Skip to comments.Why Bureaucracy, Not Your Doctor, Is Making All Your Medical Decisions
Posted on 12/27/2019 9:20:57 AM PST by Kaslin
With the current third-party payment structure, you doctor does not practice as much medicine on you as insurance executives and federal bureaucrats do.
Americans, who practices medicine on you? The answer may seem self-evident, but it is not. In our current health-care system, millions of nameless, faceless government or private insurance bureaucrats practice medicine on you without a license for medicine.
You may think your life is in your doctor’s hands, but it is not. The bureaucrats, not you or your doctor, make your medical and financial decisions. Consider these health-care decisions:
Your doctor does not express your diagnosis in words such as arthritis, asthma, or heart failure. If a physician or hospital wants to be paid, they must use a letter-number diagnosis listed in the International Classification of Disease (ICD-10) code book, which turns 1,400 human ailments into more than 68,000 codes. Examples of these diagnoses include: W55.21 (bitten by a cow); W61.33 (pecked by a chicken); V00.01 (pedestrian on foot injured in collision with roller blader); Z63.1 (problem with in-laws); and my personal favorite, Y92.146 (injured at a swimming pool within a prison).
Once a diagnostic code is established, you expect the doctor to recommend the correct treatment by the most experienced operator in the best facility at the optimal time given your medical condition. In reality, you will receive whatever the insurance carrier allows, whenever the carrier allows it, at a contracted facility, by a specialist on the insurance carriers panel. All those medical choices are made by nameless, faceless bureaucrats, not your personal medical caregiver.
Clinical advisories and guidelines written by federal administrators have become medical mandates. These treatment plans generally work well for large populations but do not allow for the specific idiosyncrasies, variations, or allergies of individual patients that only their personal physicians know. Although wanting the best care for you, if the doctor deviates from the approved treatment plan, he or she risks reprimand, financial penalty, and even loss of clinical privileges.
Since you watched your doctor write your prescription, you assumed he chose your medication. Reality is otherwise. The medication you get is decided by a pharmacy benefits manager (PBM), a company contracted by the insurance carrier or health plan. Only the drugs listed by the PBM are available to the prescribing doctor, based on step therapy.
Also known as fail first, step therapy starts with drugs that have the cheapest price, largest rebate to the PBM, and least risk of adverse reaction. These are the drugs the doctor can prescribe, even if they are not the right medications for you. Only after you have taken them and after the doctor proves to the PBM that the medication failed, can a second, stronger set of drug options become available. Eventually, the PBM may allow the doctor to prescribe the drug he or she wanted for you in the first place.
Recall the promise, if you “like your doctor, you can keep your doctor, assuring patients they could choose their doctors. While the doctor shortage before 2010 did limit patients options for personal physicians, the Affordable Care Act further reduced the possibility you could have the doctor of your choosing in the following way.
Obamacare raised costs to all insurance companies by expanding eligibility and benefits, reducing medical underwriting, and increasing administrative burdens. Insurers offset the increased expenses by narrowing their medical panels.
In other words, they fired physicians, eliminating them from their contracted panels. Privately insured patients were forced to choose their doctors from a much smaller pool than previously. It is worse for Medicaid patients: Nationally 31 percent of physicians do not accept Medicaid patients, and in Texas, less than half do.
Money is an incentive used to reward preferred behaviors and outcomes. He who has the gold makes the rules. In health care, he who controls the money determines what is preferred. As third parties rather than consumers decide what your doctor is paid, third parties rather than consumers determine the outcome. As a result, the outcome is not timely care.
Covering 180 million Americans, private insurance companies preferred outcome is profit. The longer they withhold payment, the more money they make. Thus, insurance carriers delay, defer, and deny patient care.
The federal government is the third-party payer for 140 million Americans through Medicaid, Medicare, and Tricare. Washingtons preferred outcome is extension of its power. This is accomplished by expansion of the scope and reach of the federal bureaucracy.
To pay the exorbitant costs of federal bureaucracy, Washington diverts money from providers and hospitals to pay bureaucrats and agencies. As a result, patients have less access to care and longer, medically dangerous wait times before they can see a doctor. Some even die waiting in line for life-saving care.
With the current third-party payment structure, you doctor does not practice as much medicine on you as insurance executives and federal bureaucrats do. As a result, Americans do not get timely needed care. The only way for patients to get the care they need when they need it is to restore a direct doctor-patient relationship, without a third-party payer in between making medical and financial decisions.
Someone will no doubt exclaim, I cant possibly afford to pay for my care. The proper response is, Last year, you did pay $28,166 what did you get for it?! If each patient were in control of family health-care spending, the United States could have a free market for health-care goods and services.
Prices would plummet. Add safety nets for the disabled, blind, and aged, the originally intended Medicaid population, and all Americans would have the health care they want: affordable and accessible.
Hell, while we're at it, let's just evict ALL the Democrats.
Excellent, excellent point. 90% of the public is blissfully unaware of the truth in this.
IMO the only reason we have any support at all in this country for letting government bureaucrats control health care is that in the current environment the private sector corporate bureaucrats can be even worse.
Go back to cash-for-service and the control returns to the patient.
You got that right
In This life
you need to learn to take care of your own health
do not go to a doctor and less you have to
People familiar with the Keto diet and its politics also know full well that government is (indirectly) forcing doctors/nutritionists what to say to obese/diabetic patients.
And that wouldn’t be so bad, if it weren’t the absolute worst advice possible (eat often, with lots of carbs).
While making a very valid point, even this writer misses the point. It's not even the Doctor's responsibility to "make your medical decisions". That's why they're called "YOUR" medical decisions. The doctor is your knowledgeable consultant and adviser for medical issues, like your plumber is your consultant and adviser on toilet issues (if you can't do plumbing yourself), but YOU are supposed to be making the decisions.
This is BS. Hospital executives have been rolling the government and insurance companies for years. $28,000 emergency department bills for the treatment of a sore throat aren’t caused by government bureaucrats:
Lifestyle is the biggest determinant of the use medical care. Period. Bulk insurance means that people who don’t abuse themselves pay for the care of people who do. Self-abuse is rising explosively. Handing the bill to someone else incentrivises self-abuse.
I want insurance which groups me with people who don’t abuse themselves. If that could happen it would lower my insurance bills by about 75%.
I cant possibly afford to pay for my care.
With the exception of a catastrophic illness or disease, the vast Majority of Health Care can easily be paid out of pocket, and it actually pretty cheap.
$1100 monthly premium
if you need a Knee Replacement you spent over $20,000 plus anther 30-40% COPAY in the Thousands of Dollars, All in about $30k for the year
Oklahoma Surgery Center,Total Knee Replacement $15k ALL IN at a surgery facility with the Lowest Infection and Mistake record in the Country.
Bookmarking this one.
And if your doctor thinks marijuana could benefit you, your government may never allow it.
I agree with that. I've been fortunate to have an excellent health plan through my employer but I hardly ever have to use it. I consider that a GOOD thing. Health insurance is not something I'm interested in getting "my money's worth" out of, that's for sure.
So I just eat good, exercise and stay away from doctors except for physicals - maybe once every third year at that.
About 10 years ago, I had a doctor that put me on blood pressure mediation and I pushed back on it. But he insisted so I took them for a year or two. My blood pressure actually went UP and that doctor would give me stronger stuff. Finally I stopped taking the darn things and changed doctors. Next physical, my new doctor never said anything about my blood pressure.
If you can get to old age without any prescriptions, that's a good thing so far as I'm concerned.
My dad was a WW2 and Korean war Navy doc. Practised general medicine for 50 years after.
Near the end of his practice, he was called on the carpet by a medical review board because he did not use the “proper” number of stitches on a facial wound (he used “too many” because it was on the face and wanting to minimize the scar). There were “policies” to be followed. His billing was delayed.
That’s when he decided to hang up his stethoscope.
I’ve seen a lot of doctors over the last few years and I’ve learned you have to manage them and not let them manage you. In order to that you have to know what’s going on. I try to get every doctor’s report of my visit to them. A few automatically give them to you, but some you have to ask for.
I do my best to understand what the hell is going on with me and why they are doing what they’re doing. The best way to do that is take the initiative to research everything you can about what you’re being treating for in order to determine whether you’re being cared for properly. And, if not, discuss it with your doctor to get it sorted out and to make sure you’re comfortable with the direction in which you’re going.
It ain’t easy. It takes a lot of work. But you need to understand the you hired the doctor and you are responsible for managing your contractors, and that’s really what they are: people you hired to work for you.
I’m fortunate in that I’ve had 35+ years of experience managing contractors, and I got damned good at it. It’s very satisfying to know that you are the one calling the shots, and you usually have alternative options if they fail you.
I’ll have to re-read the article to see if the author pointed out that YOU are largely responsible for what happens, but sure ain’t easy to do.
Um, where has this guy been for the last decades, ICD has been around for a long long time because this thingy called Medicare requires that there be a standard by which billing is conducted. Now it twerent so bad until madam pelosis and bathhouse barry gave everyday Americans a unlubed proctological exam and started squeezing the bejeesus out of doctors forcing them to participate in the electronic records farce and so driving many small efficient practices (and doctors) out of business.
Unfortunately no matter if we completely destroy barrycare you can't put the genie back in the bottle, you just can't stop and turn the Titanic that is the federal government bureaucracy.
I know, my wife has been Certified Professional Coder and owned her own medical billing service for decades and I have to hear about this BS everyday.
And this is the real truth about why you cannot get Vicodin any more but, are told to take over the counter meds such as Aspirin, Acetaminophen, Ibuprofen, Naproxin Sodium, etc.
They aren’t looking at efficacy. They are looking to control costs and they went and demonized a particular drug that was working for many people.
But, that is only true for working Americans.
There are plenty of people on givernment income who easily get these drugs you and I cannot get, because we are the producer class and they need us to go to work every day and pay taxes so the givernment dependent class won’t uprise...
Even Lyrica has been reclassified, like Vicodin, as a Class II narcotic, which is hilarious.
Case in point, this past year I was infected with a bladder bacteria. In the past a 14 day regimen of antibiotic pills cleared the problem up. This last time however the Dr only prescribe a 7 day treatment. He said the gunmen would not approve more. After three relapses and a near death experience in a hospital from sepsis the infection cleared up. So much for cost cutting.
Heh. I have no health insurance and pay everything out of pocket, just like with car repairs, plumbing and electric on my house, etc.
The government rarely gets involved because I do it all myself - or the Lord does it as an answer to prayer.
Our culture has become addicted to health insurance. In a Godless society, this life is all you have, so you value its preservation and “physical” quality more, and will pay any price to keep it as long as possible.
I’ve left that culture. And saved at least $50,000 in after tax dollars because of it. That’s a lot in a part of the country where you are making good money at $16 an hour. :)
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