The US healthcare monopolies, and how cost shifting costs us

Most of us are sick and tired of being financially raked over the coals any time a physical problem presents itself and we need to use the services of a hospital, or similar facility.  The US healthcare system is unique in that we have health insurance, which is usually employer based, Medicare (a government system with its own quirks, but generally fair), Medicaid (under funded, facilities and doctors are under paid).  This of course does not include workers compensation and auto insurance type cases.

Every year, we pay more and get less.  The insurance industry would like us to believe that the cost continues to skyrocket as we age, however, the problems are much deeper.

Insurance companies break up our medical care visits into two areas mostly:  Office based visits (you pay your co pay) and hospital based and procedural based services (the most costly, and more often subject to a deductible and co insurance payment).  If you visit your doctor, weather in a hospital owned office they work in or in their own private office (they own or work in someone else’s practice), typically, you pay your co payment. Our office falls into a third category  – chiropractic and physical therapy which generally is looked upon as an in office visit with a specialists co payment amount.  Since what we do is really rehab, and should have a lower co-payment amount compatible with the service, there should be a third category but insurance companies have reduced patient visits by making visits to an office like ours less affordable as the co payments, regardless of need.  People who require our services know what I am talking about.

The major problem is that since hospitals, who are running deficits in many cities have to take all people and Medicaid does not pay enough.  They balance the cost on the back of others through outrageous facility fees (no basis for the cost other than they own the market) and outrageous test fees (my son recently had a sleep study I figured be under $1000 and my insurance company allowed $4250 for electrodes, sleep and a guy in a booth for a few hours watching a bunch of people on monitors).  When I experience this gouging, I really feel I am in the wrong business.  Many doctors feel the same way when the facility gets $2500 for hosting the procedure for the hour, the doctor gets $600 and the anesthesiologist gets another $500.  This is why many specialists have invested in surgi-centers which have lower overheads, get the same outrageous fees, do not have to take medicaid, but do bill mostly out of network with pie in the sky fees and usually get paid more, while writing off the rest. Of course, many of these facilities pay themselves off quickly, and provider the specialists a nice side income, to make up for their lower in or out of network fees.

In the last few years, facilities like Sloan Kettering have gamed the system their own way by using fear to sign up people with family histories of cancer, and creating monitoring programs in their doctors offices.  Three years ago, they began billing these visits as out patient, exposing people like you and me to the hospital side of the fee schedule, where they make more money by billing as if you visited the hospital on an outpatient basis, when in reality, you visited your doctor in their office, which in the end, costs everyone more.

Ah, the games.  The insurance industry themselves shave off a large percentage of what is paid in to pay the administration, and to purposely bungle claims requiring doctors to maintain staff to collect money to stay in business.  The insurance companies seem to act like government;  We messed up health care design and management big time so we are trimming the fat, strangling the workers (doctors) and then passing the cost on to you, while paying to advertise how good we are and purchasing marquis rights for stadiums and highway advertising.

One more wrinkle – medical doctors who have grown tired of having to be reimbursed poorly and give 10 minute office visits, when many patients clearly need more, have created concierge care.  Basically, you pay for medical care twice, once through your insurance and the second time to your doctor so he can work less hard, concentrate on your health as you pay him a yearly fee which is often hefty.  He will likely limit his practice to under 1000 patients, however, at 1000 per person, you do the math and then he gets paid by insurance.  These motives are not so pure, since I would also like to make $500k per year as well convincing a health scared public that if they pay me this type of cash, I will keep you healthy.  I can go into this myth of doctors keeping you healthy but that is a totally different discussion.

Where does this all lead?  We need a single payer system that pays doctors and facilities fairly, more than Medicaid, and make it so doctors understand how to budget themselves, rather than having 15 different fee schedules from different carriers.  We also need to change the paradigm because todays primary care doctors know little about the musculoskeletal system, yet are the primary care doctors for this huge problem that has huge costs as we age, but is largely ignored until the parts go bad and need to be replaced (knees, hips, etc).

Todays blog sounds like a huge rant, and perhaps it is, however, many of us have been raked over the coals with medical fees even in network that are allowed, are outrageous and the public at large is as usual being taken advantage of, but because of fear of illness and sickness, we succumb to paying these fees.
Perhaps, more of us need to call the system on its BS and negotiate with the bill collectors when they see we are not giving in.  I work hard for the income I make and so do you, and I believe value should be financially rewarded.  When I cannot wrap my head around fees that make no sense to anyone, and have no justification, other than it is allowed, something has to change.

what to you think?  As always, I value your opinion. Email me at [email protected]