I would like to commend my wife's sister for making the choice to re-enter the world of academics and try to increase her financial independence. She works as a med aide at a local assisted living facility. She is single and has a seven year old child.
She has some tough choices. Being a full time mother, employee, and now student. Life ain't easy She related her desire the other day to leave her job, which has full health benefits, become a full time student and join the ranks of the medicaid while she gets her degree.
At this point we had a long conversation about insurance, reimbursment and the likes. Last year, while ON her current private insurance plan, she made a visit to the emergency room with "chest pain". She knew very well it was not "chest pain". Afte the ER charge, ER doc, CXR, EKG, labs-->$750 to be told what she thought all along, pleuritis. I told her she could refuse any and all tests. She had no idea. She felt like she was forced into the tests. We talked about defensive medicine and the implications of NOT ordering those tests for a physician to get it wrong, just once. The docs hands are tied. The ER is a place of exclusion, more so than making the diagnosis. By nature of going to the ER, they need to include or exclude you in that category. They are not necessarily there to make the diagnosis. Clearly, they can make the diagnosis, but that is not their ultimate goal. That is what your primary care doc is for.
Regardless, the crazy thing is, her premiums probably run at least $4000 a year and her ER deductible still forced her to pay the entire $750. This is a racket Her insurance covered not a dime. Imagine if her premiums were 1/2 that ($2000) Here employer would save money, $2000 per employer. Now imagine if her employer gave just 1/2 of that 1/2 ($1000) by putting it into a tax free HSA account to be used for any medical expenses ( even things not currently covered like, OTC meds, contacts, glasses etc.). And imagine if the employee paid an equivalent $1000 of tax free money into the account, financed in part by the decreased premiums she has to pay.
She would now have $2000 a year in her account, tax free and available for a wider variety of services. If she spends less than $1000 in the year, which many do, she comes out ahead, with money to be used for future medical expenses.
But back to the original discussion. Should she go on the ranks of medicaid while in school? I warned her that in this area, most docs will never see you. You will be bound to the ER for primary care services. I explained the economics of the situation. She offered to pay her doc more.
Ah, there in lies the problem. I explained quite clearly that medicare/medicaid does not allow "balanced billing". Even if the patient chooses to pay more, it is illegal for her to charge more. It is also illegal to charge a cash paying customer a fee less than medicare pays, if that docs accepts medicare. In other words, medicare would want that smaller fee. So, they won't pay more and you can't charge less. How absurd.
She was surprised that it is illegal to pay the difference between what we charge and what insurance collects. Here is a potential medicaid patient willing to pay her fair share, and the system won't allow it. Why? I have no idea why. Both patient and doctor win. Patient gets access, Doctor gets their fair fee.
She talked about using chiropractor services, about how they offered to "work with her" as an uninsured client. This is capitalism. This is how it should be. Right now, we can't "work with her". It's either in or out. If she's in the medicaid system, nobody will see her. If she's out, we can't charge her less than the medicare fee schedule or it's considered fraud. Even though the cash only model allows for lower costs because billing/collections/ resource utilization is lower.
This socialistic model is killing primary care.
The system if broken.
2 Outbursts:
So how does Medicare supplement works? Doesn't the insurer that sells Medicare supplement in fact pays more? How the insurer can do it if it is illegal?
Medicare supplement pays your 20% copay, it doesn't pay your doc more. Medicare B says you must pay a deductable of about $130 a year, then Medicare part B (for which you pay your premiums) will then pick up 80% of the costs.
Your Medigap insurance for which you also pay premiums picks up that 20% that medicare says you must pay.
No where in the system is your primary care doc paid more. Medicare says your visit is worth $80. So they pay 80% of that and your medicare supplement pays the other 20%.
Now, if your doctor charges $125, he can only collect $80, no more. There in lies the problem. Medicare rates are substandard for primary care, when compared to other specialties and that's why the massive shortage of primary care is coming.
Medicare is set to cut that rate from $80 to $50 over the next 5 years, while the cost of all the docs expenses will continue to go up (rent, gas, health insurance, nurses, retirement plans, you name it). It's all going up and the reimbursments are going down.
This equals primary care exiting the medicare system and you the medicare patient left without a primary care doc. It's not your docs fault, its the systems fault. Call your Congressman to change the laws as the currently stand. This gives a good summary of how medicare works.
http://en.wikipedia.org/wiki/Medicare_%28United_States%29
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