Thursday, 26 May 2011

Something horrible

I just learned something horrible about US health care. Now, I have been living it for the past several years, and I know quite a bit about how horrifically stupid the payment system is. Practically every US resident has had at least a minor experience of inconvenience that is incomprehensible to most Canadians. But I just learned from someone something that takes the cake and that I never realized.

OK, so, I always knew that American health care providers, no matter how compassionate, practice wallet-based care. Even the ones who give pro bono care at charity institutions are doing so in the knowledge that they are forgoing payment---and give care only to the very poorest.

So, fine, *sigh*, that is health care kepitalism for you. If you're the uninsured working lower class, you're pretty much screwed. I don't like it, it's inhumane and absurd, but that's what falls out of the belief system that underlies it.

But here's where it gets weird---for people who are lucky enough to have employer-sponsored insurance.

To control costs, US private insurers have special deals with certain family doctors and specialists. The big ones, with a very large number of them. This is called an insurer's "network". Under normal circumstances, this actually works out not all that differently from, say, OHIP (or substitute your province's plan) plus a user fee. If you go to an "in-network" doctor, you show the card, pay a (relatively) small user fee, and you see the doctor or have surgery or whatever. The insurers act like OHIP/whatever in this case and negotiate lower rates for themselves in exchange for driving business to these doctors. So you have to do some due diligence to make sure that you go to an "in-network" doctor. A US insurer is, in theory, like a sort of decentralised provincial provider.

But if you go to an "out-of-network" doctor without insurer-negotiated fees, you either bear the full cost yourself, or many plans pay out 80% and make you pay 20% of that doctor's fee in order to discourage "out-of-network" use. OK, so far so good, you can avoid these doctors. (Actually, many people---Americans---don't realize...)

Or can you? Say you're having surgery. That can involve a bunch of medical professionals. So, you show up, talk to your surgeon's assistant, find out that s/he is "in-network", and get onto the operating table. And it's all good. Right?


Quite a few of those professionals, you see, may NOT actually be "in-network." Particularly anaesthetists and pathologists and so on---the latter you might not meet or know is treating you. Oh, they may be working in the hospital or clinic. But they all bill separately.

So, a few months later, you could find a nasty surprise: a bill from your anaesthetist. And guess what. Being "out-of-network", the anaesthetist or whatever can bill whatever they want, and your insurance can pay either 0% or 80% or whatever. But of course, the anaesthetist has no incentive not to bill thousands of dollars for a half-hour's worth of work.

And despite the fact that you had no idea, you are now in potentially unexpected debt-peonage to an anaesthetist---since medical bankruptcy has been made very difficult.

But, it gets worse. Billing errors abound. What if, say, your "in-network" doctor fails to keep his/her registration with the insurer current. Then the insurer won't pay the full-amount. So, you'd imagine, this is the doctor's responsibility, since s/he made the error, right?


It's your job to pay the entire bill, or the portion that the insurer won't pay for "out-of-network" costs. Even though it was the doctor's billing error.

THAT is why people who tell you that medical care should be subject to the "free" "market" should be put in the stocks for months. Not just the inhumanity of the idea---that is ideology---but the inherent lying and fraud involved. That is also why the doctors (specialists) are greatly at fault in the US system, not just the insurers. Because doctors can choose to put their patients into debt-peonage.

I had no idea until someone explained it to me, and apparently many Americans born and raised here have no idea either. You're screwed despite the fact that you have good insurance. So you can do everything right and still be wrong.


double nickel said...

My fully insured sister-in-law from Minneapolis once had to shell out $10 G's for emergency surgery for her daughter because she had the misfortune of becoming sick in her hometown 200 miles north of the city, where the physicians were all out of network.

Anonymous said...

The NCC ws founded on this issue. They objected to the gov't insurance not the gov't run hospitals.

The Mound of Sound said...

Yes, US "free market" healthcare horror stories abound. They can't understand why their health outcomes are so miserable compared to universal healthcare nations. So they try to blame it on obesity, smoking and gunplay which most credible studies have already factored in. They pay vastly more, they get vastly less and they're left sicker at the end of the day. 30 cents of the US healthcare dollar is siphoned off to administration costs associated with private healthcare regimes. Then you factor in malpractice claims and insurance costs that leave doctors so terrified that they prescribe all manner of unwarranted tests and procedures just to cover their asses.

One of my favourite healthcare horror stories is about the lady a whopping bill for ambulance and paramedic services because she failed to get them "pre-authorized." She wasn't able to seek pre-authorization because the car accident had rendered her unconscious.

American healthcare sucks but many of them are deluded into believing just the opposite.

Anonymous said...

So why isn't someone turning this great post into 3 paragraphs and a glossy to be left at all doctor/hospital waiting rooms?

James said...

oh irony! this just happened to me. I googled it & arrived at this blog. And yes it was the anaesthetist. So friendly & charming knowing he was going to stiff us shortly after!

Námo Mandos said...

Huh! This post has only been up for a couple of days and it's already getting comments from random victims on the Internet. Just goes to show.

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