HEALTHE CARE FOR ALL (How to Fix Nursing Homes and Prevent Pandemics) a book authored by Jerry Rhoads, CPA, LNHA, FACHCA
Certified auto mechanics work with diagnostic computer systems to guarantee they know the problem before they incur costs. Then they get our approval to proceed and find out who will pay the bill. Insurance or warranties, if involved, will be notified. The car gets fixed and we are responsible for upkeep and prevention.
While for our health care physicians, hospitals, therapists, pharmacies use diagnosis codes, tests and procedure codes to justify treatment, and get approval, before sending our insurance company a bill. It bypasses us in the approval process without us knowing the cost, problem by body system, price and an acceptable outcome.
Automobiles are repaired and problems prevented based by computer diagnostics by mechanical systems to isolate root causes to the problems being experienced. Then repair and/or prevent costly future breakdowns. The outcome is guaranteed before payment.
While health care physician approaches, usually without a care plan, write orders for treatment using symptoms to establish a billable diagnosis code justifying tests: blood tests, stress tests, vital signs, arriving at a diagnosis code that qualifies for billing and procedure codes for treatment and prescription medication. Payment for inpatient care is made on admission diagnosis codes, prescription codes and procedure codes for discharge. Outpatient care proceeds with the doctors’ order for referral to specialty service providers who perform treatment and process insurance claims. There is no requirement for proof of outcome. There are malpractice claims filed by expensive attorneys if mistakes are made in the delivery of care. That’s the only accountability for provider results.
Automobiles have preventive maintenance plans by mechanical systems … oil changes, check tires, check brakes, check transmission fluid, check radiator, belts, exhaust system, air exchange, exterior and preservation of interior cleanliness, change filters and ignition plugs based on mileage, age and warranties, justify insurance claims or our personal review of the outcome and bill.
While health care approaches prevention with annual physicals, prescription drugs for blood pressure, cholesterol levels, blood thinners, diabetes blood sugars, pain killers, depression meds, psychotropics, EKG, EEG, CT scans and encouragement for better weight levels and exercise activities. All based on age and insurance coverage. Prevention in health care is not yet covered by insurance unless it is a diagnostic or therapeutic. Health preservation isn’t generally insurable for exercise, weight control, mental health, diet, weight reduction.
Health care utilizes 77,000 diagnosis codes, 9,000 procedure codes, 14,000 drug codes for billing and documentation referred to as the patient medical record. Payment is made by ICD (international disease codes) 10 diagnosis codes, medical procedural codes and prescription drug code dictionary. Payment is made externally by private commercial insurance policies, Medicare, Medicaid, VA, Champus which means the patient isn’t internalizing the cost nor are they evaluating the outcome and holding the provider accountable for cost and price.
Insurance isn’t directly paying for prevention and preservation of health and fitness because it’s too expensive and not considered a necessity. In other words, we personally don’t internalize the need for having it. Even though a pound of prevention for the individual insured is worth thousands of pounds of overweight insured lives the cost isn’t yet enough to get individuals to internalize the reason to lose weight and get fit.
By privatizing the benefits and internalizing the cost of health and fitness by covered lives will health care be managed and cost effective.
