My New Year's Revolution: The Supplement War
Getting Rid of the Junk

Comparing Apples to Apples in Healthcare

EDITORIAL NOTE: This sabbatical/hiatus was planned to last two weeks which means I should have been back on Monday, but it will go on a a little longer. I will return on Thursday this week.

Some good friends, all met through blogging, are filling in for me while I take a two-week sabbatical from Time Goes By. Today’s guest blogger is AQ who blogs at Always Question.

He is a grandfather, a retired Navy Corpsman and a Red Cross Disaster Services Volunteer. “Otherwise,” says AQ, “I’m just a guy.”

I came across an article recently which served to remind me that, as the Obama administration moves to address health care reform, the insurance and health care industry lobbies are going to be formidable influences on the finished product. I think it is critically important that we as consumers become aware of what is at stake and make our voices heard.

At the risk of sounding like another whacked-out conspiracy theorist, it occurs to me that the media may be playing for the other team on this issue, and by other team I mean the insurance industry.

Insurance companies have nothing to do with health care. They take money from us and they pay it to providers unless they can find of a way to keep it. Meanwhile, as corporate media outlets lose readership or viewers, the revenue from advertisers becomes increasingly important to their bottom line.

This headline from Reuters, More Suffering From Chronic Illnesses, and other pieces trumpeting the spiraling cost of health care could lead one to believe that universal health care is unsustainable and/or unaffordable. But we're not necessarily getting the whole story. As we speak, the health care industry and the insurance industry (they are not the same) are stacking the numbers.

I don't think anyone would dispute an increase in type 2 diabetes. Our appetite for processed carbohydrates is well documented by now. Our unhealthy lifestyles are probably also responsible to a great extent for an increase in high blood pressure and high cholesterol.

At the same time, the industry has also been lowering the diagnostic bar on some of these conditions. Cholesterol used to be high at 250, then 200 and now there is movement to treat people with a low density lipid level over 100. The same has been happening with blood pressure with an upper number above 120 now being called "prehypertension."

In 2004, the Centers for Medicare and Medicaid Services (CMS) began taking the risk out of Medicare risk contracts with payments adjusted for risk through a model called Hierarchical Conditions Coding. The purpose of this scheme was to "appropriately" reimburse insurance companies for the necessary care of Medicare enrollees. (My question then is, why are the taxpayers paying for a Medicare Advantage Plan at all? If they bear no risk then they are superfluous cost centers.)

The upshot has been coding classes held throughout the health care industry to learn to combine diagnosis codes for maximum reimbursement from CMS.

For instance, I have high blood pressure and high cholesterol (and history of cancer and I'm fat, etc.). As a commercial patient, my doctor gets paid to refill my blood pressure meds and/or my cholesterol pills. When I become Medicare eligible, if I choose to join a Medicare HMO, the insurance company will be reimbursed for every condition I've ever had so long as they can document that I've had it (and they're pushing for universal electronic medical records).

If I never show another cancer cell, the American taxpayer will still pay for my cancer. The example they typically use in class is diabetes, and with correct coding they can quadruple the monthly payment from CMS.

There are going to be challenges in implementing universal health care. One heart/lung transplant can fund a prenatal program for a small town for a year or more, and we will need to talk about those things.

I'm just saying that when I see a report that ends with a comment on how hard it's going to be for us to implement universal health care with the world's most expensive health care system, it makes me wonder. Reuters never does cite the specific reports they're getting this "information" from.

[The story bin at The Elder Storytelling Place is empty so until some new ones arrive, let's revisit some from the archive. Today, Gilbert Lake from Joy Des Jardins. All elders, 50 and older, are welcome to submit stories for this blog. Instructions are here.]


You have confirmed what I've thought. They really are out to get us. I swear that my primary care doctor is in the pay of the insurance and pharmaceutical companies. My endocrinologist isn't -- he is actually logical and listens. He is also an elder which means he went to med school when doctors weren't just in it for the money.

We Americans need to demand the kind of healthcare we deserve. A few lines to those people in Washington who are supposed to represent us would help.

How fortunate I feel after reading AQ's posting and Kay's comment! The health care providers whom I regularly see (Internist and Dermatology PA) have each talked with me about my "conditions" (very like AQ's); but, they tell me that, unless they prescribe something for me, they leave it out of my records so that the insurance company cannot access it. What made me think that all health care providers were as rational as that?!

AQ -- I think I get it. The current Medicare law creates incentives to describe us all as being as sick as possible? And rewards this.

Do we have any non-incentivized data about our health?

Because I keep running into questions like that, I've avoided trying to understand the details of various health plans. But somehow, we the people who need doctoring, are going to have to fight our way through this maze in order to demand something better from our politicians. Otherwise they will just keeping doling out loot to the insurance companies.

Good article here on moving to universal healthcare, pointing out that we will have to move forward from where we are:

I thought I knew everything about this issue but you have provided yet another reason that we consumers must push for (Single Payer) Universal Health Care. Cut the bloated insurance industry out of the equation. Thank you.

I always favored the single payer solution, until I read, in the Jan 26 issue of THE NEW YORKER, an article by Atul Gawande called "Getting There from Here". That made me think about what a really complicated problem achieving universal health-care is. Gawande makes a good argument for building on the system we have. I recommend the article.
On the subject of "Advantage Plans", that's just another of the Bush Administration's hoaxes on seniors. In the old Medicare information books that we used to get in the 90's there was information comparing Medigap plans, which are easy to understand and standardized by Congress. They are, in my opinion, the best way to get further coverage. But the Bush Administration has eliminated this from the information book in order to push people into the Advantage Plans which are hopelessly complex.

Thank you, cognitive.

Well, in theory a single-payer plan would be great; but, its major flaw is that there is no incentive for people to do what they can to take care of themselves (via diet/exercise/stress reduction) or to minimize the demands that they make on the healthcare system. I have known too many people who turned the tables on the insurance companies (and everyone else who carried the same insurance) by demanding every test known to man--whether there was anything wrong with them or not! Personally, I find that unconscienable! Wish I knew how to solve those issues.

It's hard to know whom to trust for information on the actual cost of necessary care in America today; everything is suspect. We haven't even begun to define necessary care.
Of course there will be over-utilizers in a single-payer system, and there will be under-utilizers. We can't use that as a basis for denying necessary care to those in need.
Think about this: we're already paying for all of this now, plus the operating and marketing expenses for insurance companies and medical management companies. What we aren't paying for is preventive health programs to reduce these expenses and improve overall community health.

Very thought-provoking article, AQ. Yeah, defining what constitutes "necessary care" means different things to different people.

I see this with life and death issues some patients are experiencing who have swallowing problems. Some want comfort measures only, embracing Dr. Nuland's words in his book "How We Die" -- "pneumonia is old people's friend." Other patients and family members are perplexed by how many tests to pursue and when to accept their condition without further measures.

I'm a strong believer that each of us at all ages need to engage in the dialogue about what constitutes "necessary." No one knows when such decisions might need to be faced at any age. Also, young people need to consider these matters in relation to their aging parents, and aging adults need to think about the situation for their own sakes as well as that of their grown children.

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