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About Rebecca S. Busch
Rebecca S. Busch, RN, MBA, CCM, CFE,
CHS-III, CBM, CPC, FIALCP, FHFMA is CEO of
Medical Business Associates,
Inc., and author of "Electronic
Health Records An Audit and Internal Control Guide”
and "Healthcare
Fraud Audit & Detection Guide.” |
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Past Articles
Healthcare
Reform...Not Behind Closed Doors!
Healthcare
Reform: The Application of Business 101?
"Reforming"
Healthcare Reform |
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Social Bookmarking
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Rebecca S. Busch
Healthcare Reform...Please, Not Behind Closed Doors!
December 8, 2009
US Senator Mary Landrieu of Louisiana
stated in response to initiatives to move the
healthcare reform package onto the debate floor “My
vote should in no way be construed by the supporters
of this current framework as an indication of how I
might vote on the final Bill.” A statement she
clarified after securing the receipt of a $300
million dollar bribe for her home state of Louisiana
while contributing toward the baby steps in the
passage of healthcare reform.
Ms. Landrieu, as a twenty year veteran healthcare patient advocate, let
me introduce you to one of my patient fall out victims of today’s health
care system. Her name is Mary. She is from Illinois and is 45 year old
veteran registered intensive care nurse with fifteen years of working in
addition to her nursing “job” as a medical auditor of hospital bills and
medical records. This is her recent experience:
“I need help” she states “I am in massive amounts of pain and cannot
walk” she further elaborates that she had injured her knee that day. She
rated her pain as an 11 on a scale of 1 to 10. She goes into see her
doctor. She is told that she may have torn a ligament in her right knee.
They are not sure. She asked “Should I get an MRI to understand the
source of the pain?” “No” responded the doctor. Upon physical
examination, she was told “You have to go to physical therapy for six
weeks.” She asked “What is exactly wrong with my knee – I have never
been in this much pain!” He followed up with “I am not sure; however,
the insurance company will not pay for an MRI unless you go to physical
therapy for six weeks first.”
Unable to barely walk – she attended her first physical therapy session.
The therapy session was initiated. Mary experienced excruciating pain.
The therapist told her “I have no idea why you are in such severe pain!”
The therapist did not stop the therapy session – the therapist continued
without understanding why Mary was experiencing increased pain during
the treatment. As Mary left the session she collapsed from the pain on
her way out the door and sprained her ankle. Now she has two injuries to
deal with. By nightfall she called me. “I am in so much pain I don’t
know what to do!” I told her “You have no choice. Go to the ER – now.”
In the emergency room they did a physical exam and a “doppler study”
(avoiding the MRI scan that would cost about $2,220) to determined the
following: It appears that Mary injured a ligament. She developed a cyst
(a pocket of blood below the knee from the original injury) and the
therapist ruptured the cyst during the physical therapy session. The
blood had no where to go except her knee cap. The blood sitting within
the knee cap was the cause of the unbearable pain and subsequent visit
to the emergency room for a price tag in excess of $7,000 dollars. The
attempt of saving $2,220 resulted in an additional expenditure of
$12,000. Please note this does not include the costs associated with the
sprained ankle.
Ms. Landrieu this is an experienced registered nurse and medical auditor
who fell through the cracks of our healthcare system! Imagine what the
typical consumer has to endure. The conversation between a doctor and a
patient (who happens to be a nurse) should never be “This is the care I
recommend based on what will be paid!” I hear this type of story on a
daily basis. What other types of horse trading activities are occurring
in the market place?
The American Medical Association (AMA) was facing a 21 percent cut in
physicians’ reimbursements – President Obama promised to suspend this
cut back if he received support for his healthcare reform package. The
AMA, keepers of the Hippocratic Oath of do no harm. In the horse trade
transaction by the AMA to reduce and avoid the reductions in the rates
of physician compensation are they compromising the relationship between
the patient and the doctor? Will the AMA advocate for integrity of a the
doctor patient relationship in any healthcare reform package?
Please let me introduce you to another one of my patient fall out
victims. His name is Doug who lives in New York and has been battling
multiple myeloma. He has and continues to have ongoing issues ranging
from his employer benefits as an employee and the receipt of benefit
services. His employer did not inform of his rights to obtain disability
while he was employed. They offered instead to let him take a few paid
weeks off to address his illness. Eventually his division was shut down
and he was out of a job. Even though he requested an application for
disability from Human Resources – they never provided him the form while
he was an employee. Once he was discharged from his employment he lost
his right to his disability policy. The following is another example of
one of his healthcare encounters.
Doug called me “XXX insurance company is denying my Doctor’s
recommendation for a stem cell transplant?” The reason “They are telling
me that it is experimental and will not pay for it at this time.” I know
from my years of audit experience that this insurance company has paid
for this procedure in the past. My advice to Doug “Write a letter and
state the following: Please tell me what ICD-9CM code and respective CPT
codes were utilized to render an opinion that my doctors’ recommendation
was experimental?” I had Doug fax and mail the letter to the claims
supervisor. I received a call from Doug – four days later. “I just
received a letter stating that they will cover my procedure!” Anyone
reading this article – if you do not understand the world of ICD and CPT
codes you cannot fully advocate for yourself!
I am not expecting the average reader to understand what happened in the
case of Doug. However, the typical consumer today cannot understand the
dynamics of getting and paying for healthcare. I do not know of any
legitimate doctor that is not frustrated when their plan of care is
driven by rules that do not allow for individual consideration. A reform
bill that further buries the rules of the game and how choices are made
will result in chaos. Our “human capital” is the essence and backbone of
this country. We cannot allow the demise of our health as individuals or
as a group fall into these gaps. This discussion of improving “health”
in the United States should not be driven by “horse trading.” Horse
trading is the opportunity to buy a vote in the passage of healthcare
reform to satisfy the “what’s in it for me” syndrome. When this takes
place we compromise our ability to maintain integrity in the process of
creating a reform package that has substance to address the real issues.
Another example of horse trading is reflected within the pharmaceutical
industry.
Dear pharmaceutical industry, please do not forget that you are an
employer with employee benefits! The reform package WILL affect your
bottom line. The price tag for your horse trade of a 10 year limit of
$80 billion on cuts in prescription cuts along with preventing the sale
of lower cost legitimate Canadian prescriptions from entering the US –
victimization of the average consumer. Eventually it will catch up to
the pharmaceutical industry in lost sales. Why? The Canadian ban does
not help the individual who is facing limitations in household budgets
for badly needed medications. The result is an increasing victimization
of these individuals who will fall pray to buying cheap counterfeit
prescription medications. Take for instance operation
code-named Pangea that was a world wide effort to crack down on
prescription “cheap” medications. Medications made with cost efficient
ingredients such as drywall material, antifreeze and yellow highway
paint. Consumers who do not have enough money will not be buying YOUR
drugs. They will be looking for a cheaper option. Thus the increase
potential for victimization of consumers who need their prescriptions
but cannot afford to pay US retail prices. Imagine the price tag we face
in our emergency rooms across the country as these patients are admitted
with adverse complications from drugs made with antifreeze and the
provider struggling to figure exactly what is wrong with the patient?
The chaos has only just begun.
Finally ladies and gentleman of congress, please keep the following in
mind as you write your reform bill. Your efforts are creating the
infrastructure for healthcare in which your constituency will receive a
direct impact. It is a package in which you as members of congress are
exempt. However, you will be indirectly impacted by your policy. The
parties such as providers, payers, pharmaceuticals, equipment companies
and so forth that provide care to all citizens including those members
of congress – you will be subjected to the chaos you create. That is
unless you intend to build government owned hospitals, government own
pharmaceuticals, and government owned professional staff – that will
only be dedicated to treat and care for the exempts parties of the
reform package. Please – do not reduce the essence of our health, our
well being, to a series of horse trade transactions. |
