Marin Independent Journal (California)
Copyright 2007 Marin Independent Journal, a MediaNews Group publication
All Rights Reserved
By Dr. Tom Gross
Editor’s Note: Dr. Tom Gross is the emergency medical services director for the Novato Fire Protection District. His column appears every Monday.
I have been writing this column for several years, and I would like to continue at least until my goals are met.
I want people to realize that our medical system has strengths and weaknesses, and that we want to improve upon the weaknesses without discarding the benefits. I want people to realize that the solutions to these problems must involve providers of medical care and their clients.
I want providers and patients to remember that we are not enemies, but that we have more in common than may seem evident. I may be a medical provider, but as a recent patient, I have a collection notice on my desk for $120,000 for bills to the hospital that Blue Shield has not yet paid four months after my surgery.
Blue Shield has already agreed to pay, but because it has not yet paid and has refused to tell me why, saying only that the “computer service is down,” I am being sent to collections.
At 6 a.m. on the morning of my surgery, I signed a paper agreeing that I was ultimately responsible for the bills. If I had refused to sign, the surgery would not have proceeded. Nobody could tell me what the surgery would cost. I suppose I could have refused to sign, but I was interested in getting the cancer out of my body in a timely fashion. This style of business negotiation is often referred to as extortion and is characterized as duress.
On New Year’s Day, payments from Medicare to physicians are going down by 5 percent. If you are not a physician, why should you care? Many physicians already refuse to accept new Medicare patients. This new policy will not help to reverse that trend. Health insurance companies benchmark their rates to those of Medicare, so when Medicare disbursements go down, so do all the others.
I ask again, “Why should you care?” For removing my cancerous kidney this year, my surgeon was paid 20 percent of his usual fee by the insurance company. Taking into account malpractice insurance rates and the cost of maintaining an office and staff, even when he is in the operating room, at those rates, he won’t stay in business to take any other kidneys out next year.
Unlike my surgeon, the anesthesiologist for the same surgery refused to accept the insurance rates, and billed me for the service directly. I was told that I had to pay $2,500, even though my insurance carrier had told me that my maximum, “out of pocket” cost per year was less than that. I had not read the fine print.
An economist recently described how Medicare spending, now at 20 percent of the federal budget, will rise in the next 30 years to 50 percent. He also reported that 80 to 90 percent of Medicare payments go for care provided in the last 60 days of a person’s life. In other words, most of Medicare payments do not even help people very much.
I serve on a committee that negotiates medical insurance rates. The cost of medical insurance premiums has gone up 87 percent in the last four years. Unless your employer is an oil company or an insurance company, it is unlikely that your company’s gross income has kept up with that. Therefore, insurance premiums are taking an ever bigger bite out of your employers’ cash register. Most employees do not see that; they just see that they cannot get a raise.
Businesses soon will go under because they cannot provide health insurance for their workers. Not only will workers be unable to get a raise, but they will be unable to get a paycheck. They’ll be eligible for MediCal, but they won’t find a doctor who will take it.
One night I walked down the halls of a hospital ward. I noted that three-quarters of the patients had been hospitalized because of lifestyle-related issues - mostly tobacco, alcohol and the chronic effects of sedentary consumption of unnecessary calories. The people who continue to smoke, who drive while intoxicated and who refuse to adapt a lifestyle of moderation are partially responsible for raising insurance premiums for the rest of us.
You can blame the pharmaceutical companies if you want, but you should see what they pay in product liability over decades of the life of a product. They are the only ones making the medicines that lower our cholesterol, so that we can keep eating too much fat, and that lower our blood pressure, so that we can keep enjoying our right to smoke.
I have discovered that most of the medical problems pertain not to the medical technology that is available, but to the movement of the money; that is, who pays, how much, to whom, for what and how late?
Universal health coverage is a noble goal. It is also a Pandora’s Box. We should watch out what we wish for; we might get it. Without monitoring what we are buying and how much we have to pay, we will be sending the insurance companies a blank check with our signatures on the bottom.
As the Godfather once said, “It isn’t personal; it’s business.” It is a business that has a lot in common with extortion and loan sharking, with considerable arm twisting and threats.
Watch where the money goes and where it ends up. I am being sent to collections because one of the parties did not live up to its obligation. My employer paid its share. I paid my share of the premium, and my deductibles and co-payments. The surgeon accepted the payment under the conditions of his contract. The hospital provided the contracted service, and an agreed rate. However, the insurance company has failed to pay. This is where the money has stopped. The patients are being held captive and so are the physicians.
If you think that there is one solution to this multiheaded problem, then you are dreaming. The problem involves the physicians, the insurance companies, the government (oh, no, not the government!), the pharmaceutical companies, the unions, the hospital administrators, the malpractice lawyers and, yes, the patients.
This year we will be exposed to debates over health care, universal coverage, mostly about who pays and who receives. Please be a part of the debate. Ask your providers’ opinions as well. We need to account for where the money is going. Let’s not buy anything until we know what we are getting and how much it is going to cost.