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Reloop, do you mind if I tap your knowledge a wee bit more?
Let's say my insurance agrees to pay x for my proceedure, if I only needed x-2 they still get x, but if I needed x+3 they would still only get x...thus figuring that some would need x, some x-2 and some x+3 and it would all work out in the wash. I can live that, although I'd like to see the numbers to see if in fact the numbers are close. And it does make me wonder, if the goal then shifts to forcing people into the x-2 slot.
How would you fix it? I always thought a sliding scale clinics would be a good answer, but after reading how payment is made, that might just prove to be a nightmare.
Reloop, do you mind if I tap your knowledge a wee bit more?
Let's say my insurance agrees to pay x for my proceedure, if I only needed x-2 they still get x, but if I needed x+3 they would still only get x...thus figuring that some would need x, some x-2 and some x+3 and it would all work out in the wash. I can live that, although I'd like to see the numbers to see if in fact the numbers are close. And it does make me wonder, if the goal then shifts to forcing people into the x-2 slot.
How would you fix it? I always thought a sliding scale clinics would be a good answer, but after reading how payment is made, that might just prove to be a nightmare.
A lot would depend on what insurance you have. DM me with the company. I don't know if I can answer for sure - many policies have done some major changes in preparation (and more than likely fear) of Obamacare. You may have to wait for your Explanation of Benefits and try to sort through that.
Be that as it may, we do have a couple of clinics in the Bangor area. PCHC comes to mind. They have a sliding scale setup. As is with every relatively new endeavor, it's met with both hostility and praise. Personally, I believe it has really alleviated a lot of traffic in the ERs for simple things like sore throats, etc., and it has assisted many people who had no coverage at all, thus saving a lot of money in the long run, and I think that's great. My own Doc transferred there, and although I miss the small office atmosphere of her former place, I'm extremely happy with her competency and care, so I followed her. I also like the fact that walk-in care for there on the weekends costs me a $20 copay whereas walk-in at the EMMC walk-in clinic ends up going to my deductible and is usually around $135.00 to treat the overnight ear infection my son chronically suffers from. This agony is always sudden onset, and usually on Saturday. Hospitals have charity care too, and that is a sliding scale set up. That's particularly good for those who are self-employed and don't have an option to get on a spouse or partner's policy. Not everyone qualifies for that, but a good many do.
Be that as it may, PCHC also applies for every grant they can get their hands on to help offset costs, so that's not endeared them to some of the other practices, or even their own employees, some of whom feel pressured to "get 'em in and get 'em out." Still, it's obviously needed. We have a great deal of uninsured workers in this area. It's helped contain costs by keeping them relatively healthy.
I won't even pretend to know the perfect scenario for fixing it; however, I do believe that a good start would be for the state to help small businesses pool together to at least offer some sort of reasonably affordable health insurance option. Most small business owners I know would love to offer something to their employees, but they don't have the financial power to do so and compete with the larger chains. I also feel very strongly having worked in mega-retail before with access to financial numbers that they should be required to offer healthcare coverage to their employees if nothing else. They make enough money to do so, and I don't care what anyone else says to the contrary. There's no excuse for them not to offer some sort of 'in' to an affordable plan. Their stockholders wouldn't be missing out on much. At least, that is, if their CEO's can part with a few hundred thousand dollars in 'bonus' money. Just my .02 there.
Thank you so much reloop, I fell I have a much better understanding of the system now.
And thank you for the offer to look at my insurance, it was meant as an understanding thing more than my personal insurance. Other than that, ours is going through all the changes with the Affordable Care Act stuff, I'm not even sure if they know what they are doing now, except raising our rates.
Thank you so much reloop, I fell I have a much better understanding of the system now.
And thank you for the offer to look at my insurance, it was meant as an understanding thing more than my personal insurance. Other than that, ours is going through all the changes with the Affordable Care Act stuff, I'm not even sure if they know what they are doing now, except raising our rates.
You're welcome. I know there's a lot of hate and discontent out there when it comes to what's coming from healthcare around the corner. I contemplated not posting at all, but every once and a while I feel the need to explain how things work behind the scenes. I realize people only see one side of it (and it's usually it's the bad one and half the story unfortunately).
I'm wary of some of the changes that are coming down the pike as well. The "Bureau Of Nosy Statistics" whom I suspect are behind some of the more seemingly intrusive triage questions, are among them. But, it's not just them - private insurance companies are looking for every single stinking excuse not to pay a claim as well.
I find that sad because it does directly affect patient care. If one is worried that the insurance company is going to balk about paying a claim because of a triage question, the simple fact of the matter is that the patient may feel compelled to lie. Who can blame them with the cost of medical bills? Electronic Medical Record and other software companies also make their bread and butter by selling products designed to be streamlined for every provider in the country. Is this good or bad? I think a little of both. The bottom line is the bottom line. We have to be willing to bend a little when it comes to the delivery of healthcare if we want to maintain good healthcare IMHO.
I'm not particularly trustful of the government in general, but I try to look ahead to see where things are going. I suppose it remains to be seen what will happen; however, one thing I do know: There's no way the past way of paying for "the greatest healthcare in the world' could have continued as it has been.
It's simply not sustainable. Be that as it may, I'm glad you had a good experience with EMMC, and I hope your insurance company does what they're supposed to do.
You're welcome. I know there's a lot of hate and discontent out there when it comes to what's coming from healthcare around the corner. I contemplated not posting at all, but every once and a while I feel the need to explain how things work behind the scenes. I realize people only see one side of it (and it's usually it's the bad one and half the story unfortunately).
I'm wary of some of the changes that are coming down the pike as well. The "Bureau Of Nosy Statistics" whom I suspect are behind some of the more seemingly intrusive triage questions, are among them. But, it's not just them - private insurance companies are looking for every single stinking excuse not to pay a claim as well.
I find that sad because it does directly affect patient care. If one is worried that the insurance company is going to balk about paying a claim because of a triage question, the simple fact of the matter is that the patient may feel compelled to lie. Who can blame them with the cost of medical bills? Electronic Medical Record and other software companies also make their bread and butter by selling products designed to be streamlined for every provider in the country. Is this good or bad? I think a little of both. The bottom line is the bottom line. We have to be willing to bend a little when it comes to the delivery of healthcare if we want to maintain good healthcare IMHO.
I'm not particularly trustful of the government in general, but I try to look ahead to see where things are going. I suppose it remains to be seen what will happen; however, one thing I do know: There's no way the past way of paying for "the greatest healthcare in the world' could have continued as it has been.
It's simply not sustainable. Be that as it may, I'm glad you had a good experience with EMMC, and I hope your insurance company does what they're supposed to do.
Good posts; I have worked in healthcare for almost 30 years, and your explanations are right on the money.
One last note before I close out my end of the conversation. Note this quote from above:
"Eastern Maine Medical Center has cleared the final regulatory hurdle in a more than $17 million deal to sell its dialysis clinics to one of the country’s largest for-profit dialysis chains."
Have you ever wondered why you go to one hospital for services and get 2 or 3 different bills from other providers who, for example, read your xray, or processed your blood tests, etc.?
This is outsourcing. Is it good? Well, I suppose that's for each individual to decide. I think it has its good and bad points; however, deep down, I don't feel that putting anything healthcare-related into a 'for-profit' status is ever good. It adds more hands in the till much like HMOs did in the 1990s. It seems the costs of healthcare really started going up when we had for-profit bean counters telling doctors what to do. There was a large backlash with that practice, so now there are physicians who are hired by insurance companies (and are often getting paid more to 'consult' than to actually practice). I'd like to run the 'then and now' numbers for that practice, but alas, I can find none. Go figure.
So now, instead of getting one bill from the hospital proper, a dialysis patient will get several - including one from the dialysis chain. We can expect more of that I believe.
I recently heard about EMMC's plans for expansion, and I'm going to try to stay on top of this; it sounds like it will become a major force in Maine healthcare, 2nd perhaps only to Maine Medical Center in Portland...
I recently heard about EMMC's plans for expansion, and I'm going to try to stay on top of this; it sounds like it will become a major force in Maine healthcare, 2nd perhaps only to Maine Medical Center in Portland...
I agree. The healthcare foundation also has a lot of smaller hospitals under its umbrella now. They had little choice but fall in due to finances. It's no surprise there. I know Blue Hill Hospital, C.A. Dean, Inland Hospital, Sebasticook Valley, and I believe TAMC (The Aroostook Medical Center) are under them as well.
Bangor has become a healthcare 'hub' if you will IMHO. EMMC is a Level II trauma center. I'm not sure what level Northern Maine Medical is, but EMMC's central Maine location and access to LifeFlight EMS services gives it importance in such a rural state as ours. Their transfer center is busy all the time.
I'm still not sure about how the outsourcing will pan out. To me, anytime you remove entire offices and staff from a nonprofit and farm out the work to a for-profit, that for-profit is going to naturally have a profit margin to maintain. Will it then be able to make more money? Perhaps. I'd like to see the fine print. While I'm sure that not paying wages and benefits for a group of employees will help save costs for the nonprofit hospital, I'm not exactly sure how it's going to save you and I money in the long run.
I don't live in Maine right now, but it's a possibility in the future...
I know that the project won't be finished until 2017, and eventually they do plan on bringing on more staff physicians, and thus more clinical and administrative staff, as well. Hopefully, all will have access to an affordable health insurance package, ad not have to fish around for a more expensive private plan ( although there are no indications that this would actually happen)..
Do you have an opinion about St. Joseph's in Bangor?
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I know there's a lot of hate and discontent out there when it comes to what's coming from healthcare around the corner. I contemplated not posting at all, but every once and a while I feel the need to explain how things work behind the scenes. I realize people only see one side of it (and it's usually it's the bad one and half the story unfortunately). 
