Wednesday, July 04, 2007

Sicko, the rest of the world, San Francisco

Sicko, apparently, is doing pretty well at "the box office" so far. I read this past week that the Weinstein Company is going to give it a very slow, gradual release. Their notion is that if it sticks around long enough the national sentiment will catch up with it.

I though Sicko was pretty great. Like every other Michael Moore effort, it has a mix of astute, relevant points as well as some inexplicable rhetorical shortcomings. Here, his most ingenious idea is to focus the movie not on uninsured people, but on people with insurance; the people who you don't expect to have a stake in the notion of universal health care. The movie's point is that these are also people for whom their insurance coverage is more nominal than practical.

The latter half of the film is an extended comparison between the best-case-scenarios of other countries with American worst-case-scenarios. The differences are vast, though it might be that this is supposed to be a surprise to us: that the poorest people of the richest country are worse off than the middle classes of poorer countries.

Kurt pointed out that these international anecdotes are not presented as endorsements any particular national health system, but rather as a rebuke to commonly cited arguments against an American one (that it's necessarily more expensive, that it will slow service delivery, that it will punish doctors, etc). This is reasonable enough (it's a movie after all, not a conference paper) but it seems like he'd both score an extra rhetorical point and blunt his critics if he just acknowledged, for instance, that Fidel Castro may have this health care thing right, but he's also a repressive dictator (or, Fidel Castro may be a repressive dictator, but he does have this health care thing right).

A comprehensive documentary on the subject of the failings of the American health system would be Shoah-like its proportions. Still, a nice complement to all the stories of how insurance companies fuck over their policy holders would have been a segment on how insurance companies also fuck over their network doctors. My theory is that for every individual who swears there's nothing wrong with their health coverage, there's a doctor's office that spends huge amounts of staff time and money making the insurance company look good to that individual.

The doctor's office I worked for was in-network for dozens of insurance plans. They also employed at least two full-time "billers," people whose only job was to deal with insurance billing, denials, and appeals (they often worked overtime). The daily bullshit of verifying coverage, verifying billing addresses, Blue Cross Blue Shield of Texas had dozens of them, getting pre-authorization was left to receptionists with extra time. (Anyone who thinks a state-sponsored health plan is bound to overly bureaucratic and would micromanage the doctor-patient relationship should spend some time listening in on these phone calls.)

It was practically a novelty when an insurance company would reimburse a claim on the first try. They more often rejected claims, and they looked for reasons to do so. The patient, procedure, and billing codes might all be exactly right, but you could be rejected for, for instance, spelling cholesterol wrong. I can't speak to intention, but my guess is that they know that a certain number of rejected claims will not be appealed, or corrected and re-submitted. If the claim is not re-submitted, or is rejected again, the doctor's office will either absorb the loss, or bill the patient.

In my anecdotal experience, it's safe to presume a patient, or a patient's employer, pays into an insurance plan in good faith (i.e., they pay their premiums on time). I can also presume a doctor's office bills the insurance company in good faith (i.e., that they never having defrauded an insurance company). There's no reciprocal good faith on the part of the insurance company. Every claim, every office, is treated as suspect; the goal is, apparently, to pay for as few of them as possible.

In Public Affairs school there was a saying, "perfect is the enemy of good" (meaning, there not find a single solution for all problems). I'm sure that France, Canada, England and Cuba all have problems in their national health care services. But what we have right now is a total fucking disaster (except for San Francisco, which is now rolling out a universal health care program to cover its residents).

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