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 carrier’s 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. Washington’s 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 can’t 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.
The problem is that under your model if (God forbid) you go out and get hit by a bus or something, get hospitalized and don’t have insurance, the legal vultures will strip you of your home, your property, and pretty much anything you’ve ever worked for in order to pay the bill. Many of us don’t see doctors hardly at all, but carry medical precisely so that we don’t lose our homes as the result of an accident.
Go back to cash-for-service and the control returns to the patient.
………………………………………
That would put the enormous health insurance industry out of business.
Notice under Obamacare that lawsuit reform was not addressed. Lawyers in Congress protecting their brothers and sisters. If the government really wanted to address all cost, then there would of been lawsuit reform.
Some years ago an idiot at some bureaucracy decided that since the average hospital stay for pneumonia was 3 days that 3 days was all they would pay for... The result? Doctors were keeping patients in the hospital for three days who could easily go home after one day and sending seriously sick people home when they needed to be in the hospital five days.
There are ways to fix incentives so they mimic healthy choices but the fruitcakes running the left haven’t figured this out and our side wants to pretend it’s not an issue.
Hi.
With President Trump signing the Community Care Act, I receive care quickly (a couple months) and the quality of care is better now than 40+ years ago.
Got a hole in my retina and cataracts. Sheesh.
5.56mm
The problem is that under your model if (God forbid) you go out and get hit by a bus or something, get hospitalized and don’t have insurance, the legal vultures will strip you of your home, your property, and pretty much anything you’ve ever worked for in order to pay the bill.
My daughter was injured back in the 90’s at the private school she attended. They expected our insurance to cover it, but we had a #10,000 deductible policy and it WAS on their property. They had to make a mad scramble to dust off their policy and use it to pay for the injuries. i.e. almost all accidental injuries are covered by some form of insurance paid for by someone (i.e. the bus company).
BTW, if someone treats me without my permission, I owe them nothing.
My health insurance reform proposal of 2016 allowed for all-the-doctors prescribe drug plans.
It is silly for patients to have to take second-rate drugs when the company making first-rate drugs would be happy to accept say $1.7 million(all-the-doctors prescribe) instead of $1.5 million(current total) from say Empire Blue Cross for wonder drug D.
There would be no drug coverage appeals under my Plan Offer/Drug Maker Acceptance plans. A drug would either be in the plan 100% or not eligible for the plan’s reimbusement.
My proposal also had a Federal Drug Marketplace where people could buy drugs from participating drug makers at income-based pricing.
“control returns to the patient”
Stethoscope-carrying gods don’t take orders.
“ICD has been around for a long long time”
ICD-10 multiplied the number of codes over ICD-9 a few years ago.
“free market for health-care goods and services”
Not even one of the 50 states has such a free market.
Our country is very corrupt.
“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.”
In that case, they are trying to minimize addiction.
My pharmacist neighbor had a knee operation and he said his addictive “pain killers” fell short of the desired effect.
We are headed towards “evidence-based” medicine, slowly.
The long-term result is intended to be cookbook medicine.
Of course, evidence isn’t always as much as some Democrats and health care managers would wish it to represent.
Brilliant of them to decide that they’d pay for only the average, when it’s a given that roughly half the cases will be longer than the average.
They should have looked at the annual average for the institution and compared it with the average nationwide and looked for explanations for a discrepancy. Then the hospital could keep the inevitable people who needed more than the average longer, while still providing an incentive to send the ones home that could go after a day or two.
Idiots.
Reminds me of that old joke about the politician who was mortified to learn that half the public were making less than the median income.
“Some years ago an idiot at some bureaucracy decided that since the average hospital stay for pneumonia was 3 days that 3 days was all they would pay for... The result? Doctors were keeping patients in the hospital for three days who could easily go home after one day and sending seriously sick people home when they needed to be in the hospital five days.”
Most hospital payors such as Medicare use Diagnostic-Related Group (DRG) payment.
The hospital will send you home in a day if they think they can, but they might not get an outlier payment until the tenth day of another person’s stay.
Nonsense.
The PBM is contracted by the insurance company or government agency providing the insurance and administers the insurers' decisions regarding formulary.
This fallacious line of argument sounds like the one being made by the pharmaceutical lobby which has been advertising on Mark Levin's show among others.
If we eliminate third-party payers we eliminate the organizations with any leverage to negotiate or control drug prices.
Coincidence?
Have “THEY” asked you yet if you “present as the same gender you were born?”
I will tell you that the lady who asked me that question got an earful!
It was nothing personal, mind you; I was polite, but persistent in telling her that it was not a question I was going to EVER answer! None of their damn business!
Seems the HHS Dept. has gone queer! Or trans! Or something! And is forcing “Health Providers” to question on us poor suffering taxpayers on our gender preference!
This should not be news to anybody.
Yes courtesy the bathhouse barry school of taxpayer shafting, to be fair they screwed both doctors and patients playing no favorites.
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