Before we begin, let’s admit that a complete list of behind-the-scenes actions would fill several books. In our limited space we are trying to provide a sense of appreciation for what most folks don’t realize. Keep in mind:(1) any attempt at a national health plan will need to address ALL these unrealized activities; (2) they change because the world changes either due to regulations, pandemics, economics; (3) the priorities change as other factors change; and (4) the organizations that pressurize the scene are in themselves dynamically changing constantly. Let’s get specific…To view any game you need to know the “players”. In this game we have providers of care (doctors, hospitals, etc.), insurance companies, big “pharmaceutical companies, employers and, oh yea, you—the consumer. All these “players” have different goals and go about reaching them in different and sometimes conflicting ways. Profiting by providing medical care/medical insurance was at one time considered heresy…no more. Some insurance companies deny all claims the first time they are submitted just to hold onto the funds a little longer. Next, managed care plans…These use doctor and hospital networks as their “in-network” providers. In return for a hefty discount, the employer will send his/her employees to specific providers of care–thus filling up the waiting rooms of those docs and hospitals. Did you know that self-insured major companies–those who accept and pay claims from their own funds- DO NOT ALWAYS GET THE DISCOUNTS EVEN THOUGH THEY BUY INTO THE INSURANCE COMPANIES’ NETWORKS? And then we have the term “case management”. This process allows the insurance company employee-doc to second guess and direct the care for seriously ill/injured individuals even though the company doc never sees the patient. It’s all designed to save bucks for the insurance carrier and/or the employer. Hospitals use what they term a “discharge planner”. Originally this person’s role was to keep a specific number of beds available by looking over the admitting docs shoulder every step of the way. Today that position has been politicized to the point that discharge planners try to hang on to good paying patients as long as possible; and discharge poor paying patients asap. It got so bad with low paying Medicare patients that Medicare instituted a “re-admission penalty” for any Medicare individual who was re-admitted within 90 days. The logic was that the care was incomplete when the first discharge occurred…the hospital just wanted to rid itself of a low paying customer. Think how that might play out in a national health care plan. Now to “big pharma”. Remember the epi-pen debacle of a few years ago? So many games are played with drug costs that many books have been written on just that topic. A current scam is the availability of some drugs on a “0” cost basis until you’re hooked. That’s when the pharma company contacts your doc and coordinates an on-going Rx that somehow gets OK’d. And finally we address malpractice insurance. Did you ever stop to wonder whether your docs graduated first or last in his/her class? You’ll never know but shouldn’t you have that info if you’re going to put your life and the lives of your family in their hands? Consider all the docs who are now in group practices. Some groups have high performance standards — no doubt. But some may be a collection of docs who couldn’t afford the malpractice premiums if they were sole practitioners. Think about it. There are so many other “sidebars”—as the lawyers call them– but space does not permit listing all we know. Just remember: you are the patient and you have rights…ask questions…do your internet search on your docs and feel comfortable about your choices. As a doc once told us “doctors will stop acting like gods if patients will just get up off their knees”.
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