The Industry Backed Into a Corner

I hate the health insurance companies! (4.00 / 2)

I could go on for HOURS on this topic.

Like when United Healthcare owed me $10,000 for six months and it took writing to the Chairman of the company and threatening to take it to my Congressman to get paid.

Or when Anthem, in their infinite wisdom, decided that my son, who has Aspergers and was undergoing serious bullying at school and clinically depressed, not to mention the fact that his parents were going through a long, bitter divorce, no longer needed to see a therapist.

Or about the same time, that my daughter, who was dealing with being diagnosed with Type 1 diabetes and the same long, bitter divorce, not to mention suffering from PTSD because she was in the car when her father (who also has Type 1) went hypo and crashed into a truck, also was not in need of therapy.

Oh, this is just the beginning of my "I HATE THE U.S. HEALTHCARE SYSTEM" rant, but I'll spare you the rest of it. I can already feel my blood pressure rising, and I usually have low blood pressure. But that's what thinking about this stuff does to me.

I lived with the National Health Service in the UK for 15 years. Is it perfect? No. But is it better than what we've got? Hell yeah!

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by: saramerica @ Thu Dec 20, 2007 at 12:59:26 PM UTC

The Insurance Companies are Very Motivated Now (4.00 / 1)

They are finally waking up to the fact that if their industry doesn't begin meaningful self-regulation, then the American people will legislate them out of existence. I have posted many times about my own personal and family healthcare/insurance nightmares. My gut reaction is that a single-payer system would solve many of our ills. However, the capitalist in me still believes that a properly managed and regulated private insurance system might still make more sense. At the very least, it is a more realistic goal given the general resistance to nationalized healthcare, and the insurance companies wield tremendous power and influence - and are not about to go down without a fight.

I believe that the real issue of concern is healthcare security Whether through a public or private system, every American needs the security that quality healthcare will be available when they need it. Within a private model, the only way to make the system work is to mandate coverage for all - and require that the insurance companies accept everyone and anyone, regardless of medical history.

The concept of insurance is old and simple - it's a pooling of risk. They make money on the healthy people and spend money on the sick people. Their goal, of course, is to make a profit by spending less on care than they take in from premiums. [I like to call this the fitness club model. They make all their money on the people that join but don't show up. If all the members suddenly started working out regularly, the gym would quickly go out of business.] This is why mandatory coverage is essential. The larger the pool of insured, the lower the risk for the policy issuer. With more people insured, they can still earn a profit even at lower premium levels. Furthermore, mandatory coverage prevents people from opting out of coverage until they get sick, which really does create an unfair situation for the insurers.

Whether they do it on their own, or through government regulation, I see several changes needed to make a private system work (far from an exhaustive list, this is mostly from the issues I've dealt with personally):

1. Doctors make ALL healthcare decisions. Administrators, actuaries, and accountants at the insurance companies are not to be involved in the care-management side of the business.
   
2. Drug formularies are to be outlawed. Every insurance company must cover all FDA approved medications, up to the maximum approved dosage. (New Jersey has already done this with great success.)
   
3. Doctors are free to prescribe whatever they feel is the best medication to treat the patient. The insurance company may not mandate the use of "preferred drugs," over-the-counter medications, or step therapy."
   
4. Patients may choose any (non-network) hospital or board certified physician, and the insurance company must pay the fair-market rate for services rendered. The patient would be responsible for any additional payment if the doctor they choose charges above market rates.
   
5. Insurers must cover any and all treatment provided during a hospital stay, including "hidden provider" charges. (Recent CT legislation has eliminated the problem of hidden providers.)
   
6. Insurers shall be prohibited from limited access to care that a board certified MD deems necessary, including mental health treatment. (today, most insurance plans limit mental health and therapy to a certain number of visits per year, even if the patient requires more.)
   
7. For life-threatening illnesses, in cases where conventional treatment has failed, insurers must cover the cost of "experimental" treatment (some limitation might be appropriate here, such as only late-stage trials, for example.)
   
8. Decisions regarding the length of stay for hospitalization shall be determined by the patient's doctor (or maybe a medical board at the hospital.) Insurers may offer suggested guidelines for lengths of stay for various conditions/treatments, but the medical professionals have the final word. (i.e. no more women being tossed out 12 hours after giving birth.)
   
9. Insurers must cover all legal, medically acceptable treatments and procedures, including abortion and birth control.
   
10. Doctors and healthcare facilities must accept an assignment of insurance reimbursement as payment (i.e. the insurers will pay directly to the provider instead of the patient making payment and waiting for reimbursement.)
    
11. The insurance industry must agree on a set of standardized applications, claim forms, diagnostic codes, etc. and create an industry standard electronic claims filing/processing system (eliminate runaround created when insurance companies reject claims based on technicalities, and reduce administrative costs for providers.)
    
12. For procedures that require pre-approval, the insurer must respond with a yes/no within two business days of request. An independent medical review board in each state will have the authority to overturn a declined pre-approval. (Pre-approvals are still necessary for many treatments because too many unscrupulous doctors still try to obtain coverage for elective procedures, which drives up costs for the rest of us.) Insurers may not require pre-approval for emergency procedures.
    
13. Reconstructive surgery following an injury/accident/medical procedure may not be considered "elective" and must be covered (e.g. breast reconstruction following a mastectomy, skin grafts and plastic surgery for burn victims, etc.)
    
14. For employees that receive health insurance through an employer, they shall have the right to decline the company plan and apply the full premium amount to a private or other group plan of their choosing.
    
15. People that are not eligable to participate in a group plan (such as an employer) will be able to buy into a State or Federal employee plan.
    
16. Employers (above a certain size?) that do not provide employee health insurance will pay a Healthcare Security tax, which will be applied towards premiums for the uninsured.
    

I could certainly go on and on, but these are some of the most critical and frustrating issues I have dealt with. It's quite possible that once all of the required and meaningful rules are enumerated, the health insurers may just throw in the towel and favor a single-payer system. Of course, I haven't addressed the issue of premium payments for those that can't afford health insurance. Obviously a government program must be put in place to help pay for this coverage.  

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by: Neal Fink @ Thu Dec 20, 2007 at 15:42:50 PM UTC

conflicts of interest, drug industry; defining "universal" (0.00 / 0)

I completely agree that the intrusion into the patient doctor relationship has changed that relationship for the worse and added a layer of tremendous stress in the already stressful experience of being ill.

The geography of provider self interest  has changed over the past couple of decades.

How to prevent abuses by doctors whose interest in the patient conflicts with financial gain?  Ownership of clinics, xray machines, drug company stock, labs, or physical therapy facilities ideally would not influence judgment, but somehow the basic conflicts of interest would make sense to address.  At the very least, drug industry paying doctors as "consultants"  or influencing their choice of drugs is another area to somehow address.

To maximize the benefits of a large pool, my understanding is that the way to do it is with one large pool.  

Allowing multiple plans and therefore pools and asking the state to pick up those motivated not to sign up for the private policies they are offered because it is unfavorable coverage for their medical condition loads the government insurance pool side with exactly the population the insurance companies want off their books.  that may be touted as universal health care but it is not.  Cynically, it is politicians using the vehicle of the government for subsidizing the insurance companies and guaranteeing them maximum profits in exchange for contributions to keep them in power.

The cost to taxpayers would be enormous.  Having done a plan touted as "universal" but decidedly anything but that, the insurance companies could sit back and wait until the appeal of faux "universal health care" and its cost allowed them to claim victory and once again convince the public that private health insurance is what they want, not this ridiculously expensive "public" stuff.  

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by: greenpeas @ Thu Dec 20, 2007 at 16:43:52 PM UTC

[ Parent ]

As a former member of what I used to call the CT State (4.00 / 1)

"Losers Pool", I can tell you that the State mandated coverage was expensive and had no prescription coverage - so I was laying out over $2,000 a month for my family's medications and sometimes waiting as long as six months to get reimbursed. Fortunately at that point I was married and had the resources to lay out that kind of money for our medications. Nowadays, I'd be bankrupt.

Now that I have writing income I can get somewhat better coverage as a small business, but it's still pretty dodgy because of all of our pre-existing conditions. And at least I have prescription coverage, although I was unable to get dental.

It's REALLY, REALLY frightening to me. Along with civil liberties, healthcare is my number one issue in the next election.

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by: saramerica @ Thu Dec 20, 2007 at 16:50:15 PM UTC

[ Parent ]

Conflicts of Interest (0.00 / 0)

There probably should be regulation to eliminate the conflicts of interest you describe.  Many of these conflicts are an outcome of managed care. Being a doctor used to be a financially rewarding career. In the days of managed care, doctors now receive pennys on the dollar for their services. The complexity of dealing with the insurance companies has driven administrative costs through the roof. Add in huge malpractice insurance premiums and repayment of huge medical school loans, and the profession quickly loses its (financial) appeal. One way doctors attempt to stay ahead is to pump patients through their offices like an assembly line. Another is to employ physician's assistants and nurse practitioners that end up treating patients with far less supervision than appropriate (these professionals are an important part of our healthcare system, but should supplement and not replace the function of MDs.)  The more business savvy medical professionals have figured out that the best way to make money is through diversification. This is why doctors now own clinics, operate expensive diagnostic equipment (and use them more than medically necessary), do their own lab work, and participate in other related ventures. Medical professionals perform an invaluable service to our society. We should reward them in a comensurate manner.

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by: Neal Fink @ Fri Dec 21, 2007 at 01:34:50 AM UTC

[ Parent ]

These suggestions are all well and good but... (0.00 / 0)

it assumes that there will be voluntary compliance by the insurance industry or a good partnership with government.  You can just forget it; those SOB's will never relinquish one red cent of profit without a lengthy fight.  They need to be legislated out of the health insurance business, period.  They had their time and chance, but blew it by being greedy and mean-spirited in their pursuit for the last possible dollar.  Fuck'em.  Single-payer is the way to go.

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by: snorwich @ Sat Dec 22, 2007 at 22:28:50 PM UTC

[ Parent ]

Idealism vs. Realism (0.00 / 0)

Many of us agree that single-payer is the ideal solution. But, realistically we're not going to get that anytime soon. There is absolutely no support for it among the current leadership in DC, or among the serious contenders for the White House in 2008. We should certainly work to elect people that will move us towards the ideal solution. However, even if we're very successful, it will take a long time.

In the meantime, we need to identify solutions for which support can be garnered among those currently in power. Everyone seems to finally agree that there is a problem, which is a big accomplishment in itself.

Starting from the assumption that the insurance companies are not about to walk away with their tails between their legs, what steps would you take to get us moving in the right direction?

I posted some ideas above in this thread, and more from a very unlikely source in another diary.

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by: Neal Fink @ Sun Dec 23, 2007 at 02:55:23 AM UTC

[ Parent ]

State by state is the way to go. (4.00 / 1)

National healthcare for some reason is too big a nut to crack, so it will be up to the states to take any meaningful action.  The same goes for many issues that the Feds have dropped the ball on.  It's 2am and I am too tired to cite examples, but I have seen some great ideas on Stateside Dispatch.  At the moment I am in an "off with their heads" mood.  I have little patience and even less sympathy for Republicans and their antics.  We almost had  single-payer here in CT if it weren't for weak leadership.

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by: snorwich @ Sun Dec 23, 2007 at 06:55:06 AM UTC

[ Parent ]

I agree... (0.00 / 0)

That is why I definitely support bills such as Connecticut's recent pooling bill that would have allowed people to buy into the state employee pool.  This would have given the pool more members, hence more bargaining power and would have made healthcare more affordable for many working and middle class families in CT.  Like snorwich, I think the state by state method is the only realistic plan to improve our healthcare system.  As more states reform, the movement will gain momentum, leading to an eventual restructuring of the system on a federal level.

PS: Last session, SB-1371 (I'm pretty sure that was the number) would have created the Connecticut Saves Program.  I canvassed for several months collecting letters to support this bill.  Similar to Medicare, all one would need to do was enroll to receive insurance.  Unlike Medicare and Medicaid, enrollment would be open to everyone, regardless of age, income, or pre-existing conditions.  It did very well in committees until it was filibustered out of nowhere.  It is very realistic that this type of bill could be passed in Connecticut, all we have to do is convince our politicians that they cannot get elected again if they do not do the right thing.

"Join the resistance and there will be no resistance." - My Grandmother

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by: Rusty5329 @ Sun Dec 23, 2007 at 19:00:06 PM UTC

[ Parent ]

somewhat related news... (0.00 / 0)

American Cancer Society finds that uninsured patients are tested for cancer less often than those who have private insurance, have increased likelihood of developing late-stage cancers, and lower survival. Press release here.

Previous studies have shown that uninsured and Medicaid patients are more likely to be diagnosed with late-stage cancers, in large part because they can't afford preventive services and cancer screening. This report looks at the relationship between health insurance status and cancer care more closely, weighing demographic and socioeconomic factors as well as race.

"This report clearly suggests that insurance and cost-related barriers to care are critical to address if we want to ensure that all Americans are able to share in the progress we have achieved by having access to high-quality cancer prevention, early detection, and treatment services," said Otis Brawley, MD, chief medical officer of the American Cancer Society, when the report was released.

"There's class warfare, all right, but it's my class, the rich class, that's making war, and we're winning." - Warren Buffet

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by: joesaho @ Thu Dec 20, 2007 at 16:24:33 PM UTC