6. Access Problems
Submitted by Dr. JG Kaplan on Mon, 2010-03-01 08:27
When patients require specific therapies and an insurance company makes the frail or sickly patients jump thru hoops, denying or delaying care, it's time to move away from the insurance model. How furious should we be when the insurer uses technicalities to refuse coverage, makes patients wait incessantly on the phone, transfers calls to G_d knows now many departments and then, after seemingly hours, the connection breaks, etc.?
Returning to my own experience [Article 3] getting post-op wound therapy, I was stuck with huge out-of-pocket expenses, I later learned from the Wound Center that patients more needy and less well off then I were refused vital therapy.
(It is this kind of crap that motivates me to write this column.)
Anyway, we all know that these refusals, delays and denials are mostly in the interest of maximizing corporate profits at the expense of patient's lives or limbs.
Is that any different than a doctor ordering the wrong test, wrong specialty consultation or wrong med and then making the patient pay for the wrong care?
Can we excuse fractionalized care where one hand (err, doctor) doesn't know what the other is doing?
Is that different from predictable, repetitive, avoidable mistakes in the hospital setting?
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- This happens daily, for example, when patients use the ER rather than a medical home (their doctor's office) for routine or non-urgent care.
- This happens when insurance companies, in the guise of increasing patient accountability, levy co-pays and deductibles (which we all know have more to do with revenues than making patients think twice about visiting a doctor or ER, especially in a time of (perceived) need or anxiety. It's the old parable about the balloon: when you squeeze it one place, it pops out in another place.
- We note: "increasing copayments for ambulatory care reduced the use of outpatient care among elderly enrollees in managed-care plans, but this decline was offset by an increase in hospitalizations, particularly among enrollees with low socioeconomic status and those with chronic disease. Increasing copayments for ambulatory care among elderly patients may have adverse health consequences and may increase spending for health care."
Trivedi AN, Moloo H, Mor V. "Increased Ambulatory Care Copayments and Hospitalizations among the Elderly." [Free text] N Engl J Med 2010;362:320-8 [Brown University]
Academic Med Centers
Academic Med Centers ---- Watch for the HIZ --- The Healthcare Innovation Zone, an integrated health care system that uses Academic Medical Centers* as its base: The (HIZ) Pilot Act of 2009 (HR 3664; Rep Allyson Schwartz and along parallel lines, the Senate's proposed Center for Medicare and Medicaid Innovation. [Ref. 6] The idea is to create an efficient, cost-effective system of health care that proves to have reasonable access and quality. The component players include individual and groups of practitioners, hospitals, various payment approaches and they would relate as in a "highly integrated care delivery system…that would promote quality and 'bend the curve,' (ie, participanmts would commit to cost containment below the rate of local health care cost inflation."
To coordinate the care, HIZs would have to receive "safe harbor" protections from antitrust and self-referral regulations; they would also need broad-based payment-waiver authority for Medicare to not only improve outcomes and coordinate the care, but also include patients with other coverage "(eg, Medicaid, private payers, and their own self-insured employees) under the same payment approaches and delivery system redesign."
* "AMCs are uniquely suited to integrate the full range of health services, to collect data about clinical outcomes, and to redesign educational programs to prepare future physicians and other health care professionals for a 21st-century health care system."
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