I spent a lot of time in Germany - 2 years to be exact - and found Unity’s post about Health 2.0 taking off in Germany very interesting http://wisdom.blogs.com/health/2007/11/health-20-takin.html (see the original post at http://gigaom.com/2007/11/17/health-20-gaining-traction-in-germany/). Both systems have something to learn from one another, and here are some tidbits.

I got to experience the German healthcare system firsthand. It was interesting. From a customer service standpoint, it left much to be desired. Office hours were sporadic - worse than a college professor with tenure. However, there was a policy in Germany: Just go the doc during hours and take a seat. They HAVE to see you if you get there before close of office hours. From that standpoint, I can see why there might be some resistance to a ratings system. Their system just doesn’t make for the best customer service. As an ailing patient I was there for 3 or 4 hours and feel certain that I spread the love of my virus to many others.  And I felt worse when I left. But I got seen and did not have to make an appointment. Nice. Kind of like a retail based clinic.

During another stay I had a professor who took ill and wound up in the hospital for an appendectomy. When I visited, he assured me it was a very good hospital. I looked around the ward that he shared with at least 10 other men. I noted the open window and the lack of air conditioning at the height of summer. Looking back I realize it was a cultural thing. There is a greater sense of community in Europe. People convalesce and recover together, not in private isolated rooms. They breath in the fresh air, not the airtight container with windows that do not open like here (presumably to keep patients from jumping out of them due to being driven insane by being in isolation all day long).

I’m not going to pass judgement on either system, but there has to be something that we have to offer each other as we try to change this crazy notion of healthcare in the U.S.

I just saw the Paul Potts’ story that has flown across YouTube. As we all struggle with our daily challenges, including healthcare concerns either as Caregivers, Providers, Employers, or even Insurers… it is important to embrace those glimmering moments that impress upon us that even against all odds that that which we never thought could or would happen CAN happen. 

Just as a British cellphone salesman can sing opera and win a million dollar recording contract (yes, opera. He went to choir in school to avoid school bullies) — even something as staid, inflexible, and unchangeable as the U.S. healthcare system can be improved by its ultimate consumers… people like you and me.

Here’s to changing healthcare.

OK call me naive. I thought my healthcare provider was working for me. In all fairness, it usually does, but this past incident reminds me that they do not always.

I recently had a provider’s office call me back for a follow up - some photos. Pretty simple really - they had already done it once. Problem is, the insuror said the pictures were not sufficient to determine if they would approve the procedure. So the nurse called and asked me to come back. I asked who would pay for that. The other end of the line went quiet for a moment, the nurse clearly taken off guard by the question, but she quickly understood that it was a customer service issue and said that if the pictures weren’t good enough that they would not charge me to retake them. Satisfied, I went in.

At the front desk, the woman asked for the co-pay. I explained the situation and what the nurse had told me. I had distracted the lemming from its path and now it was left to wander, “I don’t know how to do that.” She looked around as if something on her desk might explain. She made to get up and go ask, then sat down. She looked around the desk again (what the hell was she looking for?). And then she had a spark of an idea. “I know what I’ll do. I’ll make it a follow up visit with no charge.” Worked for me.

Got the photos. Went home.

Then the bill for my co-pay arrived. And an EOB arrived. They charged my insurance $33 and wanted the $20 co-pay from me. I called the provider’s business office (part of a large medical center). They put it in for review.

I got another statement. They wanted $20.

I called my insuror. I explained to the lady on the other end of the line what had happened and that either my provider was a poor photographer or my insuror was unnessecarily driving up my expenses on the matter by asking for uneccesary procedures.

Here was the basic response.

Our contract with the provider is that they bill us, and we pay them. That agreement you made was a private side agreement. We have no control over that. They bill us, and we pay them.

So I asked, “Basically what you’re telling me is that I might get my co-pay back, but you’ve sent them the $33 and they are going to keep it?”

“Yes, sir. They bill us, and we pay them.”

I think I went over her head in my understanding of things with the next part. “So you’ve paid out $33 that was not supposed to be paid out, and I’m going to be underwritten with that as an expense when it comes time to renew and establish my rate for next year?”

“Um. That’s our agreement with them.”

It’s not the amount. It’s the principle of the thing. I got them to write off the co-pay. They kept my $33 paid by my insuror.

They bill us, and we pay them.

Thanks.

I was having a peaceful Tuesday afternoon, happy that it was finally under 100 degrees for the first time in weeks, when my boss sent me and email titled “Fwd: Google Alert - “medical bills”. Well of course I opened it (it’s from my boss), but I had no clue what I was about to read.

The email says: Google News Alert for “medical bill”

And the top headline reads:

“Drowning in medical bills, man kisses ailing wife before throwing …
Ottawa Citizen - Ontario, Canada
Her medical bills ranged from $700 to $800 US a week, and she has no health insurance, according to court records. In April, her husband petitioned the…”

I suggest only daring individuals check this one out. (Now do not be fool by the Ontario Canada publication, the incident took place in Kansas City, Missouri.) Talk about snapping out of the joy of a beautiful day. The man literally did not want to face his wife’s medical bill any longer, so he threw her to her death off their balcony.

If you are interested in the other wonderful headlines Google News Alert had to offer for “medical bills” here you go:

Identity thieves go medical
TheNewsTribune.com (subscription) - Tacoma,WA,USA
Study your medical bills and health insurer’s explanation of benefits. *Report suspicious transactions to your health insurer’s special investigations…

Medical Insurance Refuses To Pay Maternity Bills
KUTV - Salt Lake City,UT,USA
Allstate is now paying for all the covered medical bills for the pregnancy and birth. That is exactly why Brett and Ashlee purchased medical insurance in …

San Diego Hospitals Sue County Over Prisoners’ Medical Bills
KPBS - San Diego,CA,USA
The dispute centers on medical bills run up last year by prisoners of the sheriff’s department. The hospitals say the sheriff’s department has to pay the …

AHHHHH…..What is the world of healthcare coming to? Is this what the crisis is driving people to do?

Let’s hope that the system gets repaired before this kind of story becomes the majority rather than the minority.

For the individuals out there that still think we do not have a problem with our healthcare system, check out some of these stories. Maybe ask yourself… if you were having these kinds of medical problems or expenses “What would healthcare drive you to do?”

Chris Fleming of Health Affairs Blog has highlighted the debate surrounding State Children’s Health Insurance Program (SCHIP) reauthorization, discontinuities, and enrollment in his blog. Undeniably this is such an important topic. I wrote a research paper this spring on uninsured children and the variations across SCHIP. Unfortunately the discussion is warranted (referencing the first article and second article he pointed out in Health Affairs). There are gaps in coverage, low enrollment, and eligibility changes and interruptions.

Though the function of my research paper was not to express my opinion, rather to report information, I certainly developed one by the end of it.

Reading all of these different individuals’ research on the SCHIP debate frustrates me.

• First, they cannot seem provide me with any new information in addition to what I discovered last spring.

• Second, how is everyone missing the point? Really. I want to read an article by an individual that has an opinion on how our policy makers have failed once again and created a patchy program. I do not need to read more statistics. Give me a solution.

Consequently I have decided to share my opinion on the topic…. And I would love to hear anyone else’s opinion or proposed solution.

To me SCHIP is about developing and supporting the youth of our country. We have developed and supported our country’s children for years through public schooling. We give every child the chance to succeed in life through educational opportunities from youth to adolescence. “Knowledge equals power”… right?

Well kind of. In this country it’s more along the lines… “Knowledge and health contribute to wealth and wealth equals power.” For this reason I believe that every child should additionally be afforded the chance to maintain a good bill of health. I cannot see how anyone, especially children, who doesn’t have access to a doctor, or medication, or any other care they need from the health arena (e.g. psychiatry, physical therapy), can truly succeed in school, much less life.

The answer is not about increasing enrollment, making single mothers, fathers and families fill out application forms, standardizing eligibility, or closing gaps in coverage. The answer is providing every child with free education and free healthcare.

If this were the premise of childhood (free education and free healthcare) I might reconsider my opinion on needing a more “universal” healthcare system. Who knows, I might even believe that our government was providing children with an equal (well at least a more honest) chance of succeeding as adults.

At the end of the day I simply wouldn’t feel so bad about turning people loose at 18, expecting them to contribute to society and figure out their own healthcare.

We were all told as children to respect our elders, and obviously our country does that. We provide social security and healthcare (Medicare) to the individuals that have contributed to what our country has become today. This country also needs to learn to value our children, the future contributors, by giving them every opportunity to learn and remain healthy throughout childhood.

We’ve all seen it - the EOB (Explanation of Benefit) with the bold lettering that proudly declares THIS IS NOT A BILL. So what is it? We called around to some insurers to find out about it and to see if they had a guide for the high math that they so often employ.

“It’s pretty easy.”

That’s what the customer service guy on the other end of the line had the audacity to say. Must be the kid from calculus class that always worked every problem at the end of the chapter. I asked him if they had a guide on how to read their EOB. They didn’t. But to his credit, he was willing to talk me through it. He started out, “It has THIS IS NOT A BILL written on it in big letters.” Thanks.

Another customer service rep said, “A guide? No we don’t have one, but you know, that’s a really good idea. We should do something like that.” His must not be so easy to read as Mr. Calculus’ or maybe he was sitting in the back of the class with me.

But there are a few insurers who put out a guide. There is even one - Humana - that publishes a guide to reading their EOB and [GASP] they have it available for download. The Humana EOB is one of the best I have seen for ease of understanding, and still it’s four pages long (And the first guy thinks people don’t need a guide? Yeah, and we didn’t need the teacher to work another problem on the board because we all got it - hah!).

Why was I doing this? Well we wanted to see how many different layouts and subtlties of semantics existed in the EOB world. So we had a small competition - see who can collect the most EOB forms from different insurors. Loser buys the coffee (Chistopher and Katrina, how do you take your java? Starbucks or Bongo Java?).

So now, in an effort to redeem myself, I am throwing it out there.

IF YOU ARE WILLING TO SHARE YOUR EOB WITH ME, POST A COMMENT.

DO NOT post your e-mail address in your comment. You have to enter it to post a comment, but it is not publicly available - it is only available to me. I’ll e-mail you with my direct e-mail address and/or fax.

You can strip off the personal data.

I don’t need to know who you are, your addess, your subscriber ID or Group ID or employer or any of your family member names. I don’t need the claim number, who you saw, what they did, the service date, how much they billed, how much your insuror discounted it, how much the insuror paid, how much was your responsibility, how much went to your deductible (OK, if you have a guide that might be helpful).

Yep. Send me your EOBs. I’m a glutton for punishment. It’s time for me to learn that high math that I thought I would never need in the real world.

I’m sure you have witnessed a variety of conversations about America’s healthcare crisis, I certainly have. I spent a whole semester senior year studying our disheveled system in Fundamental Issue of Medicine, Health, and Society. I heard presentations from health economists, alternative medicine practitioners and read several informative books on what I assume is only the beginning of our country’s problems with healthcare. The more information I consumed, the foggier my mind got. Insurance methods seem anything but consistent, Medicaid has so many restrictions that only a certified Medicaid specialist could really know what’s allowed and what’s not, and everyone seems to want to blame someone else for our problems.

My very first paper in Fundamental Issues was based on the book “Mama Might Be Better Off Dead,” which highlighted the foes of our current healthcare system, and asked the question “Who’s to blame for America’s healthcare problems?” I dwelled on this question for days trying to figure out who’s to blame. I literally put the paper off until the very last minute, starting my very first paragraph (with no direction at all) at 9pm the night before it was due. All I could think was “who’s to blame, who’s to blame, who’s to blame” when luckily about an hour into it my head cleared… “if only it were that simple.” Obviously it’s not simple at all… that’s the whole point. There is no easy answer to the question “Who’s to blame?”

There are a lot of people and things at fault for where our system stands today, however I have whittled the answer down to four easily identifiable entities within the healthcare arena.

So for your reading pleasure here is who I think is to blame for our current healthcare problems.

1.) Individuals

A certain level of responsibility rests in the hands of each individual. People must learn to value good health and strive toward achieving healthy states. Though some personal choices unavoidably correlate with socioeconomic status such as food availability and exercise, decisions to add extra salt to food, drink alcohol in excess and continue to smoke do not. These habits can be altered and controlled by the individual. Additional factors such as compliance and communication influence personal responsibility.

However, personal accountability for one’s own health represents a convoluted American ideal. The medical system embodies a stigma that holds individuals morally responsible for getting sick and seemingly ignores the compounding socioeconomic problems. Yet, the importance of personal accountability cannot be dismissed or blamed on some other aspect of the system. Refusing to wear a brace, not taking medications due to undesirable yet manageable side effects, and failing to get children immunized are not choices complicated by socioeconomic problems of the medical systems themselves. Rather they represent choices in the domain of personal responsibility that could have positively influenced an individual’s health had decisions to comply with medical advice been made.

2.) Physicians and Health Practitioners

The basic concept that doctors should provide their patient with complete, competent, and consistent medical care dominates societal aspirations for the profession. Unfortunately this is easier said than done for many doctors. There still seems to be no consistent system in place for following up with patients. Many people still receive care from doctors that are poor communicators, who fail time and time again to address the true extent of their patients problems (Don’t believe me? Read some of the true stories out there such as “Mama Might Be Better Off Dead” and “The Social Medicine Reader”). Typically it’s hard to ignore a doctor’s direct responsibility for the level of care they provide their patients.

Additionally, doctors need to stand up and address issues regarding the difficulty of providing complete care for their patients in such a patchwork system of healthcare options. Doctors hold a large amount of knowledge and power in American society. This fact just further elevates the responsibility doctors should take for the care they provide their patients, the manner in which they use their knowledge, and their power to offer patients the most effective care available.

Wonder who else is to blame? Check back, I’ll be sure to let you know…

My three year old is a born entertainer. She has curly red hair, a personality that just grabs people and she’s a born talker. One morning on vacation recently, she and I were up before the rest of the family. I told her to be quiet so we didn’t wake anyone up. I fixed coffee, and we headed for a walk on the beach in the early morning. We got outside on the porch, and she shook her head, “Whew! Now I can talk!” She’s pretty good about letting us know how she’s doing.

Shortly before we went on that vacation, we noticed a bug bite under her right arm. Nasty little bite, but anything looks bigger and worse on a three year old. We took her to her pediatrician ($20 co-pay, $182 billed, $95.82 in network price, so $75.82 paid by insurance) and got a prescription for an antibiotic (Rx card co-pay $35, retail price $65.89 – no idea how much the insurance kicked in, but that’s another story. Three days later, she began to run a fever that spiked very quickly to 101 and within minutes to 102, we headed for the children’s hospital. It’s only 5 minutes drive from our house – a fantastic testament to the real estate mantra - location, location, location.

An IV, some acetaminophen, an additional antibiotic prescription, $100 ER Co-pay, and we were good to go again. When hospital Super Bill #1 arrived, it was for $705.11. In network discount brought it to $358 (that’s a 49% discount!). Our insurance paid the $258 balance.

Three days later, the fever was back, she was getting spots – little purple spots on her body – all over. Visited the pediatrician again ($20 co-pay, doc billed $55, but the in network discount dropped it to $34.38 so the insurer paid $14.38). If the spots get worse, go to the ER we were told.

At the ER that evening (oh yeah, the spots were worse and the fever was back), we had two IV sticks (not popular with a very loud and vocal three year old) and ultimately had to do a femoral stick to draw enough blood to check for Fifth Disease or Human Parvo Virus (not related to the dog virus). The experience was traumatic, so much so that they encouraged me to leave, but I can’t shy away from something – just not in my nature. Even the doc who did the draw was visibly shaken.

Through an alternating regimen of acetaminophen and ibuprofen, we got the fever under control, paid the $100 ER visit co-pay and went home.

The super bill for visit #2 (Super Bill 1 of 3 | Super Bill 3 of 3) came to $3,667.40. I can’t even begin to tell you what it was they charged me for. Christopher Parks took a passing glance at it. Things seemed to be as expected. I’m waiting on the EOB. I expect the in network discount to bring it down to $1600 or so, but I don’t really know. However, I am naïve. The EOB arrived before I had a chance to post this blog entry. I paid the $100 ER co-pay. My insurer paid $258. For those of you keeping count, THAT’S A WHOPPING 93% DISCOUNT!! The $258 is probably the standard negotiated rate between my insurer and this provider for a Level 1 ER visit. Still – that’s a big difference.

Alas, we wound up back at the ER with her again – maybe related, maybe not. I’ll let you know how that visit and the MRI the following day stacked up.

All told, here’s how the episode of care stacked up:

• $4,328.29 - Billed - 100.0%
• ($275.00) - My Co-Pay - 6.4%
• ($3,447.09) - Network Discount - 79.6%
• ($606.20) - Insurance Paid - 14.0%
• $0.00 - Balance - 0.0%

Imagine had I been uninsured.