What is wrong with healthcare in America and why the solution is far away?

QUINNSCOMMENTARY · Post by **QUINNSCOMMENTARY** » Fri May 08, 2009 6:22 pm

There is a lot wrong (and right) with health care in the United States, one of the things that is wrong is patient expectations and perceptions.

Consider this real life example (a typical case).

A patient undergoes surgery and during the main procedure, the surgeon performs a secondary procedure, same incision, one use of the operating room, one anesthesia. During this procedure, the surgeon engages the services of an assistant surgeon.

When the claims are processed, only 50% of the second surgical procedure is paid and the assistant surgeon is denied. Why, because a second procedure performed at the same time as and in conjunction with a primary procedure does not warrant a duplicate payment as if there were two separate procedures. Why wasnâ€™t the assistant surgeon paid, because it was not required by the hospital and because there was no indication that it was medically necessary. All health plans, including Medicare apply a medical necessity standard. If they didnâ€™t costs would be more out of control than they are now.

So, what does the patient (employee) do, he blames the insurance company for not paying what the doctor charged. He appeals the claim to a review board and it is again the denied. In this case, the review board is a committee of the employer because this is a large self-insured plan and the â€œinsurance companyâ€ is acting only as an administrator and has no financial stake in the payment of claims.

Nevertheless, the insurance company is the bad guy. When the employer panel upon appeal hears the claim, an independent third party reviews the entire medical record and agrees that there is no medical necessity for the assistant surgeon and that the second procedure is merely a form of unbundling the billing.

Oh, did I mention that neither the surgeon nor the assistant surgeon participates in any health benefit plan, often a good indication of a high fee or the practices that caused the denial of this claim.

The patient is on the hook for $6,000 and of course, he blames the insurance company and now the employer.

But what is missing, well at no time did the patient question the billing practice of the doctor, at no time was there any thought of going back to the doctor and saying what gives here, why are you charging these fees, why was an assistant surgeon necessary when no one else thinks so?

Now you know one of the fundamental problems with the health care system in the US is the failure of patients to accept responsibility or to hold health care providers accountable for their practices. The doctor is always right and the insurance company is always wrong.

qsducks · Post by **qsducks** » Fri May 08, 2009 9:04 pm

Try sitting in the ER with an injured child and having to watch all the peeps who have no health insurance get to see a doctor/xray, etc. before you. It sucks and yes, we have insurance. 6 effing hours to see a doctor!!!:-5:-5:-5 And to think we came in before they did:-5. Mind blowing to say the least. I was at that point freaked out, asked the doctor and that was his response...the no insured get to get in first...totally sucks.:-5 And you know who pays the bill eventually...yes, us!!!:-5

weeder · Post by **weeder** » Sat May 09, 2009 5:02 am

August 2004... I had surgery to remove a melanoma from my left arm. 12 inch scar but only one surgery. I had hired a plastic surgeon, skin cancer specialist to do the job. Insurance paid ALL of her bills. Office visits and surgery. I was thrilled. Then she threw in a bill for an assistant surgeon, who just happened to be her father, who fronted her the money to open her office, and who she often cinsulted with. Insurance would not pay him. I wrote her a letter telling her that surely she had made a mistake billing me for his being in the room. That insurance comapnies do not pay for second surgeons, and that I was not paying for him either. I hired her. She never said a word about a second surgeon. She simply wanted to collect an additional fee as she felt nothing had come out of my pocket. Mercenary, greedy and wrong. I never heard another word from her.

QUINNSCOMMENTARY · Post by **QUINNSCOMMENTARY** » Sat May 09, 2009 6:31 am

qsducks;1185751 wrote: Try sitting in the ER with an injured child and having to watch all the peeps who have no health insurance get to see a doctor/xray, etc. before you. It sucks and yes, we have insurance. 6 effing hours to see a doctor!!!:-5:-5:-5 And to think we came in before they did:-5. Mind blowing to say the least. I was at that point freaked out, asked the doctor and that was his response...the no insured get to get in first...totally sucks.:-5 And you know who pays the bill eventually...yes, us!!!:-5

I doubt the reason for your second class status here was their lack of insurance, something else is going on because few hospitals are rushing to provide uncompensated care.

QUINNSCOMMENTARY · Post by **QUINNSCOMMENTARY** » Sat May 09, 2009 6:33 am

:rolleyes:Scrat;1185776 wrote: What about all of the people who bring their kids in for the most mundane things, a case of the sniffles? What about all of the prescription drugs consumed by Americans? We're the most drugged out society in mankinds history. Look at people like Octomom who have litters of kids. What about baseball players that drink so much they destroy their livers and then get transplants. What about convicted murderers getting heart transplants? I read how some not too bright condo dweller in downtown Seattle was charged $700 to find out she had a case of athletes foot. Maybe she should have known what the hell it was to begin with with that "education" she had.

Maybe she just needs some basic hygiene lessons.

I can go on and on, what we need is a little triage at the door of the hospital and to keep in mind stupidity is supposed to be painful. The drunk who runs his car into a telephone pole needs to call his family, to pay the doctor bill.

If you expect a little responsibility from people they'll usually be up to the task.

All good points, we are our own worst enemies and yet, we expect some politician to fix it all with the passage of more laws, ain't gonna happen.

QUINNSCOMMENTARY · Post by **QUINNSCOMMENTARY** » Sat May 09, 2009 6:35 am

weeder;1185939 wrote: August 2004... I had surgery to remove a melanoma from my left arm. 12 inch scar but only one surgery. I had hired a plastic surgeon, skin cancer specialist to do the job. Insurance paid ALL of her bills. Office visits and surgery. I was thrilled. Then she threw in a bill for an assistant surgeon, who just happened to be her father, who fronted her the money to open her office, and who she often cinsulted with. Insurance would not pay him. I wrote her a letter telling her that surely she had made a mistake billing me for his being in the room. That insurance comapnies do not pay for second surgeons, and that I was not paying for him either. I hired her. She never said a word about a second surgeon. She simply wanted to collect an additional fee as she felt nothing had come out of my pocket. Mercenary, greedy and wrong. I never heard another word from her.

And the fact you never heard from her again reinforces the point they are just looking for more cash. Some other person (most) would have paid their bill because they were afraid to upset the doctor. More likely they would have blamed the insurance and put the balance on a credit card and then we could read all about the bad insurance companies not paying.

Lon · Post by **Lon** » Sat May 09, 2009 7:12 am

TRIAGE------Most ER's practice this procedure. This means that the most serious conditions get treated first irrespective of how long they have been waiting. Some one with chest pain will be seen before another with a gash in their foot.

Lon · Post by **Lon** » Sat May 09, 2009 11:22 am

By the way, why do we pay for cosmetic surgery anyway? That is elective. A scar is not life threatening.

Health plans typically do not pay for cosmetic surgery but most will pay for reconstructive surgery. There is a big difference.

QUINNSCOMMENTARY · Post by **QUINNSCOMMENTARY** » Sat May 09, 2009 2:47 pm

Scrat;1186000 wrote: So far I have not been in any hospital for any length of time except for once when I ended up being a component in a 480v power system. Bluecross got quite a bill for that I'm sure and I definitely was very disappointed in the system.

A lot of Xrays and blood tests later I was discharged from the hospital after about 2 days and told to go home see a spinal surgeon and a therapist. All I had were some small 3rd degree burns on my hands/fingers (I have a very unique set of finger prints

) and a crushed/bruised disc in the 3rd thoratic vertabrae of my back.

A few days later I went to see the surgeon. I remember I the surgeon coming into the room with my chart, looking at the Xrays and papers ect and asking what we were going to do about it. He said I had a broken back and that in order to correct the problem he could operate on it.

I remember he specifically said I had a broken back. I also remember the first doctor showing me on the xrays the cloudy area where the inflammation was around the spinal column. I essentially had a bruised spine (?) and while very painful at the time it certainly was not broken. I decided to think about surgery and went to the therapist. That was a freaking joke, he gave me a few rubber bands to play with and told me to not strain anything, showed me some exercises to do and told me to show up every 3 days for 4 months.

Part of my problem then was my all but bed ridden state, a lack of physical activity that was almost total. After a couple of weeks the pain had subsided little to none so I dumped the therapist and got a part time job unloading trucks at UPS. It hurt like hell for a few days but it made my back and shoulders stronger and to this day I have no problems.

No surgery, 4 therapy sessions. And a feeling that I was being taken advantage of by people who didn't really know what in the hell was going on led me to make my own decisions to make myself better.

The experience was weird. I don't trust our medical system as it is in any way shape or form.

As for triage Lon I was talking about fools who go out drinking and driving and wrap their cars around poles at high rates of speed. Send them a bill, not the taxpayers and insurance companies. That goes for kids doing stupid human tricks on skateboards too.

Our system is seriously broken in more ways than I care to know. What is to be done, I don't know. I think weeders post is a great example. By the way, why do we pay for cosmetic surgery anyway? That is elective. A scar is not life threatening.

Lon is right health plans generally do not pay for cosmetic surgery and neither does Medicare, but thee are exceptions such as a person or a child with a severe scar on the face from an accident, that may be covered or as Lon said reconstructive surgery is not only covered but mandated by law in many cases.