Healthcare Part III: Fixing a Broken System

By: Dale J. Buchberger, PT, DC, CSCS, DACBSP

Last month’s article left off speaking of the coding aspect of health care and how the insurance industry creates and maintains an inefficient system. Now, I will itemize key areas of repair that will improve the efficiency and delivery of healthcare in the United States.

It is a common misconception that the health care system is broken. The health care system is not broken; the third party reimbursement system is broken. Health care services in the United States are the best in the world.

Health care has become a contract between the health care provider and the 3rd party insurance company. The patient has become a bystander in his or her own care. Yet it is the patient (or patient’s employer) that pays the premiums for “discount” care. That is exactly what they get, “discount” care. The basis of the insurance industry is to sell a product the buyer won’t use. You (your employer or both) pay excessive premiums, an excessive co-payment and the insurance carrier pays a minimal reimbursement. In the process, the insurance carrier laughs all the way to the bank. As an employer the insurance plan we carry costs $10,000/year for an employee plus one dependent. That is not a type-o. This is how the health insurance industry is killing small business and choking the economy in the United States. Just this week a patient confided to me that they “couldn’t continue to be treated because I can’t afford my co-payment”. His co-payment was $50/visit. This means his insurance carrier paid $5 of the $55 contracted fee. The formula is simple: Excessive premiums + Excessive co-payment = Insurance carrier price gauging. Fix the price gauging and many of the dominos fall into the correct place. The insurance carrier’s portion should not be less than the co-payment.

Because of these complicated discount contracts health care offices are forced to hire excessive staff to process the minutia of paper it requires to receive the discounted fee. Some offices not only have insurance staff but they have specific individuals for each specific type of insurance such as Workers compensation, Medicare, group plans etc. They even have to hire special “coders” to figure out what to bill the carrier or minimize rejected claims for the discounted fee. So as I said in last months article, simplifying the coding and billing procedures is the first line of correction.

In the meantime, insurance carrier CEO’s continue to receive inflated salaries and inflated year-end bonuses. Why don’t they receive the 2% cost of living increase the rest of us hope to receive? They receive the 7-figure bonus and we receive a double-digit increase in premiums. The providers don’t see an increase in reimbursement and there is no improvement in care.

Below are my key points in the process necessary to repair the access, delivery and reimbursement of health care. This is not the entire plan but it is a start.

  1. As previously stated in article two, the ICD9 system needs to be restructured and expanded to provide higher specificity to treatable diagnoses. Higher specificity allows for better tracking of utilization.
  2. Expand the CPT system to include new and more effective treatments.
  3. Control administrative expenditure in 3rd party insurance companies. Reimbursements should be improved and premiums reduced before CEO’s bonuses.
  4. Eliminate insurance industry sponsorship of sporting arenas.
  5. Eliminate pharmaceutical company advertising on television. Wouldn’t you like to watch the news or a television show with your kids without being bombarded with Viagra and Cialis advertisements?
  6. Unify billing procedures for group, individual, Medicare, Medicaid, workers compensation, Etc. This in and of itself will reduce the paper chase and improve efficiency.
  7. Establish reasonable and customary fees NOT discount fees.
  8. Place the emphasis on quality care to fix problems instead of cheap care to band-aid problems.
  9. Reduce 3rd party over regulation!
  10. Establish real penalties for “insurance carriers” that clearly use “deny and delay” tactics.

My last recommendation would be for all federal and state elected officials including the President of the United States to pay an increasing percentage of their healthcare benefits over a four-year period. They would be responsible for 10% per year, cumulating at 40% individual contribution at the end of the four years. If they have to pay for it like we do they may actually try to fix the problem.

This is my top-10 of readily correctable health care issues. As you can see there was no mention of cutting services and no issue of raising the deficit. It is also evident that there is a direct connection between the price gauging of the health insurance industry and the state of our economy. Correcting many of these problems will allow health care providers to do what they were trained to do; care for you and your family.