Image from Mike Moreu

As long as we’re herding cats on healthcare reform, let’s ask a critical question…What is the timing for the changes being made for healthcare reform? Not “when will it get passed” but rather “when will the changes, whatever they end up being, go into effect”?

Logistically, it’s a nightmare.

Healthcare Reform Will NOT be here by January 2010

Employee populations have already been underwritten for 2010. Rates have already been set. Policies are already in place. Open enrollment has already begun. Surely no one would jump in front of that rolling momentum even though the government has the authority to do so. It takes a full year to do all that needs to be done for a health plan when it is business as usual.

[cats like big balls of yarn, and this is a BIG one]

Imagine the implications of just two details…

1. Insurers Have to Cover Pre-existing Conditions
2. Insurers Cannot Drop Clients with Extreme Expenses.

In short, the very business practices on which insurers, doctors, hospitals and every company that provides health insurance have built their business are undermined. Wow!

[think two wild feral cats left to their own devices in the barnyard]

Insurance companies would be SCRAMBLING…

• to change rates.
• to underwrite to new standards.
• to negotiate new provider agreements
• to develop new policies.
• to train people on the changes.
• to print new materials.
• to engage countless attorneys to understand and interpret changes.

[think of the crazy old cat lady with 72 cats in her one-bedroom 650 square foot apartment]

At the same time, employers would be scrambling to understand and reevaluate their business model as their health plan costs changed. They would be looking to alter their plan in an effort to control their rates and protect their business. They would be struggling to educate their employees. And struggling to meet a bottom line with new rules on one of their single largest line item expenses – health insurance.

[think of the animal shelter stuck with the crazy cat lady's 72 cats - what the hell do we do with these?]

Docs and hospitals and other care providers are little better off. They would have new rules on what is or is not covered. They would be left to figure out how much they could expect in income on those “Good Samaritan” services they had been providing for “free”. They would have new systems and rules to evaluate. Their very business model would shift.

[think of the vet trying to provide services out of the goodness of their heart, but faced with the financial implications of having to spay ALL 72 cats]

Cats would be living with dogs. And January 2010 would be here.

A Similar but Not Related Video that Conveys my Thoughts on This…

I have learned not to put complete blind faith in my Insurer. I do NOT blindly pay outstanding balances from providers and assume that my Insurer processed the claim properly, and neither should you as this story will show. Even though I’m a pretty savvy healthcare consumer (this IS what I do for a living – understanding the healthcare industry), this one had me confused for while.

My wife took my kids to a Clinic for their flu shots (No, I didn’t go and get mine, and that makes me far less of a person than those of you who did). Flu shots fall under “well care” on our plan, so there is no charge.

But then I got a bill from the clinic, an in-store deal – very convenient (I know, I should have gone too, stop already). The bill must be a glitch I told myself. I decided to wait and see if they figured it out rather than spend time on the phone with them and with my insurer. Then I got a statement for the bill again. Odd, I thought.

And then, I got a nice letter from Insurer asking me to confirm if I had another insurance plan. I procrastinated, was moving residences, etc. and did not answer that letter. I did not make the connection.

Doing something else entirely, I logged in to the online view of my insurance account (which I must say is a weak “silo” view of the information my insurer has). They only had two claims for the past year. That was wrong, I knew. Hmmm. Must’ve logged into the account for our previous policy (still active 2 years after moving off of that plan – can you say “we never update”). Yup. Logged out and logged in with the other username/password combo and suddenly, there are my claims for the year on my current plan.

Only then does it dawn on me. The clinic submitted the claim on the old insurance and did not confirm new insurance, or if they did, they simply accepted that my insurance info was current with them. My previous plan and this plan were with the same Insurer, so it’s an honest mistake.

So now my Insurer has denied the claim on my old insurance plan. The clinic wants their money because the Insurer denied it. Now I’ve got to go and straighten out both of them because my insurer who had BOTH policies is not able to do a simple lookup on my SSN and determine yes, I do have another policy AND LO AND BEHOLD IT’S WITH THEM!! Who’d a thunk since they only have 65% of the entire health insurance business in the state.

It’s only $60 bucks – 2 flu shots at $30 each, but it’s my $60. It’s money they planned on spending in the plan, so it’s paid in. Most folks would have simply assumed that the shots weren’t actually covered and paid the $60.

Thankfully, I called the Clinic’s 1-866 number, and Mona was very helpful and walked through things with me and resubmitted the claims.

Don’t put too much faith in your Insurer.

First off, thanks for all of the concern and support from so many people over the past few days WRT my surgery. It seems I’m telling people things and repeating myself and I hate to bore anyone, so I’m putting this together to give folks the details and use my own experience as a personal example of why change:healthcare does what it does.

Why change:healthcare Does What It Does:

The business end of things…My doc will bill my insurer somewhere around $6,124. However, the allowed amount with my insurer is $2,904. Per the FANTASTIC staff at Dr. Bonau’s office, “double check with [insurer] to be sure and I don’t even know if they will tell you an exact number but you can try… The procedure codes are 36478/36479″

They also pointed me to the insurer’s financial counselor complete with the phone number.

Had I been uninsured, the amount would have been $6,124. On a different insurance, the cost would most assuredly been something OTHER THAN $2,904. And had my surgery not been Medically Necessary, and I had simply done self-pay without submitting a claim, I may have been expected to pay $6,124. Keep your eye on the peanut, now which shell is it under?

change:healthcare helps people sort through all of that.

My Status:

I’m doing well. 48 hours out of surgery the wrap is off, I have to wear a support sleeve on the leg, but I got on my bicycle on the stand in my home office. Rode for an hour at a moderate pace on an easy gear. Felt great to move again. Doing well.

So well in fact that I failed to take the prescribed ibuprofen today (day 2 post surgery). Should have taken some on waking up at 6 AM. After lunch, I started to feel it a bit, and finally got the anti-inflammatory into my system at around 2PM (Kids, do NOT try this at home).

The Procedure:

The procedure I had is called laser ablation or a phlebectomy. It beats the living crap out of the other option which is the traditional vein stripping I had done 25 years ago (I describe the traditional method below).

With laser ablation, they do a local anesthesia and then they insert a catheter into the leg near the vein. they run a fiber optic cable into the vein and use a laser to cauterize the vein closed. I literally stood up from the procedure and walked out the door. The other method would have left me bed ridden for several days and as much as 6 weeks from any significant physical activity (Boooooooooo).

The degree of discomfort during the procedure was less than that of getting some ink. Post-op, the discomfort is minimal and far less than the discomfort that I used to live with on a day to day basis. I did not realize how much pain I was living with day in and day out.

History:

I have a long-running history of varicose veins. My first surgery was at age 16 on both legs. Had a second surgery at 18 on the right leg. That would have been 1983-85 time frame. There was no ultrasound in those days to see what was going on inside, so they did what they thought was best, but in fact it turned out to create future problems. So here I am today some 25 years later dealing with it again.

I went to Doctor N., Head of Vascular Surgery at a large academic hospital which shall remain nameless. I told him the procedure I wanted – laser ablation. He told me the veins were not big enough and that the method would be the traditional vein stripping.

In vein stripping, they put you under general anesthesia and make numerous small (1-2 inch) incisions all down your legs, tie off the veins at those spots, cut them and pull them out. Bad news. Long recovery times (6 weeks) and severe bruising of the legs all along the path of the veins. That’s what Doc N. wanted to do to me. I declined.

A good friend of mine I ride bikes with had the same condition and recommended Dr. Bonau instead. My buddy told me that he did not realize how much pain he was living with until after surgery. Pre and post, the relief is hard to believe. I am ever so grateful to my fellow cyclist.

I can only imagine how many differing opinions there are about how to solve our healthcare crisis.  But how many opinions are out there about what is wrong with our healthcare system?  Dare I start a list…

Anyhow, in doing some recreational reading and email sorting this morning, I came across a link to an article (sent from a colleague) “Government Contemplates Financial Bailout While Taxpayers File Bankruptcy for Medical Bills – When Will Congress Intervene in Skyrocketing Healthcare Costs?”  Great title, right? As I read through the article I couldn’t help but wonder how many people think that our healthcare problem should be “solved” by our government. Yes, yes, please let the government solve our healthcare crisis (read: tax payers pay for it).

I do not have beef with the article, or with the government “solving” problems for that matter.  The piece is very well written and highlights the problems and costs Americans are facing in relation to their health expenses.

I guess my question lies in this last paragraph, “The unacceptable result of all this is that an increasing number of Americans are foregoing expensive but much-needed drugs and treatments, including those for serious conditions such as diabetes and high blood pressure, which if left untreated can result in worsening conditions, hospitalizations, or even death. The problems in our health care system need to be addressed by Congress now.”

Hmmmm, so what does Congress do… implement a mandatory exercise hour across America?

Our solution has to be a JOINT EFFORT.  This is not solely the government’s problem!!

Yes, a lot of this is their fault. However, I would argue that there are five major players in this mess, one of which is the government. (See my previous posts for the four contributors – since then I have added one). The other four: doctors, pharma (newly added), individuals, and insurance companies. Unfortunately, I have yet to appoint percentages of blame.

The majority of Americans know our system is failing, but are unwilling to make any sacrifices or changes. We have had a third party paying for our care for far to long, with ever increasing bottom lines and stricter rules for coverage. On top of that, the government cannot bail us out of our obesity (or sub other unhealthy behaviors) and sense of entitlement. Insurance companies sure aren’t going to help either.

There are three things that are going to help fix this system, and individual accountability is one of them.  We have to stop running to the doctor every time we have the sniffles. We must make health and wellness a priority – and start exercising.  Second, is transparency.  No one really knows what the true cost of healthcare is.  Guess what folks; an office visit does not cost $20.  To be accountable, cost and quality information must be available to consumers.  Last, is competition.  By being accountable for our decisions, and knowing the true cost and quality of healthcare, providers can begin to compete for our care. Until doctors/hospitals have to be accountable for the quality of care they provide and the amount they charge, nothing is going to change.  Every other market has competition, why should healthcare be any different.