Archive for category Lack of Access to Care

Tiers of U.S. Healthcare

A recent U.S. presidential-candidate debate included proposals on Medicare-for-all, care for illegal immigrants and private insurance: supposedly a three tier system. Exactly which existing tiers would be removed, which would be funded and how would the budget for care work?

Consider the layer cake of U.S. healthcare, as it exists. Start at the top where little figures of a bride and groom might stand. That is the highly-privileged care provided to members of Congress and many government employees (“Cadillac” health plans with a large percent government subsidized plus pre-tax perks). That insurance provides good care (not as good as the care in the French system, but pretty good).

The next tier is the “CEO” or “rich guy” healthcare. They have so much money they don’t need insurance. They just buy what they want at big name hospitals with private suites staffed by nicely dressed doctors in suits and young nurses with little pointed hats. The motto is “whatever you want”. CT scans of everything happen at least once a year and heart tests proceed just because “you can’t be too careful”. And, heavens, the food you like is on your diet. Rating of care: poor.

The next tier is a hodgepodge of layers or “options” offered by many insurance companies like Blue Cross, UnitedHealthcare, Aetna etc. These are mostly provided through an employer group plan. And, sometimes purchased individually at a higher cost if the person is part-time or retired before age 65. Some plans have high deductibles and high co-pays that financially make care difficult to obtain. Some closed panels of providers limit where a person can obtain care and limit the options for moving or travel. The insurance companies scrape off 15% of the icing (administrative fees). Rating of care: fair to good.

Next is the Medicare tier divided into several layers including Medicare with a supplement (fee-for-service) and Medicare Advantage (per-capita). Rating of care is good with a plus for lower cost compared to the higher layers. Unfortunately, Medicare does not negotiate drug prices according to laws supported by drug companies. Rating of care: good.

Next are decorations of socialized medicine. These include the Veterans Administration, Indian Health Service and various levels of military healthcare (Tricare). Rating of care: good.

Next is Medicaid. A State run and federally supported insurance for the poor. It is limited by budgets and willing providers. Rating of care: fair if you qualify, but many who need care don’t qualify for a variety of reasons.

Finally, the bottom layer. The layer for those with no insurance and no funds. All States require emergency rooms to provide care to “stabilize” a mental or physical illness. Anyone can obtain health care in the U.S. based on this nearly insane model where people wait until they are really sick to receive care in the most expensive setting. The bills, which none in this layer can pay, are astronomical and serve only to further bankrupt the unfortunate. Rating of care: poor with no connection to a primary care provider or mental health follow-up.

In conclusion, the recent superficial debate about healthcare seems to hinge on hot-button issues like rich insurance companies, greedy drug companies and desperate immigrants who become sick. Of course healthcare costs money — only a politician would say otherwise. The healthcare system we have or will have is exactly what we plan.

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Something Less than an Ambulance — will it fly?

ambulanceER doctors never ask the question but often think: “Why did you call an ambulance for a sore throat?!”  The trip costs at least $1000 and stands a chance of not being covered by insurance.  The ambulance crew feels bad they don’t have a more appropriate option but if you call an ambulance — you get an ambulance.

Kaiser Health News reports the South Metro ambulance company in a suburb of Denver Colorado is trying a new service.  An ambulance that is basically an ER in a box.  Equipped with lab tests, bandages, sutures and a few medications they go to a home to treat a problem rather than transport a person to the ER.  It costs about $500 — at this point, it is something insurance will not cover.

Here are two extremes:

  1. A single parent picks up their child from a family member after working 2 jobs at fast food restaurants.  The parent just got the jobs after 3 months of being unemployed.  The primary care doctor’s office is closed and the parent is expected at work in about 7 hours.  But, the child has a fever and a sore throat. The bus they usually catch to go to the hospital does not run after 8 PM.  The parent calls an ambulance.
  2. A woman drops a martini glass and cuts her finger.  Her husband thinks she needs stitches but he has some after hours stock trading to do before bed.  He tells the butler to call an ambulance and get the problem resolved.

The first case is common for Medicaid families.  No resources, no car, and not much to lose by calling an ambulance.  But, something to gain by not missing time at a new job and it helps the child on both counts.  The ambulance and ER visit may cost Medicaid over $1000.  But, during the day a visit to primary care might only cost $50.

The second case is crying for concierge care.  The family has the cash to pay for someone to come to the house and put a few stitches in a finger.  But, instead the problem clogs up the ER that should be dealing with heart attacks and car wrecks.  Again, if the problem happened earlier in the day a primary care office or urgent care clinic could have solved the problem.

One could see Medicaid having a fleet of mobile treatment units just to limit the financial losses in the ER.  Actually, a good idea.  Both cases might have solved their problems by taking a taxi to an urgent care clinic — if one was open.

Will the “ER in a box” find a place? — at least a place where someone will pay them?  The idea leans toward the concierge model.  No insurance is going to pay for an ambulance when a taxi will work.  No insurance company will pay extra just for the convenience of one patient.

Nice idea, but it’s not likely to fly financially.

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Lack of Access to Care – The Wallet Biopsy

One of the most telling statistics comes from the 516 people who were sick enough to be hospitalized overnight but did not have insurance at some time during the year.  40% did not get the care they thought they needed compared to 10% for those with insurance.

  • The well insured:  Access is usually not a problem.  But, if the patient does not have an established place for care before an illness it may be difficult to get a timely appointment for evaluation or hospital follow up.  Some patients with Medicare will run into the “our practice is not taking any more Medicare patients at this time”.
  • The under-insured:  Major health issues are usually resolved.  But, not having the money for the expensive drugs prescribed at hospital discharge is a problem.  Not being able to find an outpatient healthcare provider when covered by Medicaid (title 19) is a huge problem if no provider was established prior to a hospitalization (your appointment might be in 6 months).  High dollar deductibles and lack of drug coverage can overwhelm someone on a tight budget.
  • The uninsured:  Serious issues are usually resolved at the hospital.  For example, some uninsured pregnant women show up at the hospital just hours before delivery.  The babies are delivered but with more complications since they did not get prenatal care.   Uninsured care generates a huge debt which is often not paid directly.  The debt is offset by cost shifting to insured programs.  (In political terms this is often called “the safety net”)  When a person is making an appointment and the scheduler asks “what insurance do you have?” the answer “none” will often not lead to an appointment.  Most health care providers and pharmacies have an astronomical fee for someone paying cash.  The high fees originated back in the old days of “usual and customary charge” paid by insurance companies.  Now the tables have turned — the insurance company dictates what they will pay, which is not what the hospital or doctor charges.  Unfortunately, the uninsured will be expected to  pay more than Medicare, more than insurance companies and more than Medicaid.

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