In the previous post in this series, I said that in order to get a simple and obvious mistake corrected, I had to make 17 phone calls to the hospital’s billing office, 15 calls to my doctor’s office, 9 calls to the insurance company billing office, and 4 calls to the radiologist’s billing office.
What is also noteworthy is the large number of people I spoke to during this saga. In my calls to the hospital billing office, I spoke with Jennifer, Sherry, Sharon, Linda, Megan, Michelle (twice), Heather (twice), Kim (twice), Sarah, Mia, Amy, Caroline, David, and Michael. In my calls to the insurance company I spoke with Dema, Dennis, Pam, Vicky (thrice), Linda, Lynn, and one person whose name I forgot to note. In my calls to the radiologist’s billing office I spoke to Debbie, Marva, Debra, and Colette.
All these people are employed just to deal with billing issues and customers who have questions and problems with billing. When you consider all the people and time involved in this one simple case, is it any wonder that the bureaucratic costs are so large in the private health insurance system in the US?
My conversations with the people in the billing offices of the hospital and radiologist’s office and the service call center of the insurance company were mostly cordial and friendly. They seemed to be genuinely trying to help me but they were all stuck within this awful system. The only exceptions were David in the hospital billing office (who seemed like a smart-alecky know-it-all who was unfriendly and seemed to be annoyed at my persistence and kept insisting that my efforts to rectify the error would fail) and the ‘coder’, the person in the hospital billing office responsible for putting the code numbers on the treatments that were submitted to the insurance company.
This coder in the hospital billing office was clearly a key gatekeeper to the process and is a shadowy and mysterious person. Early on I had found out that the billing code for a bone density scan for someone with osteoporosis was 733.00 and that for a routine bone density scan was 733.09 and I used this information in all my calls to try to get the code on my insurance claim changed from the former to the latter. I was told at one point that the coder felt that I had no business knowing the code numbers for the various diagnoses and anyway that changing the code number would not influence the insurance company. I responded that it was not the hospital coder’s business to decide what my health insurance company would do and that she should simply put the correct code and leave it at that. I asked to speak with the coder but apparently no one speaks directly to this mysterious and august person. I was amused but also irritated at the idea that I, the patient who was responsible for paying the bills, should not be told how the diagnoses should be coded. It seems to be part of the plan to keep us in the dark as to how the system works so that we meekly accept their decisions.
One of the lessons that I hope people will take from this is that in order to deal with this bureaucracy, one needs to be really patient and persistent. Also, you have to keep your medical records and know what they say. I have also learned when dealing with the customer service departments of any business to keep notes of the date, time, the person spoken to, and the gist of each call. Since almost every time you get a different person, you cannot assume they know the history of your case even if it is on their computers and it helps to quote the results of previous conversations to them, because when you seem knowledgeable, they respond better.
I am also very polite to the people I speak to since they are not the problem, although I am sure that at times my weariness and exasperation with the system came through in my voice. The people who work in these call service centers are also stuck in this system and I am sure that they get yelled at a lot by angry people. Most of them sympathize with you and want to help but are limited in what they can do, so it is not fair to vent at them. It is the people in the higher levels of the insurance companies and hospitals, the people we do not usually encounter, who are the ones who try to find ways to deny coverage and thus increase their institutions profits, as Michael Moore’s documentary Sicko so clearly demonstrates. They are the villains.
I recount my experience in such detail as an illustration of what people have to sometimes go through. The sad fact is that it is probably not unusual. In my case, I was finally successful at getting the error corrected and the bills paid by the insurance company. But many people will end up getting stuck with the bill, either because they got fed up with the runaround or were paralyzed by the Byzantine nature of the process or did not have the time to waste on all these phone calls or were overawed by the system. Even I was tempted at times to say the hell with it, pay the bill, and move on. But given my hatred for this system, I was determined to not let it defeat me, and so gritted my teeth and fought it all the way.
It is important to realize that this kind of thing would almost never happen in a single payer system of the kind found in most developed (and many developing) countries. In those systems the patient deals only with the health care provider and all these tedious bureaucratic matters are negotiated behind the scenes between the single payer entity and the health care providers out of sight of the patient. As far as the patient is concerned, you go and see a doctor and the doctor treats you according to their guidelines and that’s it. You do not have to deal with any billing office unless you have some kind of supplementary private health insurance system in addition to the single payer one.
The solution to the problems that plague the US health care system is to adopt a single payer system and eliminate the private health insurance industry except as a form of supplemental insurance. The easiest way to do that would be to extend Medicare to everyone. The private profit-seeking health insurance industry is a parasite that sucks the life out of the health system by diverting huge sums to the shareholders and top executives and to pay the bloated bureaucracy needed to keep track of all the unnecessary paperwork. It has to go.
And this is why I never go to the doctor anymore. I am getting to an age where I should be getting checkups and tests, but I can’t bring myself to go because every time I went in the past I’d have to deal with stuff like this. Also, I change jobs somewhat regularly, so I change insurance just as regularly -- actually, more frequently since sometimes employers change companies to get lower rates. Each time I change insurance companies, I have to make sure the people I see are in network. I was long ago beaten down enough to pay for charges I shouldn’t have paid for…now I’m beaten down to the point that I don’t even see the doctor. I’m an insurance company’s dream customer.
My hassles with glasses aren’t as labyrinthine, but still awfully frustrating.
I need glasses because of pediatric cataracts. Very few optometrists make glasses for that, since nowadays most people that develop cataracts get surgical implants at the same time to fix the problem and therefore don’t need glasses (and most people that develop cataracts are senior citizens, not 1 year old babies). Places like Lenscrafters don’t even know what these kinds of glasses are.
Sometimes they get covered by my medical insurance. But not always, and it varies heavily based on everything from which insurance provider I’ve had to how they code my eye exams/problems at the eye doctor to even whether or not the person at the insurance company can be convinced to cover them as like an essential prosthesis rather than as a regular pair of glasses.
Also annoying: I paid for the separate vision insurance because I thought it would cover my glasses. When I finally needed a new pair? Nope! Even though that insurance was very cheap through work, it was still frustrating knowing that I paid into this plan for a few years only to find out that the only places that take that kind of insurance are places like Lenscrafters. Those vision plans expect glasses to cost around $200-250, while mine cost around $750-800. Hence why nobody that can make my glasses will both with the insurance.
Finally, because I can’t ever tell if I’ll be able to get them covered, nor can I always tell when I might need a new pair, I have no idea if I should be putting money into a health savings account or not, and if so, how much I’d need to put in.
It really is depressing when you think about the state of the “healthcare” system in the US. It’s such a joke and everyone knows it’s broken yet it still goes on the same way and talk of changes or fixes brings out the worst in politicians.
jpmeyer,
One of the points of insurance is to cover those large costs due to rare conditions, but as your case illustrates anyone who has anything that is unusual will often find that their needs are not covered. The financial model of the for-profit health insurance model is to get insurance premiums from people who don’t need anything.
I have worked for nearly twenty years with people who have Medicare and Medicaid. The problem with this “single payer” system is that neither the patient nor the provider has to care about the cost. I could give numerous examples of the kind of waste that results. Here are some:
1)A disabled client was sent home from his day program when it was discovered that he had head lice. The program manager asked that he be dropped off at the Emergency Room. (Drop him/her off at the ER is a frequent refrain at work places like mine). Being the frugal immigrant I am, I piped up to say that there were over- the-counter medications that could treat the problem, and that’s what was done.
2) I recently accompanied a client to an appointment with a specialist. This specialist was about to order a lab test when I mentioned that this particular test had just been done on the orders of the primary care physician. The specialist then asked that the results be faxed to him--i am certain the test would have been duplicated had I not spoken up.
3) A regular occurrence in Emergency Rooms, especially those in urban areas are those patients who are addicted to pain killers who turn up with an “ailment du jour,” When no one directly involved with the treatment has to worry about the cost, it is much easier to do some tests and write out a prescription than study the records of peoples appearance at ERs, and argue with an insistent patient about whether he/she really needs the medication.
The health care system is broken in many ways but to maintain or expand a system where those making the decisions about treatment are so far removed from those paying the bills, is not going to solve the problem. A single payer system would be great--if it can be tweaked so that the patient or the doctor, (preferably both), have some incentive to avoid waste.
P.S. In comparing ourselves to other countries, remember that no where else are health care providers so much under threat of lawsuits. As we say in work places such as mine, where we care for disabled clients,”No one ever got sued for an unnecessary trip to the ER; you can’t go too often”
Sithi,
The problem with the current Medicare and Medicaid system is that it is forced to deal with that pool of people (poor and old) who have higher health care costs. Countries that have single payer systems for all cost less than half per capita than the US.
People have calculated the cost of lawsuits on the US system and it is actually quite small.
Mano,
The point I was trying to make is that to expand Medicaid and Medicare as it is now, is to perpuate a system rife with waste. In other countries with universal health care, doctors in the “government system” are salaried, so right there you have taken away the incentive, which a fee-for-service system provides, to overuse services. I read somewhere that defensive medicine adds something like ten percent to the total bill--that may have been wrong.
Sithi,
The system where doctors are government salaried employees (like in the UK) constitute only one form of single payer. In other forms (such as in France and Canada) doctors are in private practice just like in the US but there is just one national insurance system (that covers everyone because it is not employer based) that reimburses them so it is very simple and straightforward.
As for defensive medicine, the costs of this in the US are not easy to pin down accurately but good estimates put them in the 2-3% range of total health care costs, which is nowhere close to explaining why health care in the US is at least twice as expensive as in any other industrialized nation.
Mano,
I completely agree that the US system needs an overhaul, and that a single payer system would be best. That isn’t what I am arguing about. All I am saying is that the Medicare model as is now exists also has a fundamental problem in that it rewards volume and not efficiency. Since you mention Canada here is an excerpt from an article I read: ( I will now rest my case).
In Canada, physicians are paid predominantly through a fee-for-service model, or payment for each service performed. Although it has led to what some consider a more equitable reimbursement system for the intense workload of doctors, growing evidence suggests it is emphasizing quantity of patients seen and services performed over quality of care.
“The system that we have in Canada incentivizes volumes,” said Stirling Bryan, director of the Centre for Clinical Epidemiology and Evaluation at Vancouver Coastal Health Research Institute.
The growth of health-care spending dedicated to doctors has outpaced that on hospitals and drugs in Canada for the past four years, according to the report. In 2010, physician spending is expected to rise to more than $26-billion, an increase of seven per cent from last year.
Dr. Bryan said the figures demonstrate spending on physicians is threatening to spiral out of control while potentially eroding patient care. Doctors are paid for each consultation they provide or surgery they perform, which provides a perverse incentive to do more even when it may not be warranted, he said.
“What is the quality that we’re getting for the volumes we’re delivering?” said Dr. Bryan, who is also a professor in the School of Population and Public Health at the University of British Columbia. “Are we doing surgeries on people who might not need surgery? The incentive is to do the surgery, not necessarily to do the surgery on the person who really needs the surgery.”
He said Canada urgently needs a “fundamental reassessment” of the fee system and to ask tough questions about the type of care being delivered.
Sithi,
I agree with you that a fee-for-service model has incentives for over treatment and can thus incur unnecessary costs. One hopes that doctors are professionals with ethics and that that kind of practice will not be widespread.
But if that is not the case, it is not hard to think of ways to control those doctors that do this. Especially with a single-payer system, there will be only one database which can track the practices of each doctor and thus monitor and discipline those who abuse the system.
I am amazed at the bureaucracy and would have expected a more efficient system in the US. You would be surprised to know that there is much less bureaucracy in Malaysia, where I live. How could the system had become so very complexed? But to add to a comment from Sithi, do note that we have salaried doctors in the government system. Without much incentive, it can also head in the opposite direction.