Saturday, July 16, 2011

Health Care Regulatory Malpractice

Back in mid March I went through Aortic Valve replacement surgery. I’m one of the “lucky” ones who have group medical insurance through my former employer. It’s not free though. Here is how the stats for my procedure break down:
Days in the hospital: 23
Doctors and PAs involved in my treatment: 28
Gross charges billed to insurance: $265,136.49
Amount paid by insurance: $246,013.49
Out of cost paid by me: $915.00
Monthly insurance premium: $1,159.52
These are not the final costs; bills continue to “trickle” in. Of the 28 physicians I can recall actually seeing maybe ten.

When President Obama took office, he pushed through an initiative to revamp the medical insurance industry. To my thinking less than half the job has been addressed by this legislation; he focused on the insurance side of the overall health care issue, leaving the medical delivery system relatively untouched. This is like having the fire department trying to save your burning two-story home by trying to put out the fire on the ground level only – the whole upstairs is still a conflagration.

Each of the 28 doctors billed insurance separately, and multiple times for each time they looked at my chart. That means 28 separate financial transactions, not including the labs, hospital, et al. Heck, if a couple of these doctors just wanted to pick up some side revenue, they could have falsely claimed they provided treatment – the insurance company would have no way of knowing. Nor would I.

Pharmaceutical companies charge outrageous prices for their products. True many likely had high product development costs. But they also par with auto companies in the amount of time and money they spend on prime-time television advertising. I have seen as many as three pharmaceutical ads during one spate of commercial breaks. Who pays for that? I can guess.

The two largest medical providers in town share common real estate and parking lots. But they do not share patient medical data between them via their independent computer systems. Yesterday my cardiologist faxed a blood draw request to the lab in the next building. Yes, in the 21st century – FAXED!

I know people love to gripe about government, and Big government at that. But the city doesn’t have two water departments, there is only one DMV in town, people can apply for Food Stamps and Unemployment insurance compensation in one building. More importantly, NONE of these government agencies have CEO’s who draw million dollar annual bonuses.

It all kind-a makes me sick.


Nance said...

Between us today, aren't we just rays of sunshine!

American medicine's best hope right now is a second Obama term. His administration has been driven back from further work on health reform, but a second mandate might get that ball rolling again.

Sometimes, we have to wonder that any of us are ever saved by our insane system, but I'm ever so glad you were!

DJan said...

The last time I was in the hospital in Boulder, I was unable to get those statistics you showed. The insurance company didn't allow me to see all the costs, only what I owed. In 2000, I was able to see this information, and I remember being astounded at the costs for my accident after two weeks in the hospital and ten days in a rehab hospital. Although my care was wonderful, it must be twice as expensive a decade later.

Glad you had the surgery and are now relatively "normal."

Anonymous said...

There is something fundamentally wrong with a system where, say, a newly married couple just starting out in life cannot afford a basic necessity like health insurance.

The industry is corrupt because of all the money to be made; and it seems the GOP in particular is committed to ensuring the obscene bonuses continue, while otherwise responsible people who get waylaid by health issues are denied access to adequate health care -- and/or have to file for bankruptcy because their medical amount to more than the purchase price for a nice home.

Anonymous said...


Robert the Skeptic said...

Nance It seems as though policies must reach crisis mode before they are acted on in this country. We continually put off the hard decisions then end up at the fiscal emergency room for the fix.

DJan Makes you wonder why the insurance company would want to insulate you from the costs?

Dissenter Health insurance companies are among the highest profit-making corporations in in America currently. And they are big contributors to the GOP as well.

Anonymous Yeah, I had difficulty understanding it as well.

billy pilgrim said...

i wonder how much of that went to malpractice insurance premiums?

with the aging population and constant development of more costly procedures the odds are it's going to get a lot worse before it gets better.

Jayne said...

Robert- The burning building with the fire being doused on the first floor only is the perfect analogy.

We a need a helluva lot more revamping. I don't have much confidence in Obama, but then again, I don't have much confidence in any politician.

The cost of medical care is outrageous. I get anxious reading this waiting for my bills to come in from my recent hospital stay. I'm sure they'll be nothing close to yours, yet the out of pockets will be significant. My husband and I are both self employed and we pay enormous monthly fees for family coverage. You'd think, in the event of an emergency--which has been rare, thankfully, that our costs would be covered. It's easy to see how well the insurance industry does when you're hit with the bills, on top of the insurance you already pay. Kind of makes you feel like both industries count on the fact that we're willing to pay anything to be treated, healed, cured, and we are taken full advantage of.

Very frustrating. But you are well, Robert--thankfully--which makes us all smile. And our insurers are counting on you agreeing with them: that your costs compared to the total costs are not outrageous.

It all make me sick, too.

Marylinn Kelly said...

This is one of the subjects about which I cannot think for too long or my despondency would become paralyzing. As we are looking at the possibility of there being no Social Security, disability, military, etc., checks come the beginning of August, I have a friend who says, not even half joking, "next they'll just send us the black pill." I know these are two separate issues, yet they do connect, much to our horror.

Robert the Skeptic said...

Billy From what I understand, a goodly portion of a physicians overhead is malpractice insurance. There was a program on public TV comparing malpractice insurance between American and German physicians, in Germany it was a tiny fraction of the American doctor's premium.

Jayne The "fee for service" model is extremely costly rather than paying for outcomes. Individual billing for each procedure is a very costly and inefficient way to deliver service.

Marylinn There is a lot of misinformation swirling about. Social Security, for example, is insurance for which we have been paying premimums all these years. Social Security is NOT part of the budget deficit, but most Americans don't know that.

Medicare is expensive primarily because of the cost of medical delivery cost increases of which I spoke in this post. Changing this system can keep Medicare viable.

Unfortunately, The Republican Ryan plan is designed to take taxpayer funds and give them to Private medical insurers. Yet another in the obscene transfer of wealth that has been going on for the last 30 years in this country.

Charlie said...

ObamaCare is a joke, and Obama could have 15 terms without anything changing. The bill was written by the health insurance companies, 2,500 pages of gobbledygook that neither the Pres nor Congress read or understood.

Two changes have been made:

1. People with pre-existing conditions cannot be turned down for insurance—they make up a separate "pool." There is no restriction, however, on the premiums for that pool—which, as you can guess, are sky-high.

2. Easier procedures for disputing a claim. My procedure used to be less than one page; now it's four pages, with the warning that they "may not apply to my policy."

Until Americans realize that the country is run by insurance companies, banks and Wall St., and oil companies, nothing will ever change.

Robert the Skeptic said...

Charlie I agree wholly, the two Obamacare issues you mention, particularly the pre-existing condition abuse needed addressing. But you are quite correct that, like most legislation, it is written by the industries it is intended to regulate. Like the Foxes authoring Hen House protections. Corporations run our government, not the "people".

Antares Cryptos said...

Much has already been mentioned in the comments. The cost of R&D are actually lower than the cost of marketing, which includes "free" lunches and dinners for people associated with the health care field.

Umbrella corporation;

BTW, did you watch Repo men with Jude Law? It takes "health insurance" to an extreme level as only scifi can.

MartyrMom said...

I find it amazing that the pharmaceutical companies seem to have no rules or regulations on how much they can charge.

I know I want/need the medicines I take but I never knew until the other day when I "accidentally" received a bill on my Humaria (an injection for Rheumatoid Arthritis)......the cost? a mere $1000 per injection. Luckily I have good cost?? a pittance at $5 per shipment (12 injections, 3 month supply)

Robert the Skeptic said...

Cryptos No, have not see "Reop Men", read the IMGD synopsis.. glad I wasn't doing THAT kind of repo in my younger days.

MartyrMom You know, the Republicans are hammering about the "costs" of Medicare on the national debt. One cost saving measure they could take is repealing the Bush Era law the Republicans passed PREVENTING the government from negotiation drug prices from the big pharmaceutical companies... or did they forget?

Paul said...

Are we living the dream Robert ? Or living a nightmare ?

secret agent woman said...

The insurance companies need to be taken out of it completely. We need a single payer national health plan, plain and simple. The same care ought to be provided to ALL our citizens.

And I can say from being on the provider side that it's not always as it appears. Insurance companies set my rates as they choose and the rates have been declining over time so that I have to see more people just to avoid and income drop. And the rates I get paid are lousy to begin with. I'd happily sign on to work for a national plan.

Robert the Skeptic said...

Paul Dream/nightmare, black/white... nothing in life, least of all your question, can be rendered so simply and be of any useful relevance.

SecretAgent I agree with you 110%. The opponents of single-payer will decry that the "government" can't do anything right. I find this stereotypical attitude just as tedious and offensive as I do stereotypical attitudes about gender, nationalities and ethnicity. Only the mindless generalizations about government seem to remain unchallenged in our society. Oddly I hear little complaints about the availability of cheap and clean water, transportation systems and food safety, just to name a few.

Critics point to anecdotal incidents of bad outcomes from single-payer medical delivery in other civilized countries. Like we don't have similar, and likely more, people denied care or suffering due to lack of "access" to supposedly the best medical care in this country?! Europeans don't hold "bake sales" or place donation cans at the check-out counters of convenience store to raise money pay for some kid's cancer treatment.

I wonder how much medical treatment could be provided to Americans for what it costs us every day to chase the Taliban in Afghanistan.

The Mother said...


I guess I picked the wrong day to wander back.

As a provider, I have a somewhat different take on all this. First, there is no way to bill extra on any patient--the payor system is massively cross checked. Plus, there are checks on the level of documentation required for each visit/charge. If we don't meet them on a single visit, we may be charged back on EVERY visit over the last ten years.

Second--yes, it's sad that we still use faxes. But unless a doc is willing to put up the big bucks for HIPAA compatible email and ftp solutions, fax is the cheap way to be safe. Which is why most docs still use faxes--it's a lot better than going to jail.

Third--We see a patient for an hour, and get, from Medicare or insurance, maybe $100. Is our doc's time really only worth $100 an hour? PLUMBERS charge $100 an hour. Docs go to school for 8 years, then take 3 to 8 years of residency/fellowship before they earn a penny over minimum wage. Do we really only think they're worth $100 an hour? Not to mention the vast support staff required to bill that $100. I pay $7 of that to the billing specialist, $14 to the med tech, $20 to the nurse. And I have to keep paying the rent and keep the lights on.

Feel free to rant all you like about your huge bill. But you're alive and you only paid a grand total of $3000ish to make that happen. I'd say you're damn lucky.

Robert the Skeptic said...

Dr. Mom Well this is important to hear from the people who are DIRECTLY affected by this. First I don't know why so many physicians were on my case. Radiologists and Lab, sure... But why each cardiologist had to bill separately still seems inefficient. I get bills sent from 5 separate geographic locations though my service was provided directly in town.

Secondly, One provider was able to communicate via computer record. The Faxes were when different systems were not compatible. Sure I understand the FAX covers one's liability, but is that the only way to communicate? Why do I not have a "master" medical record that any provider can read regardless of the logo on their stationery?

Why not a decent salary for a physician? Why should they have to peel off a huge amounts for malpracitce insurance which I am guessing you and your compatriots do and increases every year? As the documentary by T.R. Reid showed, doctors in the UK and Germany made a decent upper-middle class living. Then again they went to college paid by the government as well and didn't need to repay thousands in educational loans.

Yes, my huge bill was paid because I was, as you say "damy lucky" to have insurance. My kids don't - they would be bankrupt for a lesser procedure as many Americans are each day. What about the unlucky people in this country for which medical costs are the second leading cause of bankruptcy?

I cannot imagine that you would not agree the current system is unsustainable. Medical care needs to be universal, affordable and people who chose to enter this profession need to make a decent living saving lives.

The Mother said...

Of course I agree that the system needs changes, but I maintain that anyone who isn't directly involved cannot possibly have a good idea of what those changes could be. Politicians, for example.

Electronic records are being foisted on docs who are ill prepared to use them in a misguided effort to create that "one chart that everyone can read." But you can't! There are 14 bazillion, equally outrageously expensive systems out there, and they are all mutually incompatible. Mine is completely electronic, but doesn't meet the "standards," because my doc insists on listening to the patient and taking notes, then dictating an electronic report, rather than sitting with a computer in his lap keying in data while the patient talks, pulling boiler plate pieces together to make a record.

And I know docs who still don't have wifi in their office, because they just can't afford to put cash into the technology while medicare keeps slashing their reimbursement.

The best, biggest thing we can do to trim health care costs isn't making docs pour money into systems that will slow them down and eat into patient care. It's something that people don't want to hear, though.

We need to stop spending massive amounts of money to keep the terminally ill alive a few more days. End of life care is THE biggest health care expenditure in this country. It eats 70-90% of health care dollars, depending on which study you read.

It's time to get real and get serious. Stop letting patients and their families decide that we "need to do everything, doc. Keep her alive at all costs!"

That would free up health care dollars for the young and healthy who need preventative care now before bad things happen.

AND the payor system needs to properly reimburse for that well care, instead of assuming that the doc barely spent any time on it and paying 1/4 of what they do if a patient is sick. Maybe then people can afford to go into primary care instead of cardiovascular surgery.

The Obama program is a mess. No one knows how to implement it, because it was just a bunch of old, tried, bad ideas cobbled together in a frenzy to try to put something out there. We need a committee of providers, payors and economists to put together something that would actually work, without bankrupting society or turning health care back to the dark ages.

Paul said...

Robert, I think therefore I am or am I ? Please elucidate...

Robert the Skeptic said...

Dr. Mom I didn't want to get into the Intricacies of computer systems other than I did used frustrate me when I would see Dr. W and he would paw through this inch-thick folder trying to find the paper with the results of my blood draw the previous week.

It also frustrated me that, after a decade of seeing Dr. W, I had to change physicians because he was not on the only insurance company "choice" available to me this year. Doc W knew me well and I loved the guy.

I had no idea how much the end of life costs effected the cost of medical care. Of course, the opponents of Obama'a program wailed a hew-and-cry about "Death Panels". I wholly agree with you that too much costs are put into people who will not get better and are going to die anyway. In Oregon we passed "Death with Dignity" and Washington to the north has followed. But the Northwest is not a strongly religious region. Good luck getting something like that passed in Texas!

The Obama program did nothing for me, my premiums continue to rise 13% - 16% each year. My premium is now my highest monthly expense. As far as provider compensation, how much of that cost is billing and claims administration? Medical insurance seems to be a very lucrative business according to Reuters.

I agree, the point of my article was that the Obama Plan, for all the gnashing of teeth it caused, is a spit in the ocean and doesn't address the core issue. But we as a country will likely deal with it as we deal with our other issues... when it becomes a crisis.

Paul "I think" you are off-topic.

Sightings said...

Good post, interesting discussion. And Robt. I'm glad you're well.

I admit I know nothing about how the medical system works, but it does seem obvious that end-of-life costs are way too high (I read in England, if you're in a life-support situation, they give you a year; if you don't get better by then they stop artificially feeding you -- I don't know how much money that saves; but I don't think it's such a terrible thing.) It also seems that malpractice insurance in America is way too high. I don't know about anything else.

But everyone is always ragging on the insurance companies. Well, your insurance company spent 18 YEARS worth of your premiums for your one-month hospital stay alone. I can't see them making much money off of you. (No, I do not work for or invest in any insurance company; my own insurance co. does make some money off of me, but I've been lucky, no major bills in recent years.)

The Mother said...

We have a much bigger crisis looming in 2014, when the Obama plan goes into effect.

Two bad things are going to happen, really fast.

1)All health care will be controlled by the hospitals. Not the doctors, not the patients. Big hospitals with lots of leverage will then get bigger, and docs will all be on salary, and hospitals will be able to extort any amounts they wish. Docs will have no choice, no control, and no capability to protect their patients from big health care. (this part is already starting, btw.)

2)The uninsured go on the medicaid system in the states, which is already underfunded. Anyone with health insurance will have to choose whether they want to pay the astronomical premiums heading their way, or pay the government "penalty" for not buying insurance, which is already lower than most insurance plans and certainly will be in the future. So even those who CAN afford care will be on the government dole.

The system, as outlined to go into effect in 2014, is insolvent already. Medical economists are predicting bankruptcy by 2016.

Paul said...

Robert forgive me, but thinking of Obamacare distorts my consciousness...:-)

Robert the Skeptic said...

Dr. Mom I can likely attest that most of us have little to no idea of the scope of this problem beyond the sound bytes issued by the media. I fear the current system is unsustainable but I confess I don't have the answers.

Paul I'm speculating that you have some sort of insurance coverage, and further, that your insurer hasn't cancelled your policy, refused coverage, or eliminated enrolling you entirely due to pre-existing conditions. I am critical of Obama's policy on this issue, but probably from an entirely different perspective than you.

Stinkypaw said...

It is enough to make anyone sick...

crnelius said...

I would love to comment, but I am WAY too busy paying bills from an emergency room visit over 3 months ago! I think anyone with medical training with 20 miles of the hospital has either sent me a bill, or is planning on it... The bills just keep coming in. It's a never ending stream!... I feel like "The Sorcerer's Apprentice" in Fantasia!

Orhan Kahn said...

I'm sorry to see your country crumbling in such a vicious and selfish fashion. I really hope your grand children recover the American Dream of freedom for all, including the right to live healthy and not spend the rest of your life paying for it.

Robert the Skeptic said...

Stinkypaw As Dr. Mom says, I am one of the lucky ones. But this country is headed for a worse crisis if this isn't addressed soon.

Crnelius Same here, the bills continue to trickle in, probably will for months. This CAN'T be an efficient way to pay for and deliver medical services. In the UK they don't know what medical bills are!

Orhan You put your finger on the key word there, "selfish". Nobody accomplishes things without help and collaboration. We cannot be a nation of independents each doing our own thing and expect to be successful. Collaboration is NOT Socialism. But convince our Tea Party morons of that.