Tuesday, November 4, 2014

Can Medical Care Be Free?

     I'll start with a personal note. I recently made an appointment for my annual checkup and was told that if I wanted to see a physician's assistant, then the checkup would be free -- fully paid for by Medicare -- but if I wanted to have the checkup with my doctor, then it would cost me $185.

     Would my Medicare Advantage plan pay the $185? No. Medicare Advantage only applies when Medicare has already paid its share. If Medicare doesn't pay, then Medicare Advantage doesn't pay. So, if I want a checkup with the doctor, I have to pay $185.

     At first, I was appalled. I thought medical insurers want us to focus on prevention, which is what an annual exam is all about, because prevention costs less than treatment. And my doctor knows me a lot better than a physician's assistant who's never even seen me before. So I feel like I'm trying to do the right thing, yet am being penalized for it (although I do not know if this policy is set by Medicare, or somehow set by my medical group).

     But I recalled a conversation I had with a friend of mine recently. Honestly, I wouldn't want to trade places with him. His wife has Parkinson's and a few other medical issues. He has a family history of heart problems, and has been wearing a pacemaker for several years now.

     Last spring he went into the hospital to have his pacemaker replaced. He was complaining about the bill. He said the original bill came to $135,000 for the procedure. His insurance company (he's not yet on Medicare; he still has medical insurance through work) negotiated the fee down to $70,000. Then the insurance company paid $63,000, or 90 percent.

     So my friend got billed for the $7,000 balance. He refused to pay it. In his view, if the insurance company was only going to pay $63,000, then it should have negotiated a $63,000 price. Why should he be stuck in the middle?

     Now, mind you, my friend could afford to pay $7,000. He's a lawyer. He's not rich, but he makes a good salary (even though, at age 66, he's scaled back his working hours). Anyway, his pay is at least good enough for him to own a second home in Florida and drive an Infinity.

     But I could see, he really didn't think it was fair for him to have to pay $7,000 for his pacemaker. Then he revealed that the hospital is now suing him for the money. And he expects to turn around and sue his insurance company.

     Now, put aside the fact that he's a lawyer and is more familiar with the court system than most of us. He's disputing the bill his way. But I wonder if I was in his position, would I dispute the bill? I'd do it my own way -- probably call them up and plead poverty and try to settle for a lower amount -- but would I be right in trying to get out of paying that $7,000?

     Then I read a story in the NY Times called "Unable to Meet the Deductible or the Doctor." A woman got insurance through the Affordable Care Act, but the policy has a $6,000 deductible. (By comparison, according to a survey by the Kaiser Foundation the average deductible for individual coverage in employer-sponsored plans is $1,217.) She had a brain aneurysm in 2011. Now she's supposed to get a brain scan every year. But according to the report, she skipped the brain scan this year -- because she'd have to pay for it herself, since she's responsible for her first $6,000 of medical bills.

     The idea behind a high-deductible plan is that it protects people from going bankrupt if they get a severe illness. But it leaves them on their own for less-than-catastrophic situations. And in many cases, people will simply skip the care they need, because it costs money. Sometimes they can't afford it at all; sometimes they can afford it but it would cause some hardship; and sometimes they just don't feel like they should have to pay.

     The Times story cites another woman who has a plan with a $1,000 deductible. She avoided going to the doctor for an ear infection, because she'd have to pay for it herself. Another person was "shocked" when they were billed "over $1,000" for an emergency room visit. And the list goes on.

     No one expects doctors and nurses and medical technicians to work for free, do they? And all that machinery costs a lot of money. We're not outraged when we have to pay our rent, or use our own money to buy a car or go to the grocery store -- all expenses that are just as necessary as accessing medical care. So why are we outraged when we have to pay a few hundred, or even a few thousand dollars to save our lives, or extend our lives, or alleviate excruciating pain?

     One problem with medical bills is that they are so arbitrary, so random, so completely out of our control . . . and so ridiculously high that they seem unreal. It's like funny money.

     I don't know the answer. But I'm not so outraged anymore that I have to pay $185 to see my doctor. I just hope he doesn't find anything wrong with me . . . I'm not sure I can afford that!

17 comments:

Florence said...

Tom, I have Humana Medicare Advantage Gold plan and I see my doctor every year for my annual physical and do not pay a co-pay at all. You might want to see if it is available in your area.

In all honesty though, I think a single-payer, universal health care plan would be more much efficient than the current morass we all currently try to muddle through. IMHO.

Anonymous said...

We have Kaiser advantage for seniors we pay thru our union and it is not cheap..we only get DO who are young and happy to be working..I went to their hospital for the endoscopy and colonscopy and it was fine..But I notice how the employees work 10 to 12 hour days and they are miserable in some areas, so I get in the first one in x-ray for mammogram and other stuff I need to have the lab ladies and gentlemen are nice, I don't use their pharmacy too expensive cheaper at Target..One must navigate everything growing old is not for sissies at all, one must be vigilant or one could end up paying for a bunch of shit you don't need or want, just my opinion, we are not wealthy people at all, the lawyer you speak of sounds like all the other professionals I hear bitching when waiting to see my DO who is always on some grand vacation someplace hmmmm?

schmidleysscribblins.com said...

Tom, cough up the $185. Owing to lack of foresight on my part, I have limited dental coverage and as a result, I have laid out $3000 for dental bills this year. I'd gladly trade.

I have been told by medical administrators I know that the Affordable Care Act is the culprit behind many of the changes in Medicare, such as no longer paying for certain medical equipment.

However, as usual, the pols keep us giving spin. The most burdensome changes have been postponed until after the 2014 midterm elections, so by the time they kick in, we won't understand why the changes are occurring.

I was attacked the last time I wrote it, but the ACA is deriving some of its coverage via changes to Medicare Advantage plans. (David has one through he former employer.) The thinking seems to be if you got one, you can afford to pay. Don't know if this is true in general, but I suppose we should be grateful for anything the government covers these days.

Please read Atul Gwande's last two books..'.Better' and 'Being Mortal.' Excellent.

Linda Myers said...

We have Group Health Cooperative of Puget Sound Medicare Advantage coverage. My husband had a cardiac arrest in Tucson last year. No reciprocal medical agreements between Group Health and any facility in Arizona. The bill was $212,000. Our share? $1,050 for three days of hospital visit copays. Guess we're lucky with our coverage.

I also had my annual wellness exam just last week, with no copay.

Dental insurance for retirees is dreadful. $51 a month in premium for a maximum $1500 of expenses. So far we're covering our own, but sitting here with a toothache I wonder at the wisdom of that.

DJan said...

I have a Medicare Advantage plan that is decent, but I pay what I consider to be a fair amount for it. My sister who lives in Florida has a much cheaper and better plan, because there are so many more seniors there. My dentist is the largest amount I pay out every year, for coverage that is poor at best. One day perhaps we will have a single payer system, bit I doubt it will happen during my lifetime.

Stephen Hayes said...

I guess I'd just settle for using the physician's assistant if it was just a routine medical visit.

Olga Hebert said...

The original bill was 135,000 and the insurance company got them to accept 70,000? So if you can't afford insurance at all, you would be billed the full amount so insurance companies can make deals. Or are the original prices hideously inflated to begin with? And I thought an annual "wellness visit" was covered under Medicare because prevention is the goal.

Madeline Kasian said...

I am a Nurse Practitioner and a retired Medical Office manager--I assure you MEDICARE does not insist you see a P.A. vs. your Doctor.YOUR DOCTOR"s OFFICE has instituted that policy. A medical practice can pay an NP or a PA much less than another physician! And they usually have the PA's and NP's do ALL the "routine" work such as patient physicals.

Of course, I am biased, but I believe NP's and PA's usually give BETTER care than the M.D.

Get to know your PA and make sure to bring up any specific history you think they need to know when you go in for your physical.

Good luck!

P.S. Your insurance policy is a contract like any other contract and you are liable for the % of copay that goes with the contract you purchased!

Pam said...

Madeline has spoken truth. Medicine is a business and management decides fees and practices. My daughter is a nurse in a clinic setting where NPs and PAs provide the majority of patient care. The training they receive prepares them well for general patient care. In the past few years, most of our friends have opted to see PAs or NPs for general health care, and have been very satisfied. As for the future of healthcare in our country, I'm afraid that huge gap growing between the rich and poor will be evident in the quality of health care we receive. Those who can afford care will receive it, and many will fall between the cracks. I wish everyone were entitled to excellent health care...and good food to eat...and a warm home, but who's going to pay?

Barbara Bomberger said...

While I appreciate that you doctor "know you", I also encourage you to give a PA or nurse clinician the benefit of the doubt. I see the above for my skin, gyn, and other checkups and am thrilled. My son sees the pa in our practice since he's a guy. In both cases I had issues where I've had a docs treatment or surgery but the pa was extremely thorough.

Anonymous said...

We don't have dental insurance the dentists in our county are the highest in Washington state! Seattle has free dental insurance for seniors at clinics run by in my opinion dentists who are angels on this earth, the largest printed newspaper showed the long lines for free medial and dental help at Key Arena the basketball areana twoweeks ago, we will never get it here in Clark County even Portland Oregon dentists are cheaper, I guess they figure if you live in Vancouver Washington you are gonna pay cause it is a sweet community..but one cannot go the food bank regularly it is running low, no dental place here for people on retirement and social security budgets, no living wage jobs how wonderful can it be, if I could have gotten a decent govt. job in seattle in 1978 we could have gotten a much better home cheaper, wonderful suburban schools and our daughter would have graduated from the Uof W. university if Washington but one cannot go back in time..I just get pissed that people think that this area is so damn wonderful with no housing reasonable, no decent jobs, no medical or dental care reasonable how wonderful can it be and many are starving fleeing from Portland and from California and it does rain about 200 days of the year so it is damp and cold no thank you we are considering moving to another area which is open to seniors...I mean kinder to seniors!!!!!!!!!!!!!!

Anonymous said...

I get my physical each year from a CNP, takes much more time than the doctor.

Tom Sightings said...

Hmmm, maybe I WILL see the physician's assistant instead ...

Janette said...

I see a Dr like I see a dentist. I get the work done by the PA /hygienist and the Dr looks over the work.

My nephew (30Yr old) has had several heart issues and has been fully covered- until this month. He finally lost COBRA and has not yet signed up for ACA. He went to the hospital on Saturday. YoW! They did not even admit him for lack of insurance - he was stable.

One payer system. It is the ONLY way to go!

Anonymous said...

I am befuddled by your lawyer friend. He's lucky to have health insurance through employment -- with a company that can negotiate against the provider -- a huge advantage. His plan covers 90% of incurred expenses. If they negotiated to $63,000, he'd still owe $6,300 per his existing plan parameters. I'm not a lawyer, or a HC professional, but I can't understand his outrage. There are very few employer-sponsored plans out there that would cover 100% of incurred expenses. He should pay up and be happy, or find a job with Google.

Kirk said...

We have a friend who's a GP. Her practice is forced to charge Obamacare patients up front, since they almost always skipped paying other than the initial copay.

Insurance is pretty much worthless if you can't afford the deductible. For a lot of these people $6K does mean bankruptcy.

And I would have let the PA do the physical. When traveling I've had complete physicals done at Bumrungrad hospital in Bangkok. All the tests are done by PAs, and a doctor reviews everything at the end. These people are better at doing the routine testing than physicians anyway.

Dick Klade said...

I had a terrible experience seeing a PA when my regular doc wasn't available. I was put on the wrong meds and went from mildly sick to extremely ill. Went back, and my doc rebuked the PA, changed the whole regime, and apologized. I'm confident many PAs are just fine, but that one wasn't. Sorry if this makes your decision more difficult, Tom.