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with Rod Moser, PA, PhD

Stories from behind the examining room door, as told by Rod Moser, PA, a primary care physician assistant with more than 35 years of clinical experience.

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Monday, October 20, 2008

“I Do Not Have Health Insurance”

Several times per week, I have a posting on the Ear, Nose, and Throat message board that mentions that the person posting does not have insurance, or does not have the financial resources to pay for a medical visit. With the economic crisis we are all facing at this time in history, I suspect we will see more and more uninsured Americans. One physician in our office stated just today that three of his patients lost their jobs, along with their insurance, and would not be returning for on-going care. This is just the tip of the financial iceberg.

For the most part, medical care in the United States is embarrassingly expensive. Since I am on the inside, I am often in a position to justify many of those charges to my patients. Insurance is equally as expensive and not all people have insurance benefits with their jobs. In most states, automobile insurance is required – it is the law. Health insurance is optional. I find that inconsistent with common sense since a liver transplant is considerably more expensive than fixing your bent bumper. Unless you have unlimited resources, going without health insurance will devastate your family in the event of a medical crisis. The government will end up paying the costs for the uninsured only after your resources have been depleted. The U.S. does not have universal health insurance, so those people without insurance must pay for their medical care.

When I was a child back in the 1950′s, we had one general practitioner in our town. I don’t believe my parents had any insurance. An office visit was $3.00 (this included medications in most cases), and a house call was $5.00. Even at those prices, adjusted for the 1950′s, this was still a pretty good deal. We were a lower income family; so fortunately, I did not have to utilize medical care very often. At age 18, I had appendicitis, but my mother must have had health insurance by that time, otherwise she would have told me how much it cost.

The cost of a routine office visit in my practice is $141.00, or at least this is what is billed to the insurance companies. Insurance companies typically negotiate these fees and will reimburse considerably less. A cash-paying patient will pay about $98. There are some quick-clinics at the local pharmacy that charges about $65. An urgent care clinic will charge about $75. People who have insurance will typically pay a co-payment of $10 – $30 for their entire out-of-pocket expenses.

Like medical care itself, insurance premiums are astronomical. I have many infants and children in my practice, some who were born with special needs. A parent of a 2-year-old child last week told me that her medical bills are over three million dollars (so far). It only takes a few of those for insurance companies to raise their rates on healthy people to make up for it. In Ancient China, doctors were paid a fee to keep people well. If you became sick, the doctor had to pay you!

I have always been very sensitive about charges, but in my current practice, I have no control over fees that are charged by the medical foundation. I am on salary. If I were in private practice, I would have been bankrupt from giving away free or discounted care. The cost of routine medical care has skyrocketed to the point of embarrassment. The cost of using liquid nitrogen to freeze off ONE common wart is about a $150, and one treatment may not do the job.

When I see a patient or perform a procedure, I put down a billing code that represents what I have done, the complexity of the visit, and the time spent. This code is translated into a bill, either sent to the patient or the insurance carrier. I am basically out of the loop.

Medical providers can “down-code”. In other words, they can put down a lesser billing code than what was done. Providers can also not charge for certain “simple and quick” procedures, like removing ear wax. The cost of removing earwax in my office is well over a hundred dollars for the procedure alone. If it only takes me a minute or so to clear out that ear canal so that I can properly see the eardrum, then I do not charge extra. However, if I spend a half hour digging out an impacted amount of earwax from some obsessive Q-tip user, I am going to charge extra – about the cost of 30 boxes of Q-tips.

When I know that a patient is private-pay (paying with cash or credit card), I tend to down-code or cut them a break if I can. If I have samples, I tend to give it to them. There is nothing like paying for an expensive office visit, only to be dinged again at the pharmacy. Medication costs have skyrocketed, too.

When the antibiotic Augmentin first came out, it was expensive compared to plain ‘ol amoxicillin. A full-course to treat a middle ear infection in a child could be $65 to $80 or more; amoxicillin was only about $10 or $15. My wife and I were traveling in New Zealand years ago, so I compared some of those prices with a Kiwi pharmacist (chemist). Augmentin in New Zealand only cost about $8.00 and was from the same pharmaceutical company. Why? According to the chemist, the entire country of New Zealand negotiated a lower price – and the cost is not increased to the consumer. In the U.S., we pay top dollar for the same medication. Of course, Augmentin is generic now, and the price has dropped (sort of).

The Veterans Administration and some large HMOs do negotiate for cheaper medications for their patients. When I worked for the VA years ago, it would drive me crazy. I would get someone controlled on one blood pressure medication, only to discover that it was now not available. I would have to change it to another one. Six months later, I would be told that that medication is not available, and I would have to go back to the original one that is now suddenly available again, now at a cheaper cost the government, of course.

The cost of medications has driven many Americans across the border to Canada or Mexico looking for deals. This practice is highly discouraged by our government, and is really illegal in some respects. People on fixed incomes who are paying more than half of their monthly income for medications for cholesterol, blood pressure, or diabetes are desperately looking for ways to reduce their costs. Smuggling medications across the border happens every day. I have personally witnessed people being hassled over a bottle of blood pressure medications they bought in Mexico, while tons of cocaine and marijuana seem to make it across okay.

Our government sites safety as their primary concern. Fake medications made in China are showing up everywhere, even in the U.S. Look-alike medications are being sold by the ton in Mexico to tourists. When someone shells out some cold hard cash for a bottle of Viagra before the cruise ship leaves, there is little recourse when those little blue pills fail to work. Maybe you get the real Viagra, but maybe your little blue pill is just that – a little blue placebo from China. Personally, I would not have any problem buying medication in Canada, but I would be a bit leery of some of those Mexican pharmacies along the border.

When it comes to buying food or buying gasoline, someone without health insurance tends to set priorities. Food comes first, followed by rent or mortgage. Then comes automobile costs. The lowest on the list tends to be routine medical and preventative health care. Emergency medical care tends to get attention, even in the worst of economies. When you have an arrow sticking out of your head, you don’t typically wait a few days to see if it goes away on its
own. A guy in a neighboring community was shooting arrows into the air. Not understanding gravity, he inadvertently hit himself in the head with one of those falling arrows. He hesitated going to the ER because he did not have insurance. I am surprised that the arrow didn’t go all the way through since there appeared to be nothing inside his skull.

If you don’t have auto insurance, you are screwed if you wreck your car. If you blow your engine because you can’t afford routine maintenance and oil changes, you are screwed because auto insurance does not pay for repairs. If you do not have health insurance, and choose to ignore your crushing chest pain, you may not need health insurance anymore – you so need life insurance for your family. If you do not go to the doctor because you have a cold, you will probably be fine. Colds are self-limiting and you don’t really need a doctor to tell you that again and again. Of course, if your cold seems to be turning into pneumonia, you are going to have to make a big decision. Should I take the chance of dying, or use my credit card or hard-earned cash to get some medical care? Get the care. Borrow some money or worry about paying the credit card later.

My auto mechanic charges $90 per hour (even if he fixes my car in five minutes). He is a high school graduate and makes more than my own hourly rate in my clinic. Is it fair? Probably; he can fix my car – I cannot. Of course, when he cuts open his head when he slips on some grease, I am not going to reduce his cost by down-coding him. I am going to get even.

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Posted by: Rod Moser, PA, PhD at 9:00 am

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