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What’s Wrong with the American Health System?

What’s wrong with the American Health System? Misinformation-Disinformation and Lies. The American People, including most of our lawmakers do not understand how the health system works.

There are two parts to the American health system ,the delivery of care and the financing of care. In other countries there is only one answer to “how do we deliver care and how do we finance it?” In the US there are many thousands of answers.

In the US, the delivery of care is regulated by the Department of Health  and the Department of Education in each State. Health Care providers are licensed to provide a defined service under a set of rules which include obtaining a level of education and experience and maintaining the proper facility and equipment. It is this part of the system that we point to when we say the American Health System is the best in the world.

However, the Financing of Care is regulated in many different ways. The Federal Government funds and creates the rules for Medicare. Each State receives some funding from the Federal Government for Medicaid coverage of the poor, while the State and Local Governments create the rules under which they will pay for that care.

Most people in the US get their coverage through private insurers, either through their employer or through an individual policy. Insurers can define the delivery system they will pay for, as long as they abide by the rules of their State for licensing of health providers and minimum regulations for reserves, showing that they can pay for the services they offered in their policy.

The Affordable Care Act (ACA) seeks to refine the guidelines underwhich States receive Federal Funding for Medicare and Medicaid and to mandate minimum standards for private insurers. It also intends to raise revenue to fund the changes through a new tax.

There is no question that it is a complicated system for which those who are healthy and have coverage are perfectly satisfied. It only becomes a problem when you are sick and need to find funding for your care. The opposition’s suggestion as to an alternative to the ACA is to allow the purchase of insurance across State lines, which would nullify the protections established by the State who represents the needs of their constituents.

Their other suggestions is to reform the laws under which a patient could receive damages in the case of malpractice. Their claim is that providers could lower their costs, which may be true to some extent, but is defensive medicine the only driving factor in rising health care costs?

As a small business owner, I am disappointed that the reform path chosen by our Government did not provide for a Public Option or even better for the Single Payer system that works so well for other countries.  I am angry about the new tax.  I would agree to pay for getting a comprehensive coverage package and to pay for my share of protecting the poor, however I do not see the ACA accomplishing this.

I am happy that there is a discussion about what our health care system needs because I don’t see either side laying down their misinformatiom-disinformation and lies long enough to find a solution to our funding problems.

Written by Caryn Isaacs, Patient Advocate and Health Policy Expert. Reprinted from LinkedIn group; Adult Children Caring for Aging Parents, discussion started by Ray Ashton 2nd, Founder, STAR Preventive Wellness – CEO, AFFECTS LLC Houston, Texas Area

July 23, 2012 Posted by | Uncategorized | , , , , | Leave a comment

You have to be in it to win it.

A leading physician practice management consultant called me today to ask about marketing a new Article 28 multi-specialty practice. I suggested to her that she look up the record on who was recently approved in NYS and to call them for their marketing plan. Are referrals still based on friendships or hospitall connections? Are Accountable Care Organizations or Insurance Plan Preferred Provider Organizations going to run the health care delivery system?

Here is the last chance for providers and others to be heard about how the ACA will be implemented in NYS. You or your organization can attend these meetings, no charge. lf you want your opinion in the record, make sure you put it in writing and send in advance or be there to testfy.
CON Redesign Special PHHPC Planning Committee,
PHHPC Committee and Full Council Meetings:
June – December 2012
6/21/12 – Albany Special Planning Committee: Driving Health System Improvement in New York State: Policy Priorities and Tools
7/25/12 – Albany Committee on Codes, Regulations, and Legislation
Committee on Public Health
Special Health Planning Committee: Innovations in Financing and Organizing Health Care: Implications for CON and Health Care Regulation
7/26/12 – Albany The Establishment and Project Review Committee
8/9/12 – Albany PHHPC Full Council
9/5/12 – Rochester Special Planning Committee: Regional Health Planning
9/19/12 – NYC Special Planning Committee: Establishment, Governance and Financial Feasibility
9/20/12 – NYC Regular PHHPC Committee
10/11/12 – NYC PHHPC Full Council
10/12/12 – NYC Special Planning Committee: Access and Public Need
10/30/12 – NYC Special Planning Committee: Review Draft Report
11/14/12 – Albany Special Planning Committee: Discuss Revised Report
11/15/12 – Albany Regular PHHPC Committee: Adoption of Report by Committee

Contact me if you have a question or comment. I get lots of comments on LinkedIn  groups from professionals in the field. How about letting the public in on our conversations,

July 16, 2012 Posted by | Uncategorized | , , , , | Leave a comment

Fight Against Cost Shifting – Pricing vs Costs

One of my clients was in Mayo Clinic for a very severe illness. Mayo charged $50,000 for the week of care. My client feels that saving her life was certainly worth the cost. However, Medicare allowed only $800 of the billable services. For some of the itemized services, Medicare says the negotiated price was lower and therefore the patient would not owe the difference between the charged amount and what was paid. Her AARP Medigap policy payed the 20% co-pay of the reduced amount, considering that Medicare, the primary payor had negotiated the lower price.

The problem for the patient comes in where some of the itemized services were considered “uncovered services,” meaning there was no code for the service such as the hospital charged for an exam which included doing a test to determine the cause of the patients distress. It makes sense to most people that when you go to the doctor or hospital that first they exam you and then they do some tests based on their initial exam. Not to the insurance companies though. The test was considered an uncovered service because it was done on the same day as the exam. All right, I can see the test being part of the exam, but Medicare paid for the lower priced exam and not the higher costing test, which was needed to understand how to treat the patient.

In the current law which is a part of the Affordable Care Act (ACA) which has already been implemented (and has nothing to do with the mandate or patients using emergency rooms for primary care) the “regulations” (the provisions in the ACA) state that providers can charge the patient for “uncovered services.” So, Providers now realize that since the EOB reads “uncovered service,” they have the right to charge the patient for any “uncovered services,’ according to the insurance policy and the regulations.

Medicare is aware of this issue and their website, http://Medicare.gov states that they are looking into how this has been affecting beneficiaries, but at this time, they regret to say that the patient must pay the bill. This means that the language in the portions of the ACA that have already been implemented have caused this cost shifting.

In another demonstration of cost shifting, a client went to the hospital in pain which was determined to come from a very large kidney stone, which caused a severe infection. After a stinit was put in to hold the stone from causing more damage, the patient was sent home, still in pain with antibiotics to wait for the infection to clear. A week later, she was to report to her PCP to get a referral for a urologist. She waited three hours in the office only to be told that the doctor was too busy and a Physician’s Assistant would write the referral. Another week went by until the Urology appointment. The Urologist made a referral to a facility where a procedure could be done to break up the stone. The patient was in a lot of pain, so she asked the Urologist office if they could do anything to hurry up the appointment process. They were able to schedule the procedure for the following week at a facilty an hour away, which was the only one approved by her plan. Then, the day before the facility was to do perform the procedure, the patient gets a call that they have to reschedule because the patient only had the referral to the Urologist from the PCP and not for the procedure. Specialists cannot give referrals because that might be considered a conflict of interest. So now the patient has to wait another week to see the PCP’s Physician Assistant for a referral to the facility to remove the stone, which they were not qualified to do in the first place which is why they sent the patient to the Urologist. The facility schedules patients a month in advance, so now instead of the expedited procedure, the patient will need to go to the back of the line. Then, the paitent will need to go back to the hospital to have the stent removed. All the while, doctors and hospital are being paid for visits and the patient is paying co-pays out of pocket for visits and medications. In this situation, the insurance company and the patient are over paying due to over-regulation.

Until the doctors (AMA) and hospitals (AHA) do the hard work of determining a pricing mechanism for services instead of allowing the insurers to use a lowest negotiated rate policy, we will continue to see cost shifting with the patients on the losing end.

I am hoping that today’s students are learning how the regulations are developed, so that our new policy wonks will demand a real economic solution to health care costs instead of a political one.

July 12, 2012 Posted by | Uncategorized | , , , , | Leave a comment

The health system is changing before our very eyes.

We recently have a number of complaints from patients who have been stuck with large medical and hospital bills for things that used to be covered. Patients are going in for an ultrasound and being billed privately for use of the room. People are getting medications in the hospital and getting a gigantic co-pay bill because the medication wasn’t submitted correctly. As the health care system makes changes to protect themselves from the Affordable Care Act, how do patients make sure they have enough coverage? In this article, firefighters are questioning which coverage will be better, the one offered by the government to the public or the one they have for themselves?

http://www.washingtonpost.com/national/health-science/seasonal-firefighters-face-many-dangers-without-health-insurance-union-seeks-federal-coverage/2012/07/09/gJQAUMWHZW_story.html

July 10, 2012 Posted by | Uncategorized | , , , | Leave a comment