"Sonny's Corner" is a regular column in Prairie Fire, featuring commentary on civil rights and justice issues. Our friend and Omaha colleague, Joseph P. "Sonny" Foster, died suddenly at age 54 in August 2005. He left an uncompleted agenda, as did many of our civil rights and justice mentors and heroes. We shall attempt to move forward on that unfinished agenda through this column.
Tyler Williams is a pen name for the following essayist, but the bio at the end of the essay is an accurate description. Loyal readers of Prairie Fire who have read our mission statement (twice published on the front page of the paper) may remember the possibility that, from time to time, pen names might be used to protect the personal or economic well-being of the author. This is the first time in five years that we have used this policy. We do not believe that the failure to reveal the true identity of the writer in any way diminishes the importance of the message within the following essay.
Heaven forbid you get something stuck in your rectum. Let’s overlook the how, what and reasoning behind (sorry) your ailment and think about what happens when you walk gingerly into your physician’s office and receive treatment/ medication/post-traumatic event counseling, etc. Perhaps you didn’t realize it, but the reimbursement your physician will receive for rectifying (again, sorry) your situation will most likely differ based on the health insurance you have. We’re not talking about the variance you as a patient will pay based on plan, coinsurance, deductible or premiums; we’re talking about the money the physician gets.
If you have United Healthcare, your doctor might get one amount, say $75.34. If you have Humana, it could be just $40.28. Those amounts could also differ depending on which contracting group or groups the physician associates with in his or her market and the way in which the physician bills the service (as outpatient surgery, minor procedure or accompanying different levels of exams). Of course, if you have Medicare, Medicaid or Tricare (military health benefits), the physician could also receive different payment amounts, or none at all.
Each one of these differing amounts has been painstakingly negotiated.
Oh, yeah, the CPT procedure code or codes used on claim forms for “removal of foreign body” or the appropriate Evaluation and Management (E/M) code has also been determined, negotiated and periodically reviewed and revised by a different bureaucratic process.1 So have the diagnosis codes, modifiers, revenue codes and format of the claim form.
Directly or indirectly, each of those negotiations has involved numerous health care administrators, consultants, attorneys and their counterparts over at the insurance plans and/or government. The outcome of these negotiations results in changes to the way physicians’ bill services and must be communicated and implemented by coding specialists, office staff and accounts receivable departments. Starting to get dizzy? That’s a different code.
While the regrettable matter of an item getting lodged in your bottom did not, itself, raise the price for health care, the determination on how much the physician should be paid for removal of such item was an enormous pain in the butt, and one that raised the price of our nation’s overall cost of health care in ways that are impossible to calculate.
Right now there is a push to raise the eligibility age for Medicare from 65 to 67. The logic seems reasonable enough; people are living longer, no one currently closing in on that age will be affected as the change won’t take effect for many years and the new Accountable Care Act will guarantee that insurance companies cannot reject enrolling someone based on previous conditions. The governmental savings aren’t even reasonably questionable.
The overall cost, however, has not changed. We’ve just rearranged deck chairs on the Titanic. People aged 65 and 66 will still need insurance coverage, and this will need to be paid for by either employers, the individuals themselves or state governments that will need to add low-income seniors to the Medicaid rolls. The addition of these older people to the existing insurance pools will raise the cost for all younger and healthier participants. Costs have simply been removed from the government’s ledger.
So how do we lower the cost?
Per capita, we spent $7,960 on health care in 20092—the latest year that data is available for all industrialized countries. For that amount we received care that was, by most benchmarks, pathetically lower than the rest of the developed world. According to the nonprofit Population Reference Bureau, in 2011 we had an infant mortality rate below 47 other countries and should expect to live shorter lives than the people of 40 other countries.3,4 Of course, none of these countries pay near as much for their health care. Norway is the closet to the U.S., spending $5,352 per capita.
So, we spend more and get less with almost no debate on ways to change and lower the price; we merely shift who pays how much of the bill.
As Nicholas Kristoff illuminated in a 2009 New York Times article, there is one group of the U.S. population that enjoys the world’s best health care according to almost all measurable criteria, and it’s the group receiving socialized medicine.5 Medicare beneficiaries have the best end-of-life care and the cheapest medicine, hospital stays and treatments of any seniors on the planet. Critics of any kind of socialization of medicine are quick to point out per capita spending per Medicare beneficiary is higher than the national average but fail to recognize that the costs of covering seniors is always going to be higher than the national averages, regardless of overall costs or where that burden lies.
It’s undeniable that significantly reducing the myriad of bureaucratic expenditures—which results from negotiating the ways and means of reimbursing health care providers for privately insured Americans—could dramatically reduce the amount physicians would need to be paid in order to recoup enough to pay the salaries of coders, administrators, regulators, attorneys and clerical positions currently inflating our health care spending. A single-payer system could do this. Adding the increased cost of senior care would be more than covered by the savings.
Reconsideration of the fee-for-service model itself might be an even better place to begin the reforms.
We can temporarily ease the pressure a particular segment of the economy feels from our bloated health care system. We can shift costs and cope with a deteriorating condition that will eventually become terminal. But until we remove the offending impediments to lowering costs, we will continue to suffer with an increasingly irritating obstacle up our national ass (not sorry).
1. Gregory Warner Marketplace for American Public Media, www.marketplace.org/topics/life/health-care/battle-over-billing-codes