#192 Musings Beyond the Bunker (Wednesday November 10)
Good morning!
Several weeks ago we received a couple of statements from our health insurance provider, United Healthcare. For those of you who have Anthem Blue Cross or Blue Cross Blue Shield, as bad as they are, you are living in a veritable nirvana of health care by comparison. But it’s all relative. They’re all bad.
It is axiomatic that health care plans and their statements of benefit are difficult to understand. I think it’s intentional. We live in an age of data, data slicing, spreadsheets and technology. But the manner we are delivered information about our health care options and costs is unnecessarily confusing. I am an attorney who works with complex legal documents and financial reports all the time, but I am more often than not flummoxed by the complexity of these statements. There is no explanation for the impossibly complicated method in which this information is delivered.
As an example, recent statement of benefits calculated that $0 was billed, $0 was deducted as savings, $0 was paid, and yet that we owed $9. This is silly and unimportant but emblematic of the problem. Other statements of benefits have multiple calculations (in network, outside network, covered, discounts, deductibles, etc.). The entire system is obfuscating. And that’s its beauty. Because no one “really” understands, there is little opportunity to complain about a particular item and it is impossible to “see” the system at work.
Another statement of benefits says the amount billed is $20,000, but the “discount” received by the insurance company is $18,000, leaving $2,000 due. How, exactly, does this math work? If uninsured, is the patient looking at a $20,000 cost? How are these “discounts” established and what do they mean? For that matter, does “list price” mean anything at all?
DECIDING ABOUT TREATMENTS
The real crazy thing is that doctors are being second guessed by nurses employed by insurance companies—companies whose profits are directly related to the amount of money they don’t pay out for needed medical care.
The insurance providers would have us believe that they are doing their part to “keep medical costs down” by ferreting out the unnecessary procedures and over-prescribing. But I suspect this is a solution in search of a problem. Oh, I’m sure there are doctors who are over-prescribing and there no doubt is a rational basis for questioning high-cost long term prescription medications. And there is a lot of cost incurred in late-life herculean measures. But unless there is more widespread fraud in the medical community, among doctors who spend nearly a decade (and sometimes more) learning their craft and working for less than they otherwise could command in other professions than is apparent or reported, the “default position” should be that doctors know what they’re doing. And yet, diagnostic tests, procedures and treatments being recommended by doctors—doctors who, in least in theory are adhering to their Hippocratic oath and have a more intimate knowledge of a patient’s history and present health status than an insurer (whose incentives are not consistent with patient care)—are being denied all the time. Many of us have stories like this.
DENIAL OF CLAIMS AS A BUSINESS PHILOSOPHY
I have some bad back pain, brought on no doubt from more activity than the human body was meant for, in decades of skiing, working out, hiking and playing sports. After having tried anti-inflammatory drugs and physical therapy, my primary physician suggested an MRI. Then a chiropractor recommended an MRI. Finally, a spinal specialist recommended an MRI. I never received an answer from the insurance company regarding coverage.
A week later, the MRI was denied by the insurance company as “not medically indicated as a treatment” (forget that it’s actually a diagnostic test and not a treatment). So these bean counters, set on reducing expenditures, overruled three health professionals. And this wasn’t a long-term treatment plan. This was a diagnostic tool in order to determine the extent of the problem, which would inform the treatment plan. The denial was made by a nurse without access to my physician’s records. I have heard that many of the people denying treatments aren’t even health care professionals.
I was able to opt for the MRI recommended by three doctors and pay for it myself, pending possible reimbursement. The sad thing is that many patients don’t have that option to do so (the cost was $1,200, which was reduced to $600 if I paid cash), because they don’t have the financial capacity. I’m convinced that the insurance companies are banking on disapprovals being blindly accepted by patients/insureds. It is a craven economic calculus. Few people have the knowledge, energy, stubbornness and/or financial resources to take on these insurance companies. As a result, they will not have access to the diagnostic tools and medical treatments they need, as recommended by their doctors. It is a tragedy.
THE BOTTOM LINE IS THE INTERMEDIARIES ARE DESTROYING HEALTHCARE
As long as we have a system that places the ultimate determination of medical care in the hands of those with the incentive to deny treatments prescribed by doctors, we are doomed. These middlemen are trying to save money and boost their profitability.
And it’s not just in insurance. It’s also the inroads of venture capital funds in purchasing and consolidating operations of emergency rooms, urgent care centers and surgery centers. We have shifted control of these healthcare centers from medical professionals (who admittedly are at least partially motivated by profitability) to those whose sole purpose is reducing costs and care.
It’s bad and getting worse.
Have a good day,
Glenn
From the archives: