What Large US Health Corporations Won’t Tell You

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Photo of Dr. Gomez in Zion National Park.
Dr. L.E. Gomez is an expert in diversity and inclusion issues as well as a proponent for Medicare for All.

If the average US Citizen understood our healthcare system well, they would put far less trust in its ability to improve their health state and they would invest far more energy in trying to avoid getting sick and needing medical care. If you are not significantly ill, you are better served avoiding excessive and unnecessary medical care and its associated costs.

Insurance, the care you need based on age versus what you can afford:

Insurance providers of every type (from Medicaid for the least able to pay to the most luxurious private carriers for the most affluent in our society) are acutely aware there is little incentive for young, healthy individuals to enroll in a health insurance plans, with the possible exception of those for catastrophic care or accidental injury.

As for those that are a bit older but still, in generally decent health, with only episodic need of medical attention, if they have the ability to afford an occasional night out on the town, paying cash is a far wiser approach than paying for health insurance. Hence, high deductible plans with limited coverage outside of routine care. This is especially true in the case of dental insurance which generally charges you monthly well in excess of out of pocket cost, while covered routine care is minimal, and far below the cost of a once or twice yearly uncomplicated exam and dental cleaning.

What if you’re a bit older and not eligible for Medicare yet? If you’re over age fifty and expect to need to engage with increasingly expensive routine medical care that passes for the minimum standard, we would be prudent to consider how much we expect to pay for expensive procedures such as screening colonoscopies and mammograms etc. Always request a discount if you are paying cash as you are saving private providers a great deal of time, energy cost and paperwork by not going through insurance providers to reimburse them for care.

What if paying the equivalent of a date night is beyond your means or you are out of work? Community controlled health centers such as Mid-Atlantic Community Health Centers in my adoptive home state of Maryland, D.C. Primary Care Association (DCPCA), such as Bread for the City Health Care, offer sliding scale payment schedules based on ability to pay. You are also more likely to be given sound advice on whether you need a specialist than if you go to an emergency room where, for medico-legal reasons, referrals to specialists will almost always be the default position. Ultimately, these clinics are federally funded but they are also a better option than hospital emergency departments for non emergent care.

What if you are fairly sure you do not have a serious emergency but cannot wait for an appointment at the public health clinic? Consider urgent care centers for routine convenience care if a more moderate cost is tolerable.

Insurance, the debate over single-payer, universal healthcare and “providers”:

We currently operate in a free market system where various insurers provide a variety of products to cover part or all of our healthcare needs, but this does not cover every citizen. A single-payer health care system is one that covers all medical bills for every citizen, regardless of whether you are able to pay into the system or not. Such a system would consider health care as a right, which means you are eligible for care simply because you feel you need medical attention. The extent of that care can be comprehensive or basic, such that private care options can still coexist along with the single-payer system. The confusion comes in when you consider that the US already has an incomplete form of single payor system known as the Centers for Medicare and Medicaid, which includes the Children’s Health Insurance Program (CHIP). The reason it is not a comprehensive single payor system is that the entire population does not currently qualify for Medicare, Medicaid & CHIP. Attempts to cover more of our citizens include proposals to expand Medicare coverage to those 55 and over rather than the current age 65.

Why are proposals to expand coverage so difficult? The problem begins with lobbyists formulating language for lawmakers in order to undermine the relationship between clinicians and patients through subterfuge, such as that created by convoluting terms such as ‘providers’ so that hospitals and health insurance corporations are defined as equal to physicians. However, corporations are not equivalent to healthcare providers and in many states, doing so is illegal. Corporations are, at best, facilitators of healthcare provision. Healthcare management companies then should not engage inpatient care as if they were providers. When they do we all suffer. Here is why:

The theory goes that a single payor system would yield immediate cost savings in the form of price fixing for services, including salaries. Physicians and other healthcare workers increasingly beholden to governmental oversight through benchmarking fear further loss of revenue and control as a result of the increased scrutiny required to justify current salaries. In reality, the impact on physician practices does not need to be a requirement of a single payor system and clinicians could still elect to opt out of the system if they so chose. The true cost savings are not in these relative small margins of private practices or even in slightly higher margins from affiliated outpatient surgi-centers, but in larger health system hospitals and in private insurers. Read on to find out why.

The major generators of cost for medical care are not physicians and clinicians involved with routine patient contact and treatment. The highest costs are generated by the use of facilities, medico-legally driven unjustifiable overuse of unaffordable interventions and unchecked resource utilization. Consider the potential savings from eliminating the incentive for revenue generation from publicly traded large cap (market capitalization of over $10 billion) such as Aetna, Alfac, Anthem, Humana and United Health Group. The administrative costs of operating these private health insurances include multi-million dollar salaries that have never been proven to increase the health state of patients. Given the lobbying power and marketing ability of those powerful corporations, it should not come as a surprise that the messages that filter down to the electorate is often one of fear that assuming the cost of care would be too great for taxpayers to bear. The irony of the argument of course, is that taxpayers are a major source of the revenue for large cap health insurers such that we are already paying for the unaffordable system of healthcare we frightened into not funding. In fact, there is no justification in terms of health outcomes for administrative costs to comprise the bulk of health expenditures whether considering a corporate management group of any portion of the health care system. Costs should be determined by clinicians having contact with patients and their clinically indicated need for utilization of resources. Cutting out the ‘middle man’ is an essential element to achieving reasonable reductions in cost and finding affordable solutions to rising healthcare costs.

Dr. Gomez is an advocate for the ethical practice of medicine which he believes will one day lead to the elimination of health disparities and improved healthcare states for all patients. He chairs the Diversity & Inclusion Committee for the American Academy of Emergency Medicine where he also serves on the Government & National Affairs Committee. He supports the underrepresented patient population on the Maryland American College of Emergency Physicians Public Policy Committee and through the lobbying efforts of the NMA.

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