Since the AMA, IMO, has the most well documented studies available to the public on the subject of managed care, I will stick with the details of how this directly impacts them. Hospitals, rehab services, skill nursing facilities and others are all having to deal with the same issues so one can pretty figure that, to one degree or another, the problems affect them in much the same way. At the bottom of this page you can download a copy of an AMA report titled "Impact of the Health Maintenance Organization Act of 1973". Although the final conclusion of the study is stated by the AMA to have "very little direct bearing on the managed care industry", I disagree. I think that the original legislation and its subsequent amendments and modifications has had a tremendous impact on, not only the managed care industry, but the entire healthcare industry itself. Through the sheer nature of the capitalistic practices of for-profit organizations, the managed care industry has shaped what we know of today as healthcare. I do not believe that this impact can be understated. The 2 sections titled "Market Penetration in the Private Sector" on page 2 and "Health Plan Mergers" on page 3, is evidence of the growing power of the managed care organizations dictating healthcare on their own terms. As I stated in my last post, market penetration of these organizations have seriously limited the choices healthcare providers can make when it comes to contractual obligations. Couple that with the practice of mergers and we (doctors, hospitals, patients) end up with fewer and fewer choices in the decisions that we can make for what kinds of healthcare we receive and how we pay for it or get paid for it. I don't even want to hear about how much they are having to pay out for services. They made $7 Billion last year.
Like the previous post, I will stick with AMA data since its readily available and very detailed. When providers enroll with managed care organizations, much like Medicare/Medicaid, they are given a comp program of codes that organize and document their payment structure. Providers have to use these series of codes to bill the insurers and there damn well better not be any mistakes or they don't get compensated. Unlike Medicare/Medicaid, these programs contain clauses that are part of the contractual payment structure. These clauses hold firm that the code themselves are proprietary and protected under copyright and anti-trust laws. NOT ONLY DO THE INSURERS WITHHOLD HOW THE PAYMENT STRUCTURE IS CODED AND DERIVED FROM; THEY CLAIM ANTITRUST PROTECTION SO THAT IT CAN NOT BE divulged TO OTHERS; INCLUDING TO THOSE THAT THEY ARE CONTRACTUALLY OBLIGATED FOR PAYMENT !!! This is an enormous problem. As you can imagine, it leads to ambiguity that they claim is protected by law. Essentially, if you get stiffed in your payments, not only do the insurers NOT have to provide coded proof of the error, you can't use it AS proof to file an appeal since you aren't allowed to dissect the damn code! Dr. James Rohack, Chair of the Board of Trustees of the AMA, gave testimony to the National Association of Insurance Commissioners on June 13 of last year on this subject. You can download a copy of that testimony below. It not only describes in detail the problems that this system has, but he also provides testimonial proof how this system is being used to withhold or discount payments outside of the agreed contracts. So NO achilles, providers are NOT being "compensated for their gross costs". On the contrary, they are being ripped off. How many of you here own your own business? What would you guys do if a client behaved in this similar fashion when it came time to pay you for services/products? GO TO THE DAMN COPS AND FILE A REPORT OF LARSONY?!?!?! In any other business sector, this behavior is theft. But nooooo......not this one.
I wish this were true. I would like to believe that it will come true. However, the nursing shortages have lasted for almost 2 decades now and is only getting worse. What a lot of people don't understand is that nursing is not medicine; its "care". Its either specialized or holistic, but it doesn't exist within the healthcare system independent of itself. A nurse, of any degree, can not administer "medical" care without a doctor's order; whether it be verbal or written. Although orders can be written for situational considerations and left "standing" for future use, it is, none the less, a set of instructions left for the nurse. Outside of those parameters, a nurse can only administer "care"; this includes details like nutrition, hygiene, etc. Under present conditions, nurses have found themselves in situations of increasing responsibilities that they were never intended to have to deal with. It has become an increasing demand of the system. However, the educational requirements have stayed much the same due to the fact that their educational structure exists and operates independent of doctors' "orders". Therefore, the nursing student experience consists of little more than just "care". Experience gained in "medicine" is pretty much left for OJT for the most part. So what happens, more often than not, nursing graduates find themselves in for much more than they bargained for. Its tough enough to find candidates that even want the job, much less ones that will hang around for the ever increasing amount of bullshit involved in the profession. So no, I don't anticipate any radical changes for the better in the nursing issue without radical changes in their educational structure (regardless of any severity of "market forces"). THAT will takes a looooonng time.
Great post. That's exactly how I feel. The consumer knows nothing, and the medical profession wants to keep it that way.
These quotes you speak of are not so much self-imposed but regulated and restricted by several factors. First of all, medical schools are attached to teaching hospitals and other facilities that help financially assume the liability costs of having students work in their facilities. Subsequently, there are a limited number of schools because there are only so many existing facilities that are willing to take on this added responsibility. Second of all, the available number of "teachers" are not that great. While the salary is higher compared to other teachers, much like a lot of other professions, it is more lucrative to practice than teach. Therefore, the financial incentive compared to the level of added responsibilities (these students "practice" under a "teacher's" license) is way out of whack. In both these ways the quota system is really not self-imposed out of anything more than necessity. This also pretty much goes for nursing schools as well, so we've got the same problems there as well. Medical education is 4 years + undergraduate to include internship. Then depending on your specialty, its another 4 - 8 years of residency. Residents don't make squat. Hell a lot of nurses these days make more than residents. Doctors don't make serious money until they get out of residency. By that time their level of debt is enormous. The first few years earnings after that is pretty much dedicated to paying off debt. A lot of doctors are retiring early or simply leaving practice altogether. That tells me the bullshit to pay factor isn't that great. So I'm not so sure how "artificially inflated" those salaries really are.
This is absolutely true. The standards of care within the industry dictate the minimums; as well as the situation. Here's one of my personal favorite scenarios: Fender bender rear-end collision otherwise perfectly healthy young woman comes in by ambulance. State trooper tells you that the damage to the vehicles are minimal and that she was pissed off and freaking out. She's definitely in the mood for civil action. She complains of neck pain, headache, and chest pain. Screening regimen: Full lab work up since you have no idea what other extracurricular activities she's been up to. Besides, the cops want to know if she's been drinking and/or on drugs. Labs HAVE to include cardiac profiles for chest pain as well as EKG as a minimum even though she's young (just to CYA). Pregnancy screen is mandatory before she can be x-rayed; can't run the risk of irradiating a fetus. Full spinal, head, and thoracic CT to make sure nothing has been ruptured or knocked loose and jiggling around. THAT folks is a typical cookie-cutter scenario, complete with a mandatory cookie-cutter treatment protocol, that happens EVERYDAY.
i share your frustration, maxpi. find a doctor that will listen to you and keep him/her. they'll still get mucho $$$ and you have to call them Dr. even though you didn't have anything to do with them receiving their MD, but at least you can control your own treatment. doctors for the most part are just as dumb if not dumber than the average person, which is saying a lot. they do usually have good memories, however, as it is necesarry to get through med school. lot's of memorization is required, which i consider a form of brainwashing. in addition there is the incentive to treat patients in the most profitable way. really a screwy system.
So anyone who's cognizant that the U.S. lacks the demographics of other nations employing socialized health is a trailer park denizen? If you think Japan and Europe with their negative birth rates and healthy homogenous populous are a proxy for the costs of implementing socialized health in the States then I suggest you look at the fiscal pitfalls of every other publicly funded social initiative in urban America. Most big cities have a form of free emergency care on the county level. I know both Chicago and L.A. do so. One gets what they pay for. The notion of "equal care" to those who can't afford it, is the code phrase of the class envy left. Are public schools equal to private? Is public transportation equal to tooling around in a Mercedes? Is public housing on par to suburbia? Are commissions cheaper for a self clearing exchange member? Life is full of inequities. When some people recognize that fact, make the necessary adaptations, and then grow up, they'll lead vastly happier and more productive lives.