Over the years we have all seen a lot of strange things. Unexplained phenomena, unidentified flying things, odd looking food (in some countries), and some general things that go bump in the night. But really the greatest mystery in the world today, where Black Magic is definitely a factor, is in the healthcare system.
Insurance companies have created a complex web of charge structures that I believe are designed to primarily confuse the patient. What other industry has co-pays, deductibles, co-insurance, family and individual deductibles and maximums, annual and lifetime maximums, in-network and out-of-network providers and percentage cost structures with each, and a laundry list of other charges.
But let’s not just make this about the insurance companies. What about the providers? We used to have a doctor’s office…and a hospital. Now we have those, AND urgent care clinics, community medical centers, surgery centers, specialty offices (e.g., radiology providers, labs, etc.). And all of those have cost structures that have their own place in the world of insurance. Be careful what side of a clinic you are treated by – if a facility offers clinic and urgent care services even when you thought you were walking in for a clinic visit you get a bill for urgent care services… for a cough. But why is it that “bill shock” even exists in healthcare? Well, go have surgery. You’ll get a bill from the facility; a bill from the radiology guys (the doctors that “read” your X-rays and MRIs); a bill from the lab (tests before the surgery); a bill from the anesthesiologist (if you got knocked out); and somewhere in there, a bill from your surgeon.
This gets even better: Now you need at-home equipment after surgery for your knee, or foot, or nose, or … whatever was worked on. That equipment has a cost (spoiler alert: in a recent experience we found one of those – exact same one – on Amazon for 90% LESS than the doctor and insurance wanted to charge).
Now that list of services I just mentioned… well you should hope they are all “in network” – how many of us have gone into a provider (ER, office, clinic, or whatever), only to find out that they took your insurance, but one group in the chain of care was “out of network” – seriously? Why is that my problem? Answer: It’s not. It was deceitful on the part of the provider to throw that into the mix when they said they were “in network” in the first place. And what about things like MRIs – when you can private pay for an MRI often times for half, yes, half, of what your out of pocket would be using your insurance? True story…
I could go on and on – and I worked in the industry for a long, long time and oversaw (and approved occasional write-offs in) med billing during that time. With that background, I still think this is a confusing mess. But where does this thought of the day lead to? I can promise you it is not “Medicare for All” – anyone who has dealt with the government on anything in the past should know that giving this to them would be a disaster of such proportions that we would want, if not beg for, our current system to come back. Having dealt with government healthcare in Medicare and Medicaid, as a billing provider, my experience has been often worse than working with the private industry. And those of you that followed my posts over the years may recall my comments to Sen. Udall and Sen. Bennett when they asked my input on the Affordable Care Act prior to their vote 9 years ago: My verbatim response to both of them was to “fix the costs before you go anywhere near this bill, otherwise it will financially fail” … and here we are, a severely bankrupted Obamacare, right on schedule.
So, what is the answer? First – there is not a single silver bullet. But – the Executive Order recently signed by the Trump Administration to force hospitals to show pricing to patients is a good step – going further than the Colorado law that only mandates the 50 most common procedures. The requirement they next put in place to reveal drug pricing on TV ads where the drugs cost more that $35/month is another good step (Pharma is now fighting this in court, and the rule was recently struck down in Federal court, but the battle isn’t over). His stance that the US should pay “most favored nation” pricing is one I total agree with – where we pay the same price as the lowest price in over countries); that Executive Order is in process, along with a bill from Nancy Pelosi that does something similar. But this all goes back to the premise mentioned earlier: Until we get the costs for healthcare under control, no program is going to work to help provide healthcare coverage beyond what we have today.
