The right to health care for all is the right to enrich a few.

$ HEALTH

Diminished integrity in health care

An unfortunate, but obvious fact; in America emphasis is on accumulation of wealth for a few rather than the overall welfare of all. Our health is no exception. Powerful lobbies in Congress and just about every state capital work to maintain dominance and keep the money rolling in while Americans pay more and get less than in any other advanced nation (see Corporate Lobbies).

Pharmaceuticals

Glaring, of course, is the pharmaceutical industry, with higher prices in this country than anywhere else, despite most drugs created and manufactured here.

In addition to highly paid lobbyists, enormous amounts are spent on advertising to a public incapable of comprehending what they are being sold. Shouldn’t it be left strictly to the professionals? Oh yes, physicians are also compensated for prescribing those drugs so they get us from all ends.

Why is this system legal?

Don’t you find it absurd that the government has consistently refused to negotiate prices with drug companies? The recent Inflation Reduction Act allowed for only a limited number of drugs to be negotiated by Medicare. Shouldn’t they all be negotiated for all Americans? Shouldn’t this be a priority for all elected officials who care about their constituents?

And let’s never forget how pharmaceutical companies have created drug addicts of so many by propagating use of their opioid pain killers.

Hospitals

Huge hospital conglomerates dominate (see Public Health Shortchanged); despite being non-profits, their primary mission seems to be revenue rather than health care. Don’t be fooled…despite these corporations inability to distribute profits, the control of capital can be doled out to contractors, equipment manufacturers, consultants, salaries as well as powerful lobbyists.

Whereas, you would think that those who heal should be entitled to the greatest compensation, it’s hospital administrators who receive the highest incomes. Money rules! (See Addendum 2)

Insurance companies

The costs for the solicitations from insurance companies that stuff our mailboxes provide an idea of the huge return on investment to corral our business.

Each plan is different in services and drugs covered. Before the Affordable Care Act was passed, most refused those with prior conditions, leaving the most needy to face destitution and a possible death sentence.

And doctors too

Even among doctors, our healers, the profession of highest esteem; with an oath dating back to the ancient Greeks; many are being compromised. There is no doubt that doctors should be well compensated but pressure within a corrupt system permeates the atmosphere within this environment. Whereas the majority of doctors today are still dedicated to principles defining their profession, the financial aspect has become a much greater factor within a structure that increasingly legitimizes; in fact, encourages; corruption among providers.

In an age of deregulation, prices are set by providers. With costs for health care considerably better regulated elsewhere and regulation virtually non-existent in America, we pay much more for this most vital service.

Here is a summary from a typical Medicare Advantage insurance plan in the State of New York.

Prices billed by providers are exorbitantly high. However, the insurance company pays a relatively trivial amount. There are methods though that many providers have found to compensate for the difference and insurance companies are compliant. But are they ethical? Some don’t even appear to be legal!

Have you experienced things like this?

Fortunate in having been healthy all my life, as age creeps up, conditions develop. And there are always the unpredictable illnesses and injuries. As expensive as it is, with costs rising through the roof, insurance is a necessity.

Convenience a priority and former health providers retired or on the verge, I chose as my primary care physician a doctor on the next block. Dr. T did not inspire confidence but if a real problem arose, I could be referred to a specialist.

When symptoms appeared and continued to worsen, Dr. T seemed determined to figure out the cause himself even if it killed me. Compounding the situation, he was quite mercenary. If we exchanged a few words, he demanded a co-pay.

Testing didn’t seem to provide a clue and his prescriptions were of no help. It was becoming very expensive paying for his failures as my health continued to deteriorate. If not controlled it could be deadly. Greedy and incompetent; bad for anyone, reprehensible for a physician!

Lifesaver

Describing the problem to a neighbor, a nurse in a major hospital, she recommended a specialist. Needing referrals, I sought them from Dr. T who, demanding his co-pay, grumbled resentfully, “So, you want a second opinion?” He provided me with one visit, although insurance allowed more.

Dr. A, on first visit, inspired confidence. Dr. T’s records provided no help so tests were readministered; some rather uncomfortable. With results in, several medications were prescribed and progress monitored regularly. A condition that never disappears, with proper treatment can be brought into remission. Dr. A saved my life!

New primary care

Upon my first visit to Dr. A, I related what had transpired. Recommending Dr. X as a primary care, upon returning home, a quick phone call and Dr. T was history.

A good reputation as a doctor, Dr. X was friendly and easy to talk to, something often missing today. So, once Dr. A had my condition under control, I figured it was time to have a complete physical examination.

The exam turned out to be a revelation into the economics of many medical practices today. The routine seemed to have no end; test after test performed; redundancies abundant. Referred to other physicians for testing as well, some administered the same or similar procedures. Although insurance refused payment for direct duplicates, they approved those serving the same purpose.

In all, the exam took three months to complete. Tedious and time consuming, at least there were no out of pocket expenses.

Many in the medical profession pile on as many procedures as possible while reciprocating referral fees. Doctors in these informal networks seek maximum income within a system corrupted by its very nature.

Medicare

Health insurance in this country is a mess and often undecipherable. Due to elimination of doctors or varying costs of necessary medication, I had already changed insurance companies a few times. Reaching the age, it was time for Medicare.

Medicare Advantage plans offer many more benefits…but which one? With plan solicitations bursting my mailbox, it took some heavy research to choose the one best suited. Trust in any of them is not an option as their zealous pursuit of our business provides their motives!

Insurance companies are far from steady in the benefits they dole out to providers and creation of their drug formularies. This necessitates reviewing the plan every year, changing companies accordingly.

Relapse

For several years my condition was in remission…then a flare up. Tests were performed and medication prescribed. Obtaining proper medication was a battle since some were not on the company’s formulary. Dr. A fought hard and I received what was needed…at a price. Undergoing testing at Maimonides Medical Center and by other physicians however, revealed how widespread integrity had been further compromised throughout the system.

Baseless charges

Shortly after being tested by Dr. A at Maimonides, with a procedure that appeared to have no out of pocket expense, a bill arrived from the institution for an emergency room visit co-payment. Since I hadn’t been to the emergency room, I called my insurer, Health First, only to be told, without any reasonable explanation, that the fee was acceptable. Grudgingly, I paid.

Not only the hospital

Referred by Dr. A, Dr. G performed a specialized examination to find the cause of the problem. Having submitted the co-pay, about a month later a bill arrived for another $50. Calling Health First, I was told that the co-pay was $95 although no indication of that amount was noted anywhere by the company. Calling his office, a member of Dr. G’s staff said that it was because he used a specific instrument. Simply part of the examination, nowhere was it noted as an extra charge nor was I informed of this in advance. Again, I grudgingly paid.

Not being satisfied with Dr. G’s prognosis, Dr. A referred me to Dr. R for another opinion. Dr. R performed the same exam with the same instrument, of which I was informed in advance. There was no charge above the listed co-payment. Suspicious! No more Dr. G.

The hospital is greedier

About seven months after my test at Maimonides, having already paid for the non-existent emergency room visit, a bill arrived for an additional $200. Approved by Health First, numerous complaints resulted in several different reasons, none of which made sense. (I’d love to get hold of their claimed recorded phone calls.) I have not paid this one but filed a complaint with the state, received a file number and still awaiting a ruling about which I am not optimistic.

I have since changed insurers but suspect the practice is commonplace, allowing extra income for providers at patient expense while insurance companies keep their payments to a minimum.

None of the extra fees described were the out of network surprise bills we hear about today, but all in network. The fraudulent practice of bait and switch is apparently rampant through our health care system!

New insurance, new games

I had done my research in seeking a new insurance company online and called to confirm that my providers were in network and drugs on the formulary. The listed number brought me to an agent who established that everything was in order; doctors covered and necessary medications surprisingly low with Wellcare. Turned over to someone to sign me up, the information was again confirmed; in fact relating how the low cost of my medication allows me to escape the donut hole; the gap in coverage.

As the year began, with a new insurer in place, I still had not received benefit materials. Before calling Dr. A for a new prescription, I visited the site to confirm the information provided. The site was a mess; despite entering my zip, it took me all over the country for providers with no formulary in sight.

Not a good start to a relationship!

Outright lies

Upon calling customer service, I found that the true cost of medication was substantially higher than told. They suggested filing a grievance on my behalf. The fact that this was a case of outright fraud, I filed and persisted in requesting someone from the legal department. This was, after all, another classic case of bait and switch.

A couple of days later, after spending an enormous amount of time convincing an agent from Wellcare that I was serious about demanding action, I found myself on the phone with someone from an agency that deals with fraud in the industry. A very official sounding person asked detailed questions about what had transpired and clarification of facts. A report was filed and I was provided a web site and report key for which a password was created. No word…again, not optimistic.

Both of these insurance companies were highly rated in the state listings. Isn’t anyone paying attention?

Another revelation

In dealing with the situation, I came across something very interesting about insurers’ relationships with pharmacies. Large networks are reimbursed differently than small retailers, allowing them to charge less, devastating small businesses. In effect, the little guys are being chased out of business with government complicity.

In New York State, a bill was passed in both houses of the legislature to allow small pharmacies to join networks, leveling the playing field and lowering drug prices for everyone. It had originally been vetoed by former Governor Andrew Cuomo.

Recently, Governor Kathy Hochul signed an extensive health care bill. Lost in the fanfare was her veto of the sections that would protect individual pharmacies. Lobbies at work; retaining the dominance of the giants while the little guy loses again!

Who is on our side?

Tacitly legal corruption built into the system is one of the many reasons we pay more and get less. In the end, money is prioritized. For the large corporations; pharmaceuticals, hospitals, insurance, etc.; it’s all about $$$!

1/2022

Revised 9/2022

ADDENDUM 1

Additions and revisions

Since the original posting, experiences have taken me further into the corruption inherent within our health care system that allows insurance companies, pharmaceutical companies and facilities to capitalize on the most vital of protections for individuals in America.

Originally, names were omitted but I am now compelled to mention the institutions involved since they are the primary culprits in the name of corporate profits. Although corruption filters down, physicians are also victims of a system that encourages exploitation. Whereas those who heal should be on the highest levels of compensation, the greatest amounts go to excessive compensation of top administration and contractual partners, including the lobbyists who work to create this system. Physicians are too often pressured to make up for the diminutive amounts provided by insurance companies.

The insurance company I eventually switched to is Emblem Health. Quoted a price for a copay by two agents, the charge was five times the amount quoted, which they later attempted to justify.

Surely, there are lobbies that advocate for the public but they are not nearly as strong as those for the industry. It is the partnership of lobby influenced government and corporate interests that drives a system in which Americans pay more than any other developed country for their vital drugs and health care.

Until our governments on every level cast off the lobbyist yoke and act on our behalf we will forever be under siege by a health industry that places money before our care.

9/2022