Well the problem is that a layman cannot understand the ins and outs of healthcare and insurance. And a single payer system does not make it easier really.
And because of the complexity of insurance and especially medical knowledge.. you can't expect the average person to understand it. Heck.. its surprising in my business (which is healthcare) how much of our practice is dictated by insurance but medical professionals don't even realize it.
Perfect example:
I started in medicine when you could send a medicare patient with a stroke to a rehab and they could get 100 days of rehab.. they would get 3 disciplines of therapy for 3-6 hours a day.
Pretty much.. no questions asked. So what happened.. well we found that patients with cva would sometimes not get better or much better until several weeks of therapy, but at the end of intense therapy, they would be walking independently etc.
BUT also what happened is that routinely facilities would treat patients that were not appropriate, that were not getting better but would simply overutilize that 100 days...
So.. in an effort to cut costs, medicare over the decades has instituted a number of restrictions or qualifications etc on sending CVA patients to rehab and the rehab they get. Now.. under MEDICARE LAW.. a patient with CVA can still be qualified for 100 days of therapy 3-6 hours a day/... but its rarely done now because of the hoops that have been put in place.
For example, the magical day in rehab was 20 days (when medicare stops paying 100%) .. and after that.. if you were in an acute care rehab.. you were discharged. Why? Because of reimbursement... but what happened? Docs stopped seeing patients get better after 20 days.. because patients left their system.. They stopped seeing that patient get better at 40 days..
Its gotten worse under Obamacare because now.. they are incentives to where the hospital gets paid better if they don't go to rehab at all. Or if they severely curtail rehab.
So now.. I have had a couple of young docs tell me a month ago... "well if a patient with stroke doesn;t get recover in 2 weeks they are never going to get it back".... AHHHHHH nothing could be farther from the truth. In facts there are numerous studies that show that CVA patients can get recover years later.
But what these docs know.. is what they SEE.. now. And its becoming a self fulfilling prophecy..
this happens a LOT in the interaction of medicine and insurance. And before someone yelps.. "single payer is better".. no.. single payer often exacerbates these problems because there is no counter insurance that does it differently that has a better outcome.
A good example... my own grandfather. My mom called to tell me that my grandfather was going to be kicked off medicare (he was in a skilled facility after a surgery at 94). Basically because they were going to stop PT (which was its own issue.. the therapist was simply lazy).
But what this meant for him was that he was not going to get the same caregivers, not going to get the other nursing services that he was getting.
So I made a call to the facility (against my family's wishes because they worried that "you would make them treat him worse".. (I mean how awful that people really think that speaking out for whats right will mean retaliation on their family)...
When I called.. I got the standard answer about medicare and how medicare paid and what it didn;t pay for and my grandfather simply didn;t qualify. (from the business office)... and I said.. "okay. tell me his RUG score"... (RUG stands for resource utilization group)
Complete silence. I said again "can you tell me his RUG score"... then the lady said "well we don't have that here we will have to get back to you". (which I know is complete bull.. that information is at the click of a button) I said "well okay but I am surprised you are taking him off medicare because he is getting diabetic teaching.. has a surgical wound you are doing daily bandage changes on, has restorative nursing program 4 days a week, and is having is intake and outputs assessed daily with medication changes.. I would expect that he would score well above the line (the line for qualifying for medicare payment) and you would be giving up say 750 a day.. for 155 a day for private pay".
The lady: "umm let me get back to you."
I said: Sure, have the administrator of the building call me when you get the information for me"..
Honest to god.. it was not 15 minutes LATER.. when my MOTHER called me and said " guess what the SNF called and your grandpa is covered for another 80 days under medicare"..
(they never did call me back by the way).
Now realize.. that was medicare which would be the same in a single payer situation. So what we really need is some advocacy that could do exactly what I did to the facility.
