Saturday, October 16, 2010

The Healthcare and Health Care Systems: What are the Rules?

How can we know the rules for the patient-physician engagement?  It's very confusing to patients and even to doctors.  What would the rules be if we get a chance to make them again?

Since that's not the case, I'll list a few thoughts about how the rules look for one family physician in Ohio (Me). 

One issue that relates to the rules is about the business model of the patient and their family. What do you spend your money on and what do you expect someone else to buy for you under various contractual relationships? 
Another issue is the business model of the third party that is paying someone else's money to the doctor for services rendered to the patient...but limited by several rules (only 4 diagnoses fit on the bill per visit; a physical involves no treatment for illness or disease; an illness or disease mgmt visit is not a physical or prevention but some insurances allow the physician to do both types of services in the same encounter, but both services will be billed ala WarmSocks blog example.  The physician only has a certain amount of bits of service to deliver per day, so one patient can't decide to use it all or no one else gets any service...etc.).

Another issue is the physician's business model, who they work for and what happens to the bills they generate and the money they generate and who pays their overhead, etc. The physician's tasks per unit of time may be mandated by the employer of the physician. They may be pressed to see more and more people per day to generate more revenue for the employer or group.

The physician is selling knowledge and skills to someone. Those who wish the physician to use more knowledge and skills for their health and sickness will be asked to find a way to pay more.  Time is limited and determined by the physician or the entity (e.g., physician's employer) that makes the rules about how money is distributed for services.

Most third parties only pay for one visit to an individual physician per patient per day.  A woman being seen for an annual woman's prevention exam generally needs another appointment or two or three if she has a problem with arthritis, diabetes, depression, needs a mole removed, etc.
The patient rarely knows the definitions listed in their payment contract with an insurance company for different types of services.  The physician also doesn't know what deal an insurance company has with a particular patient.

That's my first post about "the rules" of engagement in the family doctor's office.  It may change daily due to the volatility of "the rules".  The situation begs for the patient to take back their health care from the night.  Partner with your family physician to educate and protect each other from the buzz saw known as the Medical Industrial Complex. 

More later on health system issues after a couple posts about The Human Centered Health Home.


  1. Excellent!

    ...a physical involves no treatment for illness or disease
    I had no idea this was the case. None of my friends who I've talked with knew this, either.

    Thank you for writing this. When patients know the rules, we can avoid inadvertently breaking them.

  2. A patient and physician may mutually agree that an addendum for treating illness or disease may be added on top of the physical. This is a separate charge from the physical, which is not well reimbursed by insurance companies since it doesn't include any money to treat anything. It didn't used to be this way. Onward in the quest for the rules of health care.