Medical Mire. The U.S. medical care system is a mire. The trudge through it – accessing, receiving and worst of all, paying for, medical care is a tortuous process for patients, family and providers. It wasn’t always like this. It isn’t like this in other wealthy countries. And there is no need for it to be this way here. Change is now an active plan in the federal government, but it will take years before most people will directly benefit from changes. What to do in the meantime?

Access to Medical Care. Medical care access presents two problems. One, significant areas of the U.S. do not have adequate facilities or physicians practicing to fill the needs of the population. Two, far too many people cannot afford the care that is available.

Anyone uninsured or underinsured may find accessible, needed medical care impossible. Most practitioners will not accept Medicaid-covered or self-pay patients; they cannot take the financial risk. Those who are willing to treat this group often have overfull schedules. The unemployed, self-employed, part-time employees, and those working for a small business that cannot afford the health insurance benefits the larger companies offer – all these suffer from want of medical care access. Healthcare reform cannot be effective without improving access.

Receiving Medical Care. And then, even those who can access care are not necessarily able to receive care. Problems here are commonly functions of time and money. We’ve all experienced some of these roadblocks.

• The individual patient or family must coordinate care if it involves more than one source.
• There are orders, tests, schedules that must fit in with work schedules, and more. Mobility can be a serious problem, for the patient or the family.
• Adolescent mental health services may be available at a long distance from the patient’s home.
• Some care is not covered at all, or only in part, and that makes it unaffordable for even some people having insurance. Hearing aids, diabetic test strips, ammograms, allergy shots, imaging studies such as CT or MRI scans, can all fall into the impossible-to-receive arena.

Paying for Medical Care. Then there is the most elaborate, crazy-making maze: paying for it all. Medical care is expensive, and who pays for what part of it, is less certain than ever. The raw costs of medical treatment and care are painfully high.

• Services and technologies commonly used now, such as MRI scans and laproscopic surgeries, were not available in decades past.
• Medications are being developed at a high rate and for a steep cost, but now permit treating illnesses and injuries that would have not been addressed before.
• The basic cost of an office visit to a medical doctor has gone up due to inflation, overhead and specialist training, although it is not in the unaffordable range for most people. It is the additions to the basic office visit that have really driven costs beyond affordable.

Health Insurance Coverage. Make no mistake: The U.S.rations healthcare by economic means. People can get what they can pay for. People who cannot pay, cannot get adequate care, if any at all. And the insured must pay monthly premiums, copays, and deductibles. The uninsured, of course, are billed for everything. Only the wealthy can reasonably afford the bill if it includes a serious injury, illness, or any chronic condition, like diabetes and heart disease.

Having health insurance too is often no magic bullet.

• Plans are set up with restrictive rules on what care is covered.
• There may be limits on where (no in-home treatment or nursing home care, for example),or frequency (only twenty visits per year),
• or prior approval required (hysterectomy, back surgery),
• or there may be complete exclusions (no coverage for neuro-muscular disorders, or medical devices like crutches, or medications that are not on the plan’s approved list.)

Then, the next hurdle. Health plans kick out claims that fail to meet all the criteria required at the time the claim is submitted. The patient must then research the denial, which may require additional information from the doctor or hospital or correction of computer data. This can be incredibly time-consuming and often ineffective because the insured does not know the “insurance system,” and its jargon, codes, and practices.

After all that, when a denied claim is resubmitted, then begins the wait-and-see. The providers of care often return more forms to fill out, offer no payment for services in dispute. and patients are, in the end, forced to choose care based on primarily on cost.

What Little That Is Out There. People fortunate enough who are eligible for and can afford to enroll in a health plan can frequently choose among two or three plan types.

1. One is a managed care, HMO model that strictly limits which providers can be seen by the person / patient. Other providers will not be paid. Even providers within the HMO may be seen only with the appropriate referrals and authorizations. Managed care saves money on the administrative end. People, enrolled in managed care plans, who have primary care physicians with whom they are comfortable can avoid frustration and receive good quality basic care, including medications and therapies as needed. The tradeoff is the loss of choice of providers. For physicians the managed care model can be good: they receive a salary for their services and do not have to worry about running a business as well as providing medical care. Yet, managed care can also pose problems for physicians in that it places limits on decisions they make and discourages treatments they may find important for individual patients.
2. Another plan type is catastrophic care coverage, where the patient manages and pays all costs for routine care. Hospitals fees are generally covered with this plan type. This plan is the most affordable, but it works well only for the healthy adult. Pregnancy is not covered with this plan type.
3. The most commonly chosen plan type, PPS or POS, allows the patient to choose the providers to see. This plan pays most of the fees for medical care after a deductible is met. It has its own restrictions and rules to govern payment.

Pinball Medical Care. As we’ve seen, medical insurance payment claims restrictions and denials can trap patients and providers. Every health plan has an elaborate system for identifying and evaluating claims. The process is akin to a pinball game, with the claim bounced from one maze to a tunnel to another maze. Claims systems tend to be weighted towards denying claims that might in any way be an exception to the rule. The denials are computer-generated.

Some insurance companies then send the denial without further review, putting the burden on the patient to prove the claim should be paid. The time involved in documenting claims, treatment decisions and the claims submission process itself is a costly administrative burden for providers. Also, comprehensive medical care services commonly involve more than one provider, each of which submits its own claim. The medical doctor, the laboratory, the radiology center, the surgeon, the anesthesiologist, the pathologist, the pharmacy, the therapist, each has a discrete claim demanding payment. For self-protection some medical practices require a patient to pay the entire deductible up front. Others simply do not submit insurance claims, but bill the patient directly for the full fee.

The result of all this makes a pinball game look sedate and organized by comparison. The healthcare system generates great expense that buys no medical value. Anyone without health insurance coverage is running risks of untreated serious health issues and financial ruin. There are ways to minimize the financial risks and reduce costs somewhat, but they are not obvious or easy. For example, uninsured patients do not benefit from negotiated group rates that large health plans negotiate with providers. The full, non-discounted rates can be an impossible cost to cover.

The medical care mire in the U.S. must change. People are trapped financially in its mud, and can’t escape to the higher, dryer ground of solid medical care. President Obama’s healthcare reform initiative offers promise. Until then, everyone needs to pull on hip boots and be careful out there.For help with medical care payment problems, see “Payment Pinball.” I explain the health insurance company process used when processing your medical claim.

• For help with medical care payment problems, see “Payment Pinball.” I explain the health insurance company process used when processing your medical claim.

• For more on ways to get by with little or no insurance, or to reduce costs regardless of insurance coverage, see “Easing the Pain of Payment.”

• Finally, click here for an interesting and informative historical timeline about medical insurance in the U.S.

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