This is a tale of 2 patients.  Same illness but widely different scenerios.  This is not unusual, but real life medicine in the U. S. today.

JOE SMITH

Joe Smith is a 70 year old man in generally good health.  His healthcare coverage is provided by Medicare, with supplemental coverage through AARP.

Joe woke up on a Tuesday morning with a searing pain in his left upper back.  He called his family physician and got a 9am appointment.  Dr. Jones suspects that Joe is having an acute attack of kidney stones and orders some lab work.  Joe walks down the hall to the office lab and returns to Dr. Jones who informs him that lab work shows evidence of kidney stones.  Dr. Jones orders an abdomen and pelvis CT scan to get a definitive diagnosis. The CT scan will survey the entire urinary tract, from top of the kidneys to the bottom of the bladder.  Stones can be found in any area of the urinary tract.

 Joe takes the order form to the nearby radiology facility, where the CT is performed.  Within 20 minutes, Dr. Jones has the report which demonstrates a stone in the ureter just before it connects with the bladder.  Dr. Jones prescribes a painkiller and a treatment plan to solve Joe's stone problem.  Joe and his kidney stone part ways on Wednesday afternooon and Joe feels great.

Dr. Jones and the radiology facility file Joe's claim on his behalf with Medicare.  Within 2 weeks, Medicare sends the reimbursement to each of their offices via Electronic Fund transfer.  The co-pay and deductible due are filed on Joe's behalf by the doctors office and radiology facility with AARP.  That claim is paid within 2 weeks.  Case Closed and Joe paid a total of $15.00 for the prescription co-pay.

BOB ROGERS

Bob is a  35 year old man in great health.  He hasn't been sick in years.  Bob has a good job with what he believes is excellent health insurance coverage provided through his job.  His insurance company is ANTEA.

Bob woke up on a Tuesday morning with a searing pain in his left upper back.  He called his family physician and got a 9:30 am appointment.  Dr. Jones suspects that Bob is having an acute attack of kidney stones and orders some lab work.

Because ANTEA has an exclusive contract with XYZ Labs, Bob cannot get his lab work done in Dr. Jones office.  He has to drive to XYZ lab to get his blood drawn and pee in a cup.

Three hours later, Dr. Jones get the lab results and determines that a CT scan of the abdomen and pelvis is needed to look at the entire urinary system for a definitive diagnosis of kidney stones.

Because ANTEA requires pre-authorization for CT scans, Dr. Jones gives the CT order to a clerk that he had to hire to obtain  authorizations for various insurance plans.  He also has to dictate and print his notes on Bob so ANTEA will approve the CT order.  This delays the next patient's appointment.

The clerk sends the notes and order to ANTEA for approval.  It usually takes 24-48 hours for the actuary (not a medical person) to approve the request. 

Bob waits at home, but is glad that Dr. Jones prescribed a painkiller for him.  The pain is really like child labor as he has heard it compared to by friends that have had the misfortune to be afflicted by a kidney stone.

On Thursday morning ANTEA approves the request for CT, but only for the abdomen, not the pelvis.  This will leave 50% of the urinary tract unscanned.  Dr. Jones is furious.  He calls ANTEA and demands that the pelvis be scanned also.  After 3 phone transfers and 30 minutes, Dr. Jones finally gets to talk with a medical person who agrees that it is stupid to leave 50% of the urinary tract unexamined when looking for urinary stones.  Dr. Jones tells Bob to go the the nearest radiology facility to get his scan done. 

Bob calls the radiology facility 2 miles from his house for an appointment.  Sorry, they say.  ANTEA will not contract with us, but the radiology facility 20 miles from his house might.  He calls that facility and gets an appointment.  The radiology facility has to call Dr. Jones' office to get the ANTEA authorization number.

Finally on Friday, Bob gets his scan.  Sure enough, he has a stone in the lower ureter.  Dr. Jones prescribes that same treatment that worked for Joe and by Saturday night Bob is feeling better.  Bob has missed 4 days of work and wasn't very perky at his daughters 10th birthday party Friday night.

Dr. Jones and the radiology facility file Bob's claim on his behalf with ANTEA.  After 3 weeks, ANTEA sends an Explanation of Benefits to the radiology facility.  The claim is denied because no authorization was obtained they say, even though the authorization number was provided to them on the claim form.  The billing clerk calls ANTEA, who tells her that "yeah, we have a system glitch.  Resubmit the claim."  The claim is reworked and resubmitted and 6 weeks after Bob was scanned, the radiology facility is paid 80% of the claim.  The rest is Bob's responsibility. Bob sends the remaining amount due. Finally, a full 9 weeks after Bob was scanned the radiology facility can close their books on his case.

Bob wrote a check to the pharmacy for $15.00.  He wrote a check to the lab for $25.00 (co-pay/deductible).  He wrote a check to Dr. Jones for $30.00 (co-pay/deductible).  He wrote a check to the radiology facility for $70.00 (co-pay/deductible).

Joe pays a Medicare Part B premium of $96.40 per month. Joe pays AARP $120.00/month for the supplemental coverage.  Joe does not have deductibles.

Bob's employer pays $185/month for his insurance and Bob pays $50.00/month for his portion due. Bob has a $800 deductible and $10 copay for doctor visits.  He pays $25.00 for specialist co-pays and $100 for emergency room visits. 

So, explain to me how Medicare (single payor) is a bad thing? Explain to me how a government plan will make getting care more difficult.  Explain how the "free market" is the best way to provide health care.