The Daily

Access To Healthcare

scrabbleWithout understanding the market in which you live and access healthcare, it is impossible to appreciate the value of the services being provided. This is why many people are worried when they become sick abroad or in a strange place. Our own healthcare market can seem like one of those strange places to many.

In 2013, Time magazine published an opus by Steve Brill on the opaque nature of the healthcare market, explaining in detail what makes it so inefficient.[1] The title of his piece “Why Medical Bills Are Killing Us”, begs the question – why don’t we know more about why?

When I began practicing law, the health care market was divided up between what were then newly created organizations for delivering healthcare and health insurance – HMO’s (Health Maintenance Organizations) and PPO’s (Preferred Provider Organizations) After decades of spiraling costs, the HMO/PPO model failed. Part of the problem was that consumers of healthcare were kept in the dark about the financial dynamics that drove HMO’s and PPO’s. Another significant part of the problem is that consumers do not – in general – see their medical bills or expenses. As suggested by Brill in The Bitter Pill, the lack of open and transparent markets prevents usual market principles (like supply and demand) from operating properly when it comes to American healthcare.

Many PPO’s, for instance, created financial incentives for family practitioners not to refer patients for specialty testing. Funds from the network carrier were set aside to pay for referrals (cardiology, neurology, surgery, etc.) and the family practitioner kept whatever residual was left in the fund at the end of the year – if anything was left. Essentially, the family practitioner was paying for the patients’ referrals. Patients were not specifically made aware of these arrangements.

As a result, under the HMO/PPO model, financial incentives made specialist referrals less likely. Remember this when you have difficulty obtaining cooperation in seeking specialty referrals or treatment from your family doctor.

I can recall a case early in my career of a woman who repeatedly sought help with symptoms of a stroke and eyesight problems that included ‘floaters’. These symptoms are often caused by blockage in the carotid artery. Her doctors delayed her referral and when she did finally get an ultrasound of her carotid arteries it was done on an old machine that did not provide a diagnostic or even legible result. Nonetheless, her doctors reported the ultrasound as normal. Shortly thereafter, she lost her sight in the affected eye due to blockage in her carotid artery that could have been repaired.

If you have suffered a serious injury caused by a developing and undiagnosed medical condition, you need a lawyer experienced in litigating healthcare issues to successfully press your claim. Do not trust your case to anyone less than an expert.

[1] http://time.com/198/bitter-pill-why-medical-bills-are-killing-us/