Tuesday, August 21, 2012
how do you feel?
I began writing this as a comment to Francis Hunt's excellent essay about the history of socialized medicine in the UK and Europe and some of the circumstances regarding why it wasn't adopted in the US. Once I got part way I realized that I had far too much to say to post in a comment and that it would be more reasonable to let him know my response was here. Hi Francis! This likely will be a bit tedious for anyone used to my sillier posts but since I already wrote a serious bit about our dangerous (albeit unwitting) reliance on electrical power, I figured why not another?
Although I wasn't what is called a medical professional: doctor, nurse, radiologist et al, I did spend more than 30 years working in the American health care system in various administrative roles. I concur with the conclusions you've arrived at regarding that system and the tremendous benefits to public well being when a country has overall health care for its citizens.
My first experience working in health care was during the boom in what are known as HMO's (health maintenance organization) in the US after the Act of 1973. It required that all companies with more than 25 employees offer federally certified HMO options along with general indemnity programs like Blue Cross that some (but far from all) companies offered their employees. It was said by a number of people I knew that a major reason preventing the US from adopting universal health care when Europe and Canada did so, was the refusal of mass coverage by powerful unions who didn't want their benefits diluted. Whatever the reason, the chance never really came again. Many of the patients we saw at that HMO had never had access to doctors as a routine part of their lives; the good thing was that most working people could afford to see physicians when it was necessary.
I went from the HMO to private practice working for a neurologist. The good news then was that almost all doctors and hospitals accepted what is known as the Medicare disbursement - Medicare's 80% payment being accepted as full payment. That had changed by the early 90's as care for the elderly became more complex and expensive with evolving technology and more and more hospitals and providers were demanding full fees. By then I'd moved to the west coast of the US and was employed at a large teaching hospital. It was also pretty obvious by then that many of the people who had previously worked as management in the quickly off-shoring industrial sector had found new employment in health care administration and had their own ideas about cost benefit measures. I remember talking to someone in hospital registration where my mention of patients was met by her remark that 'We don't have patients. We have health care clients who have health care dollars to spend.'
As time went on I found I'd become a new kind of specialist in the American health care system - what is known there as a Managed Care Co-Ordinator Specialist. What a mouthful, eh? What most people even inside the US don't understand is that there are literally dozens of different medical insurance companies who have hundreds of different plans and benefits depending on which company they're contracted to in what state. You could not assume, for instance, that Blue Cross of One State provided the same level of treatment per diagnosis as did Blue Cross of Another State. Not to highlight Blue Cross alone, the same could be said of CIGNA, AETNA, and the rest.
For the last 15 years I worked strictly in surgical departments where I was directly responsible for obtaining insurance authorizations for what were quite often life saving surgeries. What has to be done in the managed care format is that you provide diagnostic proof (medical records etc. that include the numeric codes of the diagnosis - called ICD9/ICD10 codes that you can look up yourself if you're very bored) along with detailed written requests for the procedures the surgeon intends to perform (CPT codes - printed books that must be purchased). The insurance company will then decide whether to authorize or deny the procedure. Even if the case is authorized, the company will review the surgical report to determine just how much they'll pay after the fact. Should an unanticipated emergency arise during the course of the operation the telephone number of the company is provided to the charge nurse so the company can be advised of further costs. I've seen payments for entire procedures denied because a doctor made a previously unplanned repair when no proof of a call could be found. One of my co-workers knew a nurse at a large insurance company who received annual bonuses depending on the percentage of cases of which she'd successfully denied payment. People in the US would be surprised to learn just how much their care is managed and even determined by medical insurance companies.
The other half of my responsibilities those last years was that I was also tasked with determining the hospital charges and billing for equipment and supplies used for the individual procedures. Since by then I was employed in the very high tech environment of interventional radiology the price of most of the items kept in stock would raise the eyebrows of the CEO of Tiffany's. The general rule of thumb for billing the procedures was that we'd multiply the cost of the items to 400% for patients who had private insurance and 250% for those on Medicare. The hospital then had further contractual arrangements with the insurance companies that were beyond my pay level. Patients with no insurance who were ambulatory could meet with hospital representatives who would arrange sliding scale agreements depending on income. Patients without insurance who arrived by ambulance were treated and cared for until they were able to leave or placement was found. Hospitals aren't cruel places but that doesn't mean they don't have associated collection agencies either. Those places aren't nice at all.
I've never talked much here about what I was doing when I worked full time so I hope some of you have found this at least a little bit interesting. Access to medical treatment in the US has been an ongoing argument for a very long time that I feel could be best settled by offering everyone Medicare. I'm not convinced Obamacare is the best option for Americans but it's certainly better than the nothing some people have planned. Of course, I also think people should be allowed to retire earlier to make room for younger workers..
Please don't get me started about deductibles and co-pays.