Meeting the Criteria: The American Health Care 'Non-System'

David E. Drake, doctor of osteopathy and clinical professor of psychiatry at Des Moines University, brought us a wonderful opinion piece in the Des Moines Register yesterday. One that highlights the vagaries of a health care system that our own Mr. Halvorson has called "badly flawed, perversely incented, inadequately coordinated, incredibly inconsistent, strategically unfocused, and too often dangerously dysfunctional." His article shares experiences and data he accrued during his attendance at the recent Physicians for a National Health Plan conference.

With some 1,500 private health-care plans with their own confusing array of deductibles, co-pays, and allowed payments, health-care delivery in the United States comes out of a business model that makes money by denying or greatly restricting services even to those who believe they are covered by private insurance.
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Conference speakers pointed out differences in administrative overhead between a system based on a revised Medicare, 2 percent to 3 percent, versus up to 15 percent for private companies, with an additional 15 percent for profits.

He also shares some of the input given by a foreign colleague at the conference, as a contrast with the system here in the United States.

One of the speakers was a Canadian psychiatrist who makes more money than many American psychiatrists, with overhead limited to one to two minutes per day of billing on his part, with all fees billed to one central payer, the government. Speakers were clear that this is not "socialized medicine," but a central payer with physicians still practicing on their own. Socialized medicine would be akin to the Veterans Affairs' system, where the hospital and physicians are employed and run by the government.

The Canadian psychiatrist pointed out that there are regional differences by province, but that he can see a patient as often as he would like, with no co-pays or deductibles. His malpractice is about a third of what I pay, and this tab is picked up by the province as negotiated by physicians and the area health plan. If he believes a person requires inpatient care, he can hospitalize the patient without the need for pre-certification. He and the patient decide how long the patient will stay in the hospital.

This insight into the Canadian way is most interesting, and far less "socialized," than the way it is oft times presented by our political class and the mass media. Perhaps there may be ideas in their approach that we could cherry pick while developing our own?

The good Doctor's points are important ones, and are thrown into sharp relief by the second half of his column, which describes the bureaucratic nightmares awaiting him at his practice once the event was over.

I returned from the conference to see my sole employee, my office manager, overwhelmed by returned claims from multiple insurance companies, denials and a barrage of phone calls to confirm insurance coverage and get approval for outpatient care.

A few days later, I needed to hospitalize a woman who was so overwhelmed with anxiety that she was not able to function - at work or at home. The hospital admission staff told me at the outset that her insurance company would probably deny payment for her stay - that "she didn't meet criteria."

Indeed, initially the first day was denied, only later to be approved, while her three other days were denied even after phone calls from the hospital social worker and me. I was told that since she was neither suicidal nor psychotic, the insurer would not pay for her hospital stay after the first day. The decision was neither about clinical necessity nor good judgment, but about reimbursement and "criteria."

Since 1970 we have increased our number of health care providers by 150 percent, but 2000 percent more administrators. (Yes that does say 2000, it is not a typo.) That statistic alone speaks volumes on the subject, reaffirming once more that what we need is Health Care Reform Now!


SOURCE: "Health 'Non-System' Needs True Reform, Not Band Aids" 12/01/07
photo courtesy of Ack Ook, used and remixed under this Creative Commons license