Tuesday, August 27, 2013

Is Health Insurance Racketeering?


I am a firm believer that the Affordable Care Act will be bad for America.  Many others firmly believe that as well. Without going into great detail the facts can easily be found in many places I and others have referenced for the public.

The law insures a stable platform for insurers, and despite being required to spend 85% of the premium dollar on patients it solidifies their positions and markedly reduces competition in the market place.  Lobbyists and organized medicine (AMA) passed this law ignoring most physician’s opinions.  Only about 150,000 MDs belong to the AMA out of over 800,000 MDs in the U.S.A.To add to that many of the members are students and trainees who receive large discounts for membership.

The A.M.A. holds the copyright to  the CPT codes which are mandatory for billing insurers and Medicare/medi-cal actually covered by a copyright held by the American Medical Association, which refuses to allow any free or open distribution of the codes (known as Current Procedural Terminology (CPT)). That's because the AMA makes about $70 million per year "licensing" the codes.

On the other hand,

The ICD-10 is copyrighted by the World Health Organization (WHO)External Web Site Icon, which owns and publishes the classification. WHO has authorized the development of an adaptation of ICD-10 for use in the United States for U.S. government purposes. As agreed, all modifications to the ICD-10 must conform to WHO conventions for the ICD. ICD-10-CM was developed following a thorough evaluation by a Technical Advisory Panel and extensive additional consultation with physician groups, clinical coders, and others to assure clinical accuracy and utility.

While all physicians are highly motivated to care for all, the sad fact is that Obama care will not provide any sort of guarantee.  It is very complex and also fatally flawed financially and administratively. There are other fundamental flaws in the system not addressed by the Affordable Care Act.

American physicians and healthcare providers are not ready to be bull-dozed anymore by insurers, HHS, CMS and other governmental agencies.  We are fast approaching a ‘non-violent’ disruption of the current paradigm in healthcare. No physician is going to self destruct in the short or long term.

Some physicians are reticent to express their strong convictions for fear of alienation and/or reprisal by some other physicians and hospitals or government agencies. For instance in Massachusetts it is mandatory for an MD to accept Medicare to hold a medical license in that state.

Health insurers and Medicare/medical have developed “provider panels” who have agreed to arbitrary one way standards.. Insurers have no inherent legal right to set standards. Those duties are assigned to state medical boards and specialty boards. These boards are qualified to certify and license physicians as specified in state laws.

Insurers have a self interest to their shareholders and themselves to guarantee a profit.

It is redundant for an insurer to repeat the process of “credentialing” providers other than asking for documentation.  Furthermore it is even more ridiculous to attempt to supervise what providers can order or prescribe for diagnosis and/or treatment.  Our confounding event is when the insurance company won’t pay for the required service.  Unfortunately the insurers never speak  directly to their insured to tell them this directly. The message is usually given to the doctor, hospital, lab or imaging facility.  Insurance companies like to pass the buck.

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Many patients discover the costs of tests and procedures in non hospital facilities are much less than a hospital. Often 75% less than what is quoted to an insured patient.  There are several reasons for this. First hospitals are subject to  a litany of regulations and requirements which create significant expenses. Hospitals are subject to regulations and standards which may or may not add quality or value to your hospital care.  We all know about the $100.00 aspirin tablet, or a liter of salt water for $ 500.00. Really ?!  The hospital covers it’s fixed overhead much more than it needs to cover the non-reimbursed patients expenses, the losses they suffer at the hands of Medicare and medi-cal, the recapture of overpayments from Medicare years after the fact.

Despite the ACA having been passed and it is the law as some say..Prohibition was also a law that backfired and caused much harm and developed an underground market (black market)

Is  U.S. health care headed in the same direction?


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