A friend shares some truth from South Carolina in regards to health care.
This is in response to this letter.
Hi, Jamie.
I work for a group of physicians here in Myrtle Beach. My job title is "Insurance Specialist". My job -- my entire reason for being there -- is to fight with insurance companies. Now don't misunderstand -- the doctors didn't hire me as an added benefit for their patients. They hired me because it requires a full-time person to deal with the insurance companies and to make sure that ultimately the doctors get paid.
Doctors won't decide our care -- the government will. Does Mr. Slagsvol really believe that doctors are deciding our health care now? The largest part of my job is to "precertify" procedures. Say one of our doctors believes a patient needs a total hip replacement surgery. The doctor can't just go ahead and perform the surgery! He has to get PERMISSION from the insurance company. Yes, you read that right. To "precertify" a procedure means to ask permission of the insurance company -- on the doctor's behalf -- to perform any given procedure. And it's no easy task GETTING that permission! I have to first of all establish that the patient NEEDS the surgery... did x-rays confirm that his hip has degenerated to the point of no return? Is the patient in a sufficient amount of pain? Has the degeneration of the hip led to an inability for the patient to perform his activities of daily living? And what kinds of treatment has the patient tried in lieu of the surgery? Did he try taking painkillers? Did he go to physical therapy? It's only when all other options have been exhausted that the insurance company will deign to grant permission for the doctor to procede with surgery (because, of course, surgery is the most costly of all procedures).
Case in point. Earlier this week, one of our doctors set a patient up for a total knee replacement surgery. I called the insurance company (one of the Blue Crosses) and pleaded the patient's case. X-rays showed severe degenerative joint disease of the knee, including bone-on-bone contact (meaning the natural lubricant in the knee had worn away and the bones of the joint were rubbing against each other). You would think that would be enough for Blue Cross to authorize the surgery, right? But no. The "utilization review" nurse demanded that I fax all the patient's medical records to her for review. I did this. Next the insurance company required our doctor to fill out a special form (in actuality all the information requested on the form could have been found in the records, but Blue Cross required that our doctor take time away from his patients to fill it out). Fine; I faxed in the completed form. Still not enough. The insurance company doctor pointed out that the patient hadn't attended physical therapy. This was ludicrous -- the patient's condition had progressed way past the point where p.t. would help. In fact, attending physical therapy could FURTHER DAMAGE THE KNEE. Didn't matter. Finally our doctor had to get on the phone with the Blue Cross doctor and explain his rationale. What a colossal waste of time and money! And Jamie, this happens each and every day. And not just with surgeries, but with MRI's, injections, and in some cases, even simple office visits. Mr. Slagsvol feels that under the current system doctors decide our care? What a joke.
We won't be able to keep our doctors -- the government will decide who we can and cannot see. Once again, I submit to Mr. Slagsvol that under our current system, it's the INSURANCE companies that decide which doctors we can see. Most insurance companies are part of what is called a "network". Large insurance companies like United HealthCare and Blue Cross have their own networks. Smaller insurance companies group together under other networks, like Medcost, First Health, and PHCS. In order to get the highest level of benefits, a patient has to go to an in-network doctor. With many insurance companies, if you go to an out-of-network doctor, your benefits are greatly reduced (instead of the insurance company picking up 80%, for instance, they might only pick up 50%; or instead of having a $1,500 deductible you might have a $5,000 one). With most insurance companies, if you go to an out-of-network doctor, you have NO BENEFITS AT ALL. It makes me want to scream whenever I hear one of these rabid right-wingers bemoaning the fact that under Obama's plan, "patients won't get to choose their own doctor". Patients can't choose their own doctor now!
Case in point. Several years ago, my employer switched insurance plans (to United HealthCare). Well guess what? The doctor I'd been going to for years was not a United HealthCare network provider. So I had a choice to make. I could keep going to that same doctor and pay for treatment myself, or I could find a new doctor -- one that was approved by United HealthCare -- and have my care covered. Like most Americans, my finances required that I chose the latter option. I get phone calls all the time from people in the same situation. "My employer has me on a new insurance plan and my doctor isn't in the network -- but I've been going to my doctor for YEARS -- he knows me -- I like him -- he understands my medical history -- what am I going to do?" Wake up and smell the coffee, Mr. Slagsvol... we don't get to choose our own doctors now -- the insurance companies do. And it's not based on what is best for us or what we prefer -- it's based on the insurance companies' bottom line.
The government decides how much to pay doctors. Remember those "networks" I was talking about? What exactly does it mean when I say that a doctor is a "network" provider? It means that that doctor has signed a contract with the insurance company, agreeing that the insurance company gets to set their fees. This fee is called an "allowable" amount, because it's what the insurance companies allow the doctor to charge. Let's say the doctor's usual fee for an office visit is $95. A patient comes in with an insurance that we participate with -- let's use Blue Cross for example. The Blue Cross allowable amount for the office visit is $35. All the doctor can charge for that patient's office visit is $35. Generally speaking, an insurance company's allowable amount for any given procedure is roughly 1/3 of the doctor's actual fee. Does Mr. Slagsvol actually believe that insurance companies -- out of the goodness of their hearts -- are reimbursing doctors at 100%?! What a laugh!!
What has government ever done efficiently and effectively? NOTHING! Ask me about Medicare. Go on, ask me. You know all that stuff about precertification? Medicare doesn't require doctors to precertify ANYTHING. They don't have a precertification department even if a doctor WANTED to get something precertified. Why? Because Medicare leaves the practicing of medicine in the hands of the doctor. Isn't that the way it SHOULD be? And while it takes MONTHS for an insurance company to process a claim, it takes Medicare about two weeks from the time we file the claim electronically until the time Medicare electronically pays our practice.
Another big part of my job is fighting with insurance companies to get claims paid. Insurance companies will do ANYTHING to get out of paying a claim. Many providers probably give up after a while and just write the claim off and I'm sure the insurance companies save millions of dollars that way. Blue Cross, for example, will send an "Other Health Insurance" Questionnaire to its members every year to make sure that the patient's medical bills shouldn't be someone else's responsibility. Certain diagnosis codes trigger an "Accident" Questionnaire to be sent -- again, hoping that someone else will be picking up the patient's tab for medical care. On average, I get a couple dozen requests for medical records from insurance companies each week -- so that the insurance companies can see if they can weasel out of paying a claim due to a pre-existing condition clause on the patient's policy. I often have to call insurance companies to find out why they aren't paying a claim. After going through a dizzying morass of options (enough to confuse patients), I'm routed to a "claims representative" in India or the Philippines who can barely speak English and whose salary is being paid by all of us poor schmucks in the United States who are in effect being held hostage by our insurance companies.
Insurance companies tell Americans which doctors we can see, what medical care we can have, they charge us exorbitant premiums, and then don't even have the grace to hire Americans? Ask me about Medicare. Medicare is a DREAM to work with. I call one number and -- without going through any options -- am routed to a knowledgeable claims rep here in the United States (888-828-2092). If Mr. Slagsvol ever had to sit at my desk and do my job, he would come to appreciate just how smooth-as-silk the Medicare system runs for providers. The insurance companies should take LESSONS from Medicare.
Higher quality, lower cost, and 47 million additional people in the system; do these neo-Marxists think we're stupid? My response to Mr. Slagsvol is two-fold: 1.) Name calling only shows his bad manners; and 2.) he IS stupid! How can Obama's plan (like Medicare) provide higher quality care at lower cost? How much money do you think it costs the insurance companies to hire scores of people whose sole job is to look for ways to get out of paying claims? How much to send out the flurry of questionnaires, the requests for medical records (and the people to review those records)? How much to pay "physician reviewers" -- actual M.D.'s whose salaries are based on "cost control" (i.e. denying claims)? One of the insurance companies we participate with has a lovely "Provider Services Representative" whose job it is to tool around in her company car from medical practice to medical practice, always dressed in designer clothes and decked out with diamonds. She brings us gifts (paper clip holders emblazoned with the insurance company's logo, pencil cups, pens, and the like. Last time she brought me a colorful stuffed frog. I'd love to know what her salary is. Insurance companies waste money like crazy. It's not stupidity that makes me believe Obama can do this thing cheaper -- it's common sense.
I hope this long email helps you to understand a bit more about the health care industry as it exists today, Jamie. Thanks for all you do. Keep fighting the good fight!