I have referred to this contest, the seemingly endless series of one-upmanship as the GAME. Picture, if you will a pendulum that swings not just back and forth but actually between three points. One point is the medical providers. Another point is the insurance companies. And the third point is the government. Equidistant from each other, power shifts from one to the other smacking us in the ass every time it passes through the middle.
We address these issues, not with unwarranted cynicism, but with the clear eyes of a realist. If you don’t understand how the game is played you are destined to lose. The stakes are high. Health and money ride on your ability to make good, unemotional decisions. Are the tests and procedures being ordered necessary for my health or for the practitioner’s bottom line? Is the politician working to solve a problem or to collect campaign donations? Does the insurer’s new network of providers give me access to the doctors and facilities I may need to use? These are just a few of the important questions we need to answer on a regular basis. But these aren’t the only issues.
Take, for example, Elisabeth Rosenthal’s excellent reporting in the New York Times. In this article, partially reprinted in the Plain Dealer, Ms. Rosenthal details the way out-of-network physicians and drive by doctors are beating the system and costing the consumers of this country (us!) millions. Utilizing loopholes that none of us would have ever thought existed, the unscrupulous have figured out a way to over bill the patient for services that were not rendered, did not require a specialist, or were intentionally provided by someone out-of-network to evade the only cost controls our system allows.
We are all at risk.
The main subject of the article, Peter Drier, was the model of diligence. He carefully verified that his surgeon, hospital, and tests were all covered prior to his neck surgery. How was he to know that his doctor and hospital would intentionally bring in out of network providers to juice the bill? The biggest surprise was the assistant surgeon, an out-of-network sharpy named Dr. Harrison T. Mu. Dr. Mu billed $117,000 for his services! The negotiated fee for the primary surgeon was $6,200. But Dr. Mu (probably beyond shaming, but I’m willing to try) was under no obligation to accept anything less than the full billed amount. Luckily for Mr. Drier, his insurer, Anthem Blue Cross, paid the full amount. I’m not sure that Anthem had to since the bill was above anything that could have passed as reasonable.
We talk about consumer directed health care as if we, the patients, have the opportunity to make real choices. We don’t. Can you shop for a deal when they are wheeling you in to the hospital with a blocked artery? “Hold up Mr. EMT. I just got a text alert that Hillcrest is having a sale on bypasses this week.” But even if your procedure is not an emergency and you have the time to vet the key providers, there are still hidden deals with labs, technicians, and assistant surgeons. And that is before we get to fraud and bogus claims.
I recently received a call from an irate client. She used to receive services from a doctor in his Ashtabula offices. The price was under $200. The same services, now performed within a Cuyahoga County medical palace, were over $3,500. Her insurer, Assurant, allowed the claim to be processed unchallenged and applied the full amount to her $6,000 deductible. In other words, she paid the whole excessive amount. But only once. She is looking for a Cuyahoga County physician willing to accept Ashtabula like payments. Or she will drive further for a better deal.
I don’t think that The Patient Protection and Affordable Care Act (PPACA) does anything to combat these issues. There is nothing to force providers to honor the patient’s network or to even pretend to be concerned about cost. And nothing, absolutely nothing in the law, will stop patients from being abused by doctors like Harrison Mu. Stopping that is up to us. We are being forced to play this game. We have to learn how to win.