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July 1st, 2009
02:13 PM ET

Will reform stop people from working the system?

By Caleb Hellerman
CNN Medical Senior Producer

Tuesday afternoon, I was hanging out in Harlem, working on a story we’ll be running later this month. A few blocks away, the barricades were up and police were directing traffic around the Michael Jackson tribute at the Apollo Theater.

Donald Childs, a bicycle repairman, was holding court on the north side of Marcus Garvey Park. Looks like Jackson was working the system, he told me, finding doctors all too willing to give him whatever he asked: “Yes-man health care.”

People in poor neighborhoods work the system, too, Childs said. “You go to a clinic and wait for hours to be see anyone. Poor people, people around here, just expect that. It’s the norm. [But] they know what to do if you really need a doctor. You go to the emergency room and you tell ‘em it’s asthma, or a heart problem."

“My wife has pancreatic cancer,” Childs confided. “But when she goes to the emergency room, and she needs to be seen right away, she tells them it’s her heart.” It was painful to hear, but sad to say, not surprising. I’ve talked to a lot of people who struggle to find decent care for cancer.

A few yards away, I heard more about gaming the system. “There’s a dentist’s office at ____; they’re paying homeless people $10 for their Medicaid number,” Heidi Flores was saying. “There’s another one pays $15.” [With a Medicaid number, a doctor or dentist can file claims for reimbursement – in this case, presumably, for nonexistent services.] Her friend, George Cabassa, chimed in. “There’s another one where they give you a cleaning but they tell Medicaid they did everything and the kitchen sink.” He told me to check it out, handed me a phone number and strolled off.

No surprise here, the health care system we have is maddeningly complex. It’s full of rules, full of odd financial arrangements and full of loopholes.

Monday evening, I found myself relaxing in the office of the Rev. Dr. Joe Bush at Walker Memorial Church in the South Bronx, listening as he argued that we need something simpler: a government-run health system like the ones in Canada or Western Europe. The air conditioning felt good with the sidewalk still sweltering outside, but the pastor was getting agitated.

“The first thing they ask when you step up to the counter: ‘Where’s your card?’ It’s all about the almighty dollar.”

I asked about his own health coverage and learned something new: According to Bush, insurance companies consider pastoral work to be a high-risk profession – high-stress, with associated health problems. To cover himself and his wife, Bush pays $27,000 a year for a policy with a $2,000 deductible.

When I asked what he thinks of the argument that a “public option,” or government-run insurance plan, might drive private companies out of business, his answer came as no surprise: “That would be a wonderful thing,” he said, a smile lighting up his face. “It would be the best thing that could happen to America.”

That might be a dramatic point of view, but riding home on the plane I found myself wondering if a government-run system would make a cancer patient lie about a heart condition, just to get a doctor to take her condition seriously.

Did you ever lie or shade the truth, talking to a doctor, hospital or health insurer?

Editor's Note: Medical news is a popular but sensitive subject rooted in science. We receive many comments on this blog each day; not all are posted. Our hope is that much will be learned from the sharing of useful information and personal experiences based on the medical and health topics of the blog. We encourage you to focus your comments on those medical and health topics and we appreciate your input. Thank you for your participation.


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soundoff (10 Responses)
  1. Silvia MIrabella

    Great article.. our system is such a mess. Personally I don't know the answer. I do know that many people are not getting treatment or medicine they need. Yet we worry about sending medicine to other countries. I've recently become finanally devestated. I need medicine or I suffer terrible migranes. The medicine I need costs 300+ with out insurance and when I had insurance it was 200+ until I met the deductible they say they have pharmacies that help.. not true. Something needs to be done.. But what.. With all this bailout on Wall Street.. which did not jump start the economy.. what do we do.
    If the idiots in government would sometimes use a simple basic strategy to fix things maybe just maybe things would get better.

    July 2, 2009 at 10:23 | Report abuse | Reply
  2. Frustrating

    Healthcare is not a right. It sickens me to work the hours I do, and pay taxes over 30% while people are 'working the system' so they don't have to do a thing, and can go through life for free. We need to stop forcing hospitals to provide free care. Let patients pay out of pocket for basic services. Once people realize they aren't getting handouts, they'll be more motivated to work to survive. If their health isn't worth them doing something about it, then don't dump their problems on me. When they see loved ones dying because they didn't bother being productive citizens, then their attitudes will change. Heck, we patch up gang members who have been shot so they can go out and be shot again. It's insane.

    July 2, 2009 at 12:07 | Report abuse | Reply
  3. John Hampton

    I haven't ever had really bad health problems (so far, knock wood!), and am 50 years old. I don't eat a lot of meat, eat "just a little" junk food, but mostly subsist on a diet of cheap food like beans and rice, corn and cereal products, and milk. My worst vices are: I smoke, about 1.5 packs a day (determined to quit this year!) and I drink at least 1 pot of coffee per day. I walk almost every day, at least a half mile or more, and get out to the golf driving range, and the 9 hole course when I can afford to. I don't use acetaminophen products, opting for plain old aspirin instead. I am Caucasian and was raised in rural America.
    I had an occasion to have to go to the Emergency Room about 2 years ago for an upper respiratory infection (probably due to smoking). This is where MY burden upon the health care system comes in, and where a general public option would help. I am able to go to the U.K. Medical Center for emergency treatment, whether I can pay or not. The University receives Federal funding so they cannot turn anyone away. I still get a bill every month, and try to pay what I can, when I can, so that other people can also be provided with medical care, and just to have a clear conscience. I have been unemployed for 9 months from the printing industry and have had no Health Insurance coverage for over 10 years. I am sure my "loophole" for getting health care makes it more expensive for the taxpayer, and would love to have some other option so I wouldn't feel like a "drain upon the system". Hopefully starting school in August and getting education for a different job will also help. Both of these possibilities wouldn't be possible without the legislation that President Obama has helped push through. I remain hopeful for us all.

    July 5, 2009 at 08:33 | Report abuse | Reply
  4. somewhere in the universe

    no but i wish i had. i'd gone to a clinic and got blood work done, just to be "responsible". came back i had elevate cholesterol levels. six months later i was offered insurance at owrk, i told them about my blood work, as a result the insurance compay refused to even pay for a blood check of my cholesterol much less pay for statins. within 4 months of that, i lost my insurance i think for having depression (went to shrink, they refused to pay, so i don't understand why they would have cancelled over a treatment they didn't even put out for.) .

    i don't know but suspect my employer figgured if i didn't have insurance, why would they need to keep my hours up, so i had my hours cut in half. joy! if ever i get ofered insurance again, i'll lie through my teeth and that' a 100%% guarantee.

    July 7, 2009 at 03:08 | Report abuse | Reply
  5. nug

    A couple family members have health issues and must see docs regularly, they complain constantly re the care they recieve. Doc's don't take them seriously, won't prescribe treatments or meds, the attitude seems to be if we ignore it, it will go away, or better yet the patient will go away.

    I pay out of pocket for my own health care because I don not want to be treated badly. Luckily for me I'm healthy. Should I ever become seriously sick I would just be up the creek.

    July 8, 2009 at 12:31 | Report abuse | Reply
  6. wesrch

    A broader, more efficient model of healthcare, based upon understanding, diagnosing and treating disease at the earliest possible point in time. Healthcare trends are moving towards the patient for increased responsibility and power, toward prediction, clinical convergence, and productivity and information driven. The healthcare dilemma is challenging the ability to deliver better outcomes and patient care. There is a need for a fundamental change. There was a great report posted at http://www.wesrch.com title 'Healthcare Re-imagined', it focuses on challenging the ability to deliver better outcomes and patient care. Here is the direct link fot those who are interested in reading more. (http://medical.wesrch.com/pdfME1MS1000ABTI)

    July 8, 2009 at 13:57 | Report abuse | Reply
  7. Mike

    Health Care (HC) and Health Care Financing (HCF) should be and will be reformed in the near future. This is necessary since our current systems cannot be sustained because of their existing costs and inevitable trends of inflation. Before we act however, we should consider the wisdom of the ages offered above.

    On Saturday February 22, 1997 I lay on a gurney in the Emergency Room at Our Lady of the Lake Hospital in the process of a heart attack. My blood pressure was 180 / 120 and my pulse rate was over 100. I was scared, angry, frustrated, and anxious – I thought I was going to die. My emotions were working overtime and my “rational side” was on vacation. Finally Dr. Carl Luikart held my hand, looked into my eyes, touched my soul and said, “Mike, you’re not going to die.”

    Reason returned. He and I agreed on a process that would fix the immediate problem and than agreed on life changes – new responsibilities necessary to sustain the fix. It worked – 12 years later I’m healthier at 61 than I was at 49.

    As I listen to all sides of the HC and HCF debate “rage” on about what’s wrong and what must be done – I hear “scared, angry, frustrated, and anxious.” That’s the bad news – the good news is that the “near death experience” of these systems provides us a once in a lifetime chance to change behavior. All stakeholders are motivated to “stay alive.” Now let’s assure that the changes needed work and “stick.”

    As background understand that Health Care is the delivery of medicine and Health Care Financing is the funding of this medicine. The government is already the dominant force in the system. Also understand that when we speak of the consumers of HC – we must consider the needs of the patients (users), the tax and premium payers (funders), and the providers (doctors, hospitals, etc.) of this care.

    The Government is a Health Care Financer through the Medicare and Medicaid systems. Both are acknowledged to soon be bankrupt. The Government is a direct provider of care through the VA system – which though well intentioned has been shown to be very ineffective in the care provided and the number of Vets served. As an aside – Social Security is another system where Uncle Sugar provides the service – it too is known to be headed into bankruptcy. These systems are not role models.

    The one true success story in Government provided health care and its financing is The Federal Employees Health Benefit Program (FEHBP). The secret to this success is that they “outsource” the service to private sector insurance companies.

    As “we the people” consider reform – let’s take a deep breath – know we’re not going to die and understand that all stakeholders must change our lifestyles in order to assure a healthy future for ourselves and our progeny. Before we add another “public” plan – to the “trifecta of failure” that are government run systems – let’s measure twice and cut once, look before we leap, and earn a penny by saving one.

    July 11, 2009 at 07:47 | Report abuse | Reply
  8. conrad cropsey

    I don't think this – stopping people from milking of the system – is the correct question. That is an effect caused by two situations we confront – at one end doctors trying to make a profit when there is high overhead, and, at the other end, prices reflecting the fact that insures compete to sign up doctors, hospitals, and drug companies who control supply. In the first situation when prices can not be marked up, you find fraud and terrible service or miscoding, In the second situation you find price gouging.

    Both problems can be addressed by increasing supply of lower cost/overhead service alternatives. Prices drop when supply increases. Overhead goes down when providers margins are increased by cost cutting.

    Quick examples of partial solutions are:

    1) require nurse practitioner’s offices at hospitals in order to divert non emergency cases from the more costly emergency room. That could also decease emergency room staffing requirements;
    2)establish a national health data base which would obviate the need to have nurses take, and retake, and retake health information. This could also avoid repeat testing. It would also cut doctors office costs and the time required by multiple reporting and software systems;
    3) grant pharmacists very limited dispensing authority;
    4) centralize re-publication of effectiveness studies;
    5) consider allowing US based drug companies to source their product from overseas if they guarantee and insure quality. If permitted, require foreign drug manufactures to either produce here or pay for our inspectors to be placed in their plants to ensure our production standards are met.

    July 17, 2009 at 13:58 | Report abuse | Reply
  9. John Letourneau

    I consider myself a fiscal conservative, and believe the government should allow private enterprises to operate with minimal oversight.

    I understand the need for government to regulate the market place to keep the playing field level. Exploitation of gaps allow dishonest people to profit at the peril of free enterprise, without breaking laws, and thus evade justice, be it legal or moral.

    I make the above statement because my next argument will be seen as a departure from this view.

    The cost of health care in the United States will never be reigned in until profit is removed from the system. Insurance companies make a great deal of money simply by documenting procedures, and redistributing money taken in by premiums and paying institutions and doctors for services rendered. The drive for profit forces insurance companies to pay out as little as possible. Note that those persons without coverage pay a higher cost than insurance companies, because insurers negotiate with institutions from a much stronger position. The total cost to individuals and industry is staggering with government paying additional costs. Insurance companies can exist as non-profit entities and still employ many people at good livable wages. Companies can then focus on other insurance products to make profit under a publicly traded company, separate from health care.

    Drug companies also have a hand in public health, however due to their international reach can not be held to a non-profit standing. The United States bargaining as the sole purchaser of medication could have a tremendous effect on costs; we are a huge customer of pharmaceuticals.

    Why is it considered anti-American put the health and welfare of our citizens 2nd to the profit of an industry? Should it not be enough for us to do the right thing as human beings? I believe in the long run society will enjoy a much higher standard of living and yes, more profit, if we allowed people freedom from this crushing problem. As a small business owner trying to make a profit myself, I can not supply health care to my employees. I know auto industry executives would agree this puts them at a big disadvantage to compete globally.

    People smarter than me are working on this problem; I have to believe some Republican leaders must see that the potential for profitable businesses without the anchor of health care would be a positive step for the United States.

    July 19, 2009 at 13:58 | Report abuse | Reply
  10. Female Geek

    In response to John Letourneau's post ... the question is: should healthcare be a privilege or a right?

    With the present health care system, we have a re-distribution of wealth via insurance companies. However, if your take profit away, I believe insurance companies will vanish. You see, there is 'hidden profit' within the industry: bonuses, perks, etc.

    Meanwhile, the 'good' doctor must rummage through a quagmire of paperwork instead of treating the patient. A friend of mine is a physician and spends 25% of her day shuffling paper. My R.N. friend spends 50% of his day with paperwork. Meanwhile, the patient lapses into a coma.

    About 20-years ago, I read YOUR DOCTOR IS NOT IN by Jane Orient, M.D. As a physician, she documents the pending problem eloquently. She was correct; the dilemma has ensued. However, I will disagree with her hypothesis of health care being a privilege.

    Reform will NOT change America's Health Care System; sick people will always find a way to manipulate the system. I have friends without insurance who simply go to a doctor, use a fake name, social security number, etc. and receive free medical treatment. America's present health model is antiquated.

    In 1862, health care, though limited, was somewhat of a right. Doctors were charitable; some still are. Pioneer physicians would treat a patient regardless of financial capability. All this has changed; society has changed. With change, adjustments must be made. National Health Care is the only viable option.

    July 22, 2009 at 14:09 | Report abuse | Reply

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