Health Care Reform

[Maria]

I have health insurance, but it's practically worthless for Lyme disease- as most doctors who specialize in treating borreliosis do not take insurance. I can and did file a claim myself for an out of network doctor- but then found that out of network doctors have a separate deductible ($2000!) and that the health insurance company can choose to have only a portion of what I paid the doctor actually qualify to go towards the deductible.

The health insurance helps reduce the cost of the drugs I'm taking- but only 18% of anything billed from the doctor's office actually got counted towards meeting the outrageous deductible.

Insurance was happy to pay for the imbeciles at University Hospital who didn't help me at all, but they won't help pay for the doctor who actually understands what's going on.

[vison]

Your friend was not a Canadian and was not entitled to "free" health care. I have never heard of an individual doctor demanding to be paid - it's too bad she didn't report it. She still should.

However, she would have been billed by the hospital and they generally like to be paid while the patient is still there.

There are always complaints about ER in every hospital. Oz and I once waited 8 hours for an X-ray on his knee. On the other hand, my recent adventures saw me being dealt with quickly.

There are"walk-in-" clinics all over the place but you often have to wait. They are used by the sort of young (mostly)men who haven't bothered to buy health insurance. They get treated but in the end they have to pay.

[River]

I know someone who ended up in the ER at Banff. Long story involving a very stupid decision on her part, but she wasn't waiting very long and as far as I can tell she got good care. However, because she's not Canadian, she had to pay. And because she was out of her insurance network (grad student health insurance really blows) she had to pay a lot. Or, at least, she was complaining. But she's the type to complain about any little thing that doesn't go exactly her way so I take her bitching with a grain of salt.

How horrible an ER is depends heavily on the size and income level of the community it serves and the quality of the management. In the US, ERs can't turn anyone away either. For the purposes of 911 calls, they'll communicate to 911 if they're "red", i.e., jam-packed, and when that happened we'd take our non-critical patients elsewhere. Critical patients went wherever it was close. The area I rode in was small enough with tight enough mutual aid agreements that at least the nightmare scenario of not having an ambulance available never materialized, though sometimes people in the more distant suburbs had a bit of a wait because, even when you're going with your lights and sirens, it still takes time to reach a home that's fifteen miles away. But, as for the ERs...when those get packed they're the cesspits of humanity. Remember how I said they can't turn anyone away? That means that if there's no room or stall with a curtain around it, you get put in the hallway (unless you're critical, then someone else gets moved into the hallway so you can have the room...but you'll probably be too messed up to notice). I largely avoided waiting rooms because the ambulances had their own entrances but every now and then I got a glimpse. They don't tell the walk-ins if they've gone "red". Or maybe they do and the walk-ins don't care.

Some of the cesspool-ness of the American ERs (and I'm not familiar enough with any foreign system to comment) can and hopefully will be changed by people seeing their primary physicians more often. If your asthma and diabetes are properly managed, you're not going to end up in the ER. If you have insurance and a doctor, you won't be coming in to the ER to get your strep throat, flu, first trimester pregnancy symptoms, or ingrown toenail seen to either.

[vison]

5% of Americans cost 50% of your health care bill. Did you know that?

Because people do not have family doctors.

[River]

No. I knew it was ugly, but not that ugly.

One thing that really weirds me out every time I have to tap into the medical system is how slow the billing process is and how mysterious it is. I had my ultrasound two months ago and just got the doctor bill. The bill for the procedure itself hasn't happened yet. And the final cost on the bill is not the sticker price - the insurance carriers always negotiate before the bills are processed. Makes budgeting a little interesting.

The other thing that's mystifying me is why I can deliver at the local hospital less than ten minutes away but I have to go to another hospital an hour away to get my blood drawn. I know the university is very proud of their shiny new hospital, but you'd think the university insurance plan would recognize that there are lots and lots of university employees in Boulder and let us get our labs done in town.

[anthriel]

Your friend was not a Canadian and was not entitled to "free" health care. I have never heard of an individual doctor demanding to be paid - it's too bad she didn't report it. She still should.

However, she would have been billed by the hospital and they generally like to be paid while the patient is still there.

There are always complaints about ER in every hospital. Oz and I once waited 8 hours for an X-ray on his knee. On the other hand, my recent adventures saw me being dealt with quickly.

I think it's great that Canadian ER's can get paid out of pocket same day! Our hospital is spiraling into profound debt issues because of bad debt. People come in who need to be helped, and who are helped, but who cannot pay, and have no insurance behind them.

We are looking at reducing staff because of bad debt issues. That would be me, folks. Everytime I read about greedy doctors, it occurs to me I never hear about greedy lab folks. We just work.

And the implication was that that particular doctor wanted a bribe to treat that bleeding woman sooner rather than later. I'm not sure that is exactly what happened, not being there, but that is their perception. I don't know why I am so shocked, but I am.



Edited because I never really have figured out whether to use forward slash or back slash for these codes... oy....

[River]

While people blame the doctors, doctors often aren't always directly employed by the hospitals. Most of the ones who work in my local hospital are basically independent contractors who practice in this hospital and a couple others (but your insurance won't necessarily cover seeing the same doctor at a different hospital so one needs to be careful when scheduling appointments). So if you can't pay the bill, it's actually two separate entities getting hosed. It also means there are two separate bills to pay for anything done in the hospital. At least. When I had my bike wreck I had a bill for the ER and CT scan, a bill for the ER doc, and a bill for the radiologist who confirmed what the ER doc and I had already figured out: I'd broken my nose.

That said, it's not the lab techs who are greedy. Even at non-profit hospitals, the CEOs and upper management folks are bringing in 7 figures. They aren't the ones getting laid off or taking pay cuts over a hospitals debt issues either....

[vison]

The bill for my husband's heart surgery in Seattle in 2001 (he decided to have a heart attack on Valentine's day when we were there for the sale) took 90 days to get to us.

It was complicated by the fact that the bill was going to be paid by the Blue Cross on our credit card. A long story, but they got paid finally after complaining that "Canadian Insurance companies take so long to pay!" Sure, you take 90 days to bill someone and then complaiin?

No one asked us a single thing about money throughout the whole saga. Not the ambulance, not the first hospital, not Swedish Heart Centre - and that was a surprise to me. Chris had excellent, excellent care in the most high-tech place I've ever seen.

But 6 months later he had another heart attack here at home and had equally excellent care in our decrepit old hospital.

[axordil]

It's not unusual for obstetric services bills to arrive around the time of the kid starting on solid food.

[River]

Given that it took six months for the bills to arrive for my 2006 ER visit and surgery I'm not surprised. I still haven't seen the bill for the ultrasound in July or anything for the labwork I had done in May. I did, however, get the bill for the doc who read the ultrasound results yesterday. Her practice is efficient, even if the hospital isn't.

[axordil]

And the implication was that that particular doctor wanted a bribe to treat that bleeding woman sooner rather than later. I'm not sure that is exactly what happened, not being there, but that is their perception. I don't know why I am so shocked, but I am.

Given the specific cultural considerations (and language issue? Was the sister a native speaker of English?) at play, I suspect it's just as likely the doctor meant it one way and the patient interpreted it another. I find it the note of him sharing the fact he had kids in school in the US as a reason for asking for USD up front exceedingly odd.

I can very much see this happening: patient comes into triage room. Doctor notes bleeding on extremity--not life threatening. Hears patient lives in US, notes he/she has kids in US as a "bedside manner" thing. Tells patient the bill will be $100 for fixing it up and that she should return to the waiting area, since it's not a high-priority emergency, and that it may be 6-8 hours.

This is where the misinterpretation takes place. She forks over the money, and then it turns out the higher priority people are awaiting tests or a specialist to show, and there's ten minutes available to sew up the wound.

[anthriel]

And the implication was that that particular doctor wanted a bribe to treat that bleeding woman sooner rather than later. I'm not sure that is exactly what happened, not being there, but that is their perception. I don't know why I am so shocked, but I am.

Given the specific cultural considerations (and language issue? Was the sister a native speaker of English?) at play, I suspect it's just as likely the doctor meant it one way and the patient interpreted it another. I find it the note of him sharing the fact he had kids in school in the US as a reason for asking for USD up front exceedingly odd.

I can very much see this happening: patient comes into triage room. Doctor notes bleeding on extremity--not life threatening. Hears patient lives in US, notes he/she has kids in US as a "bedside manner" thing. Tells patient the bill will be $100 for fixing it up and that she should return to the waiting area, since it's not a high-priority emergency, and that it may be 6-8 hours.

This is where the misinterpretation takes place. She forks over the money, and then it turns out the higher priority people are awaiting tests or a specialist to show, and there's ten minutes available to sew up the wound.

You know, that could be exactly what happened. Or, it could have happened exactly as she described, and she was asked to hand over bribe money or wait longer.

My friend's Vietnamese accent is fairly difficult to parse through, but her sister is the one who was born to an American soldier father; she's about 12 years younger than my friend, and moved here when she was about 2. I suspect that her English is fine, but again, I don't really know.

I actually have considered that the story was augmented for effect, and perhaps it was. I would be glad of that, actually. I really do have the ultimate expectations of the Canadian health system, and all its employees!!

I blame vison.

[Cenedril_Gildinaur]

5% of Americans cost 50% of your health care bill. Did you know that?

Because people do not have family doctors.

The "what" is correct, but I'm not in agreement about the "why."

My mom is a medical professional. She described to me various situations that go on in a hospital.

One of them is a patient with what medical professionals call "TBF" - Total Body Failure. There comes a point where no amount of medical care can many any difference except to perhaps prolong life for a few more hours, or even minutes. There is no hope for recovery. The patient is dying and there is nothing doctors can do to stop it.

Family members sometimes say "let him pass away, just make him comfortable." The patient sometimes signs a "Do Not Revive" letter. That does bring a resolution to someone with TBF.

Family members sometimes say "do whatever it takes to keep him alive." That's where the problem is, because the doctor is thus bound to keep applying more and more care, even more expensive care, just to extend life for a few hours more when there is no hope for recovery. This racks up massive bills, which often the family is not responsible for.

And that accounts for a large portion of medical costs going to a small number of people.

[River]

And the ethical solution is...?

[Primula Baggins]

Not immediately effective.

Education, communication, and a shift in values. People have to understand how little "extreme measures" usually actually achieve; how rare it is for CPR to bring someone back from death to their former state of health and competence (if it brings them back at all); and what a "vegetative state" actually is, and that it will not reverse itself.

[axordil]

Then comes the *hard* part: moving from volume-based treatment models that reward quantity to outcome-based treatment models that reward quality.

[Primula Baggins]

Yes. One of the things Obamacare is designed to encourage, BTW.

From BusinessWeek.com, in an article discussing the changes already taking place as companies prepare for the law to take full effect:

Perhaps the most fundamental shift the law encourages is a move away from the traditional fee-for-service model in which doctors are paid for each test, treatment, or X-ray they provide. UnitedHealth Group (UNH) said in February it would instead pay doctors based on patient outcomes, offering higher payments for better-quality care. The company, the largest health insurer by sales, said the new arrangement would apply to as much as 70 percent of its commercial members by 2015, from less than 2 percent now. “This changes the business model, changes the reward and payment system for better care and better health at lower cost,” says Sam Ho, chief clinical officer of the insurer’s UnitedHealthcare unit.

Link

[River]

People have to understand how little "extreme measures" usually actually achieve; how rare it is for CPR to bring someone back from death to their former state of health and competence (if it brings them back at all); and what a "vegetative state" actually is, and that it will not reverse itself.

I think more people understand that at an intellectual level than they get credit for. Well, maybe not the survival and recovery rates for clinical death, but the rest - that bodies fail, that a vegetative state doesn't reverse, and so on. But when it's your family member on the line, rationality can go right out the window. Which is why encouraging people to come up with a written plan for end-of-life care is a good idea, but I think we all remember where that policy discussion went.

[Primula Baggins]

Many of the states are stepping in on that. The benefits are obvious, and when they're presented without a paranoia-inducing federal connection, people seem to be receptive.

[Cenedril_Gildinaur]

And the ethical solution is...?

I'm afraid I don't know what it is.