Managing Managed Care

Our inequitable, inefficient, oftentimes uncaring health care "system," revealed. -- Jeffrey G. Kaplan, M.D., M.S.

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Is U.S. Healthcare More About Money Than a Calling to Help Others?

62% of personal bankruptcies in 2007 emanated from medical problems, yet 78% of those who filed had medical insurance (60% private, i.e., not Medicare/Medicaid) at the start of their illness.  Adding fuel to the fire, over 90% of all hospital bills contain "gross overcharges."  [See below]. Also, it burns me that the third largest U.S. health insurance company paid its top exec. $68.7 million in 2010 and a couple of dozen pharmaceutical companies make over a $ billion in profits, yearly. 

Speaking of accountability, it is time to become aware of the trumped up costs of care and clinical inefficiency.  It's time to demand value, equity in access and ways to attract people to and support primary care.

The following inequities are attributed to the way the U.S. health care industry conducts its business:

1.     The fees paid insurance executives may be in the tens or hundreds of millions of dollars even as their rates (the premiums we pay) increase and their profits, but not the benefits they pay out, rise yearly.

2.     Two out of five working age Americans either have "medical bill problems or are currently paying off medical debt."

3.     Uninsured: "Over the last decade, the number of Americans without health insurance has risen from about 38 million to about 52 million."

4.     Medical bills are a major factor in "more than 60% of the personal bankruptcies in the United States," and of those bankruptcies that were caused by medical expenditures, about 3/4's involved uninsured individuals.

5.     Why are C-sections on the rise?  It is because a vaginal delivery costs approximately $5,992 on average, while a C-section costs approximately $8,558 on average." 

6.     More than two-dozen pharmaceutical companies made over a billion dollars in profits in 2008.

7.     The U.S.'s medical liability system adds about "$55.6 billion to the cost of health care in 2008."

8.     Hospitals are estimated to be overcharging Americans “by about 10 billion dollars every single year."

9.     A medical billing auditor claims that over 90% of the medical bills that she audits contain "gross overcharges".

10.   Americans spend about "twice as much" on health care compared to residents of other developed countries on their health care.

Michael Snyder, "25 Shocking Facts That Prove That the Entire U.S. Health Care Industry Has Become One Giant Money Making Scam." The American Dream April 12, 2011

The best cure for these ills is having informed consumers, competition in the marketplace and aligned incentives.  By “informed” I don’t mean everyone needs to become a doctor.  One can begin by trying to understand charges—not what you are paying, but rather what is being charged before insurance coverage!  A resource for understanding medical bills is "How to Challenge Your Medical Bills" by Jim T. Miller, Syndicated columnist, NBC Today contributor and creator of SavvySenior.org.  He references the Medical Billing Advocates of American who suggests that 90% of 10 hospital bills have errors on them, and most of these are in the hospital's favor. "Bills from doctor's offices and labs have mistakes too, but they tend to be fewer and further apart."

"To help you get a handle on your medical bills and check for costly errors, the first thing you need to do is request an itemized statement from the hospital or health care providers detailing the charges of the procedures, supplies, tests and services they provided you. They are legally required to provide you with this information...."

He suggests checking out resources like you would find from an Internet search under "hospital bill review” such as: Medical Billing Advocates of AmericaMedReview SolutionsHospital Bill Review and Medical Cost Advocate.  And/Or, if you're a Medicare beneficiary, you can check out your State Health Insurance Assistance Program (SHIP) at shiptalk.org, or call 800-677-1116.

Harvey S. Frey, MD, PhD, JD [www.harp.orgadds: You can also find what Medicare pays for a particular service at http://www.cms.gov/You have to enter the "HCPCS" which is basically a CPT code for each service.

It interesting (ie: outrageous) that these codes, which the government requires that you use in order to get paid, are Proprietary! They are copyright by the AMA, which charges you at least $100 to get a license to use them, for which you just get a raw data set without even a search engine.

Anyway, the codes should be listed for each charge on the bill you get from the hospital or doctor, so you can just plug them into the above website (along with your geographic location, from a list of places listed in non-alphabetic order) to get what Medicare allows.