Bend Over

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I have mentioned before how staff working for our healthcare corporation or affiliated hospital system now are on highly restricted insurance that only allows them to see physicians that are part of that system. 

In fact the system is putting tremendous pressure on primary care physicians to refer ALL of our patents, regardless of insurance, only to system affiliated specialists.

There are gaps, however, in approved specialist coverage. For instance, psychiatry has only one physician supposedly servicing the thousands of employees. A psychiatrist that quite frankly sucks. 

Or sometimes the best doctors are not part of this approved group…

So the other day I had a patient, an employee of the system, who told me that the corporate approved neurologists refused to treat her. She now has to go outside the system, at a significantly higher cost, to a subspecialist in that field but was told by the insurance company that they would not approve an in network rate despite the fact that she has no choice in the matter.

Her portion of the cost is significant, almost prohibitive, particularly given her meager salary.

Patients with Medicaid and Medicare can see this doctor. And yet this woman, gainfully employed and who wants to keep working, has to pay through the nose. 

How is that ethical or right?

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81 thoughts on “Bend Over

  1. It really is getting worse and worse. Everybody is trying to force patients into a pipeline that may or may not service their needs, and it is all done at a phenomenal cost to everybody (my family policy costs 60% of my salary! That poor woman. (Poor in a few different ways)

    Liked by 2 people

    • 60% ! Sheesh! It would be interesting to look at what percentage of people’s salaries go to health insurance premiums. It’s especially hard for families. My company policy has the same high premium no matter how many children I have. Now, my 22 year old is the only one covered besides me. She’ll have to find her own coverage soon. I hope you get a better deal some day.

      Liked by 2 people

      • Yes — I have a family plan — me, my husband and 1 kid They don ‘t even cover the dog. But I work in a small company’s with lots of sick people, which adds to the cost. Oh well. It’s only money , right?

        Liked by 2 people

    • It is never possible for a single pipeline to meet everyone’s needs. They know this and yet they press on. Now they have recruited several school districts onto this insurance plan. Teachers. Another vulnerable, exploitable population.

      Liked by 1 person

  2. From a business perspective, vertical integration like this is very profitable – you are essentially creating your own customers.and customers who have no choice. It’s a business person’s wet dream. It makes me squirm and feels slightly incestuous. First of all it removes the whole reason capitalism works – the open competition (in theory) improves services and products and is for the greater benefit. If a client has no choice then the service provider has no reason to do their best or to even care at all about the client. This is a slippery downhill slope that in some cases requires gov’t intervention (i.e. Ma Bell or even Microsoft).for the customer to even get a semblance of the value they pay for.

    And that is just why it doesn’t work from a capitalist perspective. The truth of the matter is that it should be the patient who should drive the system, not the other way around. If your corporate wants to insist that all references be done internally, then they have to make sure that they have the premiere quality service providers to best serve the patients – and it is obvious from your remarks that this is not so. .This actually introduces a legal liability – if the clients are forced to use a certain provider, then whoever is forcing them (i.e. corporate) now assumes the liability for any services rendered – or not rendered. It is no longer a viable argument that the service failed even though they “tried”. Now an argument can be made that a patient would not have died (heaven forbid) had they been permitted to seek outside help.

    Quite honestly- as much as it is a capitalist dream to have a captive customer base – in this type of case where the clients’ health and well-being can be jeopardized, it is bad business to insist on vertical integration because it could easily lead to long term lawsuits and possible bankruptcy if jury awards are involved.

    Which means your bosses are greedier than they are smart Victo. Good luck.

    Liked by 4 people

    • Many major hospital systems are going to this. It is supposed to improve quality. Whatever. Not what I have seen at all. We all know it is about the $ but no one will come out and say it. Makes me so angry.

      Liked by 4 people

      • I’d like to see the arguments that it improves quality. It circumvents the very principles that define capitalism and make it work (there are arguments against capitalism and it is far from perfect – however the big picture evidence would suggest that it does more for the greater good – i.e. the quality of life – than many other systems).

        Liked by 1 person

  3. Argh, it’s not right and it’s a terrible system that has to change. When I look at the state of our insurance system, I sometimes want to throw my hands in the air and move back to England. It may take a while to be seen for “non-essential” operations, but at least the essentials are taken care of right away. I still remembering crying at the pharmacist’s office when I asked how much my emergency back pain meds would cost (that cost me $290 out of my pocket back in the U.S.), and he said, “6 quid” (i.e. $12 at the time). He was completely baffled at my reaction, and tried to pat my shoulder, as I blubbered, handed him the money, and ran out clutching the meds, somehow feeling like I was going to be stopped and told the whole thing was a mistake. I was a struggling student at the time, and my weekly food budget was about $20 – for me AND my husband. Two years in England just made me realize how effed up our whole system is – their system isn’t perfect, but it’s a damn sight better than what we’ve got going on.

    Liked by 4 people

  4. In Canada you can go to any doctor and most things will be covered. You need a doctor’s referral to a specialist but you can request the specialist that you want and they will refer you to them. Your system needs some tweeks.
    Leslie

    Liked by 1 person

    • As a fellow Canadian, Leslie, I agree that access to our health care system is much easier but there are issues with provider supply – as there always is in any system not governed by supply and demand. As a cancer survivor, I have absolutely no complaints on how I was treated – as my illness was life-threatening and I was triaged to the front of every line-up. That said, there are unforgivably long waiting times for procedures like joint replacements – even when the pain is chronic, the wait times are months or longer. There are a lot of quality of life questions around the length of these wait times..

      And this is not getting any better here either Leslie. Under political pressure to reduce wait times – even as funding is reduced – the physicians are playing shell games , not that they have a choice. You know, I was in hospital for 10 days for an infection (actually caused by an out-patient medical procedure) The were giving me intravenous antibiotics and nothing else. I felt fine and I complained to the doctor and asked if the antibiotics could be switched to oral and if I could be allowed to go home. It was a resident and he told me that they would prefer I stay in. I asked why and he said that if I needed any imaging, it could be squeezed in when there were cancellations or over night. I asked if I would need any imaging and he shook his head. “But you never know.” The light went on in my head and I asked him if they were, in fact trading hospital rooms (at about $1,000 a day system cost – without any patient services) for shorter imaging wait times – playing the system, so to speak, in order to give the politicians what they wanted – less voter complaints about wait times. He just smiled and changed my prescription to oral, and gave me my walking papers.

      There are issues here Leslie.

      Liked by 2 people

      • I am sorry to hear of your health problems, Paul. I agree that no system is perfect. (least of all ours) . However, not having had any serious issues, I tend to look at it from another prospective. Agreed, wait times for some of those procedures can be, indeed, long. However, if I do have an emergency situation I can be seen at a walkin clinic in a reasonable amount of time. Also I don’t fear financial ruin if (God forbid) a hospital stay is necessary.
        Leslie

        Liked by 1 person

      • Depending on your financial situation , of course, but long life threatening medical problems often result in personal bankruptcy in Canada. When I was diagnosed with cancer I could not work for 10 months. I’m single and had just taken a financial risk by spending my savings on a graduate degree. I was starting form the bottom of the financial ladder again when I was diagnosed. In order to get any financial assistance I had to first sell any and all possessions. I then qualified for welfare – but guess what? – when the state is feeding the patient in the hospital, it is the rule that any and all other financial help is stopped. So, I had been renting a cheap room in a house and when I was hospitalized all other aid stopped – meaning my belongings ended up out in the street while I was in hospital and I had no home – not even a room – to go back to when I got out. I applied for Long term disability but it took 6 months for them to translate my documents as the first hospital I went to as an emerg patient, was French – and that Disability dept was English. It appeared as if I would die before i got assistance. Once they had the documents translated, they sent for more info and it went back and forth until I was discharged and then they told me because i WASN’T GOING TO DIE, THAT i DID NOT QUALIFY FOR HELP. I tried to work but the radiation treatment had caused kidney failure (a very rare side effect but radiation of the abdomen is insidious and can have life threatening side effects for 25 years) and I had to go on dialysis full time. There are a whole row of domino like effects that fell from there – each one caused by the treatment of the previous one. Right down to the fact that long term dialysis often causes a degenerative nerve condition called peripheral neuropathy – so I walk very poorly now and it will get worse until I either have to have a leg amputated or I end up permanently in a wheel chair. Since it now appears that I may very well die – just not as quick as was originally anticipated – I have qualified for long term disability. I cannot work even 1 hour .of paid time now or I lose that benefit permanently. Even though there is nothing wrong with my brain and I would be overjoyed to get a job. I figured I’d go for it anyway and spent 3 years looking for a job -0 but guess what? when you are handicapped and over 50 years old – you are no longer employable. I am very good in my field and have decades of experience, references up the ying yang, more formal education than any employer could want . I interview well because I’m a people person and I know my stuff inside and out – and I am well spoken. I put out 800 resumes in 3 years and got countless phone interviews and many face to face interviews (2nd stage). Employers saw only my handicap and a potential medical liability. I did disclose my medical situation – painting it as positive as possible – during interviews. After all there is a 90 day probationary period in Canada and there is no way I can hide my medical situation for that long. So, although I did not mention my medical or handicap in my application,. I did in the interview. I am good enough that a major retailer flew me to the other side of the country for a face to face – all expenses paid and then they said – No Thanks.

        I could go on for a book about this Leslie. Voters are told that they are safe medically here in Canada and it is blatantly false. Yes, the health care is “free” but the experience is financially and emotionally debilitating. Did you know that close to 75% of the people in the streets today have suffered either a mental or physical ,illness that put them there? And that prior to that event or series of events, they were gainfully employed, self–sufficient and many had families? True story.

        Anyway, I don’t whine or complain, and that is not what this is – it is a personal account of the high points in my medical situation and part of the reason is to make it clear that there are certain steps that you, Leslie can take protect yourself and your family.

        1) Try hard to find a job where long term disability is a part of their benefit package.

        2) If you have a partner, try to get them a job where they also have long term disability.

        3) NEVER refuse health benefits when you start a new job – even if your spouse has you covered, you never know when they will o longer be able to work or will be laid off. If you refuse health benefits when you join an organization, then if you try to join after the fact, they WILL NOT cover pre-existing conditions -0 so if you get cancer, tough luck, you’re not covered. You can offset extra benefit costs by using your benefits to cover the deductible on a spouses benefits and vice versa.

        4)Never quit a benefit program thinking that state benefits will be enough – They ARE NOT.

        5) Try (as many say and few do) to put aside some money for a rainy day – in case you get ill or laid off. These are real things that happen to real people every day with no warning.

        6) Try to secure a family doctor – a medical professional who knows what your “normal” state is and can detect changes because they see and know you and your family. Clinics are for emergencies – as much as they tell you otherwise, having a doctor who knows you is important.

        7) Don’t hesitate to have a medical problem checked, even though the system discourages it (long wait times, shortage of GP’s and long wait times at emerg. Don’t be shy – it is the professionals’ job to decide if your symptoms are important or not.

        8) Ask doctors lots of questions – don’t abdicate your health care to the system. If you are uncomfortable doing that, the take a friend or spouse with you to your appts – someone who remains objective while you are listening. Any doctor that frowns on this practice is not a doctor you want.

        9) If you don’t get along with a doctor or they have a poor manner or won’t explain, then change doctors – it is their responsibility to help you understand – it is not your job to read their minds.

        Anyway, Leslie – if even one thing I’ve said helps you in any way, then it was worth cloggin’ up Victo’s comment section with a mini-post. If you do even a few of the things I mentioned above Leslie it could make a big difference on how your life or the life of a loved one turns out in the long run. Sorry for the long winded comment Victo. šŸ˜€

        Liked by 2 people

      • Paul, I am so sorry to hear about your situation. I’m also glad that you revealed the problems with our system. They are enormous and deserve exposure and change. Thank you for coming forth.
        Leslie

        Liked by 2 people

  5. Completely infuriating, but just another example of how insurance companies have taken over our health care. My husband said his generation of physicians is to blame for giving over their responsibilities to insurance companies.

    Liked by 1 person

  6. I am not sure if this similar to bundles, where everyone is align in the treatment of specific treatment for let’s say CHF…. but we are moving to that. AND it is a mess and going to really screw with patients. We also have this thing called choice….where Home Care Coordinators see you just before discharge to help you Choice your home care agency. However, We are one provider for one hospital but if you go to another, you have to “choice” another agency…. Where is choice in anything anymore in health care?

    Liked by 1 person

    • The CHF and other disease management things are separate from this. But you make a very good point about home health not really being a choice on discharge from the hospital. You get whomever they “recommend” and that is not necessarily the best.

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  7. You might recall, from reading my blog, that I recently had major surgery. I didn’t have insurance and because I missed open enrollment, there was nothing I could get through ACA. I had to either get private insurance at $800/month for just me and there was a waiting period for the surgery, even though it was for a malignancy. So I was lucky enough to get the hospital to take me as a patient at a 60% discount. That is a significant savings and I am alive today because of the surgery. However, the hospital is requiring me to pay my 40% at a rate of $450 per month. It will take me five years to pay it off, if I can afford the payments, which I can’t. And of course, with this monthly payment, I won’t be able to afford insurance when open enrollment comes around! Catch 22.

    Liked by 1 person

  8. You know what a mess things are…I work at a hospital and a person who diesnt work gets better medical care at no cost to them. Our out of pocket medical costs have gkne throuh the roof and most people I know are unable to pay them. There is no reward for being a hard working person anymore….only punishment.

    Liked by 1 person

  9. Holy moly,
    after coming home from work yesterday, it is somehow reassuring that your system is as challenged as ours is. I am not sure how it was reassuring but it was.

    Liked by 1 person

  10. this is horrible and these insurance companies who game and rig the system for their own self-seeking profits should be ashamed of themselves.

    If healthcare were a private enterprise like anything else, buying a house or a car, costs would be significantly less and people would have the choices they so desperately need.

    People who say that it’s not possible to make healthcare delivery services this way, I generally tend to believe that they are the politicians who are bedfellows with the insurance industry and so they don’t really want anything to change.

    But you’re in the system so from your perspective, what would you say are the best ways to give patients the best most affordable choices and not have to be concerned with going in or out of network?

    Is it possible for healthcare to be just another commodity like any other good or service we purchase when we have the need for said good or service or am I just delusional? lol.

    Liked by 1 person

    • Prices are inflated. To purchase healthcare directly as a commodity as needed without insurance is just not possible. ICU stay, heart surgery? Insurance being purchased by individuals would be a fiasco without certain laws or restrictions on the insurance companies. It is probably going to have to go single payor. That has its own problems, though. It is a challenge that has no easy answer.

      Like

  11. The medical industry is now exactly that – an “industry.” Health “care” went the way of the dodo the day pharmaceutical companies started influencing everything under the sun.

    Every other TV commercial these days seems to be pushing some pill that people really don’t need…

    Liked by 1 person

  12. It bugs me every single day. Since i’m on the dispensing end of things I actually have to see the reactions to a 1$ copay vs someone who has to pay $700 for their meds because the insurance won’t cover it, unless they quit their job and go on Medicaid…..

    Liked by 1 person

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  14. That sucks! Is it the state or the federal government that controls these insurance companies and their policies? What irks me is that working in a law office, we often get cases where people’s PIP insurance pays 80% of a medical bill, then when the case settles, we call and usually get the balance reduced or waived completely. However, if the person didn’t have insurance, it would have cost more to see the doctor in the first place, and they never waive a portion for the person who pays cash. I don’t understand why the same procedure costs less for an insurance company than cash-out-of-pocket. You’d think it should be the other way around.

    Liked by 1 person

    • I agree. We offer a 30% discount for cash paying patients for that reason. Insurance companies never pay us what we bill so why should they? State and federal both have a hand in it, but this particular situation is spear headed by the healthcare/hospital corporations themselves.

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