Mini-Med #1 2017-Navigating the Healthcare System

Mini-Medical School #1 2017

Navigating the Health Care System with Stephanie Taylor MD PhD

Introduction: The basis of integrative health is the harmonious union of mind, body and spirit. An additional essential component is the health of the environment and of our socio-political system. We are in a time of rapid evolution, and it is in our best interest to understand these processes in depth and to act for positive outcomes. Medicine is no exception, and this Mini-Medical School provides basic tools for understanding healthcare USA.

Providers:

Physicians– Degree is M.D or D.O., and they are the only provider that can use the designation “Physician”. Four years of Medical School after College. Average debt from medical school alone is $170,000. In order to enter private practice, a residency is mandatory. Duration of this apprenticeship is 3-8 years depending on specialization and pay is $50-60,000/year for a 100-140 hour work week. Specialty board examinations are required, and maintenance is mandatory. Physician salaries are proportional to specialty. The ability to perform procedures dramatically increases income. Average duration of office visits is 15-20 minutes.

Naturopathic Doctors-Degree is N.D. Usually four years of Naturopathic School after four years of college. No residency required to practice. Bastyr (Seattle) is the best followed by Southwest College (Tempe, Ariz) and The National College of Naturopathic Medicine in Portland. Licensing varies by state.

Nurse Practitioner-Degree is R.N., N.P. and requires 4 years of nursing school (after high school), and 1-3 year Masters level training. They function semi-independently.

Physician’s Assistant-Degree is P.A. and certification usually requires 2 years after a four year college. PA’s require direct physician supervision, physically or by electronic communication.

Midwife-Certified Nurse Midwives (CNM) are registered nurses who have taken additional training. They are regulated by the California Board of Registered Nurses. Certified professional midwives/licensed midwives complete a three year post-secondary program in an approved midwifery school and pass the licensing exam. Licensed midwives are regulated by the Medical Board of California.

Payers:

Insurance-Persons under age 65 are usually insured through their employer. The rest are in the “individual” insurance market. State supported insurance in California is called MediCal. At 65, citizens who have qualifying earnings may have Medicare. Thirty million remain uninsured.

The cost of your premium is not everything: Your cost out of pocket depends on your deductible, formulary and covered benefits.

Medicare– It is not as complex as it appears:

Part A- Hospitalization. Funded primarily by payroll taxes

Part B-Doctor’s fees and visits. Funded by general revenues and premiums.

Part C- Medicare Advantage (combines A, B and D)

Part D- Drug Plan. Funded by general revenues and premiums.

Supplemental-Covers to 20% that Medicare does not pay.

Medicare is more financially stable since the passage of the Affordable Care Act (ACA/Obamacare), and is currently solvent until 2028. Repealing the ACA would increase Medicare spending by $802 billion over 10 years. People over 80 account for most of the spending. Prescription drug coverage is projected to grow faster than any other cost segment.

Formulary– A list of drugs covered by your plan. Your cost depends on the Tier of the drug, usually 1-5. This changes annually. You are mailed a copy annually and it is vital that you keep this accessible for reference as your needs change. Your doctor does not have access to your formulary.

The Explanation of Benefits (EOB) is an important report generated when you have a billed medical expense and you must understand and save the form or be able to access it on line. Here is an example:

Claim date and provider

Billed Amount

Allowed Amount

Non-Allowed Amount

Applied to Deductible

Paid Amount

Remark Code

11/11/2016

LabCorp

300.00

100.00

200.0

50.00

230

Changes to Healthcare considered: The Affordable Care Act instituted many positive and popular reforms: Children on parents insurance until 26, no exclusion for prior conditions, no retroactive cancellations, subsidies for low income, increased coverage for preventive services, contraceptive and maternity coverage. There are also effects on Medicare, specifically closing the Doughnut hole. There are over a hundred subprograms of the ACA and any changes will affect the entire structure. An excellent summary of the current ACA and the Ryan and Price plans are available at the Kaiser Family Foundation Site.

Summary of the ACA:

http://kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act/

Summary of the Speaker Ryan Proposal:

http://kff.org/report-section/proposals-to-replace-the-affordable-care-act-speaker-paul-ryan/

Summary of Rep. Price Proposal:

http://kff.org/report-section/proposals-to-replace-the-affordable-care-act-rep-tom-price/

Summary of Medicare Financial Outlook:

http://kff.org/medicare/issue-brief/10-essential-facts-about-medicares-financial-outlook

AARP Action Plan for Medicare:http://www.aarp.org/politics-society/advocacy/info-2016/why-medicare-matters-special-report.html

During our discussion, the rising cost of health care attributable to administrative fees was identified as a key concern. Corporations are required to articulate a primary duty to their shareholders to maximize financial return on investment. A suggestion was made to require insurance companies to be structured as B Corporations. In California, B Corps received legal status in 2012. Rather than shareholder profit, the B Corp primary duty is to create general public benefit. Further information can be found at:

https://www.bcorporation.net/what-are-b-corps

“Change will not come if we wait for some other person or some other time. We are the ones we have been waiting for. We are the change that we seek.”

-President Barack Obama

Contacting your Representative and Senator:

Rep. Jimmy Panetta

228 Cannon House Office Building

Washington, D.C. 20515

Phone 202-225-2861

https://panetta.house.gov

Senator Dianne Feinstein

331 Hart Senate Office Building

Washington, D.C. 20510