HCCD Report North Carolina 27517

Participants

1) A physician’s Assistant (lacks health insurance – can not afford insurance on individual market)

2) A Army Reservist who is about to become a full time student (Lacks health Insurance)

3) A full time Graduate Student in health policy (has insurance through graduate school)

4) A Research Assistant (insurance through job)

5) A recent college graduate (insurance through parents because she has a disability)

6) A contract Professor (prior to current job was unable to afford insurance for three years)

7) A Retired University Employer (Had to sell house and change jobs when prior insurance policy did not cover cost of husband’s hospitalization.

Major Issues

1) Since this system is profit driven, individual actors make choices (i.e. which drug to manufacture, which blood test to order) based on what will maximize individual profit. There is no economic incentive for doctors, drug companies, insurance companies or hospitals to create health, since they will often make more money by passing the problem on to the next individual.

2) Hospital fee schedule’s and insurance reimbursement polices are all arbitrary. Everyone has had prices for the same procedure change by $1000 of dollars based on whom they spoke to.

3) For those who had insurance, employment choices were made based on the employers health plan. All individuals with insurance had chronic, or family illnesses that prevented them from getting policies on the open market.

4) Most individuals did not think that insurance should be provided through jobs. However under the current system no one in the room was able to obtain an individual policy because of cost. Most members of the group were ineligible for policies because of preexisting conditions.

5) 5 individuals (all in the areas of health care or academics) had experiences where health care bills went into collection because the insurance companies delayed payments. (In all cases payments were eventually made) In each case the individual had used their professional connections to resolve the situation. This took 2-4 months for each individual, and would be difficult for someone who lacked the professional connections of the member of this group.

6) Many individuals felt that when they did seek help, they were unable to find a medical professional who could help them sort through which test they needed, which medications or treatment were contra-indicated, or how to proceed with the advice given to them by specialist. They had experience where a specialist would make a recommendation to address a specific problem that did not take into account the larger picture of the individual’s health.

7) Food stamp and school lunch programs should be altered to promote healthier foods that will lower risk of diabetes and heart disease.

Notes on individual questions. Stories have been highlighted in bold

1) Biggest problem –

When elderly people are discharged from hospital – there partners are often unable to help them. I.e. elderly couple in which an over 80 year old was expected to be the caregiver to a sick partner…hospital was in an unsafe area, had to navigate a sick partner in and out of two story house in the snowy winter
Need for social worker- helps with discharge. People are mistreated without advocate. Treatment is good if there is an educated and brave person to advocate but otherwise you get kicked out of hospitals before you are ready.
Availability of services - “if you’re poor you’re screwed” limited services that are rationed based on money.
Unscientific basis for which services we have. – Drugs are proscribed based on profit margins rather then scientific evidence
Cost of health system to individual and society. - Cost and expense to individual services. – Copay or deductible is unaffordable to some people. Others skip preventive care because they don’t want to or can’t pay the copay.
Not having insurance. – Cannot afford to get insurance on own unless you get a job if already have a chronic illness that will prevent you from buying insurance on the open market.
There is no system – decision making about what is covered is in the hands of those who want profits…what is covered is going to provide the highest profit margin .
Pharmaceuticals decide which drugs will be available based on profits and not based on which is most effective. One of the people in this groups stop being able to get the most effective drug, because the pharmaceuticals no longer found there was no- profit in a time-released lithium (eskalith –cr) lithium’s and some other drugs are not bio-equivalent. Once the patient lost her medication and was unable to work for several months, until a replacement was found
Incentive for providers to give people brand name drugs. – Which can increase co-pays.
The PA in this group saw African American patient who had high blood pressure – had lost his job, and a PA gave him a brand name medication, just because that was what they had samples for. The patient used up savings paying for medication – cheaper and effective alternatives where available, but no one talked to him about those options.
Doctors do not have time to deal with issues like cost of medicine – or side effects or other things that will impact you.
Lack of people to help you figure out which treatments will fit your lifestyle, budget. Medical needs.
Everyone from providers to system is looking to maximize profits.

2) HOW DO YOU FIND YOUR PROVIDERS?

Look in the phone book and see who is in your network…choose the closest…. you lose doctor when they are no longer in your network. – Would like a universal list of doctors with what health insurance they take. “A better business “system that list quality.
Considers Issues like how much time the doctor spends with me…if they only hear part of the problem they are not going to be able to choose the right medicine.
Would like a consistency with doctor. Or nurse.
Asks mom, uses network of friends and relatives. Uses reputation of hospital.
Would want current doctors to recommend new providers in other areas.
Many in-group had a problems with of doctors are not taking new patients, or have hours that conflict with work school, which insurance.
People need to be trained to work with the realities of the patient. (Our PA does not have health insurance, and his kids for years where unable to get health insurance…was unable to afford it because he was not guaranteed hours. (But it will have to be high deductible) he says that finding a care “a game gives me a headache to think about” –
It very difficult for members of the family with small business. Because family has heredity conductions
One participant chooses providers If the office staff is nice. She calls officers that are list insurance sent.
Etna has a tool that gives rating… but not enough people have provided feedback for it to be of use used.
An older member of our group uses a list of questions before she calls…and then narrows it down. – Asks about negative outcomes, number of past patients. - -But providers are still answering based on memory not on facts.

3) HAVE YOU HAD DIFFICULTY PAYING MEDICAL BILLS

When my relative had cancer, the state medical plan was not processing claims because of a state budget issue. The hospital handed over $56,000 that was supposed to be covered by insurance, to the collection agency. – Family knew all lawyers at hospital on first name basis because of prior professional contacts…talked with lawyer, blue cross and hospital, letters to legislators, and eventually it was paid. Then our family had to make sure credit was not destroyed. About 3 hrs a week for six months. Since plan was short, state made the decisions to pay no claims until next fiscal year. – Was given lots of response saying that this could not be appealed. , Difficulty getting prior approval, it can take months to gets approval. Even when approval was given, computer system did not reflect it so the claim was rejected.
Another individual had miscarriage and infection and husband had insurance, but it did not cover a reasonable amount. Had to sell house, and change job to one with better health insurance.
Another individual had personal problems paying medical bill. Insurance paid some…but you get lots of bills from different places…you don’t get an itemized explanation. Still have some bills on credit report. Could not afford to pay it. – Every bill should be itemized with clear explanation so that patient can understand what it is they are being asked to pay for.
Several people have challenge Ned charges on medical bill.
Group would see what true reimbursement and true cost. Uninsured people should not be paying such an enormous premium. Individual was billed $600, when insurance decided to cover it several months later they were discounted 85%.
One participant does not pay bills until they are at the collection office, because insurance company would not cover a MRI. The – Insruance would not pay because they claimed it was preexisting condition, although she had not had a laps in coverage. Choice of how much you have to pay in arbitrary for one test she was given the number of $1500, or $2600 depending on if you had insurance, not based on if insurance covered the procedure. In the end a $40 was sent to collections.
Another participant has not had an issue paying copay…can currently go to VA and just pay a copay
Since bonuses are based on denials, there is an incentive for administrators to deny claims to argue that you are saving the company money.
What we would like - Transparency in charges, and insurance reimbursement. Equity in how much we are charged for a procedure.

4) WOULD YOU LIKE TO buy in to a government plan or have an insurance exchange

PA – Yes to both
Phd Student – Yes both.
Retired – Would prefer a buying into a public plan, part D Medicare is a disaster it is too difficult for the individual to figure out which plan is best since they keep shifting.
Research Asst – Yes, is only staying at job for insurance, would like to switch fields COBRA is $500 a month.
Reservist – Yes to both.
College graduate – A public plan definitely…am not sure about private insurance.
Overall we liked how efficient Medicare and Medicaid were compared to private plans. However we were concerned that having one government plan for the country could lead to covered procedures being based on politics and not science.

5) How much does your employer pay?

$363/month for employer portion of contribution. – It is nice to have employers pay, but this is not practical for small business.
Retired university employee- State pays $380, they play $420 and then they have Medicare. Feels that employers should promote health, rather then provide insurance. It is nice when larger employers offer services such as flu vaccines, or on site primary care clinics.
Student – “I am biased because I am bitter because I don’t get paid very much and do not have insurance [through my job]”. In a reformed system insurance would not be provided through job.
Reservists – yes employers should pay, but we should have other options for obtaining coverage.
Needs to be a mechanism for transition for employment-based coverage to new system. – Give employers options and let them figure out if it makes sense to provide care, or pay extra taxes. Better for the economy if people can move around without worrying about insurance.

6) HAVE YOU HAD PREVENTAIVE CARE?

Retried university staff – “I’m loud and pushy I have gotten all preventive care I am supposed to get.”
Reservist – have had most of his care. – has been paying more attention has he gets older.
Students – preventive care for females is much higher. The student health plan covers $500. of preventative care, Which is fine for men, but does not cover all of the recommended test and vaccines for women.
New graduate – has not had all of recommended preventive care.
PA- does get all preventive care, because lacks insurance. Gets a flu shot through work.
Research Astt- yes for the services that are paid for.

6.a) What can the government due to promote primary care? –

Promote information campaigns.
Provide funding for services.
Provide better nutrition in public school. Food in American public schools is fast; school in French school is a real meal.
Government should focus on public health, vs. personal health services. Doctors are not trained to answer questions about nutrition. Need evidence based information to back up recommendation.
Subsidized fresh produce. And frozen produce. Have a bonus on food stamps so that you are not punished calories, because you elect to buy healthy foods.
Create incentives such as lower co-pays and premiums for individuals who take steps toward a healthy lifestyle
Subsidized vegetables and fruit vs. soybeans and corn.