Skip to content

Medicare – model or morass?

September 19, 2017

Whether Bernie Sanders runs again or not, universal healthcare is sure to remain a potent campaign issue. That’s regardless of whether Republicans can get their act together and repeal, replace, amend, or whatever it is the Graham-Cassidy bill is supposed to accomplish relative to Obamacare.

Is Medicare (or its offspring, Medicaid) really a good model for universal healthcare insurance for all? That’s been a question ever since the program’s inception and periodically someone brings it up, as in this Forbes 2011 article.

More importantly, how much do you REALLY know about how Medicare works? Are politicians selling you a bill of goods?

Here’s some more insight into the murky world of Medicare.

In last Friday’s post highlighting how Medicare falls short in the care department, Musings made a passing reference to something called an NCD.

An NCD is a national coverage determination, which as the name implies, defines what will or won’t be paid for on a national scale. Another facet of that is an LCD, or local coverage determination. These determinations are issued by supposedly independent evaluators, many of whom are doctors, and each claim is electronically scanned when submitted to make sure it isn’t in violation of these non-covered items.

This information is proprietary, and users of the official portals are required to agree to a nondisclosure agreement.

Since Medicare typically does not make predeterminations, the only way you have of knowing something isn’t covered is when Medicare refuses payment, although most doctors will balk at providing services for which they have been denied payment in the past.

In short, these exclusions are the product of a shadowy, little understood system that determines whether treatment for your individual health problem will be paid for at any level by the government insurance program, i.e. the taxpayers.

No one is saying that health insurance dollars shouldn’t be subject to oversight.

Some things probably shouldn’t be the taxpayer’s responsibility to fund. Things like vanity-driven facial cosmetic surgery, breast implants or hair implants might be important to you, but they certainly don’t affect your general physical health, nor do they provide a general economic benefit for the country.

That would be fine, if the logic behind the decisions was consistent, but it isn’t. Many times social justice issues, i.e. the politics of the day, influences the payment decisions.

For instance, suppose, like Mark in the Friday post, you actually need an operation. Can you get it without going through all the “conservative” treatments? The answer is almost always no, even if it would be cheaper and incidentally, more humane.

What about issues that, for lack of a better word, are trending?

The often-maligned decision of a Federal judge mandating that California’s Medi-Cal program must pay for gender reassignment surgery for incarcerated felons is an example. While that was no doubt extremely important to the person receiving the service, it is hardly of general benefit to taxpayers. Medi-Cal is that state’s Medicaid program, and it reportedly received 55 Billion taxpayer dollars from the Federal government in FY 2014-15.

And therein lies the problem.  What and how much government health insurance pays for health care seems to lack the benefit of  pragmatism, and it certainly lacks transparency.

For instance, every Medicare payment summary includes a reference to the billing code that was submitted on the claim, but what do those codes actually mean?

Take the billing code L0648, which is the number (from the HCPCS manual) the provider uses when billing the service to Medicare. How do you, the recipient of the service, know whether that was the right number to use or even if you received the service it describes?

Short answer, you don’t. There is a written description along with the code, but do the two actually describe the service YOU received?

Thanks to “Mark” from Friday’s post for letting us use his payment summary to illustrate how hard it is to be an informed consumer. He noted that Medicare had paid a lot of money for something he didn’t think he had gotten and asked Musings to find out what it was.

This piece of equipment was billed at $1200 and Medicare paid about $755. The description says: Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf ( Lso sag r an/pos pnl pre ots )

Must be a wheel chair or something big, right? Nope, it’s an inflatable back brace and a doohickey that looks kind of like a tire pump. Would you have known that from the description?

The point is, 99.9% of the people that use Medicare have no way of knowing what the government is paying for, whether the amount paid was fair and reasonable, and in the case of adjustments or denials, why that step was taken.

That’s the transparency issue and the whole question of medical care and payment is like that.

In some cases, finding these answers also costs money. For instance, the American Medical Association publishes the billing code manuals and take it from a former medical biller, they aren’t free.

Although they don’t give payment information, some  non-AMA websites will allow you to look up a few codes, usually for a small fee, and compared to what an annual subscription to the entire billing manual costs, it’s the bargain of the century.

So why this peek under the hood?

If the government had total control of EVERYTHING, do you think for a minute that things would be easier to understand, or cheaper?

U.S. healthcare costs reportedly averaged  $10,345 per person (not per household), or $3.35 trillion nationally in 2016. That includes both self-pay and all insurance payments.

That cost increases almost 6% per year.  The cost averaged $862 per month ($3448 for a family of four) in 2016. The government would have to either get that money from Y-O-U or curtail the equipment and services allowed to provide universal healthcare.

It is undeniably true that healthcare is too expensive for everyone to pay for all of it out-of-pocket, but come on now.

Do you really think that restricting us to government-only  healthcare and  insurance will solve that problem?


From → op-ed

Leave a Comment

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: