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?

Wrong.

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?

Nope.

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.