Fixing Obamacare

This is my last post about the healthcare situation in our country. I wrote this myself and it contains my experience in watching how all of this evolved over the last 30 years (actually 20 years, but I've been in the biz 30+ years) and I know that my old friends that have the same experience I do know all of this...If you want a clear understanding of HOW WE GOT HERE, take the time to read this. I posted this as a comment in someone else's post because it fit. These are just my observations as I watched healthcare costs and insurance evolve from the days when nothing was denied or questioned to where we are today.

Since my careers have been in the healthcare insurance field for 30+ years, as you can imagine, I have seen a lot of drastic changes. I have been in this business so long, I used to type my own reimbursement checks and handwrite explanations of benefits.

When I saw the beginning of what would spiral out of control and end up with providers (both facilities and physicians) and insurance companies being at war with each other, basically entering in a tit for tat competition. If we could transport ourselves all the way back to when health insurance first started getting it's feet wet and change all of the events that happened afterward, we wouldn't be in this position!!

When health insurance started becoming available for more than just the rich, the doctors and hospitals realized that the insurance companies were going to pay whatever they charged, the prices of procedures and hospital stays began to inflate (had nothing to do with an increased cost of living rate).

To counter-act this movement, to prevent employers and ins companies from going broke, the AMA created the REASONABLE AND CUSTOMARY tables to group together physicians in a given zip code and look at the procedures that could be performed by a physician and give it a dollar amount that they could charge up to.

So the physician's figured out a way to skirt around that issue, and further inflate healthcare costs, by performing unnecessary procedures that should have been included in the 'main' procedure code...example: a woman goes in to have a baby, and in the same surgical setting, she has a tubal ligation. The way the claim should be billed: Vaginal Delivery with tubal ligation, or Caesarean Section with tubal ligation. The way the claims WERE BILLED; Vaginal Delivery and a separate Tubal Ligation, etc...could make about $2000 in the way the payment is reimbursed because billed separately, they SHOULD BE performed in separate surgical settings.

To counteract, the insurance companies created Utilization Management, where we all went to training to learn to read surgical reports and medical records to determine if a global code could have been used for the procedures performed, so then was born the clinical review deductions and denials, therefore, getting the costs back under control.

All the while, this is being haggled back and forth with the physicians and insurers, the hospitals, meanwhile, in the background, began to charge $12.00 for one Tylenol, $40 for a personal care kit (toothbrush, toothpaste, lotion, etc), $20 for a meal delivered to someone other than the patient...etc...

To counteract, the insurance companies started reviewing anything that didn't directly pertain to the medical treatment of the patient and then the deductions started. The hospitals then started hiding the inflated items in other things, medical equipment, medical supplies, etc...so then the insurance companies started seeing a drastic rise in those 'generic' revenue codes on the hospital bills, therefore, inflating costs again. Then the insurance companies created entire departments that were devoted to nothing except reviewing EVERYTHING for medical necessity.

THEN CAME HMO'S AND PPO'S. For those of you that don't know or understand those terms, these are managed care organizations created to drive down the costs of medical care and keep the providers in check. This, my friends, is where it got real! With an HMO, you could no longer just DECIDE you wanted to go to 10 doctors not having any idea what kind of specialist you really needed...then the dreaded REFERRALS were created, which would put your primary care doctor in charge of coordinating your care, which is the way it should be. It sort of stopped the would be self diagnosers and hypochondriacs!

Keep in mind that through this whole 15 year process up to this point, members had to pay VERY LITTLE out of their pockets for premiums, deductibles and coinsurance, therefore shifting MOST of the burden to the employers (true story). I remember my own situation for at least 15 years...we paid very little premium, NO out of pocket for copays for visits of any type, prescriptions or hospital stays and the very worst plan we had, had a $100 deductible per person, a $1000 out of pocket and a 90/10 split.

Alas, all the millionaire doctors started feeling the crunch of being told that their days of screwing people were over. Also, at this same time was born the DRG (Diagnosis Related Group) payment methodologies for hospitals were born, basically limiting hospitals to what they could charge for a particular diagnosis...but basically all of this was wrapped around the MANAGED CARE idea. Along with this, insurance companies started hiring nurses for managed care departments along with medical directors. Another thing that devastated medical providers was the creation of the Fraud Units at all the insurance companies.

The thing is...all of these managed care practices were good ideas, they were just introduced too late in the game. Employers began getting cancelled because of the claims experience of their employees, which caused them to have to seek higher risk insurance with inflated premiums, which trickled down to the members because the employers couldn't bare all of the expense, so the premiums were inflated, employers shifted the responsibility to the members, and in a lot of cases, the members would opt out of coverage because they could no longer afford it, and they would put their children on Medicaid or they would opt for an Individual plan if they were healthy to which a lot of the times would be cancelled for one reason or another.

The physicians and hospitals were forced onto participating networks, otherwise, there would be NO coverage (in the case of the HMO), or they would get very little reimbursements because of the non network penalties, therefore, THIS started the bankruptcies and collection issues with people that were at a non network hospital and therefore end up owing thousands and thousands of dollars.

The reimbursements are so low TODAY that many hospitals have closed and individual physician practices have turned into large group practices, removing the 'personal' attention.

With this yo-yo effect, came the need for a national insurance plan, which was started by the Clinton Administration, supported and continued by the Bush Administration and put into action by the Obama Administration.

As you can see, we did NOT get here overnight as people think.

I know this was a long read, so if you made it to the end, I hope you have a better understanding of the way this all evolved from someone who has been around for the whole process.