Health Care Update

Item: I am now paying $27,000 per year for Blue Shield catastrophic care health insurance for myself and my wife. (The first $7,200 comes out of pocket. That’s our pocket.)

Item: Recently I went to my doctor to see about some hip pain. He examined me for about ten minutes. The bill was $199. When I called Sutter Health to ask how that could be, the woman in customer service seemed offended that I wanted an explanation. She said it could be more, and that the cost of a doctor’s visit varied, depending. When I asked depending on what, she said it was a government formula and she couldn’t tell me. When I asked whether there was any way to know in advance how much a doctor’s visit would cost, she said no. Question: is there any other service that cannot give you an estimate of cost in advance?

Item: according to my doctor, his office now has two employees working on insurance for every doctor or physician’s assistant. That’s not counting the insurance company employees.

The conclusion I draw is that our medical care system is broken. It’s broken even for people like me who can get insurance, let alone for the ever-increasing millions who can’t, at any price.

Obamacare is, generally, an attempt to save the system. It preserves the basic elements of individual or company health insurance, paying to independent providers. Within that framework it tries to make sure everybody can get insurance–especially those who have an ailment or a history that currently makes them uninsurable. It makes some preliminary attempts to rein in costs.

Whether it can work, I have my doubts. I’m inclined to hope it gets a chance, because right now it is the only game in town. Has anyone else offered even the shadow of a plan that would enable people who need it to get insurance? I don’t think so. If Obamacare is thrown out, or fails, we’re left with the current system, which gets more impossible every minute.

The only other option is single payer, like every other industrialized nation has. Politically, we’re not ready to go there. Yet.

Folks, we are in a mess.


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4 Responses to “Health Care Update”

  1. solutions777 Says:

    The government has created a bureaucratic health nightmare. As the government becomes more involved, the system becomes more of a mess. One of the reasons for high medical costs is the massive amount of paper work. The government is trying to totally regulate the health care system. It will not work. All it will do is reduce the quality of care while increasing costs.

    No one is doing any observation, analysis and critical thinking about the health care system.

    There are solutions, but they will not come from government and politicians.

    Censorship is evil.

  2. Doug Webb Says:

    If Obamacare is thrown out by the Supreme Court or eventually repealed by the Congress we will probably not be left with the current system. Many in Congress, and elsewhere, have been talking about two changes that would substantially reform the current system. One is medical tort reform that would take huge costs out of the system and the other is a law that would allow competition across state lines by all insurance companies. No one knows if these two would be enough to “cure” the current system but they would sure help. No doubt other changes would come along to continue the “cure”.

    • timstafford Says:

      Of course, we can make these reforms with Obamacare in place. They seem reasonable to me, tho I read that a) tort reform has shown small benefits in the states that have it, and b) states like California that have a huge market don’t have cheaper or better medical systems than states like Nevada that have a tiny one. So I don’t see that they heal the system to any great degree. But I’d like to find out!

  3. Sue Preston Says:

    Hi, Tim–a few points of clarification.

    The reason your customer service rep couldn’t answer the question is that the reimbursement formula is too complicated to do on the fly, even for people who know what they’re talking about.

    Insurers work with two codes–a CPT code, which describes what service was performed, and a Medicare code that fine-tunes the procedure code. (Nobody remembers what CPT stands for; it wears big boots and strides across the land, so it gets called whatever it wants.)

    The CPT code has its own set of adjustments for the severity of the condition, the level of expertise required to diagnose or treat it, and so forth.

    Medicare pays X for a given CPT code, but then adjusts the payment for things like the physical location of the practice (so a California doc gets more than an Alabama doc), whether it’s performed by a doctor or by a paraprofessional under the doctor’s direction, whether it was in a hospital or a doctor’s office, etc. So if a doc says “Hey, Tim, how’s the hip?,” Medicare pays X, but if an NP says it, Medicare pays .35 * X. If you’re both in a hospital at that moment, there’s another adjustment, etc.

    You can’t come up with a dollar figure until you do all that calculating. Your customer service rep didn’t stand a chance.

    It’s pretty often said that the coding system is bureaucracy gone wild, but in fact it comes up with a fairly valid rate of pay for bazillions of medical services. That huge mass of highly calibrated adjustments is a bigger achievement than the Pyramids.

    Okay, about the $199. The insurer negotiates its contract with a doctor based on the reimbursement a doctor would receive under Medicare. It’s reimbursement because the doctor is paid after performing the service.

    A typical insurance reimbursement is 105% to 115% of what Medicare would pay. (With Medicare, the patient is supposed to kick in a 20% copay, and in theory, you don’t pay that 20% when you sign up with a Medicare insurance plan.)

    Some doctors try to collect more from the patient, although they’re not supposed to (last I heard). The doctor can say that s/he is charging a “usual and customary fee” and try to collect the difference between that and what the insurer pays. Usual and customary means “whatever I can get away with.” Perhaps you were being asked to pay that fantasy fee.

    Anyway, some practices ask you to sign a paper saying that if the insurer doesn’t pay, then you have to pay instead. When I’ve seen things like that, I’ve written “I will pay 130% of what Medicare pays for the same service.” So far, so good.

    As you know, the only way to get a decent deal on health insurance is to be in a group plan or a Medicare plan, which, if the group is big enough, will force the insurer to accept you in whatever shape you’re in. If your group has a median age of, say, Hip Replacement, though, you’re still going to pay a fortune.

    Here are some ways uninsurable people get treated:

    In New York, New Jersey, and Michigan, an insurer must accept you whether you have preexisting conditions or not. They don’t have to cover your preexisting conditions until you’ve been in the plan for one year, but after that, you’re in.

    In most states, there are high-risk insurance pools for uninsurable people. You pay a shockingly high premium, but if you get the Big C, you get to keep your house. (I don’t in fact know how bad off you need to be to qualify for Medicaid.) Obamacare, if I recall correctly, will set up a federal version of the same thing.

    In a few states, there are physician practices that will handle your primary care if you pay them a modest amount of money every month, like $70. AMG Medical Group in New York City is one of them; the founder is John Muney. There are several in Seattle, and I think there are a few in California too. The name for this kind of practice was very cleverly chosen so that it slips your mind at moments like, say, this one.

    I could go on, but, hey, it’s bedtime. –Sue

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