Archive for the 'health insurance' Category

Ain’t capitalism grand

August 17, 2015

So patients are supposed to be able to receive annual check-ups from their primary care physicians without paying a co-pay.  This has been presented as a relatively recent benefit in a developing health care system moving towards more enlightenment and lower costs.  I think this benefit comes under “preventive care.”  Under Medicare such an appointment is called an annual Wellness Visit, under private insurance, it is labeled something like an annual physical.

But if the patient has a condition or a potential condition for which they are being monitored, the doctor’s office bills it as a Wellness Visit and a Sick Visit, a physical and a routine medical visit.  For the second billing code there is a co-pay.  The “free physical” benefit has disappeared and become bait for having the patient come in for an appointment for which they owe a co-pay.

Capitalism found a way around and through an attempt to shift costs away from the patient.  A check-up is now only for completely well patients, patients with no medical issues.  The definition of a physical seems to have narrowed in order to re-balance the payment scheme back to where it had been before patients were given the free physical benefit.

Different people

November 17, 2014

I had this conversation with my mother that started off about customer service departments and whether part of the hiring criteria and training focus is to keep customers at bay.  The occasion was the good news that finally her health insurance transition has been accomplished.  We were also noting that the same benefits department that had made this transition take about 6 weeks of intensive work had also made mistakes on other of her benefits.  I will note that the news of the health insurance accomplishment was relayed to me by a doctor’s office (which was trying to submit a claim), not by the employer benefits department responsible for arranging the insurance.

We ended up talking more generally about whether people who have caused damage but present an impervious demeanor really do harbor a sense somewhere of having done something they at least regret and a feeling of feeling bad about that, however much they may wall off such senses and feelings.  (If they are too successful, I think they may find it difficult to get back in touch with that part of themselves that handles such things.)

I mentioned that I have thought on some occasions when someone has caused me physical and/or emotional harm that it is easier to be me on the receiving end than I think it would be for me to be on the delivering end.  I would probably feel worse.  She replied that that thought had never occurred to her and that it never occurs to her to think about what it might be like to be them in the situation — she said she just feels anger about it, for years on end.  She also thinks more people really do not have that sense of regret and that feeling of feeling bad that I imagine almost everybody has somewhere at some level of their being, even if they are pretty disconnected from it.

Sometimes I think different people are in some ways living in different worlds, as if we are in a sense speaking very different languages of the psyche.


More on accountable care organizations

December 17, 2013

So the Accountable Care Organization returned my call, and pretty promptly at that.  What was explained to me did not make a whole lot of sense, but maybe if I try to explain it, it will make more sense.

While the letter was pretty general about Medicare sharing information from other providers with this provider (the primary care doctor), which made it sound to me like coordination of care and case management, what the person at the ACO told me was that only information from providers who are members of the ACO is shared (with other members of the ACO).  So I asked why route the information through Medicare, why not have the member provider just share the info with the ACO directly?

One answer seemed to be that the information that the provider gives to Medicare may capture different issues, issues that may have gotten left out of the medical records themselves.  (No, putting it into an electronic format does not improve its accuracy or completeness, garbage in, garbage out, and all that.)  It seems that the ACO is providing oversight of the doctor, reminding them of preventive care that is indicated by the billing codes;  to provide a more independent check on the doctor, the information that is used is not reported directly by the doctor to the ACO.

Why the patient isn’t just asked to consent to the doctor sharing information with a supervisor is not clear to me.  I see that the way the written explanation of the sharing is structured would allow for the possibility of Medicare sharing any information they have, including from providers not members of the ACO.  The person I spoke to said they aren’t doing that.  I would say what she said and what the letter said are not completely congruent, and that if the arrangement is not about coordination of care and case management, then I’m not really sure what improvements in efficiency and outcomes they expect.  It sounds as if some of the purpose of this plan may just be to pick up the slack for care doctors’ offices no longer provide, like following up to determine whether there is compliance with care instructions and medication regimens, or following up to see if there is a need for support in order to do those things.

So it sounded as if this is about providing supports to doctors — reminding them of indicated preventive care and providing follow-up with patients.  Apparently doctors’ offices are not themselves positioned or structured to do that.  But adding this intermediate layer, including routing the information through Medicare, sounds expensive to me.  I guess it’s just the cost of doing business when human beings organize themselves into groups with the social and financial incentives we have.

If the ACOs develop into something more robust and effective, then I think we run into the issue of where a patient’s information will end up — then a tiny leak in one place, including in the course of transmission, could mean a whole lot of private information being compromised.  As it is, adding more social workers and such into the mix, in order increase patient compliance, will mean more individuals having access to patient information, including, for example, having the information on laptops they carry into cars to make patient visits.  It will be interesting to see how that all works out.  Visiting nurses already do that, but I’m thinking that multiplying the number of people with access to information increases the likelihood of compromised situations and mistakes.

I think I thought that ACOs would be more like structures located within the offices of the doctors’ practice (not be a separate organization) that would provide checks and would streamline organizational practices, etc., and that the information about patients would not be transferred to new locations or to new organizations.  I guess I am concerned that, like the Affordable Care Act’s exchange website, nobody has really thought through how the whole system will work when all the pieces are put together.

Oh, those electronic medical records!

December 17, 2013

I was reviewing my level of distrust with a situation I will describe below, and concluded that I, too, have been impacted by the “If you like your policy, you can keep it.”

I have multiple family members with Medicare, and one of them received a notice that their primary care doctor is becoming part of an accountable care organization (ACO), I assume as a result of the Affordable Care Act (ACA).  The family member may opt out of having medical information shared around among their providers through Medicare and this ACO.

In the past, admittedly in a different context, one of these providers has made a point of only sharing the minimum of information necessary, as the provider has seen problems arise.

So the family member is thinking about opting out of sharing.  But we are concerned that this could mean the family member will be told by the primary care doctor that the doctor can no longer be the family member’s doctor.

The notification letter tells the recipient to call Medicare, I did, and they don’t know if that can be a consequence.  The number for the ACO gives only a voicemail option, so I dutifully left a message.  The other option is an appointment with the doctor — but we’re supposed to pay a co-pay, not to mention time, energy, and parking fees, to talk about this?  Doesn’t seem appropriate to me.

In any event, I file this under (a) the unintended consequences of storing medical records electronically, (b) distrust created by misleading promises in marketing the ACA, and (c) distrust of the medical bureaucracy in general.

Cleaning up after others

November 16, 2013

I took in my garbage cans and recycling bins this morning.  The yard waste hadn’t been collected yet.  Instead, it had been added to.

Someone put very old Christmas decorations on top of one of the garbage cans I use for some of my yard waste.  It turned out to be a wreath and some sort of garland.  I clipped off the plastic cords and labels.  Jordan put them on the ground next to the can so that at least the collection folks will take our leaves.

The issue is that there’s a collection date (one) for Christmas trees and, I think, these other kinds of evergreen decorations.  It comes in early January.  I don’t know that they will be accepted as part of the regular collection program.  If not, then I’ve got somebody else’s detritus to dispose of, kind of like a game of hot potato.

It is more interesting to me than just that sort of potential hassle, because of the discussion about whether people with good health and particular lifestyles should need to contribute to the same insurance pool as people with bad health and lifestyles that contribute to their ill health — do we help clean up after others?

I’d say part of the answer has to do with, simply, whether we can and whether we are better positioned to provide the help than the other person.  If we can provide it, in some way that is effective and does not harm ourselves, I think we should at least try.  I think it’s a continuum, between no cost to ourselves and some cost to ourselves, and that different people draw a line in different places.

Public promises

November 13, 2013

I’ve written a number of comments expressing my reaction to the discrepancy between “If you like the health plan you have now, you can keep it” rhetoric and the reality of cancellation notices.  The discrepancy seems to be due to the fact that the power to control the situation and keep a policy was not left to the subscriber, in fact, not left to the person promised, but to the insurance company issuing the policy (that, and also because of a narrowly structured grandfather clause).

I think the grandfather clause should be expanded and the control left to the subscribers who currently exist.  I think the requirement to have comprehensive coverage needs to be phased in, in order to mitigate real harm to real people.  If this is not actuarially feasible, then the ACA was not sufficiently well-crafted, in my opinion.  I suspect it needed to have reined in the insurance companies on this issue;  if they hadn’t kept changing the policies of individual policy holders, more people would have qualified for grandfathering and there would be fewer people left with empty rhetoric and higher premiums.

But my point here was not to get into health care policy issues, but to sound off, again, on my life-long study of “empty promises.”  Here the promise was made publicly and there is no lack of evidence that it was made.  It did not have strings attached when it was uttered, it did not explain the structure and mechanics of the grandfather clause and how it would function in practice.  It induced reliance and could have been reasonably expected to do so.

A lot of people think this instance of an empty promise requires mitigation.  They see the actual financial hardship, they see the psychological cost to those who relied on the promise, they see the loss of good will.

I don’t have an individual policy, but I do benefit from the public criticism and call for mitigation, because it validates my sense that we don’t just put the burden on the person who was reasonable in relying on a promise that proves to be empty.  That is not our cultural consensus, is what I hear, or at least, it is an argument that people accept as reasonable, even if they decide for other reasons, reasonable or not, not to follow that argument.

Willy and I were once promised help with health insurance which never came through.  It was after botched medical care.  The ensuing damage to my health meant that the insurance I was currently eligible for was not adequate.  Willy was upset when this became a promise that was not honored, but his larger negative emotional reaction in this instance was to the damage to my health and to the lack of acknowledgment of what had happened.  I guess in an indirect way, maybe this current public problem may help me resolve all those issues, too.  I wonder if they would have helped Willy resolve them.  For him, it was an open wound he tried not to focus on.  He actually tried at one point to resolve the issues through direct communication, but was roundly rebuffed.  (I’ve sometimes thought that the people involved thought he was motivated by me, but no, this came from him, from his heart, and it meant a lot to him.)  He was hurt by that, too.  People, I guess, have their limitations.  Willy was pretty good at seeing people for who they are, not as they present themselves to themselves, to us, and to the world, but he still got hurt.  We all do the best we can.

Focus on the primary goal

November 2, 2013

I get taken in by a group’s claims about what they are doing, just as, apparently, many other people do, at least in the contexts of charitable giving and health insurance.  In the latter two situations, we as an even larger group are willing to talk about a norm that requires a certain percent of the money taken in from donations or premiums to go to charitable works or health care, and not be diverted to the more private benefit of those administering the enterprises.  We can see that money diverted for salaries or travel is not going to building schools or paying providers.

I think we see that less well in other contexts.  I think group formation is so important to most of us that we don’t even realize when we are putting our need for exclusive social ties and positive emotional reinforcement above the purported goal of the group, its reason for existing.  I see that in the context of government, I see that in the context of the media.  “Insiders/outsiders” becomes the paramount driving force of behavior (which, of course, is a very dualistic way of seeing things).

Now, of course, some amount of social cohesion is necessary for a group if it is to persist and be able to continue in its work at all.  But that’s also true in the charity and insurance cases:  some amount of administrative expense is needed and appropriate.  It’s when that gets out of balance that we call foul, and I think we don’t even see the fouls in groups we are less suspicious about or in forms that are more difficult to see.

What I see often when a group is not meeting its goals is that they are pouring too much of their collective energy into strengthening their personal ties and benefits (could be benefits to their careers or social status or sense of self-worth and not to their bank accounts) and not enough into the goal of the organization, like governing on behalf of the common good or publishing on behalf of the audience.

Well, they can do that, it’s their choice, and maybe it serves a need that is more important in some way than the avowed, wider and more public goal of the group, in the great scheme of things.  Maybe their development as human beings is more important, maybe they need to go through this kind of behavior in order to learn something, maybe our world is more like a classroom.

We can damage the environment.  We can damage the economy.  We can cause a lot of damage for a lot of selfish reasons, including reasons driving us of which we are unaware.  We can have insufficient willingness to put our own benefit aside and see what serves.  I think people with more understanding than I, like Socrates and Jesus, got too caught up in trying to change people and keep them from this dynamic.  I think that narrowed their own options.  I think sometimes the better option is detachment.  If people want to soil their nests, and it’s the best they can do, maybe, in fact, that’s what serves the greatest good and all we can do is watch at this point.

There is a concept of attracting people to a new approach to life rather than recruiting them to it.  That orientation, among other things, assures that the people are ready and willing when they come to it.  Spending time on unwilling people is not helpful, and when we do, our own energy is diverted in just the same way as it is in the cases I mentioned earlier — it goes for someone’s personal pleasure, and that just doesn’t serve the greater good, their greater good, or mine, from what I can see.

“128, a paahking lot”

October 23, 2013

I think I’m going to have to do this from memory, because I’m not sure how to find it through a search engine online.

There used to be a radio commercial, I think for car insurance, here in Massachusetts, in which “kids” did a lot of the talking, as if they were in the back seat of the family car giving some kind of cross between a traffic report and the kind of complaints parents get from kids while on a long road trip.

Anyway, the line to cap it all off was, “128, a parking lot,” but spoken in a broad Boston accent.  Route128 forms an arc through the Boston metropolitan area and is often congested and is often referred to using the same phraseology in traffic reports.

That’s what I hear as an echo when I hear “Obamacare a train wreck,” “128, a paahking lot” (in a radio commercial using “kids”).

It must be Obamacare …

October 23, 2013

Two days in a row a doctor’s office hands us back our co-pay check and tells us there’s a credit on our account …

I actually don’t know to what to attribute this, especially two in a row.  One family member has Medicare as primary insurance, and I think there are rules about how high a percentage of the allowable cost of the visit the patient can pay.  In the other case, only private insurance is involved, same policy for many years, and this has never happened before.

For all I know there’s an accounting error in the doctor’s billing department and I’ll receive a bill later for the co-pay.

I honestly don’t know if the credit could have anything to do with Obamacare, but given how it’s blamed for all kinds of ills I don’t think it has anything to do with, I thought I’d at least raise the possibility that it is responsible for this unexpected largesse.

Private programming weaknesses

October 22, 2013

I think I could probably write one of those running counts of a particular phenomenon people often post online — mine would be about bugs and defects in computer programming in the private sector.  Over the weekend it was programming involving a private university and a payroll company.

Today’s entry involves a private medical practice, a pharmacy, and a private insurer.  The doctor wants to send the prescription refills to the pharmacy electronically during the appointment with the patient.  But if he does that, if it’s not time for a refill to be processed, the insurer will reject the prescription, and the pharmacy, apparently, won’t be able to file the prescription for later use.

The doctor suggests calling him shortly before the refill needs to be filled instead.  The patient and their family suggests just giving them the prescriptions printed on paper, which can then be taken to the pharmacy at the right moment.  That way we all avoid problems such as the doctor being on vacation or absent due to illness or accident, and communication glitches.

Progress?  We’ve moved beyond, at least, it seems, what happened to me ten years ago, when I spent a day in my husband’s hospital room on the phone with this same medical practice and this same pharmacy, trying to get prescriptions filled at the end of the month’s supply.  I swore I would try my best not to be put in a similar situation ever again.

In any case, these technological glitches have nothing to do with the government or with Obamacare.  They are easily found, in my experience, in the private sector.