HEALTH AND MEDICINE

Health and Medicine

In this day and age, it’s important to have medical coverage as well as keeping yourself healthy.    I realize that in many instances people can’t always afford health insurance, but also have a right to health care and be able to get taken care of no matter what.     With the exception of Medicare (for seniors) and Medicaid (for the truly poor), there are no comparable alternatives to comprehensive health care insurance in the United States. Most insurance companies do offer what they call “mini” or “supplemental” plans to provide additional reimbursement for specific activities in exchange for monthly premiums. These plans can be helpful supplements to—but are not replacements for—comprehensive health insurance plans.   I am quite sure that in nearly every community in this country there are clinics and places where people can go to get help even with minimal or no coverage.     But this can also present a problem as well, but this I mean that costs for health coverage continually on the rise and the possible reason for this is due to the industry trying to cover the costs of medical care that can’t afford it.  Is this right or wrong?    By medical costs continuing to rise more people elect to go without coverage due to cost.

Over 50 million Americans are currently without health insurance, with more losing coverage each day. But what is health insurance, and why is it important?

What is Health Insurance?  Health insurance is a type of insurance policy that pays a portion of medical expenses. For instance, if you need to visit a doctor, have surgery, purchase prescription drugs or get medical tests (like x-rays), health insurance will pay a portion of the expenses incurred. The portion of expenses paid varies by policy.

Vaccines, check-ups, routine physical exams—each are important to maintaining health. But those without health insurance are less likely to receive potentially life-saving preventive care.

A standard health insurance policy covers:

• Visits to primary care doctors and specialists
• Emergency services, including visits to the emergency room
• Medical check-ups, including blood tests, pap smears, etc.
• Medically necessary procedures (surgery, MRIs, CAT Scans)
• Prescription drugs

Health insurance won’t cover 100 percent of medical costs, though. Patients are responsible for small fees—co-payments—when visiting medical providers or purchasing prescription drugs.

Without health insurance, you probably can’t afford prescription drugs. It’s not uncommon for a prescription drug to cost hundreds out-of-pocket. The average cost for a prescription drug is now $71 with health insurance; a small co-payment is usually all that’s necessary to purchase a prescription drug.

When choosing the health insurance plan one must consider:

• Find out what is covered. Is your family doctor covered, or specialists like chiropractors?
• Conversely, learn what isn’t covered. For instance, some health insurance policies won’t cover acupuncture of treatment for mood disorders
• Choose between HMO and PPO. HMOs are generally cheaper, but PPOs offer greater flexibility
• Make sure your health insurance plan covers the prescription drugs you need

As medical costs continue to soar, health insurance is more important than ever. The average cost of a three-day hospital stay is nearly $30,000.   Not surprisingly that over half of bankruptcies are related to medical expenses.

Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care and health system expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is available to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization such as a government agency, private business, or not-for-profit entity. According to the Health Insurance Association of America, health insurance is defined as “coverage that provides for the payments of benefits as a result of sickness or injury. Includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment”.

Prescription drug plans are a form of insurance offered through some health insurance plans. In the United States, the patient usually pays a copayment and the prescription drug insurance part or all of the balance for drugs covered in the formulary of the plan. Such plans are routinely part of national health insurance programs. Some, if not most, health care providers in the United States will agree to bill the insurance company if patients are willing to sign an agreement that they will be responsible for the amount that the insurance company doesn’t pay. The insurance company pays out of network providers according to “reasonable and customary” charges, which may be less than the provider’s usual fee. The provider may also have a separate contract with the insurer to accept what amounts to a discounted rate or capitation to the provider’s standard charges. It generally costs the patient less to use an in-network provider.

The United States health care system relies heavily on private health insurance, which is the primary source of coverage for most Americans. According to the Centers for Disease Control (CDC), approximately 58% of Americans have private health insurance. Public programs provide the primary source of coverage for most senior citizens and for low-income children and families who meet certain eligibility requirements. The primary public programs are Medicare, a federal social insurance program for seniors and certain disabled individuals, Medicaid, funded jointly by the federal government and states but administered at the state level, which covers certain very low income children and their families, and SCHIP, also a federal-state partnership that serves certain children and families who do not qualify for Medicaid but who cannot afford private coverage. Other public programs include military health benefits provided through TRICARE and the Veterans Health Administration and benefits provided through the Indian Health Service.  Some states have additional programs for low-income individuals.

In the late 19th century, “accident insurance” began to be available, which operated much like modern disability insurance. This payment model continued until the start of the 20th century in some jurisdictions (like California), where all laws regulating health insurance actually referred to disability insurance. Accident insurance was first offered in the United States by the Franklin Health Assurance Company of Massachusetts. This firm, founded in 1850, offered insurance against injuries arising from railroad and steamboat accidents. Sixty organizations were offering accident insurance in the U.S. by 1866, but the industry consolidated rapidly soon thereafter. While there were earlier experiments, the origins of sickness coverage in the U.S. effectively date from 1890. The first employer-sponsored group disability policy was issued in 1911.

Before the development of medical expense insurance, patients were expected to pay health care costs out of their own pockets, under what is known as the fee-for-service business model. During the middle-to-late 20th century, traditional disability insurance evolved into modern health insurance programs. One major obstacle to this development was that early forms of comprehensive health insurance were enjoined by courts for violating the traditional ban on corporate practice of the professions by for-profit corporations.  State legislatures had to intervene and expressly legalize health insurance as an exception to that traditional rule. Today, most comprehensive private health insurance programs cover the cost of routine, preventive, and emergency health care procedures, and most prescription drugs (but this is not always the case).

Hospital and medical expense policies were introduced during the first half of the 20th century. During the 1920s, individual hospitals began offering services to individuals on a pre-paid basis, eventually leading to the development of organizations such as Blue Cross. The predecessors of today’s Health Maintenance Organizations (HMOs) originated beginning in 1929, through the 1930s and during World War II.

Comprehensive health insurance pays a percentage of the cost of hospital and physician charges after a deductible (usually applies to hospital charges) or a co-pay (usually applies to physician charges, but may apply to some hospital services) is met by the insured. These plans are generally expensive because of the high potential benefit payout — $1,000,000 to 5,000,000 is common — and because of the vast array of covered benefits.   Scheduled health insurance plans are not meant to replace a traditional comprehensive health insurance plans and are more of a basic policy providing access to day-to-day health care such as going to the doctor or getting a prescription drug. In recent years in the USA, these plans have taken the name mini-med plans or association plans. The term “association” is often used to describe them because they require membership in an association that must exist for some other purpose than to sell insurance. These plans may provide benefits for hospitalization and surgical, but these benefits will be limited. Scheduled plans are not meant to be effective for catastrophic events. These plans cost much less than comprehensive health insurance. They generally pay limited benefits amounts directly to the service provider, and payments are based upon the plan’s “schedule of benefits”. Annual benefits maxima for a typical scheduled health insurance plan may range from $1,000 to $25,000.

The price of health insurance for retired and active duty military personnel has gone up from $19 billion just a decade ago to $49 billion in the last year. Now, TRICARE, the government health insurance program, makes up nine percent of the total budget for the Pentagon.  By 2007, 87% of Californians had some form of health insurance. Services in California range from private offerings: HMOs, PPOs, to public programs:  Medi-Cal, Medicare, and Healthy Families

Recently a study  examined the rising health care costs in the United States pointed to increased utilization created by increased consumer demand, new treatments, and more intensive diagnostic testing, as the most significant. However, it has been noted that the group which sponsored this study, AHIP, is a front-group funded by various insurance companies. People in developed countries are living longer. The population of those countries is aging, and a larger group of senior citizens requires more intensive medical care than a young, healthier population. Advances in medicine and medical technology can also increase the cost of medical treatment. Lifestyle-related factors can increase utilization and therefore insurance prices, such as: increases in obesity caused by insufficient exe4rcise and unhealthy food choices; excessive alcohol use, smoking as well as the use of street drugs.   Other factors noted by the PWC study included the movement to broader-access plans, higher-priced technologies, and cost-shifting from Medicaid and the uninsured to private payers.     Researchers note that doctors and other healthcare providers are rewarded for merely treating patients rather than curing them and that patients insured through employer group policies have incentives to go to the absolute best HCPs rather than the most cost-effective ones.

I don’t agree with this at all, the patient needs good and effective treatment and receive the proper care they deserve and want.  If the patient is not satisfied with the doctor and care of treatment they are well within their rights to search and seek out a better doctor and place where they can get the care they need.

I know this quite well from personal experience.   I had been seeing a specialist whose expertise was wound care for an open wound and serious infection that I had/have.  It was being treated the conventional way with being cleaned and wrapped up, and truly not getting better and I was in extreme pain every time I placed any pressure on that limb which at times the extreme pain brought me to tears.   The specialist did not do a culture, even though I had mentioned about doing one, and never addressed any of my questions or concerns.  I voiced my concerns to the doctor who recommended this person to me, and finally was referred to another doctor whose specialty was infectious disease.   I went into one of the top hospitals near to where I live and received the proper treatment for the infection and wound that I have.    And yes, the culture was done right away (by the Infectious Disease specialist) and the appropriate treatment was started.   Needless to say in the coming weeks I will be receiving specialized treatment in order to clean the infection out of my system and the wound to heal.  It also goes without saying that the original doctor was not pleased with how the one specialist treated the ailment, if this person allowed it to continue treating me, I could have lost my foot or worse. I also took steps to research the best person and place to go to get the proper treatment.    And I got it because of the research I did.

I believe that everyone has the right to get the proper treatment for any medical problem, and if they have insurance or not.   While I am sure what I did was probably the extreme to research my problem, but it was the correct thing to do, and I highly recommend others to do research the doctors they use, places they go for medical treatment and so forth.   People need to better educate themselves and ask questions, not just accept what they are told as fact.  If they are not satisfied with the care or treatment they are receiving they must shop around to find the best care.   There can always be a better method of handling a situation.    Even if entails going to a special center for help such as the National Institutes of Health, the Mayo Clinic or other similar locations.    It just takes time and research to get to the proper place.   And in my instance, I was pushing the envelope before it was too late.

A key factor in patient safety is that the health care providers should be safe and fit for purpose.   In the USA, insurers will often only make use of health care providers that are independently surveyed by a recognized quality assurance program, such as being accredited by accreditation schemes such as the Joint Commission and the American Accreditation Health Care Commission.

Kathy Kiefer