Tips for Navigating the Health Care System
A veteran medical practitioner and administrator offers advice on dealing with America’s confounding medicine-insurance complex
The American health care system is complicated, difficult to navigate and can kill you if you aren't prepared, proactive and knowledgeable. From finding good doctors to being able to afford medication, the hurdles can feel insurmountable.
So says David Wilcox, who has spent nearly 30 years working in various capacities in hospitals and recently wrote a guide for patients, "How to Avoid Being a Victim of the American Healthcare System."
Wilcox, who holds a doctor of nursing practice degree, has been a bedside nurse, intensive care nurse, nurse administrator, hospital administrator and has worked in health care technology. He believes his experience and inside knowledge can shed light on how patients can work to get better results when they find themselves dealing with hospitals, insurance companies, drug makers and medical personnel.
I have interviewed Wilcox several times and am editing those interviews to point out information that may not be widely known and to help readers learn how to use that information to improve care and health outcomes.
Barbara Sadick: Recent studies have indicated that medical errors are the third leading cause of death in the United States, after heart problems and cancer. How can patients prepare before a medical procedure to reduce their risk?
David Wilcox: I've seen so many bad situations that could have been prevented had people prepared by doing research. Always ask questions. Know exactly what a procedure involves, why it needs to be done, how quickly it needs to be done and what the recovery will entail. Remember that patients and doctors should be equal partners, and patients have a right to ask as many questions as they want or to refuse treatment.
"Patients have a right to ask as many questions as they want or to refuse treatment."
Make sure to find out about doctors and hospital ratings. Good evidence-based sources are available to use when doing this research (healthgrades.com for doctor ratings and CMS.gov for hospital ratings). Don't just 'google' for information. There is much misinformation on the internet. If you're lucky enough to know a nurse working at the hospital where you'll be treated, ask about which doctors are highly regarded. They've observed and can tell you who has consistently good outcomes and who to stay away from.
A recent nurse-staffing company survey indicated that more than one-third of nurses plans to leave their current jobs by the end of the year. In addition, the American Association of Critical Care Nurses says that about sixty-six percent of acute and critical care nurses are considering leaving the profession entirely. In this overworked, understaffed profession where nurses are in short supply, patients may be getting less careful hands-on care. Nurses have too many patients to care for at one time. How can patients and families deal with the situation?
Patients who are able need to ask lots of questions. If they can't, and even when they can, it's wise to have a family member or friend who knows the patient's situation on hand to advocate for them. Patients and advocates should question everything and anything, including anything that looks or seems suspicious. Ask until you understand.
Medication errors happen to nearly five percent of patients. Before taking any medication, understand what it is and what it's for. It can be confusing, as drugs have generic and brand names. If the drug name begins with a capital letter it's a brand name drug. If it starts with a lowercase letter, it's a generic.
Some of the drugs you're given in a hospital are the same drugs you take at home. To keep costs down and if you haven't been admitted through the emergency room, you have the right to bring your own medication to the hospital, give it to the health care team and not end up paying fifteen dollars for a headache pill.
Because nurses are overworked, you and your advocates should be friendly and polite, because that will get you better care. But if there's a problem, speak up and ask questions. If you aren't getting satisfactory answers, keep pushing or ask to speak with the nurse supervisor. If your nurse seems rushed and you can wait, ask them to come back when things are calmer. That's one way you can prevent medical error. It's not difficult for an overworked nurse with too many patients to confuse one with another.
On any given day, about one in thirty-one hospital patients has at least one infection they acquired at a hospital or other health care facility, according to the Centers for Disease Control. What can patients and advocates do to reduce that risk?
First, make sure that every person who comes into the room washes their hands. That includes visitors, family members, doctors, nurses and other hospital staff. To prevent bed sores, a patient needs to be turned or to turn themselves every two hours. Pillows should be put between the legs to decrease pressure. The sooner a patient is safely released from a hospital, the less the chance of coming out with an infection.
You say that Americans spent about $535 billion on prescription drugs in 2018. That's twenty-five percent more than was spent in 2010. Pharmaceutical companies increased prices on their most prescribed medications by forty percent to seventy-one percent from 2011 to 2015. What's going on here?
"A typical consumer in the U.S. spends more for prescriptions than consumers in any other nation."
Pharmaceutical companies say they need to keep hiking drug prices to raise money for research and development of new drugs. But the government, not drug makers, funds a lot of research either directly through research grants or indirectly through tax breaks. The publicly funded research is your tax dollars at work, yet you are still being charged again and again. Since 1930, the National Institute of Health has invested nine-hundred billion dollars in research. Despite that, a typical consumer in the U.S. spends more for prescriptions than consumers in any other nation.
Being the largest health insurer and payor in the U.S., Medicare, if it were able, could buy in bulk and bring drug costs down. It is, however, prohibited by law from negotiating drug prices. If that were allowed to happen, it would seriously cut into the profits of pharmaceutical company lobbyists who pay off politicians. During the 2016 elections, pharmaceutical companies spent sixty-two million dollars to finance and influence candidates.
Another little-known fact is that drug prices vary from pharmacy to pharmacy. That's because insurance companies are unregulated and pharmacy benefit managers set the out-of-pocket prices you pay using rebates and coupons that benefit the pharmaceutical and insurance companies. To find the best prices, you can use the resource guide, Dr. David Helps, and compare the price of your medication at Good Rx to ensure you're paying the lowest cost.
Congress enacted the Health Insurance Portability and Accountability Act in 1996 to protect sensitive patient health information from being accessed without a patient's knowledge or consent. Since then, health care technology has increased dramatically and it's not difficult for your information to get into the wrong hands. What should patients know to prevent this from happening?
When your health care information becomes publicly accessible, there can be serious consequences. It can be used by insurance companies to deny you coverage. Be aware that genetic testing kits like 23 and Me and Ancestry.com can test for genes that influence your risk of developing certain conditions.
These companies de-identify your data and sell or give it away to researchers who can then re-identify you. Insurers often look for information that allows them to deny coverage. If, for example, your genetic information shows a predisposition to a serious, chronic disease, that might cause a health or life insurance company to refuse to insure you.
Before you decide to find out about your genetic profile or to seek genetic testing, think seriously about why you want the information and what you are going to do with it when you get it.
The Consumer Financial Protection Bureau says that in 2021, U.S. consumers owed more than eighty-eight billion dollars in medical debt. The figure is likely to be larger because not all debt is reported to consumer agencies. What should people do when they find themselves owing out-of-pocket expenses for health care?
Many Americans live just one crisis away from a health emergency. If you find yourself in a position where you're paying out-of-pocket for medical care, speak with a hospital finance office. You may be eligible to have your debt wiped out completely or you may be able to come to an arrangement for paying it off over time.
If you make a good faith agreement with the hospital and you're paying something, no matter how little, on a regular schedule, your creditor can't hand your bills over to a bill collector. But don't miss even one payment. If a bill collector gets hold of this information, it will affect your credit rating.
Never take out a loan or use a credit card to pay your debt as that will cause you to incur more debt in interest charges. Negotiation is the key.
A recent analysis by the Commonwealth Fund shows that the U.S. ranks only seventeenth in the world in health care efficiency, outcomes and equity despite spending significantly more than other wealthy countries. Do you see this changing?
In our current fee-for-service system, the health care provider makes money only when a patient show up sick, so there is no incentive for keeping you healthy. In a value-based care model administered by an accountable care organization (ACO), doctors get a fixed amount of money each year for your care. If you get sick and end up in a hospital, your doctor will have to pay additional costs. That's an incentive for physicians to keep you healthy, and while some physicians are part of these ACOs, I hope we see health care continue to move in that direction.