Chapter 11, Part III: Let Me Out of This Health Care Rationing Plan (True Story)
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ospitals are scrambling to form alliances, which “consolidate the purchasing power of individuals, small and medium-sized businesses to secure the best health coverage for the lowest price.? Alliances organize and streamline the fragmented insurance system, replacing health insurance brokers, agents and underwriters with consumer-run organizations–.†? [1]
Hospitals are buying out the practices of physicians who are affiliated with their hospitals.? One OB/GYN from an area explained that he had received several notices from his hospital’s CEO offering to purchase his practice.? I said, “I would hope that you wouldn’t do that.â€? His response was, “Let me explain to you where I’m at.? I have a lucrative practice, and they are offering me a lot of money for it.? If I don’t sell [the practice to the hospital] now, in a few years I’ll be out here by myself, and they won’t be offering me as much [money].â€
When a neighbor learned that hospitals were buying out the practices of doctors, he asked his doctor about it who verified that it was true.? This particular doctor was upset about the fact that the hospitals would be telling the doctors how to treat patients, when to come to work, when to go home, when to go to lunch, when to take a vacation, etc.?
Recently my husband came home from work with a health care plan his employer was offering called Alliance Choice.? “Benefits are administered by Alliance Blue Cross Blue Shield? (ABCBS) and underwritten by Healthy Alliance Life Insurance Company, a subsidiary of ABCBS.? ABCBS and Healthy Alliance are independent licensees of the Blue Cross and Blue Shield Association.†? [2]
Being aware of my concern about socialized medicine, my husband thought he was bringing home information about a health care policy that was neither an HMO nor a PPO.? Upon looking over the packet of information provided, I could see that it was a PPO and socialized medicine.? I had all kinds of questions, so I called the plan’s representative for my husband’s employer in order to discuss it.? She explained that the policy was a PPO? (Preferred Physician Organization).? That means that you can pick your doctor AS LONG AS it is a doctor on THEIR list of providers.? We discussed the Alliance Choice chart that showed the difference between two plans from which to choose.? The Network Providers option had NO annual deductible for either the individual employee or family option if you chose one of THEIR doctors, and used THEIR hospitals, etc.? The second option was called Non-Network Providers.? This plan allows you to pick your own doctor, hospital, etc.? HOWEVER, the annual deductible for the individual employee is $250 and the family deductible is three times the individual deductible.? While this option is more oriented to free enterprise, it is less financially feasible for families and those with increased medical needs.
The insurance representative had a difficult time understanding why I would be interested in the more expensive option.? I explained to her that I pick my doctor FIRST (based on his/her medical ethics) and THEN an insurance company who will not penalize me based on who my doctor is, or where he practices.?
Alliances are geographical, so there was a concern about what would happen if I needed care while traveling away from home.? The representative explained that medical treatment received OUTSIDE the boundaries of the
A flier in the
The flier explained that:? the focus of VMS is on outcomes? of care rather than the number of services provided, assesses outcomes of treatment through a process called outcomes management, and is working with providers to develop practice guidelines? that reflect best practices? statewide.? “Both patients and health care professionals are encouraged to follow these guidelines in receiving and providing care.? This approach focuses on the most appropriate care for members–it helps ensure that health care dollars are used wisely by reducing variation in practices and focuses on continuous quality improvement.†? [3]
What happens if you don’t continue to improve, or the “outcome of care†is not met?? What if your doctor feels that the practice guidelines? are not in your best interest in a particular situation?? What happens if it takes you longer to reach the desired “outcome†than statewide statistics show?? Does care then become inappropriate?? Indications are YES!!
Alliance Blue Cross Blue Shield? decides to whom a case manager? is assigned rather than one’s doctor making that decision.
I was shocked at what seemed to me to be an invasion of privacy, dictatorial mandates, and threats of reduced benefits for non-compliance? as illustrated in the following quotes:
“We will assign VMS? case managers? who will give individual attention to those members we identify as having certain health care problems.
“If you are assigned a case manager, your case management? will continue for at least six months.
“Once you have a case manager, you will need to call your case manager before scheduling any medical care.
“If you do not follow the managed-care provisions of your program when applicable, your benefits will be reduced.
“–Most managed-care programs require every person to precertify? all inpatient care.
“Your case manager? will continue to call at least once a month to see how you’re doing, to answer questions you may have, and to help coordinate your care.
“Your case manager? will also call your primary physician whenever necessary.
“If you are assigned a VMS case manager, you should call your case manager before scheduling any medical care - inpatient, outpatient or office.
“If you are assigned a case manager? and you do not call before you receive non-emergency care, you will not receive the full benefits of your program.? In an emergency, you must call within 48 hours to receive your full benefits.
“If you do not call and we later determine that the care was medically necessary, you will be responsible for the first 20% of eligible expenses, as well as your deductible and coinsurance, if applicable.
“Regardless of whether or not you call, if we determine that the care was not medically necessary and you received care from non-network providers, you will be responsible for all charges.? If you received care from network providers, you will not be responsible unless you agreed to pay for the care.?
“If you do not call or we do not precertify? your care when required, you will be responsible for the first 20% of eligible expenses, as well as your deductible and coinsurance, if applicable.? Or, if we determine the care was not medically necessary, you will be responsible for all charges.
“Regardless of whether you have a VMS case manager, if you are in the hospital and we notify you that further inpatient hospital care is not medically necessary, we will not continue to provide benefits beyond the date specified in the notice.?
“If you or your physician disagree with a decision made by a VMS case manager, you may appeal within 60 days after the decision.
“Even if you called us and we precertify? your care, we might not provide benefits.? That’s because we can only determine whether the care is appropriate for you, based on the information we are given.? We cannot verify each member’s benefits, membership limitations and medical records before certifying care.? All of these could affect your eligibility? for benefits.? Please keep in mind that we cannot determine benefits until we actually receive the claim and consider all factors that affect benefits� [4] (emphasis added).
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“We have the sole discretion to determine whether a condition is preexisting� [5] (emphasis added).
What alternative exists for the person who chooses NOT to participate in socialized medicine (HMO/PPO) and is having difficulty affording and/or qualifying for insurance coverage in the free enterprise? market?? It seems to be a waste of money to pay into an unpredictable, socialistic health-care rationing plan (or any other plan) which can’t be counted on to provide coverage when needed.
[1] “Health Security Preliminary Plan Summary,†Health Alliances, p. 21.
[2] “Your Alliance Choice Medical Benefits,†Alliance Blue Cross Blue Shield cover page.
[3] “VMS Value Management Strategies,†Alliance ChoiceAMK-663, Alliance Choice, REV 5/95, PL1#1B/Broch/VMS/rb.
[4] “Your
[5] “Your