Best Health And Wellness Info

If you're new here, you may want to subscribe to my RSS feed. Thanks for visiting!

 

The writer of the following post describes his frustration with attempting to get reasonable medical care at a reasonable cost from his primary care doctor:

My Medical Last Straw About 8 years ago Jan started treatment for high blood pressure. That locked us into our Blue Cross policies because, as you know, when you change policies even if you have something as common and innocuous as high blood pressure, …

The complaints in this gentleman’s post are pretty common these days.  Unfortunately the health care system in the United States is pretty broken.

As a practicing healthcare provider, I have some similar frustrations with health insurance and “the system”.  The really frustrating part for me is that providers who are willing to engage in ethically questionable behavior to “work the system” (as the doctor in the above post apparently is doing) tend to be the most financially successful.  There are those who cross the line and get themselves into serious legal trouble, but the doctor in the post above is practicing well within the law. 

Yes, the doctor may have lost the man who wrote the post as a patient, but I don’t imagine it bothers that doctor in the least because that gentleman was not one of his “cash cow” patients with full insurance coverage.  In fact, for many doctors like the one discussed in the post, patients without insurance coverage and who are trying to manage their health care costs by refusing to be “nickel and dimed” are nothing more than a nuisance. 

I have been in practice for more than 15 years and have accepted insurance on only a very limited basis during that time.  I made a conscious decision to maintain my independence from the controls on patient care that the insurance industry places on doctors. 

You see, most health insurance companies (it’s probably all health insurance companies, but in the interest of fairness, I’ll say most in case there’s one or two insurance carriers who do things differently),  very much dictate patient care to doctors by means of what they will and will not pay for.  In case you hadn’t figured it out, most insurance companies are primarily concerned with cost containment, not your health.  This means they will approve and pay for the bare minimum of care necessary to (hopefully) control symptoms and keep you just healthy enough that you or your loved ones (if you don’t survive the neglect) don’t sue them. 

This bare minimum of care is usually referred to as “reasonable and necessary” care in the insurance and healthcare industries.  That sounds a whole lot better than “bare minimum”, but in most cases that’s exactly what it is. 

Now, healthcare providers have to balance “reasonable and necessary” limitations with two other factors.  The first is to do enough to manage the patient so that they don’t get sued for malpractice.  The second is to get paid enough to stay in business and make a decent profit.  These three factors can be difficult to satisfy at the same time.  Actually, in my experience they’re impossible to satisfy if a doctor practices with high ethics and with high clinical efficiency! 

Most healthcare providers wind up doing things to increase the number of insurance-covered services provided per visit and/or increasing the number of visits they see the patient.  The doctor in the post above appears to be doing both.

When going the increased services per visit route, the most common approach is to add in non-treatment services, such as diagnostic tests, lab work, consultations, etc..  Why?  Because insurance companies typically pay much more willingly on non-treatment services.  Why?  I have no idea, but that has been my observation.  I’d think they’d want to concentrate on getting the patient well, but maybe I’m just being silly!

The second approach of more visits works for healthcare providers that don’t typically have a high visit number, but not so well with providers like physical therapists, chiropractors, psychologists, etc., who tend to see the patient repeatedly.  “High visit” types of practitioners get scrutinized heavily (and usually get a lot of claim denials) if they do more than the arbitrarily defined “reasonable and necessary” number of visits expected by health insurance companies.  But primary care M.D.s can probably get better overall reimbursement per case by having patients come in for an office visit on every little thing. 

Sadly, the system that is in place rewards inefficiency and ethically questionable practices by those doctors who are willing to play the game and stay just on the legal side of practice, and punishes those doctors who go out of their way to give good quality care.  In the time I’ve been in practice, I’ve seen numerous good health care providers go out of practice and/or struggle financially their entire careers because they can’t make a decent living in healthcare without compromising their standards.  As economic pressures mount, I believe we will see more and more good healthcare providers leaving practice.  In the end, this results in a high percentage of doctors practicing like the one complained about in the post above, and finding quality healthcare a difficult prospect indeed. 

Ironically, the cost-containment measures that the health insurance industry employs will only drive costs even higher for everyone through the inefficiency of healthcare by providers who have learned to play the game. 

Now, and increasingly so as time goes on, it will be important to manage your own health through cost-effective natural remedies, and the healthy lifestyle recommendations in this blog.

Share This