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Discovered: The Source of America’s Health Care Problems (Society’s Slideshow)

The United States of America is number one in the world in many fields. We are number one in millionaires, number one in billionaires, number one in waste production, and (drumroll, please) number one in military spending. One field we are certainly not number one in is health care, where we score a dismal 37th in the world. One could blame any number of factors for this, but one of the most prevalent is the ongoing battles between private, for-profit insurance companies and public, non-profit hospitals.

The Detroit Free Press featured an article on Thursday, December 1 that solidly addresses this issue. According to the article, Beaumont Hospitals are in the throes of a reimbursement dispute with Blue Cross Blue Shield of Michigan’s subsidiary company, Blue Care Network. The Blues want a 3.5% increase over three years in reimbursements, on top of a 2.5% increase to be given in 2012. Beaumont wants a 9% increase in reimbursements, and a 1.5% increase in 2013 and 2014, the article points out.

Apparently, the issue is so hotly contested, that both companies have felt it necessary to take out full page ads in the Free Press to present their side of the issue, and bash the other side for not being more conciliatory. Caught in the middle of this debacle are about 100,000 patients who are facing the very real possibility that their insurance may not be accepted at Beaumont Hospitals in 2012. Beaumont has offered neutral third party arbitration, while Blue Cross has rejected this idea as “unprecedented and a negotiating tactic” according the the Free Press.

The world of insurance is dizzyingly labyrinthian in its policies and operation. However, it is sold to millions of Americans on the surprisingly simple premise that if they have insurance, they will be responsible for a small fraction of the total medical care bill they incur. The idea is to protect them financially from any unforeseen medical circumstances that may befall them.

Doctors consistently complain about the delays in reimbursement for care provided from insurance companies. Insurance companies busy themselves with determining whether or not a medically prescribed treatment is actually covered under the provisions of their insurance. Generally speaking, any procedure that is considered to be “experimental” or “an elective procedure” are not covered, and the patient is left to foot the bill.

The latter statement necessarily begs the question, “What is experimental, or an elective procedure?” Those decisions are left not up to doctors, but to CEO’s and other upper management types who majored in business, not in medicine. An even better question at this point is “Why are we letting a CEO with a master’s in business administration overrule a physician who has had seven or eight years of medical schooling, another few years of residency, and any number of years in school learning their specialty as well as practicing medicine?”

No one that I have talked to has been able to answer that question in a satisfactory manner. However, the result of these “business decisions” have seen patients of all walks of life saddled with the full expense of a medical treatment that a doctor deemed to be necessary. Doctors have also had to fight tooth and nail with insurance companies over payment for services rendered to a patient who bought insurance in good faith, believing that just about anything a doctor told them was needed in order for them to feel well again would be covered less some sort of co-pay.

Sadly, it is evident that the rift between insurance companies and the doctors that provide the care that insurance companies are supposed to reimburse them for is growing wider. Even as the battle between Beaumont and Blue Cross rages on, patients who should still technically be covered by their insurance are experiencing delays receiving necessary approval to get certain tests or to see specialists concerning their maladies.

Barack Obama has met widespread opposition to Obamacare, which would prevent insurance companies from rejecting applicants for insurance based on preexisting conditions, force insurance companies to report where their money is going, and ensure that 80% of their money is going toward improving patient care and making them feel better. Noble goals to be sure, but it also carries a provision that all Americans must purchase some type of insurance so we won’t have nearly 59 million in this country without it.

Critics of the plan say the required insurance provision is unconstitutional and will only serve to be a boon for insurance companies. Those who rally to support it say that it is important to regulate insurance companies, and make sure that everyone has an equal opportunity to get insured despite a condition they have no control over.

Either way you weigh in, it is clear that America’s health care system is in dire straits. Costs keep rising, insurance companies keep balking at paying, and John Q. Consumer is caught in the middle of a battle between those who profit from denying necessary care (insurance companies) and the hospitals who desperately want to provide the care.

It seems that binding arbitration may be the solution, but Blue Cross and Beaumont have reached an impasse at even agreeing to disagree and letting someone else make a decision about what happens. I wonder if either side thought about asking what the patients want out of this argument. My guess would be no, because they both know that the patients simply don’t want a cloud of potential financial ruin hanging over their head the next time something goes wrong with them that they need to get fixed.

The very fact that the health and well-being of over 100,000 people may be threatened by a corporate pissing match is morally repugnant and should be stopped. The federal government should step in and regulate insurance company reimbursements so fights like this won’t happen again. They should require insurance companies to act in good faith negotiating reimbursements, and when that fails, require them to still honor their old reimbursement agreements rather than leave patients out in the cold with a fist full of medical bills.

Another solution would be to require all insurance companies and health maintenance organizations to run a a non-profit public service, or to just step in and run the companies themselves as non-profits until disputes can be settled. Government-appointed CEOs worked for fixing the auto industry, why wouldn’t it work for the health care industry?

Either of these solutions seems much better than a hospital turning its nose up at an insurer who refuses to negotiate reimbursement rates and forcing patients to be mindful of where they might be referred by a physician to get medical care. They also seem worthier than an insurance corporation playing hardball against a hospital who only seeks to give its patients the best medical care possible. Both sides need to realize that they are in an industry that should be paying more attention to the needs of its clients rather than the needs of their own pocketbooks.

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