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How We Pay For Healthcare:
Medical Insurance Problems and Alternatives
By Brian Carter, MS, LAc
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Healthcare practitioners of all medicines, whether MD, chiropractor,
or acupuncturist face a dilemma in who pays for healthcare, and
how that decision affects the quality of medicine. Insurance and
HMO's, such as they are, inevitably mean higher cost and lower
quality care. You, as patients and practitioners, do have power
to affect this problem.
Not the Best Use of Your Money
33% of the U.S. population has no (zero) medical expenses each
year. However, most people want the 'in case' benefits
of insurance (in case you get sick, in case you get hit by a car,
in case you fall off a ladder). Because of high deductibles and
unused funds (by people who aren't sick), insurance is a good
business. Your unused healthcare funds go into their pockets.
Plus, most policies have little or no provision for preventive
medicine. If you are healthy enough to not use your insurance,
wouldn't you want to use the money you've paid in for prevention?
Or to save it for retirement?
The Worst Thing That Could Happen to Acupuncture
In the first meeting of our Clinical Science II class, ER Doc
and PCOM professor, Dr. Timothy Carman, MD recalled how excited
his acupuncturist friends were when insurance companies first
began reimbursing for their patients' treatment. "What do you
mean it's great?" he asked, astounded. "Insurance is the worst
thing that could happen to acupuncture! These guys that work
at the insurance company who make $10 an hour call me up and tell
me to put my patient on this or that drug... I say, what are you
kidding? Who is this?" Insurance company employees with maybe
4 years of education regularly dictate how the patient is to be
treated to an MD who has been trained for at least 11 years. Another
biomedical professor at PCOM, Jack Springer, M.D., expressed a
similar sentiment. "Our healthcare system is absolutely ridiculous."
Sorry, No Tests Left
Lynda Harvey, OMD, L.Ac. (licensed
acupuncturist) conducts practice
management seminars. She tells the story of a woman who had
suffered head trauma and needed an MRI to be sure there was no
serious life-threatening complication on the horizon. Her MD had
used up his limited allotted number of visual studies (MRI, CT
scan) for the month. She had to call around to other MD's to see
if any of them had any of their allotted number left. Unfortunately,
they did not. This meant that her doctor had to choose: pay out
of pocket for the test, or allow the woman to go home in uncertain
condition? She went with her conscience, and chose to pay for
the test at her own expense.
Why Your MD Can Only See You For 7 Minutes
Dr. Harvey was practicing at the
time that some insurance companies began to pay for acupuncture.
Many of her patients asked her if she would take their insurance.
She let them choose. "If I take insurance, I'll have to hire someone
to do all the billing and claims, and because of that, I'll
have to see more patients each day, so I won't be able to spend
as much time with you as I do now. I may be able to see you only
for 10 minutes or so." All but 2 of the patients in her busy
practice opted to continue paying out-of-pocket.
Insurance Companies Cut Pay and Inhibit Quality Care
A standard practice of insurance companies is to enlist newly
licensed acupuncturists. These new licensees typically have tens
of thousands of dollars in debt to pay back to the government,
a long practice-building road ahead
of them, and, understandably, quite a bit of fear. 'Sign up with
us,' the insurance company says. 'We'll give you patients right
now!' Unfortunately, their typical pay is quite low, and, if enough
acupuncturists accept this lower amount, it will become the standard.
As insurance companies try to make greater profits by paying providers
less, they increase the stress on practitioners and decrease the
quality of care. Motivating people to join an organization
by playing on their fear is a cult-like practice. Another
possible unfortunate side-effect of insurance companies is that,
because they work with formularies (specific protocols for treatment)
that may not be based in Oriental Medicine, they may require practitioners
to practice in a way untrue to our medicine, and ultimately not
beneficial to patients.
The AMA Recognizes a Healthcare Stress Epidemic
The U.S. healthcare system is so bad that the consulting branch
of the American Medical Association has written an article titled,
'10 Steps To Containing The Health Care Stress Epidemic or How
to Get off the Stress Treadmill.' The article reports an 'epidemic
level of fear and stress among health care providers and their
support staff.' This is because they find they have to work harder
and longer hours for less pay. And they're frustrated that they
cannot practice medicine the way they want to.
Insurance Collection Wastes Time and Creates Frustration
Al Stone, founder of Acupuncture.com and a Licensed Acupuncturist
shares his
frustrations with collecting reimbursements (Also
at this link, a list of insurance companies that cover acupuncture):
"I had a very bad experience attempting to be reimbursed for acupuncture
treatments that I performed on two of my patients in 1998. It
took me over a year of calls every two months to Aetna. I don't
fault them for wanting to make sure that their insured needed
the treatments that I performed, but this company was so incredibly
beneath my expectations of professional respect and competence...
I could swear that had I not continued to call every other month
and complain about their slow response that the treatments would
have never been paid for. Ever. They simply ignored the process.
It was truly amazing. In the end I got paid for some of the treatments
and even those, not as much as I should have been paid. The amount
that I got paid was actually not as much of a problem as their
inability to simply handle the paperwork and get the job done.
All they did was sit on the papers, shuffled them around a bit
and then ignored the whole process until I called over and over
again. As a result of this incredibly silly, time consuming and
frustrating process, I do not accept insurance from my patients
any longer, rather I give them a super bill and let them seek
out reimbursement for the treatments."
Practitioners Opting Out of Insurance System and Succeeding
Timothy Carman, MD, cited two examples: a well-respected MD, and
a long-time practitioner of acupuncture, neither of whom take
insurance. "They both have waiting lists months long," he said.
Consumers are willing to pay for good care. And it's not news
that the care given by MD's and chiropractors who take insurance
is not satisfying the public.
Healthcare System Broken
As early as 1991, 60% of Americans already believed that their
health care system needed a fundamental change. "Of the 10 largest
industrialized nations, the U.S. ranked dead last in health care
satisfaction, with an approval rating of only 11 percent." source
Insurance companies seem to believe that they are able to provide
care that is less 'top-down' if the doctors do not control it.
Patients need to have input, they say. I wonder, how can patients
get their say if the doctor must see a patient every 7 minutes
to make ends meet?
Equally stunning is the problem of capitation. Capitation
is one of three standard insurance compensation schemes. The doctor
is allocated a specific number of patients (perhaps 1000). The
doctor gets paid a certain amount per patient regardless of whether
or not he ever sees the patient. That is why, when you call for
an appointment, you may end up talking to a nurse who is trying
to convince you that your problem is not bad enough for you to
come in. This is also one reason why doctors are annoyed by
patients with chronic diseases (the other reason being that biomedicine
often has unsatisfactory and side-effect-ridden treatments for
chronic disease).
Insurance companies and health maintenance organizations have
reduced the level of medical care and increased stress for healthcare
practitioners.
Alternatives and Solutions:
1.The MSA (Medical Savings Account)
Get your employer to provide an MSA. You can choose your own
doctor and change doctors anytime for any reason. There are no
deductibles. If you're self-employed, some percentage (it varies)
of what you save in your MSA is actually tax-deductible; your
insurance pays for itself in tax savings! If you're an employer,
look into creating an MSA instead of purchasing a high-deductible
major medical policy; your employees will be happier. As for withdrawal
of your MSA funds: At anytime the money is withdrawn for medical
expenses, it is tax-free. If the money is withdrawn before age
65 and used for non-medical expenses, a 15% penalty will be assessed
and will be reported as income. At age 65 monies can be withdrawn
without penalty but must be reported as income.
MSA links:
2. Superbills and TOS Discounts
Another alternative is the TOS (time of service) discount. Practitioners
can charge a slightly lower fee if the patient pays cash at the
time of service. The practitioner can still provide the patient
with a superbill which the patient can then submit to their insurance
company. Practitioners can combine the ideas of a receipt and
superbill (giving every patient a superbill as a receipt) to streamline
their office procedures.
The advantage of paying out of pocket for patients is that this
empowers your doctor to spend the right amount of time with you,
and to choose the best treatments for you. Choose a practitioner
that you trust and feel comfortable with, and then empower them
to help you by paying them out of pocket.
* Images courtesy of Getty
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