We will be reading and hearing a great deal about Universal Health Care in the next two years. The Liberal impulse of compassion will tend to promote plans to cover all of the uninsured, with the argument that a country as wealthy as the United States should be ashamed to have so many of its poor without coverage. The more Conservative impulse will be to structure plans, such as President Bush's recent suggestion, in such a way as to minimize the intrusion of the government bureaucracy and preserve aspects of the private system of health care that has worked fairly well but is now being stressed by the combination of the high cost of modern health care and the increasing demands on the system.
Robert Samuelson has an article at Real Clear Politics today in which he addresses some of the issues involved. In Hiding Health Care's Costs, he describes the sleight of hand that has distorted Medical care for a generation:
For decades, Americans have treated health care as if it exists in a separate economic and political world: When people need care, they should get it; costs should remain out of sight. About 60 percent of Americans receive insurance through their employers; to most workers, the full costs are unknown. The 65-and-older population and many poor people receive government insurance. Except for modest Medicare premiums and payroll taxes, costs are largely buried in federal and state budgets.
Samuelson focuses on the costs of health care and the manner in which our current approaches tend to disguise the actual cost of such care:
I don't intend to examine -- at least now -- all the new proposals. Some would do better at some goals (say, protecting the poor) than at others (say, controlling costs). But the Bush proposal does have one huge virtue: It exposes health-care costs to the broad public. By not taxing employer-paid insurance, the government now provides a huge invisible subsidy to workers. Bush wouldn't end the subsidy, but by modifying it with specific deductions for insurance ($15,000 for families, $7,500 for singles), he would force most workers to see the costs. By contrast, some other proposals disguise their costs. Schwarzenegger's plan shifts costs to the federal government, doctors and hospitals. It's clever, but it perpetuates the illusion that health care is cheap.
Within his description lies the root of the problem with our health care system. In point of fact, in America we already have Universal Health Care. The problem is that we cannot afford to offer all the health care everyone desires to everyone who desires it. In other words, we are faced with the problem that every modern state faces: how do we manage access to a limited resource that so many people believe is a "right"?
When considering the various plans being bruited about in the next 24 months, it is always wise to be aware of the predictable unintended consequences. (The unpredictable unintended consequences will emerge in their own good time.)
To that end, I thought I might add to the discussion by recounting some of my own adventures with the medical care delivery system.
After graduating from Medical School and completing my Psychiatric Residency in 1981, I was determined to offer my services to as wide a population as possible. I trained at Bellevue, the premier city hospital in New York and despite the commonly held belief that the poor in New York made less than ideal patients (by virtue of their delay in seeking treatment until late in their disease, the high frequency of concurrent substance abuse problems, high rates of severe character pathology, and cultural issues that impeded compliance) I was committed to working with the poor as well as the well-to-do. I obtained a Medicare Provider number and a Medicaid Provider number, and when I was offered a referral of a Medicaid patient I accepted without hesitation. Early in a Psychiatrist's career, he will receive referrals predominantly from the in-patient service and tends to treat more seriously disturbed patients. The patient I was referred was severely depressed and needed a great deal of attention. I would spend 15 minutes getting from my office to the ward, spend 20-30 minutes discussing her care with the Nurses and house staff, and then sit with the patient for a 15 minute session. She was so depressed and regressed that the possibility for Psychotherapy was extremely limited and what Psychotherapy she was receiving was offered by the House Staff; my job was to manage and take responsibility for her care. I knew going in that Medicaid paid poorly, ~50% what a private insurance plan would cover. I subsequently found out that Medicaid would only cover the 15 minutes I spent with the patient; my consultation time and my travel time were uncompensated. This made Medicaid a losing proposition in many ways, but I would still have considered it a form of pro bono Psychiatry if not for the post-hospitalization problems I had with the system. Once the patient was discharged, I submitted my Medicaid bills. I had billed for ~25 sessions covering a month of treatment. Six weeks later the claims were all rejected, with minimal explanation. I should add that I was and am a solo practitioner and do not have or use a billing service. I made many calls to find out what the problem was and had to resubmit my bills twice; ultimately, 18 months later, I received a payment from Medicaid for less than 30% of my usual fee. I should add that it was not the discount that led me to depart from Medicaid but the layers of bureaucracy that I was required to negotiate and the delay in payment.
Similar adventures led me to try and abandon managed care in the 1990s. Again, I signed up to be a preferred provider recognizing that the fees were less than my usual but desirous of offering my expertise to those lower middle class patients who would not be able to afford my usual fees. When I discovered that a misplaced comma, or a bill submitted two days late, were grounds for denial, I dropped my participation. I have neither the inclination nor the interest to approach my billing with the level of obsessive compulsive attention to detail that the managed care companies required.
Finally, there is a repeat of these experiences occurring once again, this time with Medicare. I was ready to drop out as a Medicare Preferred Provider several years ago but a number of older patients prevailed upon me to stay in the system. I was willing to lower my fee and see them out of the system but this would have been very difficult to tolerate for people who objected to feeling like they were getting charity and equally distressed that I would be forced (by my participation) to accept a reduced fee. My patience with Medicare has come to an end. In the last year, I have had almost a third of my Medicare bills rejected, usually with no further explanation beyond "insufficient data." At one point all of my bills were rejected because although I had my address imprinted on them, someone somewhere in the bureaucracy decided I needed to repeat, in my own handwriting presumably, the office address in a second box on the form. Of course, it took multiple calls to discover this. Most recently I sent in two forms covering 12 sessions for a single patient. The forms were filled out identically except for the dates of service. Medicare paid one set of 6 sessions but not the other because:
"Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate" and "You are required to code to the highest level of specificity".
Finally, according to Medicare:
"Your claim contains incomplete and/or invalid information and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information."
The claims rejected were in the same envelop as the claims that were paid! I also had copies of all the bills submitted and confirmed that the forms were identically filled out!
This is the future of health care if the Universal Health Insurance fetishists have their way. It will make a difficult system that works adequately for a large majority of Americans work poorly for all of us.
Universal Health Care is one of those ideas that everyone supports; who could oppose offering health care to anyone who needs it? Yet the idea collapses in the face of reality. Usually, the people espousing Universal Health Care, which really means "Universal effectively free Health Care", are the same people who attack the Drug companies and Doctors for charging too much and want to cut their compensation. As the baby boomers age, the need for Doctors who accept their insurance will increase exponentially yet the number of Physicians willing and able to tolerate the system as it rapidly descends into the abyss is shrinking. I know of no Psychiatrists who accept managed care, Medicaid, or Medicare; the young Doctors I see are uninterested in becoming part of the system and are increasingly looking at Medicine as a 9-5 job. Many of our brightest young people have no interest in spending 8-10 years in training only to graduate with close to $200,000 in debts and a system that makes their work unpleasant and much less lucrative than in the past. If we want to destroy our health care system and have an equally inadequate system for everyone, we should all press Congress to turn their shining intellects onto the problem and we can all then jump aboard together. For those who propose such advances I would advise them to be sure they are not inadvertently jumping overboard in their zeal to save the system.
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