No One is Immune to Health Care Fiascoes!

As the debate about health care swirls, the main focus has been on the millions of less advantaged citizens who might lose coverage if Republican efforts at health care reform succeed.

But many millions of relatively advantaged people are being ripped off by certain practices that have developed under the existing system. Doctors and insurance companies evidently classify and set reimbursement rates and standards in a way that is opaque to most people, which results in a crazy quilt of medical costs for the same services, depending on the amount of patient awareness and pushback.

As a result, our healthcare marketplace more closely resembles a bickering bazaar, where everything comes down to what people get away with on all sides. That state of mind has corrupted the nation’s thinking about any health system.

Now that Republican efforts to repeal Obamacare have failed (?), this dimension of the present system should not remain invisible.

Though the present system has many problems, the basic issue began when it became possible for doctors to opt out of Medicare. If a doctor takes any Medicare patients, the doctor has to take all comers. Over the last number of years, many doctors all over the country have opted out. There are a number of  legitimate reasons for them to choose to do so: the Medicare rates might be  inadequate because of a doctor’s local cost structures; a doctor’s patient base might be able to afford private rates (which also can be covered by private insurance or by the patient on her/his own), leaving the doctor with no need to accept many Medicare patients; or a doctor might be able to create concierge practices where patients can pay a yearly lump sum for most everything they might need, allowing the providing doctor to become a sort of partial insurer for that patient.

Making matters more complex, private insurers cut deals with doctors and categorize providers as in or out of network, heavily penalizing people who opt to see doctors with whom the insurance company has not been able to cut favorable deals. The result is a baffling system in which it is nearly impossible to make informed decisions regarding the cost and necessity of healthcare.

One person I know was instructed by her urologist to have an MRI. The private insurance company said they would not cover an MRI that had not been preceded by a biopsy. The doctor was wary of a biopsy because he felt the procedure would increase risk without benefit. The MRI supplier asked for $5000, which was far higher than the average cost of an MRI in the US ($2,611 in 2014). The doctor told the patient not to worry and simply pay $2500. The patient did so and the MRI was done for that sum despite the fact that that no biopsy had been performed. The whole affair seems a bit like buying a used car. There is no good reason to expect people to haggle over healthcare, but that is apparently what our system demands.

Another friend had a procedure done by a doctor who did not accept Medicare. The surgical procedure was not major, though there were some complications. The doctor initially proposed a fee of $10,000. However, it turned out that the doctor was not in my friend’s private insurance network. When the insurance company, after more than a couple of weeks of head scratching, would only cover $1000 or 130% of the alleged Medicare rate for that procedure (as if all procedures were really the same), the patient–who could luckily afford to pay out of pocket—was stuck facing a bill a great deal larger than expected. As that bill was being discussed, a few other issues came up—whether Medicare and insurance company were correct in assessing the proper cost bases of such a procedure—that had remained invisible until tough questions were asked.

These patients are the lucky ones, who can afford to pay their bills and have the education necessary to navigate our nation’s healthcare bazaar. Many more lack one or both of these qualities, and such situations would likely have been devastating for those Americans.

Now that the Republican push to repeal Obamacare appears finished, it is time to turn to the problems with Obamacare and the larger healthcare system of which it is a part—known and unknown, obvious and invisible—and make a serious bipartisan effort to improve the institutions and structures that safeguard our national health.


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