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