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?
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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.

14 comments:

marja-leena said...

Thanks for this, Susan. Yes it is interesting to learn what field you worked in and your inside views of the system. Though I was aware of much of it, it is still shocking what the US health system is like. Unbelievable that the great nation of USA does not have socialized health care, and even what is there may be reduced by a possible GOP government.

You must be relieved to be in Canada now, even though our system is not perfect. Did you know, for instance, that in BC we have to pay monthly fees for our public health plan (or your employer pays it) but Ontario does not. I don't know the situation in other provinces but we feel that it should all be the same. I fear our current leader would love to follow the US model in health care as he does in other areas.

Gina Duarte said...

What an eye-opening post from an insider.

There are many things I have to say about health coverage and I find myself perpetually engaged in dialogue with family members and friends about the various facets of our horribly cruel U.S. system.

As you know, I have family in Europe and when even a small country such as Portugal manages to provide decent and affordable healthcare for its citizens, it angers me that the U.S. has managed to fight the idea of socialized medicine on so many fronts. Both the healthcare industry (isn't everything an industry in this country?) and the government have held hands and convinced the populace that it's somehow "un-American" to have a healthcare system such as the people of Europe overwhelmingly partake of.

Meanwhile we, one of the wealthiest nations in the world, continue to lag behind other countries in infant mortality rates, basic prenatal care and nutrition, as well as overall positive medical outcomes. Our people in the working class and those living below the federal poverty line, have some of the poorest dental health problems in the developed world. How do we allow this to continue?

Sigh. My emotions run pretty high on this topic.

Thanks for an interesting and informative post.

susan said...

I remember telling friends that if I applied for a job in Canadian health care they'd have no idea what to make of my skills. I'm glad you enjoyed my post about a subject I'm very concerned about.

I didn't know you had to pay fees for your health plan. It's my understanding that the very high HST's we pay are supposed to cover those costs across the country. Yes, Harper really should go before he does any more damage. I'll certainly be glad to vote for Thomas Mulcair in 2014.

susan said...

I agree with you Gina that the US health care system is an abomination. It won't surprise you to know that many doctors and nurses agree with us but the ones who do are consistently overruled by the combination of government and big business as you describe. All of the countries that do have single payer systems funded by taxes have much healthier populations.

The one other thing that really scares me is the country is in no position to deal with a public health emergency. A major flu outbreak could be disastrous.

I'm glad you enjoyed reading the post and I hope you've read the essay written by Francis that inspired me.

Francis Hunt said...

Ah, Susan, I think we two (and everyone else who works in the health care area) could spend days telling each other horror stories. Even those of us who work in countries where the general principal of basic health care for everyone is accepted are continuously being harassed by the obfuscatory attempts of various administrative agencies to avoid paying for anything they possibly can. The neo-lib mentality has become very powerful and the people I like to call "the guys with the red pencils" have an awful lot of influence.

I think a basic sign of the disfunctionality of our public societies is the fact that discussion of what health care should or should not provide is always carried out in terms of cost. No-one asks the question about what basic quality of life our societies want to provide for their members. And, of course, once you define yourself as a hammer, every problem is going to be perceived exclusively as a nail. But our culture seems determined to reduce everything to dollars/euros and cents. So that, in the end, you do actually finish up working out - for specific people, in specific situations - how much someone's life is worth ... literally. It is a morally bankrupt approach.

Thank you for this wonderful response (and the heads up for my post :-)) - it serves to extend and deepen the debate. I'd love to see the money questions taken out of the health-care area altogether, so that I (as a nurse) could just get on with doing my job - but I realise that that is utopic. It would be a great step forward if our societies could simply advanct to the point (as I put it in my original piece) where 'the question [would] always be; “how much can we afford?” rather than, “how little can we get away with?”' Needless to say, I don't have any great hopes that this will happen.

Life As I Know It Now said...

It is very interesting to me to learn about your full time work and I'm glad you have done a post about it. I think our health care system in this country is piss poor to say the least :)

This is why I am going to an alternative medical practitioner to take care of my health. I have medical insurance and co-pays and deductibles and all that rot but I have to pay 100% of what my doctor bills me in order to get the treatment I want and deserve.

As you know, I went into menopause at age 38 and for the last ten years have been off and on hormone treatments. For the past year and a half I've been seeing this doctor in Bloomington who offers the treatment I want and think is best. I have to worry about heart disease, osteoporosis, and have had ongoing issues with UTI's due to thinning tissues and such. My quality of life depends upon the care this doctor gives me but my insurance company thinks it's okay for me to die 10 years earlier, with thinning bones and UTI's plaguing me. I shouldn't worry about having a sex life either I suppose. Except I beg to differ about all of that!!!

Randal Graves said...

MCCOS (or, MCOS) is a terrible acronym! At least our nation has improved upon that as the years have passed, at the expense of everything else, of course.

Easier to put a price on a human than on a loaf of bread.

susan said...

Yes, I'm sure we could. My husband also worked in health care; in his case as a surgical technician in a small (40 bed) charity hospital for children. Since it was a smaller place with a close knit staff of about 250 people when he started he found it very noticeable when the bean counters arrived. After 18 years the administrative staff had swelled to more than 40 from an original group of perhaps 10 or 12. At the same time there were no more surgeons, nurses, casting techs, x-ray techs, physical therapists, prosthetic techs, assistants, housekeepers, or kitchen staff hired. In other words, there has been a similar overloading of the system with middle management (at least in the US) as there has been in the public school system. I remember a number of occasions when doctors waived their fees for patients who were unable to pay. You never see the CEO's of medical insurance companies, or any corporations, doing the same thing.

Thanks again Francis for yet another wonderful essay.

susan said...


The thing that's so nasty about the American health care system isn't the quality of the treatment but the lack of accessibility. I mentioned to Francis that I've seen doctors waive their fees but I've also seen doctors who were enormously excited about the research and development grants. Many arrive in the US from other countries where they feel they've been restricted by government funded health plans and just love the open market free for all. You've never seen competition and pride until you've witnessed the behavior of super-star surgeons.

I'm sorry you've been among the many whose insurance company won't allow you to see the physician of your choice. It would be good for you if your insurance company could broaden its outlook but the AMA is a very powerful closed shop of practitioners, one that certainly isn't open to a broader definition of what qualifications are required to practice medicine in the US. The insurance companies do follow their lead.

susan said...

Are you suggesting acronyms and text talk aren't the epitome of western civilization?

Lisa Golden said...

This was highly interesting to me. Why does it feel like an unattainable dream - Medicare for all?

susan said...

It really shouldn't have been unattainable but popular prejudice puts it further off now.

gfid said...

illuminating! and astonishing that, after your years of seeing the mercenary underside of necessary (sometimes lifesaving) services, you remain objective and generous in discussing it. and the drawing... sigh.... oh, what you can do with 'simple' lines! this child wants a granny's lap and cuddles.

susan said...

There are a lot of good people who work in the American health care system - including many at the insurance companies. It's the system and those who profit from it that I abhor.

I'm very pleased you noticed the drawing. He kind of slipped by unnoticed because of the serious nature of the post but I really like him too. Cuddles from a granny and maybe a nice picture book would set things right.