Wednesday, November 10, 2010

What Is The Real Motive To Repeal Healthcare?

Why are the conservatives in this country so hell bent on repealing healthcare? One truth is that it’s all about money, but not in the way most people think. People believe, because they have been told that it’s too expensive and could bankrupt the country. They’ve been told about death panels, rationing of care and continued sky rocketing costs. They believe the big bad Government is going to take control of healthcare and over ride their trusted doctor’s good judgment.

How is it that they came to believe all of these things? Well they have proof. They have the testimonies from a multitude of different physicians. They reference the Federal coordinating counsel for effective research (FCCFER) that was included in the Stimulus Bill. They claim that the purpose of this counsel is to determine various treatment costs and they will then dictate to physicians what they can or cannot do based on treatment cost alone, with no regard to what is best for the patient.

Watch this video. It is the perfect example of how this has all been presented to the public.





Sounds convincing, right? Well, if that were truly the case I’d want it repealed too, but it’s not. One thing that many people do not understand is how the “medical system” we have in this country really works, and what is really going on that needs to be regulated. Hell, half the people in this country don’t even know how to read an EOB. The “Explanation Of Benefits” is a form sent to patients by the insurance companies and usually says, “This is not a bill”. Most people stop right there.

The current medical billing system is based primarily on two codes, the ICD9, or diagnosis code, and CPT or billing code. What determines those codes is absolutely mind-boggling, and it’s become a game that both providers and insurance companies have learned to play very well. Insurance companies will only pay if the diagnosis code justifies the billing code, or what is being billed for, so doctors have to be careful to code correctly or the insurance will not pay.

Lets look at one simple scenario just as an example of how complex this can get.

If you break your leg, there is no code specifically for just “Broken Leg”. But there are several pages full of codes for every possible combination of which bone it is, what type of fracture it is, and whether it was an open or closed fracture. (Try to multiply all of those same combinations by how many bones you could possibly break, and you can imagine how complex “coding” is, and this complexity covers every possible diagnosis, not just fractures.)

Now, before the insurance company will pay for you to have your leg x-rayed, the doctor has to make a diagnosis that justifies the need for that x-ray. The problem is he needs the x-ray to know which of the bazillion fracture codes to use. So he has to find another code to justify the need for that imaging study, otherwise the insurance company will deny the charge. A good one would be“729.5”, pain in limb, that works.

So you can see how providers would have to be very good at “creative coding” in order to justify whatever they order. Insurance companies know this and in more and more cases are requiring the provider to “pre-authorize” a test or study, especially if it’s an expensive one.

In the video it said that doctors, while still in the room would have to submit the codes to someone in Washington who will determine the standard treatment plan and then tell the doctor how to proceed. In reality standard treatment plans already exist, and you can be sure that the current “for profit only” insurance companies, (the ones currently looking at those codes and making the decisions on how the doctor will proceed), are only going to authorize the least they can get away with. They cannot have actual patient care cut too far into their profit margin. Patient treatment plans are already being pre-determined by profit driven companies. So who is it that is making the calls now on what your doctor can or cannot do?

Financial motivations enter the picture from every side. Today everything is about marketing, and medicine is no exception. Just turn on your TV, and you are slammed with ads from drug companies, (which by the way is not legal in many countries), imaging facilities, surgery centers, specialty clinics, and they are all in hot competition for your business. Doctors are not just doctors any longer they are also businessmen. Many are making bank on financial investments in these medical services and facilities, to which they constantly self refer.

It may not sound ethical, and it’s not but it is a fact that many doctors who have financial interest in medical testing facilities do use their “creative coding” to order more tests than doctors who do not financially benefit from that same testing. They are also nicely accommodated by hoards of patients who want everything possible done, regardless of cost or actual need because “That’s what they have insurance for”.

If a patient has knee pain, the first thing they want is an MRI. If a doctor owns an MRI scanner, he is more likely to eagerly oblige and find a way to code it so it will be covered, rather than to follow the standard of care guidelines which calls for more simple starting steps in an attempt to resolve the issue. They are all going for the gusto, but many of those simple knee pains could have been resolved with a cheap anti-inflammatory and rest, and without the need for an expensive MRI. But hay, patients want it, and the docs make money off it, it’s a win, win!

The question is, is it really necessary? In far too many cases the answer is no, it’s not necessary, but it is profitable. This profitability has led to an abundance of expensive un-necessary testing in just about every scope of medicine and in a large part is directly responsible for a huge increase in the cost of medicine.

This is the kind of thing the FCCFER is researching. They are not going to dictate what the doctor can or cannot do, but rather examine the efficiency and effectiveness of current behaviors in treatments. This research has the potential to put the kybosh on many providers who are currently making big bucks by ordering so many un-necessary expensive tests. That’s going to get the ones that have financial interests in these testing facilities right in the pocketbook, and they don’t like that.

Take a look at the doctor in the video. Dr David Janda is an Orthopedic Surgeon, anyone want to bet that he has a big financial interest in imaging equipment? You can see why some providers are so passionate about opposing healthcare reform. It’s not because they are concerned for how it will affect the patient, their primary concern is how it affects their bank accounts.

Then you have all the “for profit only” insurance companies who spend billions on lobbying against reform, rounding up people like Dr Janda. They put out a very convincing message attempting to frighten the public into thinking that “reform” is truly going to hurt them by “rationing care”, and that is simply not true. The bottom line is that many of these “businessmen/doctors” make lots more money without regulation, and that is their driving force in opposing regulation.

The entire medical system in this country is bass akwards. If providers were financially rewarded for keeping people healthy, instead of being able to reap outrageous profits ordering tons of un-necessary and ineffective treatments and tests, the cost of medicine would not be nearly skyrocketing at the rate it’s presently going. As well as leaving testing facilities more available for those that really need access to them and their services.

Do we need this system to be reformed? Hell yes we do, and in my opinion the first two things that should be changed is that physicians should be prohibited from having financial interests in facilities to which they “self refer”. And the other is to prohibit pharmaceutical companies from directly marketing to the public.

Drug companies spend billions encouraging the public to “Just call your doctor today” and tell them you want this latest greatest 10 times more expensive drug that doesn’t really work any better than the generic alternatives. Then they just add the cost of all that marketing to the price of the drug. Hay, it’s just another of those win wins!

That's an outrage! There is only one way that healthcare can be successfully reformed and that is to create a public, not for profit alternative to bring this collective of profiteers under control.

4 comments:

  1. Excellent piece, but you overlooked the real answer: conservatives want to repeal healthcare because a liberal--a black one, at that--actually pushed it through Congress.
    If it's repealed, it'll be another sixty years before we see anything like it again...and by that time no one will be able to afford it.

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  2. The bottom line is that doctors have become capitalists. We no longer know the small, home town doctor that would come see you in your home in your own bed with a simple phone call.

    I've seen what is happening first hand when I fell off a ladder while cutting a broken branch off a tree in my front yard. The first thing that happened is a fracture of one of my vertebra followed by a good slam to the back of my head. An MRI showed I had a compression fracture and then, because I hit my head, they also scanned it. A brain tumor was found in that scan and subsequent visits to an oncologist determined I had had it for quite some time. It is benign and of no immediate threat. Guess what the insurance company does? They cancel my health insurance because I didn't tell them about this pre-existing condition. And the doctor I was referred to for my spinal injury duplicated all of the x-rays and scans my own doctor did. The injury and lack of insurance was very expensive and after quickly going through all of my life savings, I now sit waiting until I can afford to file for bankruptcy while I am harrassed on a daily basis for rich corporations that were allowed to purchase my debt. One even sued and got a judgement against me and is constantly sending the sherrif's department out to try to collect even though I have been deemed 'execution proof' by the court.

    You have hit the nail right on the head with this article. More than likely, prior to my breaking my back, I would have been against the health care overhaul. I guess it takes having your eyes opened by going through what millions go through every day in this system.

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  3. Wow AP, that’s a horrible story. There is NO excuse for any of this kind of shit. And your comment about the specialists duplicating the same tests over again is another big waste of resources and money. It happens all the time, and the question there becomes, was that provider and his staff so lazy that they couldn’t pick up a phone and have the reports faxed, or the films sent over? Or did your provider just happen to own his own scanner?

    Luckily, not all doctors are like this, but you can bet your ass that all insurance companies are! I’m really sorry that you have to go through all that, but you’re not alone. Millions of people have had the same thing happen, and many have died because they couldn’t get the care they needed. I had a patient once that was having seizures, and I spent 2 weeks trying to get his insurance to authorize a MRI. He died waiting. 3 days after his death certificate came across my desk his insurance company finally called to give me authorization for the MRI. Needless to say, I gave them both barrels!

    More eyes need to be opened to this kind of crap, and they need to be opened quickly before it’s too late and they end up as the next victim of our “greatest health care system in the world”

    How long ago did all this happen?

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  4. My fall happened in June 2007. By August 2008, I was completely broke and into a lot of debt.

    The MRI and x-rays the specialist had done on my back were done at the same place my doctor sent me for the MRI of my back and head.

    My own doctor had x-rays on my back done in his own facility. The oncologist I was referred to had me go in for a dye cast CT to grade the brain tumor.

    It's like I wrote. I doubt I would have been in favor of health care overhaul had it not been for what happened to me. My health insurance wasn't the greatest because I had to purchase through a health risk pool because I have rheumatoid arthritis. My premiums were $350 a month and I had a $5000 deductible. Every year they were modifying the plan - especially on medications. I had a $500 deductible to pay on my medications before they started paying a share. With the drugs I took, I always met that in January. It seems to me that has each year went by, they covered less and less.

    From what I've seen pricing wise, not much will change for me other than I can not be denied coverage. To get coverage, I first have to pay into the pool for 6 months and my premiums will be about $500 a month. If I had that kind of extra cash around, I'd probably go ahead a file for bankruptcy. Something has got to change. No doubt about it.

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