What you MUST know about health insurance is that it cannot "work."  It is a concept which, inherently, can only fail.  I wrote about this many years ago.  It is one of the fundamental flaws of current society -- to think that the concept of "health insurance" can work.  (more below)

Health insurance "works" only because the healthy pay more into the system, get less, and the sick pay less into the system and get more.  At some point the healthy will see this and rebel.  Also, politicians will always vote to increase coverage.  Health care is moving toward as much as 16% of our gross domestic product. This cannot continue.  In theory it is impossible.  In practice we can probably go a bit higher, but soon the theory will bump practicality on its head.

[Image]National health expenditures are projected to total $2.6 trillion and reach 15.9 percent of Gross Domestic Product (GDP) by 2010, after having declined from 13.4 percent in 1993 to 13.0 percent in 1999. In 2008, health spending is projected to total $2.3 trillion or 15.5 percent of GDP, compared to our previous projection exercise in 1999, which forecast expenditures for 2008 of $2.2 trillion, or 16.2 percent of GDP. Since the 1999 projection, historical GDP estimates were revised upwards. In this projection, health spending as a percent of GDP increases over the projection period due to faster health spending growth and slightly slower GDP growth, relative to the most recent historical period. 

The Wall Street JournalAn article in the Wall Street Journal in March 2003, should mark the death-knell of at least the present form of government endorsed "health insurance," which relies on so-called private health insurance.

The hospital where Ms. Nix was treated, New York Methodist in Brooklyn, typically bills HMOs about $2,500 for an appendectomy with a two-day stay, compared with the $14,000 -- plus doctors' fees -- that Ms. Nix was billed. The hospital gets paid about $5,000 from Medicaid, the state and federal health program for the poor, and about $7,800 from Medicare, the federal program for the elderly, for the same procedure.

"Why does a single person get stuck with the whole bill?" Ms. Nix asks. "An uninsured person would have a lot less money than those government agencies or insurance companies."


Ms. Nix stumbled onto a troubling fact of health-care economics: Most major U.S. hospitals are required to set official "charges" for their services, but then agree to discount or even ignore those charges when getting paid by big institutions such as insurance companies or the government. As a result, almost no one but uninsured individuals ever faces the official charges. In some ways, hospital charges are like automobile "list prices" or hotel "rack rates" -- posted prices that everybody knows nobody pays. But in the case of hospitals, the pricing disparity isn't publicly known and falls most heavily on the vulnerable. America's 41 million people without health insurance tend to be young, working-class and unaware that they are being billed more than everyone else for the same services.

At the same time, charges at virtually all hospitals have soared in recent years. That's partly due to the rising costs of new procedures and drugs. Also, deregulation of the hospital industry removed limits on charges in almost all states. But some hospitals say they are raising charges to offset what they view as overly harsh reductions in their reimbursements by HMOs, insurers and the government. That would mean hospitals are effectively subsidizing their lower income from patients who are insured or have a government safety-net by boosting fees paid by the uninsured.  (source)

Very few people today can completely self-finance their own health care.  If you have health insurance, yourself, and if you are a part of society which greatly values health insurance, you generally have to "live within" the system.

For more than 70 years of my life, while raising six children, I have never had private health insurance.  I had health insurance for any part of that time when I or my wife was an employee of some group that provided health insurance, but I have never paid for any personally.   Only after writing this page did I see how my own attitude could have slid me into the same category as Ms. Nix, above.  It was not luck that I have had good health, but had I had some terrible health problem, with no insurance, I probably would have had the same type of free service as she got -- big service, big bill, and bankruptcy.

Jean Ross Friend Of Goodwill

Jean Ross, my wife, and I, have health insurance NOW, but only because we are 65 or older and Medicare is automatic.  Even though I strongly disagree with the concept of Medicare, I don't think it is wrong to take advantage of it being available to me.

So, I signed my Medicare money over to an HMO --  Secure Horizons.  You understand?  At my age, currently almost 72, the government is ready to pay about $600 per month to some HMO for health insurance for me.  You can "stay" on Medicare by itself, if you wish. I have done that before, or you can "sign over" your Medicare rights and money to an HMO. They get the money and promise to pay you various benefits.

PacifiCare, which runs Secure Horizons, the largest Medicare HMO in the country, announced premium increases for its HMO members for 2001. In some cases premium increases will be quite significant. The company pointed out that this will vary widely from area to area, depending on the level of reimbursement the company gets from the federal government, which is different in each county. For instance, they said that in Los Angeles County beneficiaries will pay no monthly premium other than the regular Medicare Part B premium, and the copayment of $5 to see doctors, $7 for generic drugs, and $15 for brand-name drugs will remain unchanged for the second year in a row. In contrast, in Pueblo County, Colorado, where Secure Horizons will be the only Medicare+Choice health plan operating next year, beneficiaries will be charged a $99 monthly premium over and above the regular Medicare Part B premium. They will also pay $15 co-payments for doctor and specialist visits, and will receive a $750 annual prescription benefit for brand-name pharmaceuticals and an unlimited prescription benefit for formulary generics.  (source)

The benefits you can get from Medicare and from an HMO are different.  You have to look at these various benefits and decide which direction to go.

I went for a while with Medicare. They I signed up with an HMO, then I didn't like that, and got off, back to simple Medicare, then felt that the HMO might be better, and that's where I am right now, but strongly considering switching again.

So, I've had lots of experience with this concept and have strong opinions about it.  I'm with the HMO, Secure Horizons, now.

[Image]Now, I had been "warned" by a friend, older than I, and into the HMO business some years before me -- he said, "You have to learn how to be a squeaky wheel!"   That sure is true, and this page, below, shows you how much I have squeaked, so far, to get service.

Let's look first at the inherent flaw in ANY type of insurance.

The first insurance ever used in the West was back several hundred years ago, in England.  At that time rich people would pool their money to send a ship to the Indies and return.  Just about any ship that made it to the Indies, and returned, meant a great deal of profit for the investors.[Image]

The investors would invest, say £100,000 to equip a ship, with merchandise that cost very little in England -- to sail to China.  There the ship crew would barter with the "natives" and pick up silk, spice and jewelry worth £5,000,000 or much more.  The profit was a sure-fire event.

But what was not "sure-fire" was whether or not the ship would return at all!

Many ships would sail, knowing that the entire journey would take many months.  Then, many months later the ship did not show up.  Presumably it was lost at sea!

So, the rich guy put up his hunk of money, and a year later he was left holding an empty bag -- with no word on what storm or pirate may have stolen his ship.

As more and more merchants began to see what was happening, some of them realized that they could "insure" this action.  Each would put up some money to pay for that trip, into a common fund -- an insurance fund.  Then, if a ship did not return, the fund would pay back these people.

They may not have made their fortune, but they didn't lose their investment.

This is the modern Western origin of "insurance."

From the very earliest times of maritime trading, it was appreciated by both traders and carriers alike that maritime risks constitute a greater hazard than those encountered on land. To try to minimise this risk, early merchants usually sailed with their goods as 'supercargo'. This enabled them not only to supervise stowage and carriage, but also to finalise the transaction for the sale of their goods, and obtain payment for them at the port of delivery.[3]

But merchants could not always accompany their vessels, nor could their presence ensure shielding from the risk to which their goods were subjected. What was needed was a contract which would protect merchants against the caprices of fortune.[4] The earliest contracts, in which the burden of the happening of uncertain events was transferred to another at a price, were not what we know today as insurance contracts at a premium. They were an extended facility of the maritime loan developed by the Babylonians in the 3rd millennium BC.[5] The Babylonian system was not a 'stand-alone' contract of insurance. It involved rather a 'premium' percentage of interest chargeable on a loan for the purchase of the goods to be traded. The lender of the money, in return for the 'premium' interest, assumed the risk of the goods in transit. (source)

This usage is reasonably sane.

[Image]There was no incentive for the crew to want to get stormed by pirates, nor by weather, so the "danger" was truly an "Act of God" as far as the investor was concerned.  In other words, the investor, and the crew, did NOT want the harm that often came.  Also, if that harm arrived, usually the crew were dead, so they had no incentive to die in order for the insurance to pay off.

As long as the insurance was to not guarantee the PROFIT, that type of insurance does not encourage the insured person to WANT the harm, or to feel that he is better off with the insurance payment than he would have been with the profit from a returned ship.

That would be sane.

But, insurance gradually evolved into a system that pays you to be sick.  In the case of welfare[Image] type insurance, it has come to pass that a person may well feel that they are far better off collecting the welfare (insurance) than not.  A woman, for instance, can often collect far more money for the next baby than she could earn in any other way.

Mothers on welfare had more and more babies since each baby bought in government money.  Often that government money was spent on crack and the babies grew up in a violent criminal environment and turned to crime.  As welfare and overcrowded prison costs drain society, corporations have less money to invest and eventually there is less corporate money to tax.  So in the end liberal policies may lead to less funding for the poor. (source)

The case against health insurance is more complicated since most people don't WANT to be sick, and the money for health insurance generally does not go to the insured person, but to the doctor.

[Image]But the simple truth is that people die!  On the way to death they get sick!  The sickness starts, usually, with something mild, but if the mild disease doesn't kill you, then a worse disease will come along to do the job.

All along the way you don't want to die -- so you ask your doctor to help.  What can he do?  He follows his best training, but he lives within a system that cannot possibly pay for every possible treatment you could need or want.

The older you get, the more serious is your disease, the more health care you are going to want and need.

Obviously, not just in theory, you want an infinite amount of health care from a system that[Image] MUST be bound to some sort of budget.  Any business has to weigh the income and the expenses and balance the system.  When the income comes from the taxpayers, the health care budget seems immune to economic reality -- but, there must be a limit somewhere.

So, health care is something which people want, always, MORE of, and they want MORE, the older they are!

No possible health insurance system can give all of what people want and think they need.

Currently it is political suicide to say these things -- so every politician must run on a pledge to IMPROVE health care -- that means, spend more money on it.

[Image]The politicians would never suggest rationing, but that is the only possible solution to this flawed system.

So, points of rationing are built into the system.[Image]

Some of the rationing takes place in the form of "unapproved procedures." The insurance company says, "That procedure is not standard practice."  Thus the true breakthrough in cancer or heart disease will languish until it can replace some other form of treatment, and make room within the fixed budget of the insurance pool to allow it.  Often the new procedure is approved as a result of demonstrations and riots.

Most of the rationing, however, is hidden from you. The government passes laws and regulations giving HMOs and other insurance forms, the job of approving health care claims -- against some sort of fixed budget for expenses.  The government makes the politically-correct claim that the insurance companies are making too much profit, and that they can reduce their profits and give the additional coverage people seem to want.

This will never solve the problem, obviously.

So, HMOs find ways to ration care and maintain their desired profit margins.

The main point of this page is to reveal some of the ways HMOs ration care and what you can do about it when it affects YOU.

Obviously, if everyone used the "tricks" described in this page, then the HMOs would have to find newer ways to ration care.

[Image]It is in setting that Jean Ross, my wife, found herself, being covered by an HMO which receives its money from the government.  She had "bad knees" which developed slowly over many years.

At first it seemed just to be only arthritis -- our own MSM should solve that problem.  It seemed to help, but after some time MSM cannot do the job.

So, she went to her "gate keeper" doctor -- the one assigned by the HMO for you to go to first.  He is called the "gate keeper" because you cannot get "serious" health care unless you FIRST go to your "primary care physician."  He gets a fixed sum of money every month for the patients assigned to him.  If he gives them "too" much attention, he still gets the same money, but is starting to starve himself.  If he is "lucky" and gets a healthy one, he doesn't spend any of his time with the healthy one, and spends his time on the sick ones.

He is "free" to refer patients to "higher level" health services. But, his freedom to do that is secretly limited.  One way or another the HMO lets him know that he allowing the "gate" to be too wide open -- he is referring too many people to expensive higher levels of service.

The limits are not likely to be ever put in writing -- the HMO knows better. They find subtle ways!

They don't renew some doctor as part of their service when his referrals are too many, or they find other ways.

I've found one way.

[Image]The HMO gives the doctor secret warnings.  The doctor is now in a bind, instead of the HMO, and it is up to the DOCTOR to do the rationing.


Well, you go to him with a "bad knee pain" and he tells you to take aspirin.  He knows that is not a cure, but he also knows that the pain will be less and he will not run over some secret quota he has from the HMO.  If you complain again?  He will prescribe a drug for killing the pain!  There are always fairly cheap drug solutions to health problems -- this is the direction the health insurance industry is pushing medical care.  This is why the drug companies love this, and why you hear all the publicity about a "senior drug reimbursement bill" that MUST pass Congress -- and which no politician dares to oppose.

Those who don't know better accept his prescription, grumble and do nothing more. The HMO, and the doctor, count on a fairly large number of "sheep" who will get poor service, but not complain.

Now, Jean and I are not sheep![Image]

So, when Jean went with her "bad knee" to the gate keeper doctor, after a few visits, and no real remedy, he used up one of his quota of referrals -- gave Jean a form requesting HMO authorization for an MRI.  The HMO can hardly afford to turn down a request like this -- since they don't want to appear to be putting their (business) judgment ahead of the medical judgment by a doctor.

So the request for the MRI is approved -- but to help the system cope with the infinite demand on the services, the approval takes a week or more, and then it takes a week or more to get an appointment with the place that does the MRI.

Then, of course, DOING the MRI is not really a final health care service, but only a diagnosis that can ONLY be explained by a doctor.  So, after you get the MRI report back, you then have to make an appointment with a "real" doctor -- in this case, presumably, with an orthopedic surgeon, since the knee problem is likely to call for evaluation of the MRI by a doctor trained in "knees."

As you then arrive at the doctors office for the evaluation of the MRI, you may not realize, as we did not, that the first person you will meet is NOT a doctor qualified to do knee repair, but another "gate keeper" whose sole job is to be pleasant and tell you, in some convincing way, WHY you are not a candidate for surgery.

Now, of course, you could have a situation where this doctor says to you, "All you need is to do some exercise."  Or, he might say, "You need some pain killer."  He could say one of those things, but if he looks at your MRI and sees that there is no possible hope for you other than knee surgery, he has his toughest job.

He has been told, secretly, not in writing, that the real knee surgeon CANNOT do more than some quota of knee surgeries.  After all, knee surgery can cost $25,000 and that is several years worth of premium income.  Be sure you realize, there is nothing in writing on this because if there were it would be evidence of "bad faith" on the part of the insurance company, and enough of them get sued, and loose, that they just don't want to make it easy for people to find out about this rationing.  The story below is about MY HMO. They are sensitive to charges of bad faith!

In January 1999, a San Bernardino County jury awarded $120.5 million in damages against Aetna-U.S.Healthcare, one of the nation's largest HMOs.1 The widow of a stomach cancer patient sued the HMO for "bad faith" disapproval of cancer therapy that promised to prolong her husband's survival. The verdict included $116 million in punitive damages against the HMO for placing its own financial interests above the needs of the individual patient. (Aetna has appealed.) Significantly, treating physicians were not held liable.  (source)

That about brings us to the point of the letter published below.  Recognize that the doctor is "on your side" and would like to give you service, but also recognize that he may lose his practice because he gives too much service.  What a conflict he lives with!

But, there is more to know about this.

You could BELIEVE that this rationing is happening in your case. But, you should realize from the above that the HMO and the doctor surely don't want to make it easy for you to prove that, and either embarrass them into giving you something "beyond the quota" or even worse, to sue them and get lots of money!

So, whether you believe this rationing is taking place, in your case, or not, you may be faced with a denial of service by some gate keeper person, and wonder how to go about getting that decision reversed.

[Image]I write this on Sunday, March 2, 2003, and tomorrow, at 9:15 AM, Jean Ross and I go to visit the doctor, as explained below -- our "second chance" at getting the service Jean thinks she needs.

Notice this important phrase -- she "thinks" she needs this service.

In the olden days when doctors were honest, they would tell you straight up what were the alternatives for you when you present some health problem.  In those very olden days, of course, you would choose and you would pay.  As soon as the payment comes from a different person who gets the service?  The system is fatally flawed!

Now, you must realize that you and the doctor are NOT on the same team. He is paid by the insurance company, and the insurance company does NOT want to pay for so-called unnecessary health coverage.

So, you may love your doctor, but you should not trust him.

[Image]That puts you between a rock and hard place.  HE is the expert!  You are not!  Here I am suggesting that YOU have to decide what service you should have. This puts a great burden on you to do your own study and research.  You could not do any better than coming to my 20,000 pages since you can count on ME to be on YOUR side.

In Jean's case, I had done all the research on damaged knees, and knee surgery -- HERE.

She and I had to read this stuff and understand it.  Then it was SHE who had to decide if she really thought knee surgery was correct for her.

Possibly if the gate keeper doctor had given her medical or logical reasons why knee surgery was NOT right for her, she would have quickly changed her mind.  But, she approached that meeting with the doctor, expecting an evaluation of the MRI report.  She did not expect what happened.

So, for Jean the next action was easy.  From the short time with Dr. Lee she easily came to the conclusion that he was rationing care, in bad faith, and that she should NOT accept his denial of service.

So, we then had to decide what to do.

I sought advice from one very good friend, a chiropractor, whose opinions I could trust as not biased by HMO considerations.  He gave me the advice to write a letter to the HMO, and to the next doctor we were scheduled to visit (Monday, March 3, 2003), and what should be said.

The result is the letter below.

Now, before you read this letter, there are still vital matters you should understand.

It is one thing to have pain and describe it, truthfully, in a way that minimizes it.

It is the old question, "Is the glass half full?  or half empty?"

[Image]The letter below is absolutely true as to all the data given -- there is no false data.

But, if you were to talk to Jean Ross, yesterday or today, and ask her, "How are you doing?"

You would get a polite and optimistic answer.  She is NOT one to emphasize the pains she may have, nor their consequence.  She IS the type of person who would put a rosy glow on her condition.

I know, because I often talk to people who go in the opposite direction.  They have a toe ache, and from their description of the "ache" it would sound like she was near having to have an amputation.

The HMOs and doctors are far more familiar with the second type of person -- who exaggerates his or her problems.

So, as I was drafting the letter to send, I realized that I would have to "set aside" the normal way I might communicate, and Jean's normal tone level, and put ONLY the truth there, but the truth in a way that emphasizes the seriousness of this health problem.

[Image]I had to write in such a way as to "push" the buttons I know to be valid -- the HMO is rationing care and doesn't want to get caught doing that.

If you accuse them too bluntly, they can get their "backs up" and just deny it all.

But, if you are more subtle about this rationing thing, they might think they can "find a way" to allow you to get the service and never admit that any rationing had been going on.

So, that's what this letter attempts to do.

It raises the issue of rationing, somewhat bluntly, but not as bluntly as I would raise that issue in a lawsuit.

It mentions the phrase "bad faith" because that is a scary subject for an HMO to confront.

It does NOT threaten legal action -- that would be far too blunt at this point.

But, you should not write a letter like this without the willingness to move ahead on an appeal, if there is precedent for one, or a lawsuit.  You certainly hope you don't have to sue, but you should have the mental attitude that you are willing to do that -- but do NOT tip your hand on this.

[Image]Let this be the iron hand in a velvet glove!

So, with all of this in mind, take a look at the letter which was sent out just a few days ago, and you can guess, along with us, what will be the outcome at the doctor's visit just another few hours away from now.


Karl Loren

on www.oralchelation.com

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