Healthcare Advocacy - A Flowchart is What?

December 27, 2022

Dec 27, 2022

Good Day Healthcare Advocates

Every day that we learn, grow and advocate for better healthcare for all of us is a good day. Thank you also to all of you advocates who have recently subscribed.

If there are specific healthcare topics you’d like to see addressed please send me a comment using the comment button. Thank you to those who have suggested topics, like Medicare reimbursement levels and sufficient access to care in a timely fashion. I will write about them in upcoming issues.

Mission

The Healthcare delivery system in the United States is a patchwork that leaves much to be desired. It is the most expensive system among the top 35 industrial countries and covers far fewer participants delivering lower levels of quality care than many of our peer nations. This blog will provide:

· Current problems in healthcare

· Actions you can take

· References.

Current State of Affairs – Where is My Flowchart?

Some of us used to be computer programmers and we learned to love flowcharts. A flowchart is a visual representation of the steps needed to solve a problem. The chart, if done well, covers all possible occurrences at each step and delivers a solution.

Flowcharts are used to diagnose medical conditions and when prescribing medications. That makes sense, we have a hypothesis, we examine, we test, we get data, perhaps modify hypothesis, rinse and repeat until we have a solution for the patient. The process can involve detective work and research to understand what you’re looking at, but it is the scientific method in action. Here is a link to a procedure used in the UK to diagnose a urinary infection Link. It is a nice example.

Here are two examples of how this system does not always operate in the patient’s best interest.

Example 1:

Knee issues. A while ago I was walking down a flight of unsafe, narrow, stairs. People can fall on such staircases. I decided to be smart and turned my foot sideways so the whole foot was on the stair. When I went forward I tore the cartilage in my knee. The orthopedic surgeon looked at my knee and said” You tore your meniscus. Let’s get an x-ray.”
I asked if that wasn’t useless because this is soft. He replied , “Of course, but the insurance company won’t pay for the MRI I need to properly diagnose without an x-ray first. It’s a “cost saving “ measure. “

My treatment was delayed by more than a week while we arranged for an x-ray, for someone to read it, the doctor to reject it and then get pre-approval for an MRI from my insurance company. By the time I had the MRI several weeks had passed.

The insurance company, looking to save the cost of the MRI, demands an x-ray since it is cheaper. They extended the duration of my pain to try and save money.

The insurance company flowchart had a basic axiom built into the decisions SAVE MONEY, not provide appropriate care for the patient. Notice there is no transparency to me about this flowchart. The doctor just happened to know.

Example 2:

I have a friend with a skin condition. His doctor knows what medicine will work to help him. It is expensive but his insurance company’s pharmacy benefit manager (PBM - remember them) have a flow chart depicting the order of medicines in order for them to cover costs. Before he could get the insurance company to pay for the correct medicines, he had to have them pay for two others (together with his useless co-pays. Again false savings (they paid for all three medicines) and delayed treatment while he tried medicines his doctor knew would not work.

The problem is that these formularies (pharmacy flowcharts) are flawed. They again have a built-in distrust of the doctor and choose to reduce cost first rather than provide the care that the doctor wants for the patient. Truthfully, it isn’t just cost of the medicine that drives them. The PBMs take kickbacks (rebates from pharmacy manufacturers) to place certain medications earlier in the formulary.

They are willing to stand between you and your provider and you can suffer a little longer, pay extra co-pays because they make more money that way.

Insurance companies are supposed to pay the bill, not determine treatment.

There are other examples where insurance companies refuse to pay for life-saving treatment because they consider it out of scope. These become so=called death panels. Every one of the more than 900 insurance companies and PBMs has them. THERE IS NO TRANSPARENCY. You can’t look up what is and isn’t covered. Sometimes they will just make a decision on the spot and for you that’s just a crapshoot.

In universal healthcare systems there are similar flowcharts and decision tools but they are all available and transparent and have to follow standardized rules about what is and isn’t covered.

In fact, in many countries, if a doctor follows the universal care flowchart treating a patient they protected from malpractice litigation and their malpractice insurance costs are about $1500/year not $200,000. This is because the universal healthcare flowcharts are built by doctors and are designed to protect the patient not the insurance company profits.

There are a lot of ways Universal healthcare can provide high quality care and better prices. This is just one area.

What You Can Do

See resources below for your senator/representative. Remember, they keep track of the number of comments. We need to make sure our numbers are high.

You can call or email your Senators and Representative and say

My name is _________, I am a constituent and live in zipcode ________.

We can all agree that we need better quality, lower cost healthcare for everyone.

I would like you to support adoption of universal healthcare, like the 17th Congress HR1976.

In the meantime, I would like legislation passed that removes the ethical conflict of interest between health care insurance companies and the doctor patient relationship. If the doctor/patient decide the treatment and it is medically appropriate, the insurance company should NOT force different treatments/tests/procedures to save money or make money for themselves via rebates and kickbacks.