The Cure: Remaking Health Care ™
Health care as seen from the other side
Ever wonder what those people behind the doctor's office counter actually do? Tamara Keith takes a closer look at the inner workings of a typical medical practice in our first installment of "The Cure: Remaking Health Care in America (TM)."
Clinic office assistant Joan Vest searches for a patient's misplaced medical file at the Spanish Peaks Family Clinic on in Walsenburg, Col. (John Moore/Getty Images)
TEXT OF STORY
Kai Ryssdal: Today we're going to start an occasional series called The Cure. About the remaking of the American health-care system. Where the real costs are. And the savings, too. Up first, the inner workings of a typical medical practice. Did you ever wonder, for instance, what all those people on the other side of the counter are actually doing? And why there are so many of them? We sent Marketplace's Tamara Keith to find out.
TAMARA KEITH: It's one of the first questions a new patient hears when they come into a doctor's office.
DOCTOR'S OFFICE: May I go ahead and copy your insurance card and driver's license please.
These days, dealing with insurance is a huge part of any medical practice. A recent Cornell study found nationwide it costs doctors $31 billion a year to deal with insurance companies. That's about 7 percent of all spending on physician and clinical services.
At Ortho Bethesda, an orthopedic practice in suburban Washington D.C., there are eight doctors on staff, and 14 people in the business office.
SHARISSA DYKE: Hi Rob. My name is Sharissa, and I'm calling to verify medical benefits for a patient.
Sharissa Dyke is an insurance verifier at Ortho Bethesda. She basically spends every day checking whether patients have insurance and what their plans cover.
DYKE: Is authorization required for outpatient MRI?
OFFICE WORKER: No ma'am.
DYKE: And who do we send claims to?
Ortho Bethesda deals with more than a dozen different insurance companies. They all have different systems for filing claims. And each company has a bunch of different plans, each with varying co-pays and deductibles and rules about whether pre-approval is necessary. This keeps the business office busy and irritates doctors and patients.
DOCTOR: She's Aetna, and she had acute injury to her knee a week ago.
A doctor walks into the business office with a patient's chart and a sense of urgency.
DOCTOR: And she needs an MRI to evaluate for a PCL tear. And I'm not sure if her flavor of Aetna needs authorization.
The MRI will help determine whether the patient needs surgery. Sometimes it can take several days and lots of paperwork to get approval from the insurance company. Other times, it's 15 minutes on the phone, only to discover.
OFFICE WORKER: Based on the information provided this particular Aetna member's plan does not require pre-authorization for service at this time.
This drives Dr. Edward Bieber crazy. He is the managing partner at the practice and an orthopedic surgeon.
Dr. Edward Bieber: It's time consuming, it's expensive to our office, and it takes up a great deal of my time that I would like to spend giving care to the patients rather than shuffling their papers.
Bieber says he's never had an insurer deny an MRI, so why all the red tape. But insurance companies say requiring approvals cuts down on unnecessary tests. MRI's cost somewhere between 500 and a few thousand dollars depending on the type. Susan Pisano is with America's Health Insurance Plans, a trade group.
SUSAN PISANO: High-tech imaging is being greatly over used and misused. It affects out of pocket costs for consumers. It affects premiums. It affects quality and safety.
Pisano agrees doctors shouldn't have to deal with so many different billing systems. She says her industry is working on it. Later this year her group will test an online system where doctors can access information and use standard forms for all of the insurance companies in their region.
PISANO: The estimates suggest hundreds of billions of dollars could be saved if everybody is using the same rules.
The American Medical Association, which represents doctors, is trying to get some of that provision written into new health-care legislation.
But that alone won't eliminate a huge source of back-office costs: Dealing with a multitude of insurance companies who each have different rules for which procedures they will cover and how much they will pay. Until that changes, there will continue to be more office workers at Ortho Bethesda than there are doctors.
In Washington, I'm Tamara Keith for Marketplace.
Comments
Comment | Refresh
From Merritt Island, FL, 09/19/2009
Actually the VA has been found in multiple peer-reviewed studies to provide better care at lower cost than private insurance (see the URL). However the conservatives who oppose universal health care say that government-run health care is inefficient and poor in quality, and say it so often, that even reporters accept it without question.
http://www.ethics.va.gov/docs/integratedethics/IntegratedEthics-Closing_the_Quality_Gap_20070327.pdf
From San Francisco, CA, 08/25/2009
I was referring to Medicare, Medicaid, and the insurance system for public employees. All seem to work very well. My understanding is that the VA and military hospitals are underfunded and do not function well. You have made an extremely valid point. I think that veterans may be better off receiving care via public insurance or via insurance exchanges. Thank you for bringing this up.
From Ann Arbor, 08/18/2009
Stefanie Krantz, if you're still checking this story, you said the government runs 3 efficient health care delivery systems. Can you be more specific? I could think of only two government- run providers: the VA hospitals and the military base hospitals. I seem to recall a bunch of stories in the last few years about sub-standard care bordering on the abysmal in both of those systems.
From Ann Arbor, 08/12/2009
Another comment, actually relevant to the segment, has occurred to me.
Much of the segment concerned itself with pre-approvals for procedures/tests such as MRIs. There seemed to be an expectation by the doctor interviewed, and by many of the commentators below, that with “reform” the pre-approval requirement would disappear. HA, HA, HA!
I can assure you that Medicare – some have characterized the “public option” as “Medicare for all” – requires pre-approval for many procedures.
From Los Angeles, CA, 08/11/2009
Let me be direct, you were way to easy on the insurance companies - where is your fact checking - MRI's don't cost the insurance companies $500 to $1000 - they pay less than $100 for an MRI - please don't be a mouth piece for insurance companies - you need to dig deeper - when they comment, you need to fact check. Health care in this country has been run by insurance companies for decades - it's clearly not working - 50 million un-insured - the highest per-capita expendures on health care in the world and yet we're ranked in the mid-30's in terms of medical performance. I say through the insurance companies out, they have had their change and haven't performed. As we've seen with banking, we're seeing with insurance - the free market is a mith it's all about greed and taking advantage of the american public.
I'm a small business owner who is sick of seeing my employee medical isurance premiums rise year in and year out at a much faster rate than inflation - when will it stop?
Ken
From Ann Arbor, 08/11/2009
Ho hum. Yet another effort at casting "insurance companies" as villains.
A lot of the paperwork required in doctors’ offices and hospital is a result of existing government regulations. Govt. wants to know this, that and the other thing. Someone has to tell them.
Not to suggest that the insurance carriers couldn’t work (anti-trust laws permitting) to streamline forms, claims, etc., so that clerical staff could go quickly and efficiently from a patient with Acme, to one with Aetna to one with BlueCare, to one with Medicare without having to change mental gears completely.
Although not part of this story, some of the prior commentaries suggest that patients go to doctors and say, “I feel like having an MRI today. Can your get one for me?” Maybe that happens, but I think in the real world people go to their doctor hoping that he or she can correctly diagnose what ails them and recommend something to get them to feel better quickly.
Cash payments. When uninsured, I did ask for, and receive, discounts form some providers. I was surprised to discover after getting insurance that even with the discounts I had been paying more for some services than the insurance carrier. And, yes, I do see what the provider gets, at least in some cases.
From Portland, OR, 08/11/2009
Yes, our system is weighed down by the inefficiencies of the free-for-all of the fragmented private insurance system. The burden of all those billing people is also matched by the unmeasured burden on patients and families trying to manage payment for their claims.
However... and this is a big 'however'... even if we magically erased the 20% administrative cost... well, that's what my premiums rose just this spring. [As a small business owner I pay 100% of our family's health care premiums and other costs.] And I expect a similar jump next year, just like last year.
Streamlining administration is necessary... but it's a one-time saving. Unless we change how we develop and deploy health care itself, the upward arc will continue.
From Las Vegas, NV, 08/11/2009
One of the factors that needs to be considered is the number of physicians who have purchased high cost imaging equipment. The only physicians truly trained to interpret these exams are radiologists. Radiologists do not refer the patients to their own machines. Rather the patients are referred by primary care providers or specialists who feel the additional exam is necessary.
In this story, the orthopedic surgeon appears to be referring to his own MRI. That would seem to be a conflict of interest. Physicians are not allowed to own their own labarotories due to conflict of interest. There is a loophole allowing them to own expensive imaging equipment which they then are forced to pay for. Numerous studies show that physicians who own their own imaging machines refer a larger percentage of patients for expensive tests. This "self-referral" is a large contributor to exploding costs related to imaging. Yet Congress is doing nothing about it.
See this recent article from the Washington Post.
http://www.washingtonpost.com/wp-dyn/content/article/2009/07/30/AR2009073004285.html?wpisrc=newsletter
From Honolulu, HI, 08/11/2009
There are more reasons we need healthcare reform than just coverage for those who do not have insurance. There must be regulations and standards put into place to keep a health insurance carrier from killing a patient either by denial of benefits or using treatments that are economical rather than effective in an effort to make money. These things really happen, the killing, I mean, and they are more likely when your insurance carrier and your care provider are the same person (or people). I have a million horror stories, and I got them all when I worked as a utilization/care manager/discharge planner/geriatric case nurse for a Medicare-risk company (now called a Senior Advantage company), until I no longer could stand being part of a system so corrupt and homicidal. When I heard the opponents of healthcare reform shrieking that reform will dictate euthanasia, I decided I had to tell at least one of my stories because no one seemed to know that the big insurance companies and HMOs have been practicing euthanasia for at least 15 or 20 years already, right under their noses, and probably with their implied approval. (It might not be euthanasia; it might be homicide.) When I was working for an HMO that administered care for many, many "lives" in California, an elderly man was admitted from a skilled nursing facility to the acute care hospital for a urinary tract infection. Yes, he was really old, mid-eighties, and yes, he was demented, but those seemed to be his only diagnoses, neither of which should have been fatal. He was brought in by ambulance,and we put him to bed. His diagnosis was pretty straightforward, and he was put on IV antibiotics. He already had a catheter in place. We called his wife, and she came in with her sons. The doctor, The Hospitalist, whose job it was to get him out of the hospital as soon as possible, preferably prior to the time limit contracted between the hospital and the HMO that would be covered by a flat rate for everything done. It was partly my problem to get him discharged to a place where he would'nt cost any more money for the HMO/administrator. So, the Hospitalist was ordered to talk to the wife to persuade her she wouldn't want her husband to have any pain, so IV morphine could be administered, lots of morphine. Well, the Hospitalist was a young, pretty conscientious man, who had recently completed his residency, and he got really uncomfortable going in to convince the wife of a patient who happened not to be in any pain, to have IV MS. He refused to do it. So, his boss, the medical director of the HMO-Medicare Administrator came in and sat the wife down for a little chat. In only a few minutes he had her declaring she didn't want her husband to suffer (who would?). She agreed with his plan to administer morphine IV at a pretty good rate. It wasn't long before this little old guy's respiration center was depressed and his respirations rate slowed steadily down to nothing. He died in about 3 days, well within his allotted, capitated admission time. Plus, he didn't have to be discharged to a skilled nursing facility which would have been covered as a skilled need under Medicare--and thus would have been an expense to the HMO. During the admission, a surgical consult was accomplished. The surgeon, early in the admission, examined the elderly patient and determined he was not a surgery candidate. When he returned to re-examine him in a little follow-up visit, he saw the patient and his IV morphine and came flying out of the room, screaming at me that this was clearly euthanasia. He threatened all sorts of things, the last of which was an immediate trip down to hospital administration to complain. I wished him well, honestly. He returned to the floor not so long afterward, very subdued and apparently contented with the narcotic analgesia for the man whose only problems were a UTI, old age, Alzheimer's, oh, and an overdose of morphine. I guess the hospital administrator convinced the surgeon of how it is with this particular Medicare organization. The healthcare opponents are so incredibly misinformed about everything involved in this matter, but their accusations of a conspiracy to commit euthanasia are so stunningly ignorant I couldn't restrain myself from telling just this one story. After this horrible experience that, to me, represented the complete downfall of American health care (it was 1995)I had to get out of nursing for awhile, after a pretty wonderful 30-year career, but there are plenty more nurses who do just this same stuff for Medicare-risk companies and Senior Advantage companies (Kaiser, Secure Horizons, Humana, etc.). They get big bonuses when the HMO's hospital census is way down (when they are working the least, they make the most money). The doctors the same thing. Think of it this way, if at the first of the month Medicare gives you a million dollars to provide all the care your members need for that month following, wouldn't you want to keep as much of the Medicare money that's already in your pocket? And how would you do that? By denying or delaying as many procedures as you can get away with. Especially, when hospital costs are 75-80% of your expenditures, wouldn't you want to keep as many members out of the hospital as possible? And if you couldn't keep them out, wouldn't you want to get them out as soon as you could? Wouldn't you load your utilization committee with members all of whom benefit financially from the denial and delay of services? The hospitals and health care providers and insurance carriers are doing the same stuff Enron did only medicine seems nicer than public utilities. I even worked for an insurance company/HMO/provider that did amputations on patients to save money on chronic extremity care. Somebody has to listen to this. Certain HMOs, administrators, and Kaiser-like companies actually kill people.
From Corning, NY, 08/11/2009
Health care in the United states is a joke, i can't beleive its even called health care, it's a scam, I don't even want to begin on how annoying insurance companies and the corruptness that goes on them is. Ever notice that like most of congress were head of HUGE corperations and some of them being insurance companies, ever notice that most of them are republican, ever notice that the republicans are fighting like hell to keep insurance from becoming free because it "wont work" Bull, the facts are plain. You cant deny them.
From Barberton, OH, 08/11/2009
We have been fortunate to have health insurance through various employers for many years. But year after year the premiums go up as the benefits go down. Then there's the constant threat that an injury, illness or change in employment status will result in the loss of coverage just as the need is greatest, followed by financial ruin. It would be difficult to design a more perverse system.
Some say that healhcare reform will reduce Americans' freedom of choice. But for most folks under our current system, the choice of doctors, hospitals, drugs, etc is limited by an insurance company, which in turn was chosen by the employer. Is it really better to have an insurance executive "between you and your doctor" than an unbiased government administrator? We would much rather pay taxes to finance a system where all Americans are in it together under a single "risk pool" than premiums to support an insurance industry that strives to cherry-pick only profitable customers. The insurance industry isn't evil or greedy, it's just an unnecessary middleman in the healthcare equation.
We support reform of the nation's healthcare financing system and believe that a nation-wide single-payer model is the best way to achieve broader coverage at lower cost.
From St. Louis, MO, 08/10/2009
My experience with COBRA over the past 18 months illustrates so well the waste and bureaucratic nature of our current health care system.
I was laid off in April of 2008, leaving one insurance program as an employee into COBRA coverage with the same insurer. I had to submit several documents and was issued a new, but identical set of insurance cards.
I was employed as a contractor, in September of 2008, moving into a new program with a new insurer; more forms and a new set of cards. That contract ended in February, 2009. I moved into COBRA for that insurer, requiring more forms and another set of cards. For some reason, I received and was told to use a second set of cards in March.
I then returned to that same contracting firm, leaving COBRA and back on the same insurance program I was part of earlier, but still had to submit more forms and received yet another set of new, but identical cards.
I know I am fortunate to be able to get such coverage, either as am employee or under COBRA. But we have to ask ourselves how many other Americans could have gotten coverage for the costs of supporting the bureaucratic efforts of my coming and going in and out of COBRA, and several times within the very same insurer.
This is a large waste of resources and only adds to the inefficiency and costs of our current health care program.
From CA, 08/10/2009
I am dismayed that the discussion about healthcare has myopically focused first upon whether or not people are insured, as if becoming insured is a magic bullet that will resolve our health care woes. The media and some members of congress have also amplified the concerns about whether or not a government health insurance plan will mean that the government will stand between us and our doctors. The truth is that health insurance companies are standing between us and our doctors by rationing, delaying, and denying care, and skimming 20% off of the top of our healthcare budget. Insurance companies are beholden to stockholders and the bottom line. One would like to think that the government is beholden to the people.
I have yet to hear a reasoned news report or speech that provides an honest comparison between our system and the systems that are in place in other countries. While the U.K. and Sweden have single payer government run systems, Canada and Germany have not-for-profit private systems. I would like to know more about how these systems work, and the benefits and drawbacks of these examples.
Shall I display my dismay and sarcasm that once again, studious voices of reason and erudition are taking the back seat to the fear mongers and naysayers? I guess I don’t feel like being sarcastic. Last year I spent half of my income on health care. I have a degree, a good job, and a health insurance plan. Unfortunately, I also have an obscure pre-existing condition that means chronic and sometimes debilitating pain; the sort of preexisting condition that has allowed me to see just how impressively health insurance companies wield their mastery in rationing care. This condition has meant having to make as much money as possible to afford medical care (and therefore taking a job I do not like and delaying my dreams), giving up on saving for retirement, resigning myself to debt, and about 15 hours a week getting to and from doctors offices and doing the “homework” that is prerequisite to getting well.
And, just in case you were wondering, I exercise WAY more than most Americans, eat a carefully planned, healthful diet, have been at this for half of my 36 years, and consider myself an active partner in becoming well. I know plenty of other people like me in the same boat. I have actually considered that we would be better off moving to Sweden, the U.K. or France, and have seriously discussed this with friends.
Did I mention that our government is already running 3 efficient healthcare delivery systems?
From Virginia Beach, VA, 08/10/2009
You have left out of your report tonight that the phrase "no pre-authorization required" is not a guarantee of payment. That's the standard disclaimer of the insurance industry. I am the Billing Administrator of a four physician plastic surgery office. Additional time is further wasted after the service is rendered and the insurance company gets our claim. We may have secured an authorization to repair the cleft palate of a child (for example), but the payer will still "pend" the claim for review of its medical necessity. It's very frustrating for patients and physicians alike, not to mention costly. Thank you.
08/10/2009
Your show disclosed that 7 percent of all spending on physician and clinical services goes to dealing with insurance companies. Now would be a good time to ask a hospital why they are willing to accept approximately $28 per X-ray from an insurer, while a self-paying patient has to pay approximately $250 for the same service, even though he is willing to pay cash at the time of the service. It seems to me that a hospital (or for that matter a doctor’s office) would prefer to take $28 in cash at the time of the service. Quite to the contrary, hospitals are rewarding the slow-paying, difficult-to-deal-with insurance companies. Furthermore, hospitals will not disclose how much they pay to an insurer. Is there something to hide?
From Reno, NV, 08/10/2009
My husband is boarded in Internal Medicine and Geriatrics. He gets very frustrated when NPR and PBS and AMP spend so much time at medical specialists'
offices. One of the crucial problems in US medicine is the abundance of specialists and the lack of primary care providers. If the percentages were inverted, we may be able to support the health care needs of the people of the United States.
From San Francisco, CA, 08/10/2009
Not long ago a doctor made a snap diagnosis, decided I had an extremely serious medical condition, and told me to get a CAT scan. Now we're talking about a big dose of radiation in this case. I was dubious, since I had none of the risk factors for that problem. I got a second opinion from a more experienced doctor and learned that the snap-diagnosis was wrong. Cost: second office visit. Savings: cost of scan and a lot of unnecessary radiation. This all happened in a health plan that did not require approval by the insurance company.
From Los Angeles, CA, 08/10/2009
Your story on health care had some facts wrong... regarding MRI's - my insurance company paid $80 for my MRI not $500 to $1000 my experience was as follows: Dr. ordered an MRI of my lower back, Insurance company said no - not without doing 4 weeks of physical therapy first - (is the insurance company my doctor?) did the 4 weeks of physical therapy missing 3 hours of work per visit - 3 times per week that's 9 hours per week 36 hours total at a cost of $250 per hour - my billing rate - total lost work $9,000. No change to my condition, physical therapy didn't help, infact a few session aggrivated the condition. MRI gets authorized, the insurance company pays MRI company approximately $80. Insurance companies are not a value add proposition!
From westfield, NJ, 08/10/2009
People need to remember that it is not always the insurance company setting what is and is not covered or what items need precertification. Most large employers in this country are self insured and therefore decide what are the covered benefits for their employees. Both company A and company B might use Aenta but have different precertification requirements. This creates yet another layer of difficulty for office staff. But what is more interesting is that patients and doctors often get mad at the insurer when they don't cover something when it is really the employer, who designed the benefit plan, they should be frustrated with.
From York, PA, 08/10/2009
The entire health care debate is bypassing some core realities:
Current system provides all the emergency care Americans need.
No system can give all the healthcare consumers can want beyond emergency care.
Employer paid healthcare is as outdated as lifetime emplyement expectations of today's workforce.
Insurance is spreading risk to many non users so a large pool can be made to pay for to an unfortunate user. Life insurance is an example. Health insurance is just bill payment for twenty-five percent operating cost. There is a better way- there has to be a better way.
Americans pay lot more for the same medications and other medical supplies than all other western countries. There is no reason for this except corporate greed and lying to American people.
Other people's money is paying for health care. No other person can say for you what you may not want to spend money for.
If we use these common sense realities we can save forty to fifty percent of our health care expense.
I am a surgeon in active practice, not a theoretical policy-wonk.
From Jupiter, FL, 08/10/2009
Just got back home after listening to your story about physician's staff having to deal with insurance company payment policies. Interested that the story commented on the amount of costs to physicians. Although valid points, compared to the costs of malpractice to a physician's practice, these costs do not compare, especially when you factor in the cost of defensive medicine such as ordering an MRI of a knee in part because the patient wants one, and can not be convinced otherwise, and heaven forbid the physician does not order one immediately and the patient ultimately is found to have something on the MRI, related or not....Mr. Attorney is never far behind. So let's not forget about tort reform in all this talk about healthcare reform because the 2 are interwined.
From Millersville, MD, 08/10/2009
I reacently was diagnosed with a "frozen shoulder" or adhesive capsulitis related to a possible rotator cuff injury. It took a over a month to receive approval for a MRI to confirm whether there was a rotator cuff tear.
In the mean time the doctor's office had to use their staff to repeatedly call Aetna and had to resubmit diagnostic information. A further note to this long process was that Aetna contracted out the approval process to another company and then another company contacted me as to whether this was due to a work injury, car accident or a slip/fall at a neighbors! Any way they can work out not paying they will try. One of the leading orthopedic practices in Annapolis Maryland is not accepting Aetna because of their low reimbusement and the practice I am using may follow suit. Help!!!!!!! Is there a solution???????
From westampton, NJ, 08/10/2009
In 2004, when my mother was 1st admitted to a "major university hospital"; I was very distressed by the STUPIDITY of the administrative systems. Given that PROCESS REENGINEERING was my area of expertise, I wrote a letter to the Chief Admin. Officer of the hospital offering my assistance to correct these problems AT NO CHARGE (i.e., Free Services - I'm happy to help).
I was NEVER contacted (not even a "thank you" for writing).
Since Hospitals assume that they will always get paid (or else keep raising their prices); Where is the incentive to be cost effective? We need a Carrot and Stick Approach to US Health Care, otherwise we're all playing with loaded dice!
From Brooklyn, NY, 08/10/2009
I worked for Ingenix, a subsidiary of UnitedHealth group, for three years as a software developer. I worked on a crack team of Java developers who used cutting edge technology to build two huge software systems: ContractManager and iCES.
ContractManager cost $150,000 a seat. It sat in the offices of large physician practices and analyzed the doctor's rejected claims and figure out ways to bleed more money from insurance companies.
iCES sat in the office of insurance companies and analyzed claims using high technology with the intent of finding ways of paying doctors less.
Our shorthand internal way of describing what we did: "Selling guns to the Hatfields and the McCoys."
Having worked for several insurance companies, I must point out that the single payer, public option is the way to go. Right now, providers and payers are having an arms race and you and I are paying for both sides.
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