NEARLY 30 YEARS AGO, my father was hospitalized for treatment of rheumatoid arthritis in a Chicago-area hospital. Not that I’m dating myself, but he was a patient in a four-person ward for nearly four weeks while various treatment approaches were tried and assessed.
Today, this story may seem like like a fantasy; it’d never be allowed to happen for cost reasons. But in the 1970s, long hospital stays were more likely to occur – particularly when insurers paid whatever providers said they owed.
Yes, my dad had really good insurance in the 1970s, and it appears that the long hospitalization had less to do with the severity of his condition than it had to do with the totality of his health insurance coverage.
Fast forward to this past week, when I was talking to a friend who shared her dilemma in getting adequate medical treatment for her 8-year-old daughter, who was adopted from Russia and has a condition called muscular dystonia.
Until recently, little has seemed to help little Julie, who has worn a brace to keep her foot in the right position. Lately, alternative treatment in the form of percussion therapy has been showing some positive results.
However, the benefits have diminished lately, because what had been 45-minute treatments have been getting shorter – as little as 17 minutes, the mom reported. And the therapy provider has been asking more questions about the family’s healthcare coverage – like if it would support an increase in payments to $200 a session. The mom estimates that the cost per hour for treatment would then be $600, and she’s investigating purchasing her own device to try and perform the treatments herself, more frequently and for a longer period of time.
When I tell these stories to people, I get a sympathetic nod of the head – and then, invariably, the person shares at least one other story of how a healthcare organization has appeared to game the system in the past for financial advantage.
The issue for the healthcare industry – both providers and payers – is that if everyone experiences at least one of these stories, it tarnishes the trust in the healthcare industry as a whole. When talk turns to reform, these personal stories are the history with which individuals consider reform discussions. Most fear that, whatever we do, someone’s just going to end up gaming the new, reformed system.
The ultimate evidence of that can be seen in the recently issued final rules for severity-adjusted DRGs. The new system comes packaged with a 2.4 percent reduction in rates, because the Centers for Medicare & Medicaid Services anticipates that providers are going to try to code more aggressively, and the 2.4 percent rate reduction will compensate for anticipated upcoding.
It’s not all providers’ faults – payers are good at the game, too. Last month’s issue of Healthcare Finance News detailed how Children’s Healthcare of Atlanta records every phone conversation with a payer and takes screen shots of every payer Web page related to coverage to provide a permanent record of what payers say they’ll cover. Why is this a good idea? Because payers’ versions of what they’ll cover can change – a provider needs a permanent record or a payer has the evidentiary advantage and can delay or deny payment.
Bad stories and gaming the system will gnaw at the roots of any healthcare reform effort, and it will undermine efforts to increase the transparency of healthcare prices.
Julie’s mom puts her criticism of the healthcare system as follows: “We’re spending the same amount of money and getting a halfway job.”
“With (the care provider), it’s dollar bills hanging all over everything,” she adds.
Until everyone believes that the system is most concerned with maximum patient benefit and not trying to promulgate dollar grabs, the path to healthcare reform is going to be arduous and hampered by heavy distrust. Systemic reform is going to be hard enough to achieve without that kind of baggage.