The One-Paragraph First Step to Solving the Health Care Crisis
Health care is a mess because the insurance companies are interfering with the clinical decision-making process. They have so many rules so that they do not pay in that they deny many legitimate claims over and over again. It should be the law of the land that to be allowed the privilege of offering insurance in the country, all insurers, HMOs, PPOs, etc. must have the same rules and regulations concerning payment and clinical decision making as the Medicare system. If they would like to offer a more robust coverage product on top of that foundation, they can do so but no added benefit can in any way change any aspect of the basic Medicare benefits structure.
In other words, the first step should be to standardize claims review and criteria, based on current Medicare standards. What's the next one?
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Technorati Tags: health care, health care reform, health, wellness
In other words, the first step should be to standardize claims review and criteria, based on current Medicare standards. What's the next one?
Related Topics:
Technorati Tags: health care, health care reform, health, wellness
15 Comments:
The insurance companies would never go for this. They are in the job of "not paying" for claims. They are making such a profit, why would they agree to minimum standards???
Doctor K.,
I believe there are some insurance companies who've 'adopted' Medicare's criteria. Some have even adpoted their fee schedules as well. But, as I'm sure you already know, these same
companies also add their own
'rules', it seems, to keep from paying claims, like someone who stretches the Constitution to avoid prosecution for a crime. If all insurance companies adopt the Medicare standard, how would they be held to it?
Insurance companies only adopt the parts of Medicare that help them financially and choose to make their own "modifications." They produce a pro-insurance hybrid that hurts the patient.
Are there any stories out there about insurance denials?
Medical Care was based on Patient-doctor relationship like Dental Care.However,third parties got heavily involved during last 15-20 years.
Quality has gone down,costs have gone up.
Doctors follow the rules dictated by a clerk of insurance co.If they do--they get rated with top stars.
Who is the biggest loser--PATIENT.
There is another problem that is emerging in many communities.Older doctors are forming alliances for referal business among Family practitioner,specialists and hospitals.This is another form of monopoly to meet the threat from insurance co.power.
Old Patient-doctor relationship is on the verge of demise as patient waits for a new face when he/she visits this new group.With time clock (requiring a doctor to see 40 patients a day),this adds to misdiagnosis.So quality is being overtaken by quantity.A Patient has to go to the doctor "TWICE" before getting correct diagnosis.
To the above post:
I have a teenage client with JRA (juvenile rheumatoid arthritis) who could ambulate only a few feet before becoming exhausted-on a good day. Some days she spent in a chair or her bed getting up only for essential activities. So in a
nutshell she relied on her parents or others to assist her with most mobility-related activies of daily living, due to the severity of her disease. Her parents wanted to obtain a scooter for her through their primary healthcare plan. Scooters were a covered under her policy, but they refused to pay because it wasn't documented that she would be 'otherwise bed confined' without it. The documentation submitted was extensive, indicating her joint deformities, her lack of endurance & limited strength prevented her from using any other mobility aid. It was appealed with additional clinical documents & denied again. The only thing that saved her was that she had a state-funded coinsurance that agreed to pay for it. Their criteria requirements obviously differed from her primary insurance. The main purpose, in most cases, for powered mobility aids is to help the individual become more independent in caring for themselves. In essence, since the documents lacked that one quoted phrase, her insurance refused to pay, despite all the other supporting information. Without the coinsurance, her parents would've had to pay up front. I could tell you many more....
The above post was for the 9:00 pm anonymous poster.
Mulitspecialty groups should be made illegal. When you combine a primary care doctor with a specialist like a urologist how in the world can the primary care doctor assure you that he is referring you to the best doctor for your problem.. Tey are business partners.
This seems like a real conflict and kick-back issue.
That actually would be a very reasonable solution. Of course the HMOs will not go for it, but who cares, as long as the politicians go for it
Ok. We don't want universal healthcare because it is one step away from communism. We also don't want a capitalistic profit-driven insurance industry and capitalistic doctors who make choices based on money.
Dr. K,
I believe if the Medicare standard would be adopted then the next step is that there would be enforcement of those documented standards, without the 'modifi-
cations' mentioned in a previous post. Would the lawmakers agree to this?
Fried Liver,
Given that all commercial insurance companies are profit-driven, maybe if we take the GREED component out, the word 'profit' won't seem so dirty, since profit is a must for survival. I'm a pessimist on this subject though because I just don't see this happening in my lifetime.
The issue is not Universal Healthcare vs. For Profit Medicine. There are many hybrid systems that can exist.
What about a government option system that citizens pay into based on income BY CHOICE. This plan- Call it "Medicare Freedom Select" will allow patients to purchase Medicare which is a more open system although a relatively low reimburser. Doctors can opt-in or out. Even if they opt out the patient will still receive a reimbursement for a doctor visit. For example- if Medicare reimburses $100 and the patient chooses to go to a doctor our of the system who charges $125.00 then the patient is only out $25.00. The current system has no such opt-out program. If you go to a non-Medicare provider you get reimbursed nothing. All benefits will be known by all parties. No more precertification or denials of claims.
We seem to have a pretty smart country. Can't we figure something out that puts adequate profit in the system to stimulate service and research and keeps the money in the system and not into stockholder hands?
Doctor K.
Dr. K,
Sounds like a pretty good concept,
like a win-win situation.
I find this whole health care system frustrating--on one hand, Insurance companies are a mess--but, there's no way I want our 'government' running our health care system--look what a mess our Social Security and every other program is! Either way---the patient is the one who loses!
The first step to improve health care is to change the philosophy of the system. Health care is a mess because we wait until people get sick and then treat their symptoms with high-priced surgery and drugs. It would be better to educate people how to live and eat healthfully and provide low-cost preventative services to fix the cause of the problem when it is still small. Most doctors are not into this concept and unfortunately neither are most patients. “Fix me quick, Doc, I’ve got things to do!”
Another option besides the insurance company/big pharma mess is to take responsibility for our own health. Read what Dr. Dean Ornish, Dr. John McDougall, Dr. Michael Greger, and other progressive doctors are saying about how to regain health. It takes more work than popping pills, but in the long run it’s much better and it is not as expensive. This would let doctors do what they went into med school for - to help people get well.
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