The Health Game: Can The Patient At Least Get a Participation Trophy?

A knee injury presented me with a choice of getting healed. The knee could either be  1. “scoped” aka “arthroscopic” surgery or 2. “Rehab.”  The knee was “deranged’ according to the “HMO gatekeeper”. I hate any procedure getting me near orthopedic surgeons and anesthesiologists and choosing surgical facilities.  It made sense to try Rehab as a first option. After all, all these “surgical facilities” have been recently plagued with scares from potential viral infections like “CoVid 19” to “killer microbial ailments.” Rehab was the deal and I went.

The “rehab facility” had a very busy traffic flow with at least 4 practitioners and a receptionist. They, additionally, had several other locations and appeared to be a good size facility. I went to 18 sequential appointments with each being about 50 minutes long. The exercises were effective and the practitioners cheerful. I was cured! It was a good experience.

As for cost, since I was not asked for any co-pays as I took my “treatments,” I assumed that my health insurance paid for my 18 treatments. It was a great deal for everyone. I had paid “premium,” used the system properly and exercised “cost containment” by choosing the cheaper option and I got better.

Well no good deed goes unpunished. I finally did get a bill. Here is what the bill showed me (everything has been translated into rates per hour and extended to be annualized with my matchbook math):

• The Provider billed at a rate that constructively yielded $521,000 annually
  • (Apparent Rule to Follow: Bill as much as you can)
• The Insurance Entities “Reimbursed” the Provider for the “procedure” at a low rate $91,520 Annually
  • (Apparent Rule to Follow: Cut reimbursements as much as you possibly can)
• The Patient paid the Provider at a high rate $99,840 Annually
  • (Apparent Rule to Follow: By plan design pass as much cost onto the Patient as you can so they only go to treatment when it really hurts)

This was crazy and it really bothered me… for one of the highest volume injuries, the patient’s costs were more than the Insurance company’s costs. Patients Cannot Win. There are just “Charges, Patient Payments, Insurance Payments, Insurance Adjustments, Pending Insurance and Patient Owes” transactions. Patients get no trophies for playing this game properly. So, they will not. And beware, there are massive costs involved to get this type of absurd arithmetic to balance.

Here are some observations to take away:

Insurance costs are a function of “claims” costs. Lots of “claims equal lots of insurance costs,” a condition which “raises premiums” for all of us.

The initial cost of medical claims in the US start out as unreasonably inflated and will stay that way unless someone does something about it.

Cost containment is a major way to fight “claims”. One motivation in my choosing the Rehab vs surgery option was “cost containment” to help my employer. A surgically repaired knee costs nationally about $11,250. “Rehab” is about 90% less.

The “copays,” in the above example, were shaped to cost the patient more than the “insurance company.” Most of the cost burden fell on the patient when using “cost containment” in an “insurance arrangement.” That should never happen.

These days, there’s a reason there are usually more “administrators” in a “Doctor’s Office” then there are “Doctors” and “Other Professionals.” A recent and serious paper by Woolhandler and Himmelstein, which looked at 2017 “medical spending levels,” placed the total cost of “administration at $1.1 trillion” for “BIR.”  That would have “provided lots of coverage.” vs “lots of paperwork.”

The industry of claims denials is a big business unto itself in America. For this example, let us call them “Big Deniers.”  “Medicare” and its private industry “counterparts and partners” are huge participants in “Big Deniers.” Yes, Medicare causes problems too.

There are many “powerful interest groups” (PIGs) that each have a stake in operating as profitably as possible in the world of medicine. They are the professional players in this game. Introducing the players, you need to keep your eye on… “Government,” “Big Pharma,” “Doctors,” “Hospitals,” “Malpractice Sources,” “Health Insurance companies/Networks” “Big Deniers” and “Providers.” But they push costs to others and say they did not. Over the years, each one has earned a black eye, and they always blame the other PIGs.

Here is an example. The retail cost of most “medical care” as it comes out of the Dr. Seuss pricing box – is artificially high. They are also usually unknown by the “patient.” Then these high fees for overpriced claims are usually reduced substantially by the insurance company’s or “Medicare networks or (Big Denier)” in a discount game. For example, an imaginary “Doctor with a Medicare” claim thinks, “I need $5; So I bill $10 to get this $5; because if I bill $5, I will only get $3 and it costs me $4 to treat the patient.”  Somebody from “Big Deniers” is at work. But why play these games at all? It’s us, the patients and insurance purchasers who will not win. And, we don’t even get participation trophies, we only get bills.

In America, our employers are required to provide healthcare for employees in many cases. Yet recently the “PIGs” and giant companies like “Amazon” have combined and are now essentially pushing business health agents and brokers out the marketplace. “They do not have a value proposition.” it is said.  But, without brokers, it will force these business insurance purchasers to become healthcare experts, a role they are not equipped to fulfill.  They must run their “other” business, not just the one where they have to play against the “PIGs.” This will not end well, and you will see all types of problems develop, all to the delight of “lawyers.”  Then there will be “governments” at the ready, to offer “idiotic solutions” which will be even worse, as they’ve generated most of the “solutions” that have gotten us here in the first place.

Here are some other factoids showing patients can’t win:

Valuewalk says of “Big Pharma,” if you’re not careful, you can pay on average $630,700 per year for one of the more noteworthy “drugs.”  Every time I see those “Pharma ads” I wonder if the “Miracle” is not the “drug;” rather than someone will actually pay these crazy prices for them. Why are they on TV anyway?

Hospitals – “Hospital costs” are running about $4,000 per day say observers (Source).

BTW We see huge differences in prices from one hospital to another and no evidence they are any better at all. Go figure.

Healthline says, “A 2009 study published in The American Journal of Medicine found that almost two-thirds of bankruptcies in the United States had a “medical cause.””

Anyway, my recent experience and research was a far cry from a Norman Rockwell painting of a Doctor interacting with a patient in his own home for $5. What has happened or… What hasn’t?

Wherever, you see any word(s) in “quotations” in this blog, it means “be prepared bring money!” Lots of it. For example, “Claims Cost” on my deal, cost me $740 out of pocket and my insurance company another $666 for my knee exercises. So, the “Rehab” people got $1,400 out of the deal. They would also get a couple of hundred thousand if all they did is watch knees like mine 8 hours a day. I’m not blaming them. They are the best actors in this drama.

Could I have done this on YouTube for free? OMG! I forgot to factor in my initial visit to the Doctors office and it’s not in these costs. I have to go.  Lastly, unless its cited, it is my opinion and nothing more.