Uninsured in NYC

My friend David called today because he can't get out of bed. Around 50 years of age, David hasn't had medical insurance in quite a few years. He is, one would call, poor, but he has some assets that make him ineligible for Medicaid; the man owns a car. He makes too little to be even pay for Healthy New York, the state subsidized HMO for the working poor.

On Sunday he was reaching into his car to pick something up and felt a small twinge in his back. By Tuesday he was nearly immobile - flat in bed, barely able to turn over. Friends are bringing him food, because he can't prepare anything himself.
So what are his options? He can take an ambulance to a well equipped orthopedist for a diagnosis and then haggle about the price; he can take an ambulance to an ED, apply for Medicaid for which he would most likely be rejected, and then beg for a price reduction; or he can suffer, which is what he is doing now.
I'm stumped.
All suggestions welcome.

Crossposted at http://www.signalhealth.com

Another Demonstration We Are Headed in the Wrong Direction

A new study by RAND is yet another demonstration of our penny wise and pound foolish policies. All our latest solutions insist patients are gluttonous overutilizers of care, demanding spurious MRIs and running to specialists for every twinge. At least, that's the current fashionable demon driving the consumerism bus. But according to RAND, in some instances, that thinking is completely backward:
Cutting drug co-payments for people taking drugs for chronic illnesses could save billions of dollars in medical expenses by prompting patients to take their medication and avoid hospitalization.

Isn't that a kick in the head? So those in Medicare D who have now reached the donut hole and may be neglecting to take their Lipitor might be appearing in the ER with greater frequency in the months to come. HSA holders (I mean the group on the edge that used to be uninsured - you know, the ones HSA designers say they were intended to help? Not those using HSAs as yet another investment vehicle)may be in the same position, scrimping on preventive care while keeping their insurance for that catastrophic event.

When I'm counseling someone on their HSA, my clients tend to think of it as, "I won't lose my house" insurance, not comprehensive health care. I wonder if Pitney Bowes offers an HSA, considering their health cost turn-around in 2001?

Crossposted at http://www.signalhealth.com

CDHPs are Much Worse THan You Think

Matthew Holt over at The Health Care Blog posted a pretty interesting article over the weekend from the Miami Herald about one of the many glitches yet to be uncovered in using HDHPs.
It seems that the young lady had an earache, went to an urgent care center (no PCP?) and got billed for $350. Part if the problem was that the Urgent Care Center was out-of-network, something that it was her responsibility to know, a fact the Center didn’t bother to tell her when she presented her health card notwithstanding. (IMHO, at least part of the reason OON providers don’t tell the patient whether they are in or out-of network is that if they are OON, they often will get paid more by a managed care plan The patient, will of course have a larger co-insurance, too.) In this case, a HDHP takes advantage of the same abusive billing practice.

But this problem is bigger. The UCC billed CPT 99245, a level 5 consultation. A consultation is different from a visit in that it requires a specific request by another provider, which, if the story is accurate didn’t happen here. So that makes it an “initial outpatient visit” coded instead somewhere between 99201 and 99205.

The second problem is the level 5 code. If we assume the level of care (5) is the same, an example of a 99205 visit could be (as close to the specialty of straight internal medicine as I could get): “Initial visit for a 42 year old male on hypertensive medication, newly arrived to the area, with diastolic blood pressure of 100, history of recurrent calculi, episodic headaches, intermittent chest pain and orthopnea (trouble breathing unless upright).” Any of this sound like the severity of an earache to you?

A third problem is that she didn’t se a doctor; she saw a nurse practitioner. That drops the code even lower to perhaps 99211, although that is usually used for an established patient.

The bottom line difference in cost? Between $200 and $300.

So unless the HDHP comes with a current CPT (professional edition), a copy of the National Correct Coding Initiative (updated quarterly; also available on line), and transparent information about when these regulations are applicable and when they are not, and perhaps an independent call center for people who can’t figure it all out, HDHPs will continue to be a deeply flawed and bordering fraudulent product.
IMHO, of course.

Crossposted at http://www.signalhealth.com