Thursday, August 20, 2009

Health Care - Part 1-7 Removing the stress from health care provision

7) Removing the stress from health care provision.
What the hell does this have to do with health care reform and won’t any new universal program just be more paperwork and hassle. Let me put it bluntly. Since returning the US from the socialist workers paradise of Germany (that’s a joke, people) I’ve had more stress and heartache dealing with health insurance than at any time in the past. I spend more time on the phone with insurance agents, medical billers and doctors about insurance and payment issues than I ever do in getting and dealing with health care.

Isn’t the point of a health care system to keep you healthy and to return you to health should you suffer an unfortunately illness, disease or accident? How can it possibly help when you are forced to battle your insurance provider to get the benefits you are paying for every month? How can it help to navigate your way through a thicket of rules and regulations that has spawned an entire industry just to manage it. I often deal with customer “service” agents or medical billing staff who seem just as confused as me about the proper billing codes they are to use to ensure that my yearly check up is billed as preventative care and comes out of the right pot of money. God forbid the Dr. perform one test not covered by that rubric, then the entire visit can be reshuffled into the regular office visit category and a long and tedious fight awaits the customer who attempts to have that visit reclassified to avoid paying the deductibles and co-pays that requires.

One of the things that amazed me when I returned to the US after an eight year sojourn in Germany was the size of the office staff required to sort through the paperwork and billing complexities forced upon doctors by the insurance industry. You may be surprised to hear that there is no medical billing industry to speak of in Germany. Dr.’s offices are smaller in Germany because they don’t house legions of personnel handling insurance issues.

Let me describe my typical doctor’s visit in Germany. I walk in, hand the office manager my insurance card, she swipes it through a card reader and hands it back. I wait for my appointment, see the doctor and leave. If I have a prescription to be filled, I take it to any pharmacy and hand it to the pharmacist who also scans my card and, moments later, I leave with my prescription.

In neither instance do I pay anything to either the doctor or the pharmacist nor do I receive a bill for services rendered or a co-pay at a later date. I pay for my insurance and, with few exceptions, everything else is covered by the insurance.

The same is true of my dentist visits and, with the exception of the frame costs, the optometrist. In that case, there is a limit to what the insurance will pay for the frame and, should I wish a more stylish one, it is incumbent upon me to pay the difference, as is only fair.

Once, when my youngest child had a mysterious skin disease, I went from doctor to doctor in search of a cure that worked. In all honesty, it might be argued that the insurance could reasonably have denied my claim since I went to so many doctors for the condition but they did not. In fact, I never heard from the about it at all. Each doctor tried something different and it never went away. Interestingly, it did get somewhat better but worsened during a visit to Los Angeles. There we went to a top dermatologist who recognized the rare condition and prescribed an unusual and, no banned, topical treatment for it. It was finally cured and our insurance, private German insurance at that point, paid it without question. That brings me to another point I will address in the future, public and private systems can live quite comfortably with one another, as they do in Germany. Many people buy supplemental policies for “luxury” features they are willing to pay for, private rooms in hospital etc.

So, for me, the stress of health insurance in this country is a serious issue. Granted, it’s not one that requires a public option, per se, but it does require a different approach and some restrictions and norms applied to the private sector.

One part of the problem is the sheer bewildering diversity of health care insurance in this country. It’s no wonder that an entire industry has grown up around medical billing. With hundreds of companies each with their own codes for each and every procedure, it’s difficult if not impossible for a small doctors office to handle the complexities of billing even a simple office visit. It’s even worse from a consumer’s point of view. Have you ever TRIED to decipher your EOB (explanation of benefits)? I have. . . from a number of companies, as our insurance has changed many times over even while remaining with a single employer. It’s migraine inducing! And when I’ve called to ask why my yearly check up was billed as an office visit and billed in full to me and applied to the deductible rather than paid in full as a preventative care visit, the explanation of the wrong billing code is less than helpful. Call the doctor’s office and they’ll insist it’s the correct billing code. How the hell should I know which code is correct and why should I even be concerned with such issues. With my insurance in Germany I NEVER faced such issues.

Another stressful issue relates back to the freedom to choose your doctor. As I mentioned, our insurance providers changed numerous times during 7 years of employment with a single employer. As the insurance provider changed so did the list of “in network” providers. Often one or more of our previously in network doctors would no be out of network and we had to choose: Find a new doctor or pay money we didn’t have to stay with the old one with significantly reduced benefits? What kind of choice is that and why do we have to make it? I thought we had freedom of choice?

Worse yet, on occasion, a doctor would mysteriously go from in network to out of network without us enduring a provider switch. My wife’s gynecologist went in and out of network so often we had to call just before every appointment to confirm her status. Eventually she simply stopped taking insurance of any kind (other than medicare and medicaid) directly and negotiated her own discounts for her patients who then had to submit the bill for out of network reimbursement.

Sound stressful enough for you? Share your own stories of health insurance stress.

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