By way of explanation, the $4 prescription is a misnomer. Some are $4. But for the most part, what the pharmacy is doing is simply reducing your co-pay to $4. They still charge your insurance for the part above your co-pay, be it Medicare, Medicaid, or private insurance. You’re still paying for the balance of the prescription, just in the form of premium paid in to your insurance that is used to reimburse the pharmacy.

So kudos to Matt who pointed out the following:

“If your copay for generics is $10…what with all the offers at Wal-Mart, etc. it seems it may almost be smarter to just act like you don’t have insurance when you go to get your generics filled and pay the $4.  It saves you a few bucks, and I would imagine reduces your insurance’s view of you as a “high-end” user.”

True. And that might work for a period of time, but eventually you will probably hit a snag. And here’s how.

Whenever you take your prescription in, the pharmacy asks Have you ever filled a prescription here before? That way they don’t have to re-enter the records. So the first time you go, you say, No I have no insurance. So far so good.

The next time, your prescription(s) may not be on the list of $4 drugs. And now it REALLY costs something. Oops, well maybe I do have insurance. Here it is.

Next time you go in, they’ll ask you if you’ve ever filled a prescription there before. Nope, you say. Hmmm. We have that name at this address. Is that you? Oh, yes. Is this still your insurance? Um, no. I mean, well, yes. Um, is that on the $4 generics list?

And even if you tell them that the insurance is no longer valid, there’s a decent chance they won’t even ask and may just run it through on whatever insurance they have on record.

“Oh what a tangled web we weave, when at first we practice to deceive.” - William Shakespeare

That’s the line that stared back at me from the printout on the prescription the bag came in.

Your insurance saved you $84.99.

Did my insurance truly “save me $84.99″ I wondered.

Like most of us with private insurance, I don’t get EOBs for my prescriptions. I simply pay a prescription co-pay of $10 for generics and $35 for brand drugs. So did the pharmacy accept $84.99 less because of my insurance? That was the implication, but was it fact?

Or did my insuror pay $84.99?

Exactly how did the transaction go down?

As someone who actually pays for their insurance and does not have it provicded for me as an employee, I wondered, since when I get underwritten next year, the expense will be considered and may contribute to a rate increase. If my insurance paid $84.99, then they most certainly DID NOT save me $84.99, but they paid out $84.99 on my behalf - semantics, I know, but I don’t like being misled, and I felt I was being misled.

How do you feel about it?

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.

For some reason no one seems to be distinguishing between these two very different ideas in health care: ACCESS and CHOICE. All of this talk about socialized medicine creating less choice within our system and long waiting periods for care makes my head hurt. I can’t help but wonder why so many people are focused on choice in health care. Are they simply confused, or do they legitimately have their priorities mixed up?

Here’s a little story. I was speaking to an individual the other day about our current health care system. What was important to this person was that they never had anyone telling them what doctor to see or what services would be covered. So they made the choice to pay a ridiculous premium every month to ensure that their health care “choices” were never restricted.

I know this is an atypical situation. Most individuals at least have to choose an in-network provider for their primary care. But even then, everyone wants the ability to choose that physician.

Another example - benefits enrollment “season”. An employer that offers its employees health care generally gives them options, in terms of which health insurance plan they would like. Sure some plans come with shiny incentives and rewards for healthy behavior, but the choice is always there for the employee to make at their own discretion, regardless of which plans are being more readily promoted.

On October 17th Vidhya Alakeson (in Health Affairs Blog) started my mind on this subject in her article titled US Health Care: International Scholars Experience Our System – What They Would Change. She said:

The design of the policy prioritizes the act of choosing rather than the outcome of the choice. Not enough consideration is given to whether the time and effort required to make a choice are justified by the value created by the choice itself, or whether it is possible to make an informed decision. In our experience, this was the difference between choice for choice’s sake and choice that led to a greater sense of control.

I could not agree more. Especially with healthcare, having a choice in no way implies that you will have control over the situation or outcomes that head your way.

Truthfully, you can never really predict how much healthcare coverage you will need in a year. You can never really predict, even with adequate research, which physician will be the best match for you (that friendly physician with the nice new office may not provide his/her patients with the best care). You can probably never really know whether the health plan you chose will fit your health care needs over the upcoming year.

So here’s my question. What’s really important at the end of the day, that you got to choose your provider or insurance plan, or that you had access to care when you needed it?

I would imagine the latter would be more popular… but then again I’m writing this for a reason.

For what its worth, here’s my opinion:

So many people are scared of universal healthcare or socialized medicine. This is not where our solutions lie… focus your energy elsewhere. I challenge those people to stop criticizing and start suggesting solutions. I challenge those individuals to be smarter healthcare consumers and stop running to the doctor every time they have the sniffles.

I will admit that access is an uphill battle. Once you extend healthcare to those millions of children and older Americans lacking coverage, you still face quality issues, treatment compliance, prescription costs… the list goes on.

However, I still advocate access over choice as deserving more attention.

I know I am guilty of being part of the problem. I paid the $20 co-pay every time I saw the doctor for the sniffles. Never once did I consider how much my office visit really cost or who was footing the other portion of my bill.

Now I am proud to say that I am making an effort to be part of the solution (rather than the problem). I am officially on my way to being an educated and thoughtful healthcare consumer. You all should join me, the air is pretty clear over here.

At the end of the day what’s really important is that I have quality medical care available to me when I need it. At the end of the day what should be a priority for Americans is finding a way to provide quality medical care to all its citizens. Stop being so gluttonous. Take a step back from the medical buffet. Remember that over-consuming is never a good idea.

My advice is to share the wealth… medical care that is. The more you focus on being a better healthcare consumer, the more room you leave at the buffet for those individuals who are truly starving.

For some reason I believe there is plenty of food for everyone. All we have to do is learn to stop going back for seconds… thirds…

No one ever said change was easy.

As Christopher mentioned, we’ve closed our Series A round this past week.

Never ones to slow down, we’re in San Francisco this week for the upcoming Health 2.0 conference hosted by Matthew Holt. But before we could leave, we had to squeeze in a meeting Monday AM before our flight with some new friends - a major healthcare company with multiple presences across the US.

We came early to SF catch up with a whole host of folks out here on the west coast - people like us who are interested in changing the healthcare industry for the better of the consumer. We’re finally getting to sit down with people face to face, people we’ve only been talking and e-mail with until now. It’s been great already, and the conference isn’t until Thursday!

And we’ve got great things going on while we’re away, too. Way to go Katrina, Matt, Matt, Mark, Prakash, and Jakob!

There are a lot of great people working healthcare from the technology side out here. Nashville (where we are headquartered) is the bricks and mortar of the insustry are. Clinic management companies literally spring up overnight. They are the children, grandchildren and more of HCA and its many spinoffs. Someone has to bring the technology and tangible together to make a change.

Scott Shreeve has been a great sounding board for us as we’ve rolled out MedBillManager, and we’re finally going to get to meet him in person.

We’re also going to catch up with some other people like Ben Heywood and Jeff Cole from PatientsLikeMe (a great site that focuses on helping people living with ALS, PD and MS). Since we have a partnership with MS, we obviously have some common interests.

On top of that Unity Stoakes at Organized Wisdom tells us they have big things brewing over there.

There’s more. So much more. But so little time. Off to another meeting.

So who’s to blame for America’s healthcare problems? In part 1 or my 2 part series, I had told you the reasons why I feel that individuals and physicians and health practitioner deserve some of the blame for our systems complications.

Note: www.charlesclarknovels.com made a wonderful comment on part 1, highlighting accountability (if you’re interested go back and read his comment on part 1). In an industry dominated by tiers of power, responsibility plays a part. However, accountability may be more important. Its one thing to be responsible for your actions, its another to be accountable for the way in which they effect others. And yes unfortunately, Stark is taking a very long nap, and many individuals are taking advantage of his slumber.

Moving on, I have two more culprits to add to my first two. Here it goes…

3.) Insurance companies

Insurance costs and the industry’s connection to employment (which is unpredictable and unstable) make private health insurance primarily available only to the middle and upper class.

As companies began to focus on experience rating and classifications of employment, individuals with minimal income or chronic health conditions have been increasingly pushed out of the private insurance arena. The cost burden of private insurance has been shifted to the employers who continue to push the additional costs directly to their employees. Individuals with the increased burden of medical problems are having to additionally handle the increased cost burden of the industry.

Arguably though, the biggest problem with insurance companies rests in their organizational structure. The solutions this industry was intended to provide have alternatively enabled the rising cost of healthcare. Rising costs have directly led to higher premiums and deductibles that place a financial burden on the individuals with private insurance.

4.) The Government

All and all, I would have to argue that the government deserves most of the blame for America’s confounding healthcare problems. Though Medicare and Medicaid have improved care to the elderly and the impoverished, the programs simply fall short of providing a solution. Still to this day, after Medicare and Medicaid were created more than 40 years ago, a large number of patients remain unaware of the services and care options afforded to them through these government programs.

Not only are patients suffering from the lack of a unified and reliable government healthcare program, but the institutions providing the care assume the burden. Under funded and struggling with the uninsured, many institutions are taking responsibility for individuals’ lack of coverage. Unfortunately there isn’t even a set amount of government money given to health institutions to defray the cost and burden of treating the uninsured. This places many medical institutions on the verge of closing every year, which would only furthers the burden on the system…

Recently Michael Moore attempted to tackle “who’s to blame?” As many of you know he has quite the art for blaming big institutions like the government and insurance companies. Unfortunately, its not that simple. Practitioners and individuals deserve some of the blame as well. But ultimately I must point my finger at the fact that our government has allowed individuals and practitioners to absorb the burden of their continued lack of unified involvement. If the government were to take more responsibility for the current problems of our system, then the other parties could not opt out of the blame. Each of these sectors, individuals, practitioners, insurance companies, and the government, contributes to the problem in their own unique way.

Our healthcare system needs a reevaluation of responsibility and collective reform of the system in all four of these sectors. Individuals need to begin to take more responsibility for their health, practitioners need to follow up and stop blaming the system, insurance companies need to consider alternative methods of coverage, and most importantly the government needs to begin to view healthcare as a basic human right before any real changes could be made.