Why is the Cost of Health Care Gone up, while my benefits went down?
[su_heading]I am HOPING and PRAYING that you READ this WHOLE Post…. I just wished I put it out a few years ago and blasted it to social media then, before our government got it’s smoke and mirrors out. This is in NO WAY a conspiracy, it is the truth based on first hand experience in the medical field and verifiable.[/su_heading]
[su_dropcap]W[/su_dropcap]orking for a pharmacy, specifically as a pharmacy tech for the past 25+ years, I have seen a lot of changes; none of them for the benefit of the physician, pharmacy or even the patient (that’s you). The state of the changing economy and the country’s education system are a big part to blame, however it truly is the voters, who don’t fully understand the issues on the ballot, cannot take the time to understand truly what or why they are voting for a specific candidate and what they stand for…even if they change their own stance on subjects when they get to Washington D.C., as MOST DO.
[su_pullquote align=”right”]There once was a time where the state assisted in helping those who truly needed medication or physician care was justified, but that time has long past and with the new Affordable Health Care Act (a.k.a. Obamacare) things have become far worse and the future looks even worse for those in the care industry.[/su_pullquote]
I will give specifics in this post about how I have seen the system change, how it changed and who it hurt, but before I do, I’d like to give you a front line report.
You see I am in a medical complex where there are, were, a lot of very intelligent, caring physicians who truly knew and cared for their patients. They even cared for generational families, treating Grandparents, parents and their children, knowing not just their name or past treatment in a chart, which for the most part has become more and more summarized. The Physicians actually knew the patients by face, sat and spoke with them, asked about not just what brings them in today, but to truly engage in real conversation about how their patient is doing in their life, how their mom or dad or kids were doing, giving that empathetic and caring time that builds relationships.
This has all but been destroyed by the red tape of the ever growing bureaucracy of the health care system.
My first encounter of the State Funded Medicare system.
For the record, I am not a racist, I just tell facts. A black woman drives up, alone, in a gold Mercedes Benz, a 500 series, with gold spoked rims, she parks in a handicap spot, with no plates or placard stating she had the ability to use that spot. The woman gets out, her hair looks amazing. All done up, fresh from the salon, accenting ribbon and those nails, I have never seen such a manicure. She walks in to the pharmacy and asks for her prescription, just like any other patient would, opens the bag and then yells in a ghetto voice, ‘where’s da rest of em’. (again only facts)
We ask her to restate the question and what she was looking for and her response was, “I usually get 3 months of birth control pills, where are the other two.” We looked up the prescription and discovered that the state NOW only pays for one one month (packet of 30 pills) and the patient must be evaluated every month. The woman yelled some obscenities, including that she would not return to our F*ckin place of business again. Was this our fault?
Now I hoped you picked up on three things in this factual story.
- The state pays for birth control and started limiting the dispensing.
- The woman was in a 500 series Mercedes (new at the time), why was she on a state funded medical program?
- The mentality of a entitled person who not only drove an $80k car, but had well over $250+ of beauty work just done. Do you think this state funded Medicare system is fair?
Okay, then read on.
Fast forward to 2001-2002 where the landscape truly changes.
If you had Blue Cross, Blue Shield, Aetna, HealthNet or some other medical health plan from your employer or you purchased it on your own, which WAS affordable at the time, you got to experience the friendly doctor who knew you. You might even agree that you worked hard for this medical plan or hard for your money to afford a plan that gave you the health care, you know the kind that the world seeks in our country.
[su_heading]What happened prior to the early 2000’s? Well I want to share this with you and this is where the bureaucracy starts getting thick.[/su_heading]
Prior to the 2000’s, providers, that is physicians, clinics and pharmacies would have to forego the promised payments of the state Medicaid system, IF the state budget had not been past. This means any services or product (medicine) that was done or given out would not be paid to the providers until the state budget was past.
Imagine your small business running on a promissory note of funds from the state for sometimes months.
Can your small business run on promises of payment after products or services were delivered?
[su_dropcap]T[/su_dropcap]he new chapter came when those nice health plans, that you and I worked so hard to afford, came to the rescue of the State of California by stating that they would “supplement the payments” so that these providers can continue to do business.
Think about this for a moment, why would an insurance company help the state?
Do you see it’s a financial gain? On paper it looked good to the state, but in reality it was a disaster to the entire system, the State, the insurance companies and those who paid for quality insurance. The insurance companies charged interest to the state for the money lent (no big surprise, right), which we all know the state could not afford at the time and tried by issuing many bonds in which funds could be transferred to try to offset this (not stating publicly, but the small print allowed for it)….but that failed to work and all of California saw higher taxes (er..’feeees’) as a result of this.
Then came the rate hikes for those that were paying for quality care insurance companies, because they gave more money to the state, they themselves needed more operating cash to operate and make shareholders happy.
Are you following the dollars yet?
This made the state indebted to the insurance companies which they now lobbied the state on important issues that would benefit the insurance companies (more on that later) and the state was now more or less helpless to challenge for fear that the money would get pulled and the state would have to declare bankruptcy….
[su_heading]All of this to support those who are now generational Medicaid recipients, do you understand the problem yet?[/su_heading]
- Did you notice at the beginning of the 2000’s your medical insurance premiums and copay’s went up?
- Did your employer drop your vision and/or your dental coverage?
- Or ask for you to contribute more of your paycheck to your medical plan?
- What about the retirement matching, did you even see that go down at this time in history?
As time went on there was born what was to be rebranded as the Medicare Part D program where even more funds were siphoned from those that worked hard, to the insurance companies, to the state paid Medicare system. Now before you get your panties in a wad, sure there were other issues that played a part in the economy and budget of the state, but this is the one that was rarely known, spoke about and the most destructive part that led to healthcare of the masses, where the cost went up, the coverage and treatment went down.
WAIT I haven’t even told you the best part yet.
The state started imposing reimbursement pricing for medical services and prescriptions and as time went on the more and more rules and regulations of payment were put in to place. (smell the bureaucracy yet?) This meant that clinics, physicians’ offices and pharmacies all had to hire medical billing assistants. Ever see those technical trade commercials in the mid 2000’s?
However, the state and the insurance companies started to be very selective with coverage, adding twists and conditions to pretty much all services and products. This led to state and insurance company educational seminars where the medical billing assistants (now turning to professionals) took classes on how to interpret all of these rules, regulations and conditions.
OKAY – Sure they were ‘providing jobs’, but at WHAT COST?
[su_heading]FACT: The State Medi-cal Manual containing the rules, regulations and conditions grew from a single 4” notebook to two 4” notebooks in a 4 year time period and with the advent of the Internet, they are no longer even published in paper. However if you printed out the entire manual, it is now four 4” notebooks. And that is JUST for a Pharmacy! (see the online version at http://files.medi-cal.ca.gov/pubsdoco/manuals_menu.asp)[/su_heading]
What happened next? Well going back to the woman in the gold Benz, there used to be a green card with 5, then 6 stickers on them. That meant that the State of California would only cover that many prescriptions per month, IF and only IF the medications were on the approved list of drugs and even if they went over the monthly limit or a doctor said there was no other treatment, there was a form for that. (which took 20-40 minutes to fill out, mail and weeks for a response – no real Internet in the Medical Community, yet) Starting around the mid to late 90’s, the state of California issued cards were then sent out and now providers had to use either a telephone to contact the state to verify patient eligibility or if the provider had Internet access (not very likely at this time period) could look up eligibility online.
Do you see how the complication grew in just 10 years?
[su_heading]FACT: Insurance companies seeing the CAPPED rates of reimbursement on state Medicaid services and medications, started dropping their reimbursement rates accordingly to the state reimbursement program, as well as imposing their own usage restrictions. Yet at the same time, the cost of producing medications, quality assurance, product testing, patents, research and more all started pushing the cost of medications up.[/su_heading]
What about the cost of your medical coverage? Just to give the state the opportunity ‘to help’ those in need, which by the way, somehow was growing at a rapid rate…. Ever learn how to communicate silently to cheat in class? The poor or ‘underprivileged’ and even the lazy people sure could communicate… and many through the social services offices, who themselves were underpaid employees refusing to use their brains for evaluation and just told anyone who came in how the system works at least how to get on it for free health care.
And the funny part was (sad really)… many who were applying, didn’t speak English, were illiterate, and many more just lazy to fill out the paper work, so the office or a friend would.
But I digress…well maybe not.
Remember those ‘very intelligent, caring physicians who truly knew their patients’, I spoke about earlier? Well recently with the Affordable Healthcare Act (a.k.a. Obamacare), they took one of three paths.
- They either closed their business as they had seen enough of what the state can do and understood all too well what the Obamacare plan would do to their business and patient care.
- Many retired early, sending out heart felt letters to their patients and recommending other offices, well the good doctors I knew did that very thing.
- The third or last path/choice was split in to two categories, those that just sold their practice to either a medical facility, clinic, doctor or business and went to work for a clinic or larger practice organization like Sharp Healthcare or Kaiser, the other doctors were usually younger, having huge student loans and did not get the chance to open their own practice so they only know they will be working at the large organizations.
This is truly a sad position, I mean to have so much red tape created in the past 14+ years that just about any provider has a slim chance of staying in private practice without a major support team of professionals, which are no longer cheap as they are now in a demand position knowing more about medical billing than the doctors and many making as much.
[su_pullquote align=”right”]Do You Understand your Health Care Plan or Even Know How to Shop for one….Don’t feel bad MOST people don’t either, because of the incredible amount of paper work, legal, benefits (lack there of), etc…[/su_pullquote]
I didn’t even touch on the switches.
These are companies that act like the middleman in payment processing between the provider and the insurance company. (More of your money out in the wind for paper pushing) They come with an entire new set of rules not to mention very complicated 40+ page contracts. We have gone from nearly 3 maybe 4 dozen down to a dozen as the more successful ones bought the smaller ones. And as they grew in size and power they also had their hand in directing the path and cost of providers, services and products. However that is entirely a post/article unto itself, suffices to say if you inadvertently breach a contract, knowingly or most often unknowingly….that severed your business from the ability to access billing anywhere from 5 to as many as 3 or 4 dozen insurance companies.
How is that a hit to your business bottom line?
These processing contracts are extremely hard to fix as they come with a full level of bureaucracy that are stumping even professional medical billers, boarding on requiring to have a legal team to navigate them.
Again do you see why the cost of insurance, doctor visits and the cost of medication is going up?
I am going give one more detailed example of just how the bureaucracy is in the way of quality care and how it is even going to become worse with Obamacare.
It should be self-evident by now that providers (pharmacies, doctors and clinics) bill processors (bowing to their conditions) in order to receive payment from a patient’s insurance, even the state of California’s Medicaid system.
The latest and greatest that I had to deal with was an audit request from a very larger billing processor about the use of a medication prescribed well over a year ago. The patient has been deceased for a number of months now and the insurance and the billing processor now want an audit? On a medication that was only $40.00. The twist to this is a requirement that was adopted by the State of California AND the Insurance Company AND the billing processor (owned by the Insurance Company) in January 2011, BUT was not given to the pharmacy or the doctor’s office for evaluation of treatment or billing?
My questions are
- Why did it take well over a year to ASK about the usage of the medication?
- Why was there not a procedure in place to inform the doctor or pharmacy?
- No disrespect to the deceased, but the man has passed, the medication consumed only as part of a treatment to offset a side effect of another required medication? (which triggered the audit well over a year later….huh?)
- Why is the pharmacy being penalized when the physician’s office does not carry a license to distribute the medication required for the treatment and relies on a pharmacy to provide it?
Sure this is only for $40.00, but let’s talk about the principle and money wasted here vs the $40.00. How much money was used in making of this discovery and then requiring the pharmacy to investigate and involving the doctor’s office to pull the chart from storage and take their time explaining the treatment so we can just pass it back up the line?
I know it took me at least 20 minutes to understand what the Audit Notice was attempting to convey, so undoubtedly it is confusing and it almost required a translator of legalize. Then I had to pull the original prescription from our achieves, research it on our computer system and make a call to the doctor. That was 40 minutes in total.
The doctor’s office had to go to storage (either courier or an employee + Gas + Insurance), look for the file, bring it back to the office and then involve the doctor. The doctor gave his statement to the nurse in 5 minutes, the nurse called me back for a 20 minute conversation because the doctor gave the wrong answer, probably to confusing question that was relayed through his staff. (travel + explanation = ~ 2 hours total)
Now I have what I need, it violates the terms set forth in a regulation that neither the pharmacy nor the doctor (with a billing specialist) knew anything about it and stumped us all, while we the pharmacy is out the measly $40.00….. or is it $40.00 at this point?
Are you beginning to understand the cost of healthcare?
[su_pullquote align=”right”]Need ObamaCare – Affordable Healthcare Act in SIMPLE TERMS?[/su_pullquote] Did you know that Obamacare is nearly 20 times more complicated bringing in repeats, redirects, nullifications, counter intuitive regulations, more restrictions in a field where computer technology is at least 5-10 years behind a large business organization? And compared to WalMart’s supply chain management solution, the medical computerized system is 20+ years behind in that type of communication and processing and far more complicated and relies highly upon human involvement, even in the billing process, now using low paid interns with little to no experience, bet they NEVER make a mistake, huh.
I am trying to express my own viewpoint, not as an employee or representative of the pharmacy, but as a human being who has witnessed atrocities in our healthcare system while attempting to place values and justifications on lives through extremely complex systems, that would rival the legal system in this country which has been built over the past 250 years….yet this (modern) medical billing system is only 14+ years old…. WOW Technology make screwing things up FAST!!!
In my own personal opinion those that are making these decisions have Failed to understand the simplicity of what was required…. A proper education! We have pandered to the lowest common denominator in the class and in society, making everyone feel like a winner or can participate and I am ALL FOR that, but consequences must be negotiated, made and dealt with. This NEW system no places a cost on the American people, their lives are now evaluated, based on a ‘condition’. How would you feel if it was you?
[su_heading]SIDE NOTE: if every American, who lost their home due to economic hardships, had just $742 extra a month, every home would have been saved. That is Financial Education, developing a healthy relationship with understanding money as a tool.[/su_heading]
The same exists with medical insurance, the more uneducated, poor people, without high incomes are now forced to pay for healthcare, personally I am excited, donate back to what you already stole from the American people, especially Californians, who work hard for their coverage and income. But that’s not the solution, it doesn’t even feel right to say that, because we should help each other and not let the Government decide how we are “helped”.
Again going back to quality education and I know that is another can of worms and all I can say about that is a diploma is only a piece of paper telling an employer that you can complete tasks and are willing to learn more at the cost of your own sacrifices to pay for that piece of paper. Bet you never thought of a diploma that way, have you?
All I can say is there is enough knowledge in this world that if you lazy parents would just point your kids toward it and encourage them, engage with them in what they learned; it will build habits that will change this country. FYI: Kids LOVE to TELL you what they just learned or show you what they were just taught…. They also mimic behavior witnessed, heard or seen.
I don’t want to hear your excuses and you shouldn’t listen to your own excuses. I suggest Googling “college dropout millionaires” and start your education to financial, business, health and a better way of life. Those people are NO BETTER than you are, they just believe they can do it….stop your whining and proof to yourself you can have a better life.
That was a rant about the knowing the issues, your constituents, the health care system, our educational system, financial learning and self-motivation.
This is my blog and I don’t care if you agree or disagree as long as you are emotionally fired up to want to do better in and with your life, than this post has succeeded.
Please share this LONG ASS post to anyone and everyone you know…. It’s time for the educational journey, one to change our world for our kids.
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