The failure of healthcare hits close to home


Several months ago I linked to an article in one of my state’s newspapers which outlined the difficulty retirees and people on Medicare are having getting doctors to accept Medicare assignments; patients are traveling as many as 100 miles to go to the doctor down in Phoenix because they can’t get seen by a doctor locally.

Well, there’s of course more to that story.  Realistically, none of those doctors has violated any law; they have simply begun telling patients that they will be happy to continue to see them — if they pay up front and deal with getting reimbursed from Medicare themselves.  Which of course patients are NOT willing to do.  I really think most people think Medicare is free  for them and that somehow mentally translates into meaning that the care is given for free.  Which of course is not true; health care is one of the biggest industries in this country.  Or, alternatively, people think they’ve earned it and that they should be entitled to all the health care they desire since they paid taxes while they were working.  I don’t think they stop to realize that pretty much, financially speaking, they paid for about one to two years worth of Medicare costs, if they have a chronic illness, and after that they’re getting health care based on MY (and your) tax dollars.  Theirs are already spent.

What does that mean in terms of doctors and Medicare assignments?  Well, it means that Medicare, being the biggest provider of health care payments in the nation, has the ability to set the standards for what and how much they’ll pay for something.  It also means that since they’re federally funded, there’s no recourse if you don’t get paid promptly, or at all, for a service you’ve provided – in some cases years ago.  And this lies at the crux of the doctor/patient problem.  Doctors aren’t willing to go months or even years without getting paid for services.  Since they’ve had to hire an entire staff devoted to simply dealing with Medicare and other health insurance companies — they all get on the bandwagon of what they see Medicare get away with regarding not just what and how much they’ll cover, but the bureaucracy as well — they simply can’t afford to continue to wait to get paid when they have to pay staff as well as malpractice insurance and their own bills.  Medicare has become quite adept at making the hoops a provider must jump through flaming and moving, with vague standards that are seemingly changeable at the whim of the claims processor (and the day of the week) which means that most claims must be sent in at least three times before Medicare will accept the claim (and this takes months to even get to this point) and months more before the claim will be paid out.

To make matters worse, because Medicare is functionally insolvent (because at this point our government is as well) they have an entire staff devoted to reviewing previous claims already paid out, and if they find ANYTHING  wrong with the original documentation, they make the provider pay back, with interest, (not to mention paying a fine for fraudulent submissions) the money already paid out.  Several hospitals I am aware of are now facing this even though some of the hospitalizations were two years ago.  This means that hospitals are having to hire entire staffs as well, to review all documentation dealing with any patient encounter, in order to prove they were entitled to the money.  Which means that an already financially strained system is being strained even more.  Co-incidentally, it means that nursing documentation on patient condition, which used to be mainly useful only for legal protection purposes, is now vitally important to the patient record as a whole; nurses may document something about the patient’s condition or response to treatment that makes the whole hospitalization justifiable even to Medicare where it might not be justifiable based merely on lab results or doctor reports.

These two are mainly why doctors are no longer accepting Medicare assignment.  They simply can’t face the possibility that, even if/when they DO get paid, they will have to face giving the money back at some point down the road.  If they make the patients responsible for payment up front, and the patient has to do the time consuming and redundant and frustrating work of trying to get reimbursed, the patients will also end up being responsible for paying that same money back (not sure about the fines or interest though).  The final reason providers are no longer accepting Medicare assignment is that reimbursement is set to go down another 20% (at last check) as of May 2011.  Many providers are barely covering expenses if they are in a solo or group practice (another financial incentive to work for a corporate group) and the reduction in eventual payment means it’s simply not worth it for them to accept Medicare.

This last reason is important because whatever Medicare does, other health insurance companies, as previously stated, follow.  This means that other insurance companies will feel free to also reduce their payments.  And they already play the game of endless refusal of payment as we know.

This hits close to home in several ways.   I was at a HAM radio function with my husband recently and was asked by one of the other members if I knew of any jobs available at my hospital.  I was puzzled and asked why, as this guy is not a nurse, nor is anyone in his family.  He replied that one of his neighbors is a nurse at our local facility and isn’t able to make ends meet on his take home pay — because of low admissions, he gets sent home early too many days and doesn’t get a full paycheck.  This is because these patients can’t or won’t pay up front to be seen by a local doctor and travel to Phoenix for their doctor visits.  It also means that if they see their doctor down there, he’s going to refer them to a hospital that is local to HIM/HER, not local to the patient…which means that our local facility, which just built a satellite hospital to accommodate our growing population, sits more than half empty a great portion of the time, and what staffing they have doesn’t have enough work (patients) to justify their presence.  The only patients that get admitted locally come from the emergency room visits, for the most part.  This is NOT a good thing in many ways.  First, it means that our hospital may end up being closed or declaring bankruptcy, which means we won’t even have a local facility to go to.  Second, it hurts the local economy by taking the available dollars to spend by employees down further, and forces them to move to other areas in order to have steady employment.  This of course has a fall down effect in that every other business that depends on those employees is hurt further and may end up closing.

The second effect this has had is that local urgent cares and doctor’s offices are doing the same with private health insurance as well — if they can’t count on being paid at all, let alone in a timely manner, they simply aren’t going to accept insurance.  My friend went to the urgent care recently and was told that they no longer accept her insurance — in fact, didn’t even have a record of her insurance company existing on their records (never mind that it’s a state funded insurance company for small businesses, never mind that she’s already used this insurance at this urgent care before) and that, if she wanted to be seen there, she needed to pay for the full cost of her visit up front and submit herself for reimbursement. Her husband said that while they were waiting to get checked in, before they were told this, that six other people were told the same thing at the window…which tells me they are simply moving to a cash up front business model.

This is a destructive strategy in so many ways!  First of all, I don’t think there are enough people left in my area who have the couple hundred dollars to plop down for an unexpected expense that they will be able to continue to operate at present capacity, if at all.  Second of all, if people even do have the money stashed away for this, they won’t have the money for other expenses and other businesses lose out.  Ultimately, this is frankly a suicidal way of doing business.  The only positive thing I could perhaps see coming out of this turn of events is that providers lower their rates in order to draw in business, much the same way as all the cosmetic/elective surgery providers have been doing for the past couple of years in the Phoenix area.  Hey, if you want Lasik, now’s the time!  It’s never been cheaper!  I don’t know of too many people who are willing to lay out that kind of cash, no matter how cheap, if they’re not even sure they’ll have a job in six months though…but what happens when doctors lower their rates is that they fire staff, do more themselves, and reduce their contribution to the economy further both by reducing staff/services and by the knock on effect of creating further unemployment and increased job INsecurity.

I knew this was coming, I just didn’t know it would be so soon!

One of the doctors I work with says that the two groups who need to be given full government funded health care are the mentally ill and children.  The mentally ill, because they CAN be productive members of society if they are kept on their meds and kept cared for (not locked up, just helped out) and because when they are in crisis, they cost MUCH more than maintenance would have.  And children, because they don’t have the ability to choose for themselves, and also because a child given a healthy start is a more productive member of society as an adult.  I think that would be a great thing myself, if there were some way to overcome the inherent prejudices against both groups.  The mentally ill, because at least in this state it’s somehow implied that it’s a moral failure to have a true mental illness, and children, because it seems that the kids are blamed for their parents having the audacity to have children if they’re poor (never mind that those same people don’t want to fund birth control).

Like it or not, we need to begin CIVIL discussions about rationing of health care on a federal level.  Call them death panels, call them whatever you want, we need them.  We simply cannot continue to provide the level of care we provide now, with no attention paid to preventative care, without some attention paid to responsible stewardship of a limited resource (limited by funds, not by anything else).  We need to have these discussions now, before circumstance and ideology force unpleasant choices on us all.

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One response

  1. Reblogged this on The Tin Foil Hat Society and commented:

    I wrote this in 2010; it’s worth re-reading and I have more to add.
    1. I recently heard of a pain management center that is refusing ACA (Obamacare) insurance plans. Reason: they pay so little as to be not worth dealing with.

    2. More and more Medicare patients are simply paying cash to see their doctor. My FIL is one of those. He pays over $200 every time he goes to see his pulmonologist, AND the staff also bill his Medicare plans.

    3. Medications are becoming ever more expensive and out of reach: the cost for Advair and Spiriva, a combination of drugs that keep the advance of COPD under control, approaches $450 per month. One must be solidly middle class with a hefty savings account to continue to afford medications in one’s retirement.

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