Is health insurance really working?
A look at one primary care physician's practice and patients inside the system
A look at one primary care physician's practice and patients inside the system
The Post and Courier
Merita Bines is examined by her physician Marshall Newton in his West Ashley office on Wednesday. Bines said her group insurance plan provides what she needs, but she sees the system failing others.
The estimated 46 million Americans who go without health insurance get a lot of media attention. But how happy are the 256 million with coverage?
A snapshot of primary care taken one September morning at Dr. Marshall Newton's West Ashley office showed a system that's working, but only just.
Many patients shared stories of frustration and near misses, such as the heart attack that occurred weeks before coverage ended. A few had no complaints but knew relatives and neighbors who routinely went without care.
When it came to fixing the problem, people were left flummoxed, their energy drained by figuring out how their current coverage works.
Newton compared the situation at his front desk to checking out at Costco and asking, "How much is that TV?" and the employee saying, "I don't know. We'll send you a bill."
That happens to patients every day.
"Nobody knows what their insurance pays," said Jeanie Lake, who checks patients out of the office.
Patient Ryan Brown, who works as an insurance adjuster, knows the game from the inside. "Insurance has ruined health care because it's all about the Benjamins instead of patients," he said.
As he checked out, he learned that his previous visit wasn't covered because it had not been pre-authorized. "I'll have to go back now and spend five hours on the phone," he said.
Even prescription drugs can create problems for patients with insurance. One of Newton's patients couldn't afford her co-pay for the cholesterol drug Vytorin, so she switched to Pravachol. Her cholesterol rose 100 points.
Patients don't want to be bothered, Newton said. They fixed it, and now they have to fix it again. "I understand patients need to take risks to get lower-cost drugs, but if an 80-year-old patient with 15 meds is stable on Nexium, then why throw them in a flux," he said.
Some patients are resigned to going without. One of Newton's morning patients was wheezing, so Newton asked him how his inhaler was working. It turned out the patient stopped using the asthma medicine because his insurance paid only $20 leaving him stuck with a $200 bill.
"I had to get the information out of him. He just accepted it," said Newton, who gave him samples of the asthma inhaler Advair and blood pressure medicine.
About 4,000 patients visit Newton's practice annually. Appointments are scheduled every 15 minutes.
Out of a staff of five, most are devoted to processing insurance paperwork. As Newton moves between examining rooms, charts pile up on his desk.
One is a lengthy form authorizing a motorized scooter for an elderly patient Newton described as a "hip fracture waiting to happen." To get the device approved, Newton must conduct and submit notes from a mobility exam, write a detailed letter touching on nine enumerated points, such as why a cane won't work, and write a prescription containing exactly eight parts.
If he misses any one of those criteria, the application is spit out. "I do want her to have a wheelchair, but I don't know when I'll do this," Newton said.
Insurance companies might argue that they pay doctors to file the necessary forms. That's supposed to be the deal: An insurance firm supplies a steady stream of patients whose payment is guaranteed.
But doctors aren't collecting most of their money from insurance companies like they used to, Newton said. Higher deductibles mean patients are paying more out of their pockets and putting the onus of collection on doctors.
Seventy-five percent of money owed to Newton's practice is owed by patients. "Insurance is not increasing payments to me to collect money," he said.
Another strain is Medicare, whose beneficiaries pay 20 percent to 30 percent less than private insurance patients, Newton said.
So, why does he accept Medicare? "We have a moral obligation to take care of the elderly," he said.
Newton saves money by having a nurse practitioner on staff, which allows more patients to be seen and is cheaper than employing another full-time doctor. Another revenue stream comes from supplying patients to a nearby medical research facility that, in turn, provides free care to some uninsured patients.
Newton became interested in primary care while working on his doctorate in biomedical engineering. "I took a big interest in the patient," he said.
But he runs into barriers daily to providing that care. Insurance won't pay adequately for physicals, preventing him from sitting down with patients to talk about their medical history and plan for their future. Preventative screening and psychiatric treatment are briar patches of bureaucracy.
"I'm not pretending I have the answer," Newton said. But two problems must be addressed — coverage for the uninsured and an easier time for the insured, he added.
Reach Jill Coley at 937-5719 or jcoley@postandcourier.com.
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Comments
jsmcadory (anonymous) says...
"I'm not pretending I have the answer," Newton said. But two problems must be addressed - coverage for the uninsured and an easier time for the insured, he added.
This statement sums it up completely!!
I pay close to 900.00 monthly to have health insurance for my family, you would think our plan was great. NOT!!!!
I had to be put under recently to have a procedure done on my jaw. The doctor did not ask me if I wanted to be put under, I was just told what was going to happen. Later my insurance said they were not paying for it because it was optional. I'm sure the doctor employeed by the insurance company that denied this as a result of my appeal, would have not been put under for this procedure. MY A**!!!!!!
September 30, 2007 at 7:46 a.m. ( permalink | suggest removal )
Brant (anonymous) says...
I'm one of those how-ever-many million of people without insurance. It's frightening that so many of us can't afford it. The company I work for doesn't offer insurance to anybody who works less than 30 hours per week; the only ones who get that many hours are managers, btw. I am on medication for high blood pressure and when my prescription runs out, I have to go to a doctor and get it renewed. Well, guess what? I don't afford to go to a doctor like a lot of people can. So I guess I'm out of luck. And in spite of what tripsa believes, I'm not alone in that boat. There ARE millions of us who don't have it.
September 30, 2007 at 8:28 a.m. ( permalink | suggest removal )
jsmcadory (anonymous) says...
I feel for you Brant. I too have been in that position and know how frustrating and frightening it is. Something needs to happen soon. Socializing healthcare and medications I don't think is the answer but definitely change is in need.
September 30, 2007 at 9:44 a.m. ( permalink | suggest removal )
RTC (anonymous) says...
What I hate about a lot of the insurance companies are the prescription drug plans. It used to be a set price for brand names and a set price for generics.
Now they have the "preferred drug list".
Who in the world knows when they visit the doctor what is preferred and what is not? If it is not on the preferred list then you will pay more.
Try telling a doctor NOT to prescribe a drug that is more expensive, and he/she will likely get angry with you.
After all they are the doctors, and they will prescribe the drug that is best suited to treat your condititon.
It is extremely frustrating, and I think a lot of people are stressed after visiting the doctor, because they are so worried about what the drugs are going to cost at the pharmacy.
September 30, 2007 at 10:02 a.m. ( permalink | suggest removal )
liam (anonymous) says...
I went for a free blood pressure check yesterday. The pressure was high as I suspected. My primary care physician has yet to tell me what my cost would be to do tests and see him for medication. No response since I told his office I didn't have health insurance. The free test was performed at a new doc-in-a-box. They gave me a very general fee rate, but didn't really know a figure. I can't get health insurance if I don't have my blood pressure under control, but I can't afford it anyway due to my current financial situation. I am one of those unemployed/underemployed/self employed people that doesn't show up on the unemployment statistics. I'm tired.
September 30, 2007 at 10:09 a.m. ( permalink | suggest removal )
majorjohnson (anonymous) says...
The government is the problem here. First they mandated that companies with over X employees provide insurance, then they mandated that the insurance cover everything from removing splinters and popping blisters to replacing lungs. It's hard to blame the insurance company for trying to cut costs where they can when they have to pay for peoples most basic health care at increased costs due to government mandates.
You should be shopping for your own catastrophic insurance, and you should be paying for your own splinters and colds and baby birthing. The paperwork alone is staggering and takes more man hours than the doctor visit itself.
As far as those 45 million uninsured, around 10 million have enough money to self insure, another 10 million aren't even citizens, another 10 million are young and choose to spend their money on beer and chicks, or buying a house, or starting a business. Another 10 million are actually covered by Medicaid. Most of the rest lack insurance only for short periods between jobs. That 45 million is a straw horse.
October 1, 2007 at 8:43 a.m. ( permalink | suggest removal )
eyfigueroa (anonymous) says...
there's been a consumer-based push for 'al a carte' service from cable companies. paying for only the channels you want. the major players of the cable t.v. industry are against it because they will no longer be able to dictate to the consumer just how much will be charged for service. they claim it will cause an undue burden. 'yeah right' the technology is there but not the will to better serve the consumer.
now let's move along to health insurance. there has been a similar push for more 'al a carte' service from health insurance coverage. right now, most plans forces the consumer to pay for coverage they don't need , i.e. maternity. of course there are exceptions but for the most part the health insurance companies have complete autonomy as to what they can charge.
in both instances congress has held hearings and nothing has come out of it. not that's a bad thing becuase it was the federal govt.'s interference to begin with that has helped to raise the cost of health care.
consumers need to become more savvy regarding their health care choices. take the time to find insurance that better fit their family's circumstances. you do it for car insurance. many people don't realize that they don't HAVE to accept their employers' plan sometimes it is more cost effective to pay for a plan through an outside source.
also, i understand how difficult/expensive it is to provide health care especially when you're unemployed/underemployed. but to rely on the government to take care of you is not the answer. if you are making minimum wage or close to it then you should do whatever it takes to make more money or develop skills to be able to get a better paying job. that may sound harsh but having done it myself i know it can be done.
October 1, 2007 at 10:49 a.m. ( permalink | suggest removal )
MMitchum (anonymous) says...
It seems to me the politicians aren't worried about our health, because it doesn't hurt them at all. They make the big bucks, and are over paid. When they retire or leave their post in politics....they still enjoy their royalties, and still receive the hard earn money we supply for them as the taxpayer. Do you see any of them stepping forward and saying...I don't need all of this, lets put them in a Honda...not a Lincoln. Let's give them the insurance we have...or maybe as my daughter at 24 years of age working at a resturant that doesn't offer insurance. So here she is a beautiful girl that can't have what others can have because of her age...she falls through the cracks of our system that royally sucks. These politicians don't have to worry about if they get old...they don't have to worry about Elderly care...we have padded their pockets plenty.
Oh, and how many houses do they have...1,2 maybe even 3...sorry but they are rich off of our hard earn taxed money. I think they should be in a pay cut category so our taxes can help us live above the poverty level. South Carolina's payscale, and unemployment needs to be looked at also. This is my state but it is a poor state. Believe me the better paying jobs are not in SC.
October 1, 2007 at 12:14 p.m. ( permalink | suggest removal )
ImplantedYankee (anonymous) says...
There are indeed well-paying jobs in SC. I came back to Charleston to take one. Contrary to bitter comments posted in other recent articles about our region's economic growth, I am neither a doctor nor lawyer, but am reasonably well paid, especially given the comparatively low cost of living here.
The real problem with the cost of health care (and the corresponding cost of health insurance) actually lies with our malfunctioning legal system which supports a greedy litigation-hungry society led by equally greedy lawyers, which have become so common that they are now the punchlines of pop-culture jokes which have lost their humor. According to the AMA, more than half of every dollar spent on healthcare now goes to pay the premiums for malpractice insurance rather than patient care.
Every attempt at reform has met resistance from politicians, most of which sit of the left side of the aisle, and many of whom are former lawyers. Even as John Edwards holds the microphone in one hand to decry the presence of "two Americas -- one which can afford healthcare, and one which cannot", he holds in the other hand the money he made suing doctors. He, and others like him, have worked to create a problem from which he now wants to "save us".
October 1, 2007 at 4:15 p.m. ( permalink | suggest removal )
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