By Lewis C. Rose, MD
It is common these days for politicians to promise
efforts to try to ensure that every citizen has
health insurance.
The insured are covered by Medicare or Medicaid,
by the Department of Veterans Affairs, the Armed
Services, and employer-paid insurance. A few are
covered by individual insurance policies. A very few
are wealthy enough to not feel the need for insurance.
Those who have accidents or ill health often
find that insurance is lost when they change jobs or
the employer changes insurers. The rest are uninsured
and have no useful health care, or rely on various
public clinics and emergency rooms. It is no
surprise that the uninsured have poorer health and
die younger than the rest of us.
An increasing number of the uninsured are
employed but have no access to employer-based
insurance or are self-employed and cannot afford
individual insurance.
Even those who are insured are often faced with
health care costs that they cannot afford. Co-pays,
deductibles, and medication costs are often sufficient
to deter people from taking their needed medicines
or getting regular health care or preventive
care. They seek health care too little and too late.
Those without insurance are not protected from
the inflated fees that providers charge. Insured
patients benefit from the fee schedules adopted by
their insurers. Even though the ER visit is billed by the
institution at $1,430, the insurer has established that
the visit was worth $820. To be a participating institution,
the hospital agrees to accept this as payment in
full for this service. The insurer pays the hospital 80
percent of the agreed $820, leaving the insured
patient only $164 to pay out-of-pocket. The uninsured
patient tries to pay the full $1,430. Needless to
say, few patients manage to pay these fees.
Even if one believes that poverty, or the new
condition called working poverty, is an insoluble
problem, the uninsured still cost us all a great
deal of money. They do fall ill, they do have accidents,
they do get health care, often too little and
too late, and they get it in ways that are much less
cost-effective, and less health-effective. A part of
the money paid by the insurance company for
that ER visit is used to keep the ER open and running
for all who enter its doors. So your private
health insurance still costs you more than it
would if all who live in the United States were
adequately insured.
There is a myth that if market forces are left to
work naturally, they will take care of the problems of
supply and demand, even in the case of health insurance.
However, several things combine in this case to
prevent the market forces from solving the problem.
Insurance is exactly designed to protect the
patient from the pressure of market forces. Under
the laws of supply and demand, increased costs
should reduce demand. Once the premium is
paid, the co-pays and deductible payments for
which the payment is re-sponsible are not high
enough to reduce the demand for health care. The
increased costs of health care are felt mainly by
the insurance corporations and government.
Demand continues to increase every year, in spite
of rising doctor fees and facility payments.
Most patients are not solely responsible for paying
their health care premiums, because the greatest
part of the premium has been paid for by the
patient’s employer. So the customer — the patient —
is insulated from the main costs of health care.
Successful lobbying by the insurance industry has
resulted in relatively poor controls. Insurers have always found it easier to pay for concrete, readily defined services rather than evaluation and management
services. Resuscitation from an overdose is easier to pay for
than gaining knowledge of the patient’s psyche, the counseling,
and the medication management that might have prevented
the despair that led to the overdose. It is easier to pay
for hospital days, for the treatment of the cellulitis, than it is
to pay for the frequent, long office visits that may have led
to diabetes control and avoided the cellulitis. Providers are
not as well-paid for keeping patients healthy as they are for
rescuing them from the results of years of neglected health.
When an employer changes the insurer of the employees,
many of them have to switch doctors. Each new doctor has
to learn anew all the things the old doctor knew about the
patient. Each of them must learn how to communicate with
each other effectively. Errors are more likely to occur, and
medical costs are likely to be higher during the transition.
The duty of the insurance company to its investors is to
pay out no more than it absolutely has to so that it can
remain profitable. The rules about clean claims are such that
insurance companies employ ever-increasing numbers of
people to check all claims so that payment can be delayed
or avoided altogether. In turn, the doctor and the hospital
must employ large numbers of people whose jobs are to
buff the claims so well that the insurer is bound to pay.
Recording the best paid ICD9 code for the diagnosis and
the best paid CPT code for the medical service provided
may benefit the doctor more than providing the best treatment.
This has led to the creation of a new career of coders,
complete with training programs, journals and textbooks.
These armies of claims processors provide no health benefits
to our patients, but they must be paid out of the health
care budget.
To base any plans for universal health care on the current
system of health insurance will perpetuate all these
problems, and the huge additional costs they bring.
Lewis C. Rose, MD is a graduate of the University
of London, England. He served in the
Royal Air Force, then went into Private Group
Family Practice in Brandon, Manitoba,
Canada. Next he served as Assistant Professor
of Family Medicine at the University of Manitoba,
and he is currently Associate Professor of
Family Medicine at the University of Texas Health Science Center
at San Antonio. He is a Fellow of the College of Family Physicians
of Canada, and a Fellow of the American Academy of Family
Physicians, with Family Medicine boards in both countries.
Opinions presented in this column express only the views of the
author and cannot be regarded as the views of Bexar County
Medical Society or San Antonio Medicine magazine. Opinion
pieces are published at the discretion of the Editor and the BCMS
Publications Committee and are subject to editing. Please send
articles or comments for “As I See It” to Editor, San Antonio
Medicine, 6243 West IH-10, Suite 600, San Antonio, TX
78201, or editor@bcms.org.
