The ABCs for Better Health Care
Preamble
There have been several attempts at improving our health care system going back to Senator Edward Kennedy in the early ‘70’s. None of the endeavors have been directed by a health care association or a provider. The last big revision was the Affordable Care Act that took effect in 2014 directed by President Obama. It only dealt with the finances of health care. The delivery of health care system now needs to be overhauled to move our ranking in the world from last to first by those who deliver the care. Many of the issues’ solutions are supported by research or commentaries that are the listed link for that topic.
This is a big change that will take time to implement. However, once accomplished, the overall health of Americans will be better. Many who are too sick now to participate in community affairs because they cannot afford basic health care will be able to become involved again and live a better quality of life.
Preface
The Commonwealth Fund reported that the people in the United States experience the worst health outcomes overall of any high-income nation even though we spend the most amount of money1. (https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022) The United States spends almost 18% of the gross domestic product on health care. This is almost twice as much as the average country in the Organisation for Economic Co-operation and Development report, which is where the data for the analysis originated. Americans die at a younger age and are less healthy than residents of other high-income countries. The United States has the highest rate of infant and maternal deaths. Obesity is the highest in the United States, almost twice other countries in the study. The United States has the third highest suicide rate.
To find a solution to this catastrophe, the etiology must be identified. The most glaring fact in the data is that the United States is the only high-income country that does not have a system where everyone has basic health care coverage. This is not the sole cause. There are other contributing factors. Most of the issues can be distilled into three categories: access to care, billing and cost. Thirty-one issues were evaluated. In alphabetical order they are: access to care; authorizations; billing transparency; board certification; choice of providers (Provider is used in a generic form to mean any individual or facility that renders health care. A physician as well as a home for hospice is referred to as a provider in this document.); coding; communications; competition; compliance; cost; credentialing; denial of care; Department of Insurance; discrepancy about the proper use of International Classification of Diseases, Tenth Revision (ICD-10), Current Procedural Terminology, Fourth Edition (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) codes; economic credentialling; electronic medical records; fraud; funding; licensure; networks; new technology and medications; paperwork overload; premiums; referrals; reimbursement; restrictive covenants; terminology; tiering; time limits; transportation and utilization. Each of these matters is analyzed, weaknesses identified, and modifications made for us to achieve our goal. Some of the modifications are common sense while others are innovative.
Prevailing objective
The objective is to reverse America’s rank in health care quality when compared to other high-income nations. In the process of reversing our ranking, we will eliminate access to care and health disparities issues as well as enhance patient outcomes. Everyone will have essential health care coverage. The reform will promote fairness in health care delivery. High standards of care will be fostered based on evidence and innovation. Coverage will be made affordable for the average United States citizen by putting competition back into health care.
Access to care
There are many barriers that affect health care access2. (https://onlinelibrary.wiley.com/doi/epdf/10.1111/1475-6773.14202) There is a group that does not have health care. In that cohort, there are the poor and the homeless. The latest study shows that 27.2 million people have no health care coverage in the United States. Of that number, 771,400 are homeless. In the group that has health care coverage there are two subgroups. There are those who do not drive even though they have a license because they cannot afford a car or are afraid to drive for one reason or another3. (https://www.wolterskluwer.com/en/expert-insights/five-key-barriers-to-healthcare-access-in-the-united-states) The other group lives in areas where the services are in short supply or are not present at all.
First and foremost, every United States citizen must have essential health care coverage. Essential health care coverage, for example, would include but not limited to such things as care from an injury, cancer care, yearly history and physical exam. Employers will be able to provide health care benefits for their employees if they desire to do so. The cost can be shared with the employee. Whether the employee pays for part or all the essential health care, it will be deducted from their paycheck and submitted to the employee’s insurance carrier by the employer on the employee’s behalf. Health care coverage above the essential plan will be tiered. For an insurance company to sell the optional health care coverage, they must participate in the essential health care coverage plan. The essential health care coverage will be standardized regardless of what insurance carriers are providing it. Covered services for the essential health care plan will be clearly delineated. The cost will be determined by the carrier. This will introduce competition into health care coverage premiums as the American people will be able to compare equivalent services with the cost. Consequently, this will bring down the cost of the premiums. Thus, making the amenities important that come with the coverage.
The optional services and premiums can be constructed to meet the needs of the business or individual purchasing it. They must be bought from the same carrier that their essential health care coverage is purchased. This will introduce competition in the market as insurance carriers will not be able to price their essential health care high to not get anyone to sign up but have competitive rates for the optional services. There are no restrictions on how the optional services or premiums are fashioned. Businesses may also cover their employees for the optional services. The employee can purchase the optional services on their own if it is not covered by the employer. The cost will be deducted from their paycheck like the essential health care coverage premium.
Those who cannot afford coverage will be subsidized by a health care surcharge added on to all the businesses’ goods and products sold in the United States. The surcharge will be calculated by taking the number of uninsured individuals times the cost per year of the health care insurance plus the annual cost of cloud storage, annual maintenance fee for the software and the annual budget of the Health Care Department divided by the national cost of goods and products sold the previous year, and then converted into a percentage. That percentage is the health care surcharge that each business will add to each of their bills. In return for essential health care coverage, those individuals will do community service4. (https://pmc.ncbi.nlm.nih.gov/articles/PMC7681163/pdf/S2045796020000906a.pdf)
They will start at the minimum wage for the state where they are living. The time required to do community service will be equal to whatever the monthly fee would be for the health care coverage divided by the minimum wage. At a minimum, they must have the essential health care plan. They can procure optional coverage by doing additional volunteer hours that would cover the cost of that coverage. In the circumstances where the number of hours is not a whole number, the hours will be rounded up to the next highest number. They must do their community service the month before they receive the health care benefits just like insurance premiums are paid at the beginning of the month that the insurance is active.
There will be a hierarchy for the use of community service starting with help the federal government may need in the area where the patient is living. Then, in descending order would be the municipal government, public schools, not for profit and nonprofits, hospitals and other health care facilities that are for profit, private schools and finally local businesses. Examples of community service include: keeping the roadways litter free, working in the recycling center, park maintenance, helping in the food pantries and soup kitchens, hospital volunteers, not for profit and nonprofit volunteers, washing and cleaning law enforcement and government vehicles, etc. These positions are not to take away jobs from those who have them, but to lend assistance where they are short staffed or there is a complete void. They will have to meet the minimum standard for each job to keep their health care coverage active. To move into a more desirable position, the individual must be doing their present job well, not at the minimal standard.
Many who do not have health care coverage work during the day for minimum wage. Thus, the hours to volunteer will be flexible to accommodate the schedule of those individuals.
They will be evaluated by the head of the department that they are doing their community service in. The evaluation form will be online (Appendix 1). The individual will be able to view their evaluations. In the evaluation, it will discuss whether the individual is ready to assume greater responsibility. Also, it will review how the individual can improve and what is needed to advance. The Health Care Department will reimburse the department chairs where those doing the community service are based on the number of volunteers that are overseen, their hourly rate and the average amount of time it takes to oversee and do the monthly evaluations.
Should an individual decide he or she does not want to do community work, they will not receive health care coverage. Hospitals will no longer be obligated to care for those without insurance. So, those who choose not to participate in the basic health care plan will have to pay for their medical care.
Those who are homeless will receive their health care by being automatically enrolled in the military. There will be no exceptions. There will be jobs available for everyone regardless of their abilities. The Community Outreach Unit, a division of the Health Care Department, will assist the military to help those areas of the country that need help.
Many of these individuals can’t find work for a multitude of reasons. The military will educate them with job skills so they can again compete in the job market when they get out. This will allow them to be contributing individuals in society. It will give them a purpose in life and strengthen their self-worth and self-esteem5. (https://journals.sagepub.com/doi/10.1177/08902070211027142) The local law enforcement will pick up those who are homeless and hold them at their headquarters until the regional military base can come and transport them to the base.
Many who are homeless have substance use issues. The military will detox those individuals so they can again be thriving members of society. Other mental health issues will be rehabilitated also.
It is reported that 13 percent of the homeless are veterans6 (https://nchv.org/veteran-homelessness/) These are the most deserving individuals in America. They were willing to give their life for our freedom. Now, when they are down and out, we have abandoned them. We help the entire world. We must not forsake our veterans. The homeless will also be funded from the health care surcharge.
Board certification was originally for physicians who wanted to demonstrate that their skill set was above that needed to pass a state exam to practice. It now acts like the state board licensing requirement. Thus, it has distorted its purpose. In the process, it has decreased access to physicians who are already in short supply.
There are legitimate reasons why physicians are not board certified. Women now comprise a more significant number of physicians than a couple of decades ago. Many of them naturally want to have a family. This is usually planned when their residency ends. There are a variety of different types of cases and a time limit that are required to qualify to sit for board certification. After returning from maternity leave, they may not see the number and or the variety of cases they need to qualify to sit for the exam in that shortened period. Consequently, they lose that opportunity for their entire career. This doesn’t mean that they are any less smart than their colleagues. These physicians have been honest about not looking for cases that are needed to make the requirements to sit for the exam. Nevertheless, they are punished for being honest.
Collecting the number and variety of cases in the required time frame is also an issue for those who do not take maternity leave. The requirements to sit are very difficult. After all, the reason for having board certification is to demonstrate that physicians are in some way providing a higher level of care than the minimum requirement. There are a multitude of reasons why they are unable to get the number and variety of cases. For instance, the area that they practice in may not have a high volume of a particular disease entity that is needed. They may develop a practice in which they don’t treat certain disease entities that are required to sit for their boards. These physicians also have been honest about not looking for cases that are needed to make the requirements to sit. However, we are punishing them for being honest.
Board certification will not be used as a requirement to be a provider on staff at any health care facility or on an insurance plan. The patients will choose their providers. If they choose to go to someone who is not board certified, that is their right. It is the patient’s responsibility to select those who oversee their health care, not the insurance companies or the employers. It will be used to demonstrate once again that a physician practices at a higher level than the minimum required to get a license. It was intended to be and will again be the ultimate test, not minimal.
A significant amount of time is spent every year by providers and insurance companies for the credentialing and recredentialing process. This is a waste of time and money as the patients should be deciding who they want to care for them. The insurance industry has taken on the responsibility of ensuring that the providers in their network are qualified. While that is noble on their part, it is unnecessary and inappropriate as it is not their responsibility to decide what provider is right for their insured or if they are qualified. Providers must graduate from medical school, pass the national boards tests, graduate from a residency program for those professions that require residency and pass the state licensing test. So, there is no reason for the insurance company to do more credentialling. The argument that the credentialling process prevents fraud isn’t supported by the facts. The patient should be deciding who they want to deliver their treatment. That also makes for better provider patient relationships when the patient is making the decision of the provider, they want to render their care. The primary care provider and local hospital can make recommendations to the patient for specialists as they have in the past, if the patient needs one.
The credentialing process will be terminated. The patient has the right and responsibility to select their providers. It is up to the providers to put their best foot forward and educate the public why they are the provider of choice. This will create competition among the providers and help decrease costs in health care.
The license to practice is presently determined by each state. This prevents the provider from working outside the state or states that they are licensed in. The license to practice will be national and not limited to a particular state even though the provider will acquire a license in the state where they practice. This will allow the use of telemedicine nationally which will assist in several areas. It will lighten the burden on transportation, health care costs and lack of services. It will also allow doctors to cover a colleague’s office in a bordering state in times of illness or injury. In times of disaster, doctors can volunteer to help in any state instead of being limited to only where they have a license.
In many cases, insurance companies have networks that providers must belong to so that they can provide care for the insurance company7. (https://www.smith.edu/sites/default/files/media/Faculty/Haas-Wilson_Physician-Networks-and-Their-Implications.pdf) This limits patients’ choice of providers. The patient is locked into seeing the network providers. There are times when the provider and patient do not get along. That circumstance does not lead to good treatment outcomes.
When physicians finish their residency program, they are limited to practice in areas where they can join the insurance plans. This prevents physicians from going to areas where there are closed networks. It also prevents established providers from hiring someone else because they may not be able to get into the network under the group listing. Networks prevent physician competition.
Networks are abolished. By eliminating networks, both the insurance companies and the providers will not have to spend time reviewing or completing applications every couple of years. When the patient has a choice of providers, it becomes the patient’s right and responsibility to see if their provider of choice matches their standards. The providers would be responsible for letting the public know about their education, training, experience and board certification and any other credentials that will make them the provider of choice. It is not the insurance company or employer’s job to select providers for the patients. The insurance company’s job is to pay what is appropriate for the care provided when it is a covered service. The elimination of networks will save a significant amount of money in administrative costs on both the insurance companies and providers’ ends since the application and maintenance processes will no longer exist. There will be no application process to get on an insurance plan as a provider. Thus, if a patient selects a provider for their care, then it is the insurance company’s obligation to process the bill for reimbursement according to their protocol. There would be no more concern about being in or out of network or for the insurance company having not processed the physician’s application. There will be no wait for a provider to see any patient as there will be no need to apply to be part of an insurance panel. There will be no more participation in the optional health care coverage. The provider will be able to decide on an individual basis if they will accept assignment for the claim. This is unlike the essential health care where providers are all in, thus participate, and must accept the insurance companies’ payment as payment in full. Accepting assignment means the insurance reimbursement goes to the provider with the copay as well as coinsurance and acts as payment towards their provider’s fee.
This will bring back competition among physicians and all other providers of health care including hospitals and nursing homes as the patient will have a direct voice in who cares for them. It will force physicians to have convenient office hours and other amenities to compete. Providers will be able to practice where they want to live instead of working where they can get into a network.
Regional shuttles will be established to resolve the problem of access to care due to transportation. A healthy society benefits everyone. By staying healthy, there are fewer sick days missed from work. Health insurance companies will have less people staying in hospitals. When they are admitted, the conditions will not be as serious. They will not be in for as long a period, thus decreasing the cost of care.
The shuttle services will be under the direction of the hospitals. Since everyone will have health care coverage, they will no longer be stuck with caring for the uninsured at their expense. They can charge a minimal fee for the services. They can acquire sponsors from the business community to support the shuttle service. At a minimum, the shuttles will take patients to the providers, all health care facilities and food shopping. This can be set up so there are certain times or days when the shuttles go to the various facilities. The shuttles can also be used to go to other stores for basic needs. This can be a separate fee for the rider or sponsored by a business. Larger heath care systems will need more than one shuttle. If there are qualified drivers in the community service group, their volunteer time can be used to drive. This will save the hospital a significant amount of money.
In areas where there is a shortage of providers, public health facilities will be established so the needs of the people in those areas can be met. Many of the facilities will be mobile. By keeping these individuals healthy, the hospitals will not have patients who are deathly sick on a regular basis because they never receive any basic health care. By guaranteeing health care access to everyone, the average life expectancy will go up. The infant and maternal mortality rate will drop.
Eye scans will replace identification cards. They will also act as the identification and pass to get on the shuttle. Thus, if someone is unconscious, the hospital will be able to know the individual’s identity and be able to access their medical records to provide quality care as all medical records must be able to interface. Eye scan will be a big step in eliminating fraud by not having numbers that one can improperly procure and use to bill for services that were never performed.
There are numerous electronic medical records both for providers’ offices as well as for hospital systems. The problem is that they don’t talk to each other. Consequently, tests get run by providers not knowing that it was already done. Providers must bother other providers for medical records that they need before proceeding with care. This requires both staff time and expense to perform this task. In times of disaster, people are transported to safe communities. They are not seeing their physician for care rendered there. Consequently, their history is not always the best it can be, particularly for those who suffer from dementia or Alzheimer’s disease.
A platform must be developed so electronic medical records systems can share patient information in the United States and get the patient’s medical history. This will be a requirement to continue to sell electronic medical records.
Billing
There are many components to billing that contribute to the poor quality of care provided. When the authorization concept originated, providers could call on the patient’s behalf and find out if the service was covered8, 9. https://carrumhealth.com/blog/how-prior-authorization-hurts-patients/, https://www.hbma.org/rcmadvisor/quarter-3-2023-volume-28-issue-3/the-impact-of-prior-authorizations-on-patient-care
Frequently, providers are now given an authorization number, and the service is denied when submitted for reimbursement. Since authorizations no longer mean that a service is covered, providers can’t tell the patient whether the insurance company will pay for the treatment. This does not allow the patient to make an informed, fiscally responsible decision. Thus, the patient is left with the impression that they may be paying the cost for the entire treatment. Consequently, patients forego treatment because they can’t afford it if it is not covered. However, this is defeating the purpose of the authorization. It is common that to get one authorization, for one patient, for one treatment can consume an hour on the phone for one staff person.
With the benefit of technology, the patient’s eye scan will be performed thus giving the identity of the patient. The ICD-10 code and CPT-4 and or HCPCS code (These are the codes that are used by the provider to bill for the services they provide.), the provider as well as the location are entered. Then the patient can see if the service they need will be covered as well as the amount that will be reimbursed. This would apply to optional service plans that patients may purchase where the patient may have some financial responsibility. This will also come into play if a patient wants a provider to deliver a service that is covered in the essential health care plan, but the provider does not participate in that essential health care plan for that insurance company. Confirmation of the interaction with all the details will be printed. This will resolve future disputes. This will save a significant amount of time and money, both on the insurance and health care providers’ ends, which can be used to provide better care.
Patients do not have access to the reimbursement from the insurance company for CPT-4 or HCPCS codes before that service is rendered to them10, 11. (https://journalofethics.ama-assn.org/sites/joedb/files/2022-10/pfor3-2211_0.pdf) (https://rest.mars-prod.its.unimelb.edu.au/server/api/core/bitstreams/83742923-609f-525c-87a2-4dff82dabf4d/content) Without billing transparency, individuals cannot be fiscally responsible. This leads to large medical debt and at times bankruptcy.
Presently, most insurance companies use the national provider identifier (NPI) number plus their own number. This leads to confusion and wastes time trying to track down a claim, particularly if the staff doesn’t have the unique number identifier for that insurance carrier. The unique identification number given by insurance companies will be eliminated. The NPI number and Employer Identification number, EIN, will be used to cross reference the provider.
Physicians must post on their website the fee for every CPT-4 and HCPCS service they provide. Likewise, if they sell products that do not have a CPT-4 or HCPCS code, then those products, clearly identified, and their fee must be listed on the website also.
The insurance companies must post their reimbursement rates for every CPT-4 and HCPCS code. Services that don’t use the standing AMA billing codes but are a covered service, must also be posted on the website. This will introduce competition back into health care. Patients will be able to make an informed decision on what care they receive, who they want to provide it and what their out-of-pocket cost will be.
The American Medical Association (AMA) developed the ICD-10, CPT-4 and HCPCS codes so that providers and insurance companies know what each other was talking about when a particular code was discussed. Over the years, different interpretations of the codes have replaced the original meaning. This has caused confusion. Time is wasted when an insurance company tells providers that their interpretation is different than AMA’s. Instead of focusing on the care of the patient, the provider must be concerned if he is meeting all the requirements for the code that he is going to bill for that insurance company. That defeats the purpose of having standardized codes and brings us back to where we were before the AMA codes were developed. There is a difference between not recognizing a code that is a nationally recognized code and not a reimbursable code. Regarding this issue, we have regressed and have not progressed.
The AMA’s interpretation of the billing codes will be the only one accepted. Insurance carriers and providers may not interpret the codes. The AMA will be responsible to continue to make those codes and descriptions available.
The explanation of benefits (EOB) and electronic remittance advice (ERA) statements vary from insurance company to insurance company. This causes confusion when they are trying to be interpreted by the providers’ offices. It is not uncommon to have questions about what is printed on the form. As a result, the insurance carrier is contacted. There are several transfers until someone is found who can explain the form. A common problem is one where a certain amount is allowed but nothing is paid. It doesn’t list if the allowed amount was applied to the deductible, coinsurance or copay. Consequently, the proper amount that should be billed to the patient is unknown as well as the reason for the statement such as applied to your deductible.
There are risks with every procedure. The greater the risk the higher the reimbursement. Regardless of what professional provides the care, assuming that it is within their scope of practice, the risk that is assumed is the same. Yet different professionals are reimbursed differently. Regardless of who provides the care that is within their scope of practice, the reimbursement for the CPT-4 and HCPCS codes will be the same across all professions for all those who provide that care. There will be no paying one profession more than another for any reason.
A standard form will be used by all insurance carriers for EOBs and ERAs with standardized reasons for the actions taken on the form. Appendix 2 has the standardized form. The reimbursement check or credit card will be part of the EOB or ERA. There will be no more sending a check or credit card without the EOB or ERA.
The present system has alleviated competition in health care12. (https://link.springer.com/content/pdf/10.1186/s13561-024-00487-6.pdf) The insurance company reimburses services that are requested by the patient and delivered by the provider. It is the insurance company who decides whether the services are medically necessary or not and what they will reimburse the provider. Thus, making it impossible for providers to compete. Consequently, the cost of health care only goes up. Insurance companies deny services as medically unnecessary, thus leaving the provider responsible since they cannot bill the patient for “medical unnecessary” services per contract. The reality of the situation is that if a patient sees a provider for something that bothers them, it is not medically unnecessary. It may not be a covered service, but it is not medically unnecessary.
It’s not uncommon that services that are authorized are later denied. Thus, the provider has the patients sign Advanced Beneficiary Notice of noncoverage (ABN) stating that the patient may be responsible for the service if the insurance company later denies it. The patient is left confused asking how can the insurance company approve something and then deny it? Thus, leaving the patient not knowing whether to proceed with the treatment or not.
The insurance companies have contracts with the providers, yet it is the patient who is paying the premium. The contracts must be with the patient and the insurance company and the patient and the provider. The contracts between providers and insurance companies will be eliminated. This will allow competition between providers and will lower health care costs.
Patients will be able to access the insurance company’s website to procure authorization for services that are going to be rendered with the use of an eye scan, entering the provider’s name, location, date of service, ICD-10, CPT-4 and or HCPCS codes. The patient will have the ability to print out the authorization approval. The insurance company must honor that approval even if it is an error on their part. Deviations will be sent to the Health Care Conflict Resolution Unit for assessment and ruling. The first offense will be an educational session with the Health Care Conflict Resolution Unit and the insurance company. After that, the penalties will be harsh and not necessarily monetary. For example, the insurance company will not be able to require any authorizations for six months. There must be a public announcement about that fact. All their subscribers must be informed in writing of the times when no authorizations will be needed. Every doctor who has submitted claims to that insurance company must be notified in writing with a return receipt, so they don’t waste time getting authorizations for patients that don’t need one.
All insurance reimbursement will be posted on their website for all CPT-4 and HCPCS codes. All provider fees will be posted on their website. Accepting assignment is when a provider will accept the reimbursement from the insurance company as payment towards the provider’s bill and get paid directly from the insurance company. It does not mean that the provider cannot bill for services that are not covered or “medically unnecessary” which will not be allowed to be used as a reason for denying a claim.
Providers may participate in the essential health care plans for the insurance companies of their choosing. Participation means that the provider accepts the insurance payment as payment in full. For the optional services, participation is not an option. If the provider does not accept assignment, the patient pays the provider and the patient gets reimbursed by the insurance company. Accepting assignment means that the insurance reimbursement goes to the provider. It does not mean that the doctor is accepting the insurance company payment as payment in full along with the copay and coinsurance. This will cause competition and lower fees now that the patient who is paying the bill has a choice. It will also level out the reimbursement as patients will not select insurance carriers that cause their financial responsibility to be high with the providers that they see on a regular basis. Thus, the patient will know what their responsibility will be for services that are not part of the essential health care plan and covered. This will allow the patient to know the cost of the essential health service and their responsibility if they want to go to a provider who does not participate in the essential health care plan for that insurance company.
Reimbursement checks come without an explanation of benefits. The staff responsible for posting payments is unable to do so until they can locate the explanation of benefits.
Explanation of benefits must accompany the reimbursement. If the funds are by electronic funds transfer (EFT), it must be clearly stated on the EOB with the date of the transfer and the transfer number. The transfer may be before or on the same date as the EOB date but not after.
The timing for reimbursement is different based on which side of the fence you sit on. It is also different from one insurance company to the other. For instance, some insurance companies require providers to submit claims within 60 days of the service provided. However, the insurance company can go back years if they see they have paid an inappropriate amount to a provider. There are logistical reasons why claims are not submitted within 60 days. The insurance has been changed by the employer, but the insurance company hasn’t gotten the new identification cards or numbers to the members. By the time the patient gets the number to the provider who treated the patient in good faith, it is over the time limit. Then there is the patient who inadvertently gives the provider’s staff the wrong insurance card. The claim is submitted and denied. By the time the provider’s office staff get ahold of the patient who must find the right card and the claim gets submitted to the correct insurance company, once again the time limit has been exceeded. This is a very common scenario. Using eye scans instead of insurance cards will alleviate this problem.
There must be a single time frame for all insurance companies by which claims can be submitted and recoupment of payment is requested. This will resolve the logistical inefficiencies in the system. The recoupment period must not be longer than the period to submit a claim. Thus, if it is felt that one year is a reasonable time to recoup incorrectly paid claims, then providers should be able to submit claims up to a year after the treatment is rendered.
Cost
Regardless of the product or service, high quality for that product or service is expensive. Health care is no different. The cost of new medication is close to a billion dollars to bring one new medication to the market. It must be recovered by the manufacturer to stay in business and continue to develop new products. For hospitals to maintain full services 24/7, 365 days a year is expensive and even more difficult in less populated areas when it comes to staffing. It is impossible for a hospital or region to purchase the latest technology without the population that would support its use and at least allow them to break even on their investment.
The cost of going to any medical professional school is costly. Taking on large debt prevents them from qualifying for a mortgage for a home when they finish school. They have sacrificed the best years of their life so they can help others. Reimbursement must keep up with the cost of running a health care facility as well as paying the providers a reasonable fee so they can service their debt and live the American dream like everyone else has the right to do.
Whenever premiums are increased to cover the cost of the insurance industries expenses, the reimbursement rates to providers must go up by the same percentage. There is no exemption in health care for rising cost of supplies and wages. Therefore, to compensate for those increases, the reimbursement rates for providers must also go up by the same percentage.
There is no competition on any front of the American health care system13, 14.
(https://www.personalfinancelab.com/finance-knowledge/economics/benefits-of-competition/)
(https://theconversation.com/what-is-competition-and-why-is-it-so-important-for-prices-234082) This has been demonstrated as one of the reasons for the health care costs being so high. The reason there is no competition is multifaceted. First, the services that are provided are paid for by a third party that has no direct involvement with the treatment and controls the reimbursement. The patient who receives the services many times must go to someone in network, or they pay a higher copay or deductible. Since they have health care coverage, they feel entitled to get everything that is warranted for their problem. These issues lead to higher health care costs with no benefit.
Physician evaluations are posted all over the internet by multiple agencies. They are easy to access. The venues to evaluate an insurance companies’ services for the public to see are not as visible nor numerous to the public on social media. Thus, it makes it difficult for the public to see what insurance carrier fits their needs best, minimizing competition.
There is no competition among physicians because the insurance company dictates what they will pay and for what. Since there are no guarantees what is covered or what will be reimbursed, providers bill for everything. Many of these charges are things that were done for free when the provider was paid their fee at the time of service. Patients don’t care what the provider charges because most times they only pay a copay regardless of the fee charged.
Besides there not being competition for the fees for treatments rendered, there is no competition at the provider’s end to offer more convenient business hours or other amenities like modern office furniture and equipment or TTY services. Providers can’t distinguish themselves because the insurance carriers have segregated them. Nothing the provider does will allow him to treat a patient whose plan is not one of the networks that the physician participates in.
Competition needs to be at every level of the health care system to bring down prices and provide better care. Patients must make the decision on what provider they see. This will encourage the providers to be competitive in price and amenities. With networks eliminated, and providers deciding whether they will see the patient and accept assignment on an individual basis, the reimbursement rates will be
more realistic as the patients won’t be going to providers who do not accept assignment or who have fees that are excessive of what the insurance carrier will reimburse as the patient will be responsible for the balance in the optional services. This too will help align fees and reimbursement. A website will be required to be a health care provider and insurance carrier. With both providers and insurance companies having to post their fees or reimbursement on their website, patients will be able to be more selective who provides their care. This will help bring the costs down and minimize medical debt.
The same agencies that evaluate physicians must provide the ability to evaluate the services of insurance companies with the same visibility and ease of access.
The best health care outcomes are when the provider and the patient work together toward their common goal15. (https://europepmc.org/article/PMC/3934668)
Frequently, directions are not followed, appointments are not kept, and medications are not taken as prescribed. There are times when the provider cannot get authorization for what is needed to get the patient better in the most efficient way. These all lead to less-than-optimal outcomes and poor-quality health care.
The first step to addressing this issue is better education by the physicians. Everyone learns and understands differently. Patient education must be tailored to the patient’s ability. The simpler it is, the better. Having standardized videos that patients can watch on different disease entities, medications and complications, as well as surgical procedures and risks will make it easier for the providers when they must explain a complicated subject. This will lead to better compliance.
While some issues for noncompliance are understandable, such as not having the money to pay for the prescription, there must be consequences for noncompliance in the circumstances where the patient has control. For example, if they can’t make an appointment, they need to call and reschedule. Not showing and not canceling the appointment is not acceptable.
For those with diagnosed dementia or Alzheimer’s disease, those individuals will be transported by a caregiver. While the patient is not responsible for not showing or not canceling, they will still have to bear the consequences.
Noncompliance is associated with less than desirable outcomes. It is poor outcomes that frequently lead to malpractice cases. If an individual does not show for 2 encounters, they lose their ability to file for malpractice against that provider. While that does not stop them from filing for malpractice against another provider, the fact that they were noncompliant with another provider can be admissible in the case.
There is more than one way to treat an illness. Physicians are a product of their education, training and experience. The cost is not part of the picture in the educational process when providing the best care for that patient. They take what they have learned and apply it in practice. However, in practice, cost is important to both the patient and the insurance carrier. Residency programs must educate the residents on the costs for everything that they do and order including medications. This will then familiarize the physicians with the relative costs of care. So, when the doctor and patient are discussing care options, they will be able to consider cost in the equation.
Insurance companies will take the information they have obtained from processing claims and share it with those doing medical research on cost effective care. The results will be shared through journal articles and seminars for continuing medication education credits to help keep costs down.
Fraud is rampant in all sectors of the health care industry: physicians, insurance companies and patients16. (https://www.conroysimberg.com/blog/insurance-fraud-costs-the-u-s-308-billion-annually/) Presently the penalty if one is caught is not severe enough to deter individuals or businesses from committing the crime. This is money that should have been used to save people’s lives. It drives the cost of health care up and detracts from the quality of the care provided to the citizens of the United States.
The penalty for the conviction of fraud will be more stringent and defined. The penalty will be preset. The judge will not be able to negotiate a settlement to avoid going to trial once a claim is filed. The judge will not be able to bargain or reduce the sentence if found guilty. In the case where it is a provider, in addition to losing their license to practice, life in jail, they will be responsible for refunding everything they fraudulently stole. That may involve seizing all their assets.
If fraud is committed by an insurance company, the same rules apply to the company that apply to the provider in addition to the following. Besides life in jail time, the CEO, President or whatever title the insurance company calls their top executive, will be responsible for refunding all the money that was stolen along with the entire Board of Directors. The Board of Directors will get the same life-in-jail sentence as the CEO since they are the ones that set the direction of the company and are responsible for what happens inside the company. That insurance company’s license to sell insurance of any kind again in the United States is revoked forever at the end of the year that they were convicted of fraud.
Those who have no insurance will be subsidized by a health care surcharge on all goods and products sold in the United States. In return, they will do community service. They will all start at the minimum wage for the state that they are living in. They will work the number of hours that is equal to the cost of basic health care plan divided by the minimum wage. There will be a hierarchy for the use of community service starting with help the federal government may need in that area. Then, in descending order would be the municipal government, public schools at all levels, not for profit and nonprofits, hospitals and other health care facilities that are for profit, private schools and finally local businesses. The health care that is earned will be provided in the month following the required community service is performed. This is no different than those who pay for their health care at the beginning of the month before they receive it, not afterwards. It will be logged into the national system so any provider will be able to pull up the patient and assure that their health care is active for the time they are seeking treatment.
The homeless will be automatically enrolled in the military, also supported by the health care surcharge. Those who have substance use issues will be rehabilitated. Those who have psychological issues will get the help they need. The goal of this reform is to have a healthier, more socially engaged society with a moral compass. They will be categorized in the military according to their skill level. Those who have no job skill sets will be educated so when they leave the military, they can get a job and be contributing individuals in society. Once rehabilitated, they can serve in combat. There are many jobs such as cooking, cleaning, maintenance or driving where they don’t need to be in the same age bracket or physical condition as a soldier but can help in a combat zone.
Their term will end when they have the job skills to get back into the workforce, have been rehabilitated if needed, have saved enough money so they have a minimum of three months of living expenses for the area where they want to live, money to purchase a used vehicle, pay for its insurance, gas and repairs as well as buy food when they get out. Those with substance use issues will not be allowed to go back to the area they were from. They must be a minimum of one-thousand miles away. If they are found back in that area, they will be put back in the military without any defined time to leave. This is not meant to keep them from their families but rather away from the influences that keep them involved with the substance use. Their family will have to travel to see them. If they are ever picked up again for homelessness, then they are enlisted in the military forever.
New technology and medications take years before they are incorporated into best practices. There are two reasons for this. First, there is very little data to support their use for a particular diagnosis. Second, the cost is above other treatments or medications that can be used to treat the same diagnosis. The biomedical company or pharmaceutical company must be able to recover the money they invested in the product as well as make a profit so they can invest in the next new product. That is the only way the quality of health care can improve.
Once the new medication or product is approved by all the appropriate agencies that need to approve it, multiple centers nationally will use the new product or medication in double-blind studies. The studies will be supported by the insurance industry and the pharmaceutical industry donating their products to different sites. Residency programs that have residents with clinics in the specialty that the product or medication will be used in will be selected as the sites for research and data collection. For services that are provided by new technology where there is no CPT-4 code, the facility will be allowed to bill and be reimbursed with a temporary standardized CPT-4 code at the average rate for the current treatment codes for that diagnosis. In cases where there is nothing compatible with the new technology, then the process that the AMA uses to calculate RVU will be used to calculate a rate.
.
The cost of health care, whether it is an individual or group policy, is at the point where it is unsustainable. Increases in the last couple of years have been in double digits17, 18. (https://www.nber.org/digest/aug05/effects-rising-health-insurance-premiums)
(https://www.gao.gov/blog/health-insurance-costs-are-increasing-markets-become-more-concentrated-fewer-insurance-companies-interactive-map) Reimbursements to providers have gone down while the cost of doing business has gone up. The only way providers can stay open is by cutting back on services. This will not move us out of the last place quality health care in the world.
Whenever premiums are increased to cover the cost of the insurance industries expenses, the reimbursement rates to providers must go up by the same percentage. There is no exemption in health care for rising cost of supplies and wages. Therefore, to compensate for those increases, the reimbursement rates for providers must also go up by the same percentage.
References
1Gunja, M., Gumas, E. & Williams II, R. (2023), U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes. Global Perspective on U.S. Health Care | Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022
2Jindal, M., Chaiyachati, K., Fung, V., Manson, S., Mortensen, K. (2023), Eliminating health care inequities through strengthening access to care. Health Service Research. https://onlinelibrary.wiley.com/doi/epdf/10.1111/1475-6773.14202
3Kluwer, W. (2022), Five key barriers to healthcare access in the United States. Expert Insights. https://www.wolterskluwer.com/en/expert-insights/five-key-barriers-to-healtcare-acess-in-the-united-states
4Drake, R., Wallach, M. (2020), Employment is a critical mental health intervention. Epidemiology and Psychiatric Sciences 29, e178, 1-3. https://pmc.ncbi.nlm.nih.gov/articles/PMC7681163/pdf/S2045796020000906a.pdf
5Krauss, S., Orth, U. (2022), Work Experience and Self-Esteem Development: A Meta-Analysis of Longitudinal Studies. European Journal of Personality, Volume 36, Issue 6.
https://journals.sagepub.com/doi/10.1177/08902070211027142
6Higgins, Jr., D., (2025), Home page for National Coalition for Homeless Veterans. https://nchv.org/veteran-homelessness/
7Wilson, D., Gaynor, M. (1998), Physician networks and their implications for competition in health care markets. Health Economics, 1998 7:179-182. (https://www.smith.edu/sites/default/files/media/Faculty/Haas-Wilson_Physician-Networks-and-Their-Implications.pdf
8Carrumhealth. (2025), https://www.carrumhealth.com/blog/how-prior-authorization-hurts-patients/
9American Medical Association. (2023), The impact of Prior Authorizations on Patient Care, Quarter 3, 2023, Volume 28, Issue 3. https://www.hbma.org/rcmadvisor/quarter-3-2023-volume-28-issue-3/the-impact-of-prior-authorizations-on-patient-care
10Pollack, H. (2022), Necessity for and Limitations of Price Transparency in American Health Care. AMA Journal of Ethics, November 2022, Volume 24, Number 11: 1069-1074. https://journalofethics.ama-assn.org/sites/joedb/files/2022-10/pfor3-2211_0.pdf
11Zang, A., Prang, K., Devlin, N., Scott, A., Kelaher, M. (2020), The impact of price transparency on consumers and providers: A Scoping review. Science Direct, Volume 124, Issue 8, August 2020, 819-825. (https://rest.mars-prod.its.unimelb.edu.au/server/api/core/bitstreams/83742923-609f-525c-87a2-4dff82dabf4d/content)
12Wagenschieber, E., Blunck, D. (2024), Impact of reimbursement systems on patient care-a systematic review of systemic reviews. Health Economics Review, 2024 14:22. (https://link.springer.com/content/pdf/10.1186/s13561-024-00487-6.pdf)
13Smith, K. Benefits of Competition. Personal Finance Lab. https://www.personalfinancelab.com/finance-knowledge/economics/beneits-of-competition/.
14Blacklow, P. (2024), What is competition, and why is it so important for prices? https://theconversation.com/what-is-competition-and-why-is-it-so-important-for-prices-234082.
15Iuga, A., McGuire, M. (2014), Adherence and health care costs. Risk Management and Healthcare Policy 2014 Feb 20; 7:35-44. (https://europepmc.org/article/PMC/3934668)
16Simberg, Krevans, Abel, Kraft, Klein, Goldberg. (2023), Insurance Fraud Costs the U.S. $308 Billion Annually. Legal Alerts (/blog/category/legal-alerts/) March 17, 2023. (https://www.conroysimberg.com/blog/insurance-fraud-costs-the-u-s-308-billion-annually/)
17Davis, M. (2005), Effects of Rising Health Care Premiums. National Bureau of Economic Research, August 2005. ((https://www.nber.org/digest/aug05/effects-rising-health-insurance-premiums)
18Dicken, J. (2024), Health Insurance Costs Are Increasing As Markets Become More Concentrated with Fewer Insurance Companies. U.S. Government Accountability Office, December 5, 2024. ((https://www.gao.gov/blog/health-insurance-costs-are-increasing-markets-become-more-concentrated-fewer-insurance-companies-interactive-map
Appendix 1
Community Service Evaluation Form
Name: _____________________________________
Dates of Service: ____/____/____ to ____/____/____
Job description: _________________________________________________________
Location (including building, if appropriate, as well as the city and state:______________ ______________________________________________________________________
Individual is always on time or early. Yes___ No___
Individual meets the minimum requirements Yes___ No___
Individual follows directions Yes___ No___
Individual receives criticism well and works on improving Yes___ No___
Individual is a team player Yes___ No___
The individual’s strength is: _______________________________________________
The individual’s weakness is: ______________________________________________
Improvement can be made by:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
To move to the next level, the following tasks need to be accomplished:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Appendix 2
Insurance Company Name
Address
City, State, Zip
Phone Number
Fax
Website
Provider:
Address:
City State Zip
Rendering NPI: Billing NPI:
Remit
Account number: CVV: Expiration date:
Patient’s name: Patient’s date of birth:
Patient’s account #:
Date(s) of Procedure/ Units Billed Allowed Paid Co-pay Coinsurance Deductible Other insurance Comment
service: Modifier Amount Amount Amount paid codes
Patient’s name: Patient’s date of birth:
Patient’s account #:
Date(s) of Procedure/ Units Billed Allowed Paid Co-pay Coinsurance Deductible Other insurance Comment
service: Modifier Amount Amount Amount paid codes
_________________________________________________________________________________________________________________________________
Patient’s name: Patient’s date of birth:
Patient’s account #:
Date(s) of Procedure/ Units Billed Allowed Paid Co-pay Coinsurance Deductible Other insurance Comment
service: Modifier Amount Amount Amount paid codes
_________________________________________________________________________________________________________________________________
Comment Codes