Reform confusion? You bet

John Taylor: April 15, 20141 Comments

So, the “free” annual physical came with a bill. I’d already provided the physician with a co-pay because we dealt with more medical matters than the physical. But because the physical included an EKG, and a previous EKG has indicated an aberration, this no longer was a preventive medicine but an ongoing follow-up of a recognized health matter.

Welcome to a tiny slice of the confusion born of how poorly we’ve all been educated about our nation’s health “system.”  It was a mess when, in 1965, we rescued hundreds of thousands of poor and elderly by implementing Medicaid (Medi-Cal in California) and Medicare. Then we tied ourselves in bureaucratic knots of fee for service, managed care, HMOs and PPOs until we were introduced to a “do-over” in 2010 with passage of the Affordable Care Act.

Plain talk? Does that really describe co-pay, annual deductible, out-of-pocket costs, out-of-network providers and, one of my favorites, the formulary?

Say you were a patient in Medi-Cal or the Medically Indigent Services Program, and taking a prescribed medication. Something good happens and you are switched to another program – say, shifting into the new health benefits exchange – only to learn that your new insurer does not carry that medication in its formulary (an inventory of medications it will or won’t provide, except perhaps as a generic).

Your pharmacist (bless all their hearts) tells you to check with your doctor about an alternative. Then you come to find your doctor is not accepting your new insurance plan.  If you’re lucky, you’ll find some other physician (perhaps after a lengthy wait) who will see you. If you’re very lucky, this won’t translate into a potentially perilously long wait for a new, insurance-covered prescription.

Surely, the Affordable Care Act has invented new troubles even as it has remedied others – allowing people with pre-existing conditions to secure insurance, for one. It hasn’t with a “Bewitched” nose wiggle remedied the shortage of physicians, access points to care or Byzantine payment system. And, with exclamation points aplenty around the country in a cavalcade of electronic and manpower glitches and political manhandling, it certainly has showcased the need for several generations of cradle-to-grave  education about heathcare and medical decision-making.

 


One response to Reform confusion? You bet

Thanks John,I always enjoy

Thanks John, I always enjoy and learn something from your column. Susan Akiyama Short Stay Surgery


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