Peter Glickman, MD, Do No Harm Productions, LLC. Follow us on Facebook at The Open Healthcare Project!
Continuing from Part 2…
WHACKED FACT #9: If you are denied coverage for a service you think should be covered, and you have employer-based insurance, your employer’s human resources department may be your new best friend. Often, employers, especially large ones, have some clout with the insurance company to make exceptions to adverse coverage policies or decisions. Of course, this forces you to reveal medical information you may not necessarily want to reveal to your employer, which isn’t exactly fair. But if you’re in a pinch, and you decide you are comfortable revealing the information to them, it can be a godsend. My family has used this tactic to get certain services covered that were initially unreasonably denied or excluded by the insurance company, saving literally tens of thousands of dollars.
WHACKED FACT #10: Lab tests, such as blood tests and radiology tests, are typically up to 60–70% cheaper at outpatient facilities compared to hospitals. Yes, this absolutely true, but your hospital isn’t going to exactly advertise this fact. If you’re interested in why this is the case, it’s kind of interesting — the higher cost hospitals can charge was built into the Medicare law, because when that law was passed in 1965, hospital care a) was far more complex than outpatient care, and b) involved the training of medical students and residents, which resulted in less efficient care, since doctors had to take time away from care to devote to teaching. Nowadays, though, outpatient care can actually be extraordinarily complex, including even surgeries and high tech imaging tests, and students and trainees can be trained at outpatient facilities, so the rationale for this premium is really no longer so rational. But the hospital lobby is strong, and this premium has been all but enshrined in law and regulation, probably permanently, by the powerful lobbyists they hire. But you CAN use this information to save yourself thousands on tests — instead of allowing the nurse to draw your blood in your doctor’s hospital-based office, or going downstairs to the radiology department, get a written prescription from the doctor and take it to an outpatient lab or radiology practice. DISCLOSURE: I am employed by an outpatient radiology facility in New York City. But I’m just an employee, not a partner or an owner. And hopefully some of you readers are nowhere near NYC, so it’s not like I’m trying to get you to come to my practice. (Although you’re more than welcome!)
WHACKED FACT #11: So is there any hope for the system to change, and to become less crazy? Glad you asked. In this regard, all I can offer is my own opinion, which as I hope you think is worth hearing by now. So here it is: the ONLY real hope we have as patients is to move as a country to a more universal coverage system. Similar to literally ALL of the other industrialized nations of the world, who actually get equivalent or better health care, usually at about half the cost or less. The most efficient way to do this is to implement a single payer system. We already have about a third of our population on single payer systems, namely Medicare for the elderly, and Medicaid for the poor, and both programs work very well (when they are funded optimally, that is, which is not always the case). For example, Medicare has an administrative cost rate of about 4% (only 4 cents per dollar spent go to admin costs), as compared to private insurance companies where the admin cost is about 30%. So Medicare, despite the fact (or more accurately, because of the fact) that it’s not “for-profit”, delivers care much more efficiently than private insurance. Studies show that patients with Medicare, or indeed ANY government run payer system, are MORE satisfied with their health care than those who are on private plans or who are uninsured (7). Also, patients in countries with universal coverage systems are generally more satisfied than US patients (8). Don’t believe the hype about things like long wait times for surgeries in other countries; wait times can actually be longer in the US, often related to bloated private insurance bureaucracies which seem intended to discourage the patient and doctor from embarking on costly treatment.
I’m always reminded of something I learned as a management consultant for big and small pharma and medical device companies before medical school — as much as you might think that government bureaucrats are terrible, incompetent, power-hungry dictators (how they’ve been portrayed by many over the past few decades), BEWARE an even more insidious creature: the private sector bureaucrat. While government bureaucracies are not always ideal (i.e. they can truly suck), they are at least in some ways accountable to the public. Most people who go into government are motivated, at least in part, by the idea of serving the public. Not so on both counts for private sector bureaucracies and bureaucrats. They survive by maximizing company profits, reducing costs, and covering their you-know-whats, not necessarily serving or caring for patients at all in the process. There are countless examples of violations of ethics, finance regulations, and even arguably common decency by health care industry corporations putting profits ahead of patients (5, 6). Plus, whereas a lot of government functions are required not to be done in secret (see The Sunshine Act), most corporate decision-making is done in secret, with stiff penalties on employees for disclosure of proprietary information. This really makes a difference.
So in summary, my advice for those who want to improve the system is this: support a national system in the US, such as the “Medicare for all” system Canada has happily implemented. Or a heavily regulated private insurance market as countries like Germany and Japan have. ALL of these systems have better health care outcomes, far lower costs, and much less hassle factor for patients than ours. We could still allow private health insurance, but we’d likely have to require plans to be at least as good as the government plan for the system to work (i.e. no “junk insurance plans”), and do things like allow large networks to negotiate costs for drugs and devices. Now more than ever, CALL YOUR REPRESENTATIVES AND SENATORS and tell them you want a sane health care system.
I hope you enjoyed this blog and learned something useful. More to come.
7. Riffkin, Rebecca. Americans With Government Health Plans Most Satisfied. http://news.gallup.com/poll/186527/americans-government-health-plans-satisfied.aspx