Health Care Reform – Let’s Demand Our Rights!

February 1, 2010

Author:  Kathy Spiliotopoulos

In my previous article, I cited “Three Steps to Achieve Health Care Reform Goals.”  I stand by those steps to reform the mechanics of the system.  In order to move forward, though, we first need our government to get their eyes back on the ball – the health and well being of the American People – AND we need the American People to care enough about this to get involved.

When you drill down below the sound bytes, reforming Health Care is a very tedious, detail-oriented, and thus boring process.  Getting the American People involved to push our government into enacting real reform requires outrage on the part of the American People at the current inequities combined with the a straight forward solution to fix the problem that gets back to “Yes, We Can!”

The Outrage

First the outrage: What comes to mind is the scene in George Orwell’s Animal Farm, where the rulers of the initially utopian society establish a commandment that “All animals are equal, but some animals are more equal than others!”  Sounds like our current Health Care System:

• Depending on where you live and who insures you, you may have rich benefits or just bare bones; you may have access to the best doctors, or be limited to those within your network.
• If you are on Medicare, and can’t afford supplementary insurance from a commercial carrier, you are subject to increasingly higher levels of out of pocket charges, and may have noticed signs, as I have, springing up in top-noticed provider offices everywhere:  “Medicare is not accepted by this office.”  You might not have access to the best doctors in your greatest time of need.
• If you are unemployed, you may or may not be able to afford the Cobra payments that allow you to continue your health care coverage for a year and a half.  You may become uninsured, and ironically have to pay more for your health care than do the insurance companies and the government on behalf of their covered people.
• If you are on welfare or have few assets, you may be covered by Medicaid, which varies in coverage, benefits and eligibility by state.  OR, you may just be relegated to a local charity clinic or need to sit for hours in an Emergency Room.
• If you are a government employees, no worries, you have a wonderful set of benefits, an a wide array of providers to choose from, all courtesy of the American people.

Current Health Care Reform Bills do include some remedies, but they are no where near ready to be enacted, and are tied to a ponderous package of caveats that will make the system worse and cost tax payers tons of money.  Thus we remain outraged that we can be denied coverage or dropped by our insurers in our greatest time of need, whether for so called pre-existing conditions or payment ceilings or other contractual clauses.

I am also outraged at the huge amount of money proposed to be spent on setting up a Health Care Exchange, and that some states can opt out.  Don’t even get me started on letting the government run another Health Care option …

The Solution –A Health Care Bill of Rights

Well I know what rights I want, let’s see if you agree:

• A guarantee of basic benefits, no matter who insures me:  Why not use the Federal Employee Program that our Congressmen and Senators receive as the standard?  There should be a single set of health benefit mandates, instead of allowing each state to form their own. Benefits can be set up in categories by age ranges, to reflect the care needed at each stage of life.  Implementation requires the cooperation of governors to give up control over benefit mandates, and instead, to empower their staff to conduct quality control, fraud and abuse prevention, and health delivery improvement activities.
   
• Access to high-quality providers.  I want to be able to search for providers and have access to information regarding providers’ qualifications and track record either by internet or phone.  Quality performance expectations and guidelines for providers should be established as benchmarks.  Credentialing of health care providers should be included. Providers who do not meet quality benchmarks can be retrained and/or culled from the system, which sets the stage for torte reform. Implementation should be at the state level.
   
• Assurance that I cannot be dumped by my insurance company or denied coverage.  This is already in the current legislation and should be enacted. However, there also must be protection related to affordability.  Being accepted or renewed for coverage is meaningless if the rates are so high that no one can afford them.  Just as there are “pools of funds” shared by institutional providers to cover charity care, there needs to be established a pool of funds (or other mechanism) funded by every health insurer and accessible by these insurers to keep rates within a reasonable range for everyone.
   
• Everyone pays their fair share.  One thing that the insurers are correct about is that if the young and healthy are allowed to be uninsured and can obtain health insurance when something goes wrong, those who have health insurance will pay more, whether through their employer, self purchased, or taxpayer funded, such as Medicare.  Costs go down for everyone if everyone pays their fair share.
   
• Those who can’t afford insurance, are covered by an existing program such as Medicaid or Medicare.  The state or federal government will be responsible for on the one hand assuring that applicants cannot afford insurance to minimize fraud, and on the other hand not unreasonably withhold coverage for a needy person.
   
• Providers charge reasonable fees, and are fairly reimbursed.  Providers, including doctors, hospitals pharmacies, laboratories, medical supply houses, etc., should receive reasonable pay for their services/products, and not be allowed to inflate charge to cover discounts given to some payers.  Medicare, for example, in many cases underpays doctors, who then must make up for the difference from their other payers, whether a commercial insurer or an uninsured patient.  If the provider cannot make up the difference, then the provider simply does not accept Medicare as payment and the patient must pay for the treatment and get reimbursed whatever they can from Medicare.  Fixing this is so fundamentally important to Health Care reform that I have written a separate article on it:  “Health Care Reform – My Fingers Never Left My Hands” 
   
• Access to Health Insurance Purchasing Tools.  We don’t need a Health Insurance Exchange, we just need an understandable way to compare Insurance Plans “apples to apples.”  To do this requires standardization of terminology in a way that the average human can understand, and mandating that all insures use only that terminology to describe benefits, providers, out of pocket amounts, limitations, etc.  There are some tools available today to help consumers select health insurance.  These are outlined in the sidebar “How to Select a Health Insurance Plan”
   
• Dispute resolution.  An independent third party, funded by the government to help those have been denied coverage or believe they have been denied their health care rights.  Rules will be needed to assure that these services are helpful and fair but not abused.
   
• Healthcare Costs are contained The costs to run our health care system must be reduced and kept in check through a series of programs implemented that address fraud and abuse, price gauging, and medical malpractice reform.  In the end health care costs come out of our pockets, whether though insurance premiums, Patient responsibility amounts on provider bills, or taxes that fund entitlements such as Medicare, Medicaid Champus for our uniformed services, and the Federal Employee Program, enjoyed by our President and Congress.

What can you do?

Demand your rights by communicating with your elected officials.  Pass this article along if you’d like.  If you do, you will need to include information regarding the author provided below, and also this website as the source www.soothesayer.com.

 About the Author:

Kathy Spiliotopoulos has spent more than three decades consulting to the health care industry, both to institutional providers and health insurance companies.  Her efforts have resulted in administrative cost reductions and improved service, saving her clients collectively hundreds of millions of dollars. Ms. Spiliotopoulos, now semi-retired, consulted independently through her company Nestor Advisory Services, and earlier in her career was a consultant with Booz Allen and with Touche Ross, now Deloitte-Touche.