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Health care as seen from the other side

Clinic office assistant Joan Vest searches for a patient's misplaced medical file at the Spanish Peaks Family Clinic on in Walsenburg, Col.

TEXT OF STORY

Kai Ryssdal: Today we're going to start an occasional series called The Cure. About the remaking of the American health-care system. Where the real costs are. And the savings, too. Up first, the inner workings of a typical medical practice. Did you ever wonder, for instance, what all those people on the other side of the counter are actually doing? And why there are so many of them? We sent Marketplace's Tamara Keith to find out.


TAMARA KEITH: It's one of the first questions a new patient hears when they come into a doctor's office.

DOCTOR'S OFFICE: May I go ahead and copy your insurance card and driver's license please.

These days, dealing with insurance is a huge part of any medical practice. A recent Cornell study found nationwide it costs doctors $31 billion a year to deal with insurance companies. That's about 7 percent of all spending on physician and clinical services.

At Ortho Bethesda, an orthopedic practice in suburban Washington D.C., there are eight doctors on staff, and 14 people in the business office.

SHARISSA DYKE: Hi Rob. My name is Sharissa, and I'm calling to verify medical benefits for a patient.

Sharissa Dyke is an insurance verifier at Ortho Bethesda. She basically spends every day checking whether patients have insurance and what their plans cover.

DYKE: Is authorization required for outpatient MRI?

OFFICE WORKER: No ma'am.

DYKE: And who do we send claims to?

Ortho Bethesda deals with more than a dozen different insurance companies. They all have different systems for filing claims. And each company has a bunch of different plans, each with varying co-pays and deductibles and rules about whether pre-approval is necessary. This keeps the business office busy and irritates doctors and patients.

DOCTOR: She's Aetna, and she had acute injury to her knee a week ago.

A doctor walks into the business office with a patient's chart and a sense of urgency.

DOCTOR: And she needs an MRI to evaluate for a PCL tear. And I'm not sure if her flavor of Aetna needs authorization.

The MRI will help determine whether the patient needs surgery. Sometimes it can take several days and lots of paperwork to get approval from the insurance company. Other times, it's 15 minutes on the phone, only to discover.

OFFICE WORKER: Based on the information provided this particular Aetna member's plan does not require pre-authorization for service at this time.

This drives Dr. Edward Bieber crazy. He is the managing partner at the practice and an orthopedic surgeon.

Dr. Edward Bieber: It's time consuming, it's expensive to our office, and it takes up a great deal of my time that I would like to spend giving care to the patients rather than shuffling their papers.

Bieber says he's never had an insurer deny an MRI, so why all the red tape. But insurance companies say requiring approvals cuts down on unnecessary tests. MRI's cost somewhere between 500 and a few thousand dollars depending on the type. Susan Pisano is with America's Health Insurance Plans, a trade group.

SUSAN PISANO: High-tech imaging is being greatly over used and misused. It affects out of pocket costs for consumers. It affects premiums. It affects quality and safety.

Pisano agrees doctors shouldn't have to deal with so many different billing systems. She says her industry is working on it. Later this year her group will test an online system where doctors can access information and use standard forms for all of the insurance companies in their region.

PISANO: The estimates suggest hundreds of billions of dollars could be saved if everybody is using the same rules.

The American Medical Association, which represents doctors, is trying to get some of that provision written into new health-care legislation.

But that alone won't eliminate a huge source of back-office costs: Dealing with a multitude of insurance companies who each have different rules for which procedures they will cover and how much they will pay. Until that changes, there will continue to be more office workers at Ortho Bethesda than there are doctors.

In Washington, I'm Tamara Keith for Marketplace.

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We have been fortunate to have health insurance through various employers for many years. But year after year the premiums go up as the benefits go down. Then there's the constant threat that an injury, illness or change in employment status will result in the loss of coverage just as the need is greatest, followed by financial ruin. It would be difficult to design a more perverse system.

Some say that healhcare reform will reduce Americans' freedom of choice. But for most folks under our current system, the choice of doctors, hospitals, drugs, etc is limited by an insurance company, which in turn was chosen by the employer. Is it really better to have an insurance executive "between you and your doctor" than an unbiased government administrator? We would much rather pay taxes to finance a system where all Americans are in it together under a single "risk pool" than premiums to support an insurance industry that strives to cherry-pick only profitable customers. The insurance industry isn't evil or greedy, it's just an unnecessary middleman in the healthcare equation.

We support reform of the nation's healthcare financing system and believe that a nation-wide single-payer model is the best way to achieve broader coverage at lower cost.

My experience with COBRA over the past 18 months illustrates so well the waste and bureaucratic nature of our current health care system.

I was laid off in April of 2008, leaving one insurance program as an employee into COBRA coverage with the same insurer. I had to submit several documents and was issued a new, but identical set of insurance cards.

I was employed as a contractor, in September of 2008, moving into a new program with a new insurer; more forms and a new set of cards. That contract ended in February, 2009. I moved into COBRA for that insurer, requiring more forms and another set of cards. For some reason, I received and was told to use a second set of cards in March.

I then returned to that same contracting firm, leaving COBRA and back on the same insurance program I was part of earlier, but still had to submit more forms and received yet another set of new, but identical cards.

I know I am fortunate to be able to get such coverage, either as am employee or under COBRA. But we have to ask ourselves how many other Americans could have gotten coverage for the costs of supporting the bureaucratic efforts of my coming and going in and out of COBRA, and several times within the very same insurer.

This is a large waste of resources and only adds to the inefficiency and costs of our current health care program.

I am dismayed that the discussion about healthcare has myopically focused first upon whether or not people are insured, as if becoming insured is a magic bullet that will resolve our health care woes. The media and some members of congress have also amplified the concerns about whether or not a government health insurance plan will mean that the government will stand between us and our doctors. The truth is that health insurance companies are standing between us and our doctors by rationing, delaying, and denying care, and skimming 20% off of the top of our healthcare budget. Insurance companies are beholden to stockholders and the bottom line. One would like to think that the government is beholden to the people.

I have yet to hear a reasoned news report or speech that provides an honest comparison between our system and the systems that are in place in other countries. While the U.K. and Sweden have single payer government run systems, Canada and Germany have not-for-profit private systems. I would like to know more about how these systems work, and the benefits and drawbacks of these examples.

Shall I display my dismay and sarcasm that once again, studious voices of reason and erudition are taking the back seat to the fear mongers and naysayers? I guess I don’t feel like being sarcastic. Last year I spent half of my income on health care. I have a degree, a good job, and a health insurance plan. Unfortunately, I also have an obscure pre-existing condition that means chronic and sometimes debilitating pain; the sort of preexisting condition that has allowed me to see just how impressively health insurance companies wield their mastery in rationing care. This condition has meant having to make as much money as possible to afford medical care (and therefore taking a job I do not like and delaying my dreams), giving up on saving for retirement, resigning myself to debt, and about 15 hours a week getting to and from doctors offices and doing the “homework” that is prerequisite to getting well.

And, just in case you were wondering, I exercise WAY more than most Americans, eat a carefully planned, healthful diet, have been at this for half of my 36 years, and consider myself an active partner in becoming well. I know plenty of other people like me in the same boat. I have actually considered that we would be better off moving to Sweden, the U.K. or France, and have seriously discussed this with friends.

Did I mention that our government is already running 3 efficient healthcare delivery systems?

You have left out of your report tonight that the phrase "no pre-authorization required" is not a guarantee of payment. That's the standard disclaimer of the insurance industry. I am the Billing Administrator of a four physician plastic surgery office. Additional time is further wasted after the service is rendered and the insurance company gets our claim. We may have secured an authorization to repair the cleft palate of a child (for example), but the payer will still "pend" the claim for review of its medical necessity. It's very frustrating for patients and physicians alike, not to mention costly. Thank you.

Your show disclosed that 7 percent of all spending on physician and clinical services goes to dealing with insurance companies. Now would be a good time to ask a hospital why they are willing to accept approximately $28 per X-ray from an insurer, while a self-paying patient has to pay approximately $250 for the same service, even though he is willing to pay cash at the time of the service. It seems to me that a hospital (or for that matter a doctor’s office) would prefer to take $28 in cash at the time of the service. Quite to the contrary, hospitals are rewarding the slow-paying, difficult-to-deal-with insurance companies. Furthermore, hospitals will not disclose how much they pay to an insurer. Is there something to hide?

My husband is boarded in Internal Medicine and Geriatrics. He gets very frustrated when NPR and PBS and AMP spend so much time at medical specialists'
offices. One of the crucial problems in US medicine is the abundance of specialists and the lack of primary care providers. If the percentages were inverted, we may be able to support the health care needs of the people of the United States.

Not long ago a doctor made a snap diagnosis, decided I had an extremely serious medical condition, and told me to get a CAT scan. Now we're talking about a big dose of radiation in this case. I was dubious, since I had none of the risk factors for that problem. I got a second opinion from a more experienced doctor and learned that the snap-diagnosis was wrong. Cost: second office visit. Savings: cost of scan and a lot of unnecessary radiation. This all happened in a health plan that did not require approval by the insurance company.

Your story on health care had some facts wrong... regarding MRI's - my insurance company paid $80 for my MRI not $500 to $1000 my experience was as follows: Dr. ordered an MRI of my lower back, Insurance company said no - not without doing 4 weeks of physical therapy first - (is the insurance company my doctor?) did the 4 weeks of physical therapy missing 3 hours of work per visit - 3 times per week that's 9 hours per week 36 hours total at a cost of $250 per hour - my billing rate - total lost work $9,000. No change to my condition, physical therapy didn't help, infact a few session aggrivated the condition. MRI gets authorized, the insurance company pays MRI company approximately $80. Insurance companies are not a value add proposition!

People need to remember that it is not always the insurance company setting what is and is not covered or what items need precertification. Most large employers in this country are self insured and therefore decide what are the covered benefits for their employees. Both company A and company B might use Aenta but have different precertification requirements. This creates yet another layer of difficulty for office staff. But what is more interesting is that patients and doctors often get mad at the insurer when they don't cover something when it is really the employer, who designed the benefit plan, they should be frustrated with.

The entire health care debate is bypassing some core realities:
Current system provides all the emergency care Americans need.
No system can give all the healthcare consumers can want beyond emergency care.
Employer paid healthcare is as outdated as lifetime emplyement expectations of today's workforce.
Insurance is spreading risk to many non users so a large pool can be made to pay for to an unfortunate user. Life insurance is an example. Health insurance is just bill payment for twenty-five percent operating cost. There is a better way- there has to be a better way.
Americans pay lot more for the same medications and other medical supplies than all other western countries. There is no reason for this except corporate greed and lying to American people.
Other people's money is paying for health care. No other person can say for you what you may not want to spend money for.
If we use these common sense realities we can save forty to fifty percent of our health care expense.
I am a surgeon in active practice, not a theoretical policy-wonk.

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