Tuesday, May 4, 2010

The (Health Insurance) Universe in a Nutshell

From Take Back Medicine:
1. WWII & FDR – Feds have problems grappling with wages and prices. Health Insurance becomes a pre-tax benefit of employment. (We start to pay for our own health care with other peoples’ money, disturbing Market Forces.)

2. 1966 – In spite of AMA concerns about socialized medicine (AMA still represents most physicians), Kennedy’s assassination provides trigger for passage of Medicare, which becomes Health Insurance driver for those over 65 AND other insurers. For many years, system is ‘cost-plus’ - Medicare pays a beneficiary a stipulated amount for service ‘X’ and physicians have choice of either accepting Medicare fees (“signing up” for Fed fee schedule) or charging patients what they can afford above and beyond physician’s personal fee schedule. This works well for physicians and patients, but not for Feds. Medicare costs quickly mushroom beyond all predictions.

3. Nixon Administration – The Advent of the HMO (Health Maintenance Organization) Industry. Doctors begin to become employees instead of private, ‘shop-owner’ entrepreneurs. Formerly unadulterated Physician advocacy for patients now grapples with split allegiances. Markedly different HMO ‘Ethics’ arise (Capitation: flat fee per year for each of a doctor's assigned patients, irrespective of ANY treatment - or none. Some HMO’s recoup funds from MD’s if they spend ‘too much’ on drugs for their patients.) Brave New Ethical World of HMO’s begins to split AMA, which cannot represent both physician ‘camps.’ AMA begins to lose physician representation.

4. 1984 - Reagan Administration: “DRG” system put into place. Hospitals are paid flat fee, based on diagnosis for any Medicare admission, irrespective of length of stay or severity of condition/ services rendered. Patients begin to be discharged ‘quicker and sicker.’

5. 1990 Fee Physician Freeze - After AMA asks physicians to Voluntarily freeze their fees for one year, Price Controls are set into place by Feds for all Medicare patients. Along with these fixed fees for EVERY covered medical service/procedure, a new, lengthy, complex rule-book (a ‘Rubik’s cube’ puzzle) is developed - and mandated - for purpose of billing Gov’t. for all Medicare patients. For first time, ALL doctors are required by law to code, and submit, TO THE FEDS - all claims filed under Medicare.

Pay Attention Now!

A. In the past, a doctor could elect to "accept assignment" from the government for his Medicare claims (doctor agrees to accept Medicare payment as payment in full). For a time, doctors felt there was some wiggle room if they wanted to avoid threats of bankrupting fines for inadvertently miscoding by NOT accepting Medicare money. (At this juncture, All Medicare payments are price controlled, whether or not a doctor ‘Accepts Assignment.” Accepting Assignment just means he is guaranteed (?) to be paid by the Gov’t. with a slightly lower fee than if he does NOT accept assignment. Of course, patient pressures have obvious consequences.)

B. In the past, a Medicare Beneficiary was defined as a covered person who received payment from Medicare. Fortney ‘Pete’ Stark, head of House Way and Means Subcommittee on Health, changed the definition of “Beneficiary” to one who is merely COVERED by Medicare. The New Rules said that if a doctor didn’t want to accept Medicare money, he had to 'withdraw' entirely from Medicare (even if he hadn’t actually enrolled). If he did so, from that time forward, No Medicare patient he treated would be reimbursed one cent by the Gov’t.

So, if we wanted to see our Medicare patients, we were forced to accept Gov’t. money.

Hang on now: A Supreme Court Ruling says that if the Gov’t. funds any entity, in part or in whole, it has the right to control any aspect of that entity.

Think about this – long and hard.

The Gov’t. takes the position that seeing Medicare patients is ‘voluntary,’ even under such circumstances. Yours truly almost went bankrupt when he told his Medicare patients he would be leaving this new system. 90% of my patients said they would continue to see me, but only 10% did. For two weeks my income equaled my expenses (NO salary at all). I closed my office, moved ten miles north where high schools were still open and acne patients were once again available. I joined health plans (which I had studiously avoided) and rebuilt a practice – after 14 years – almost from scratch.

6. Clinton Era – Attempted passage of Universal Health Insurance Plan Fails. IF it had passed, it would have been illegal to use one’s own private funds to pay for services NOT covered by this plan!!

Yes, you read that right.

[Note: The AMA, having lost many physicians from its roster by this time, obtained the Monopolistic publishing rights for the Code Book used by every physician in the country for every service/procedure he or she performs for each and every patient (not just Medicare). Curiously enough, these codes are altered yearly, forcing all doctors to buy new codebooks on an annual basis. THIS is now a major moneymaker for the AMA. Is it any wonder the AMA endorsed Obama’s Health Care Plan???]

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