I am particularly frustrated over the public option fuss. Clearly there are plenty of people already on some sort of public option, even aside from Medicare, Tricare and the VA. The hodgepodge of state low-income plans, state risk plans and other weird arrangements is in desperate need of an overhaul. California's Medi-Cal program is a mess, and the reimbursement is so low few providers will participate.
Why not consolidate everyone participating in these plans into the public option? In addition, anyone who cannot afford private insurance rates (once pre-existing conditions don't prevent you from even being eligible) should be enrolled in the public plan, with premiums and out-of-pocket costs on a sliding scale as they are for all the current low-income recipients of the various state programs. Why should the federal government subsidize private insurance industry profits by paying them to cover people who cannot afford private rates?
In addition, as I've said before, all federal employees, including members of Congress, should also be assigned to that same public option, so we can be assured the plan will be of high quality, efficiently run, with fair reimbursement to providers so there is a reasonable network available to patients. We need to eliminate the second class medical care that lower income patients receive under state Medicaid programs and a public option is a perfect way to make that happen.
Thursday, November 12, 2009
Friday, October 16, 2009
Barriers Begone!
One of the recommendations our national association (ACAP) included in our health insurance reform position paper was that we need to eliminate the prior authorizations and other hoops that providers and patients have to jump through in order to qualify services for coverage. The bureaucracy adds signficant costs for providers who are willing to make the effort, and puts patients in a bind when the provider isn't willing to play along.
Case in point...one of my clients paid several thousand dollars for a procedure that his doctor had told him was not covered by his insurance. Subsequently, after some research, I discovered that the procedure was in fact covered, but a prior authorization was required. The provider had called the insurance company, learned that a prior authorization was required and opted to tell my client that it wasn't covered, rather than going through the hassle of obtaining the authorization.
When I called the Prior Authorization department, after waiting on hold for 20 minutes, I was advised that patient's cannot request prior authorizations, only physicians. In fact the department isn't even allowed to talk to patients. Patients can only talk to Member Services, who can't do anything about prior authorizations. So, yet again, the patient gets the short end of the stick and the insurance company, by creating barriers, chalks up a few more dollars for executive salaries.
Case in point...one of my clients paid several thousand dollars for a procedure that his doctor had told him was not covered by his insurance. Subsequently, after some research, I discovered that the procedure was in fact covered, but a prior authorization was required. The provider had called the insurance company, learned that a prior authorization was required and opted to tell my client that it wasn't covered, rather than going through the hassle of obtaining the authorization.
When I called the Prior Authorization department, after waiting on hold for 20 minutes, I was advised that patient's cannot request prior authorizations, only physicians. In fact the department isn't even allowed to talk to patients. Patients can only talk to Member Services, who can't do anything about prior authorizations. So, yet again, the patient gets the short end of the stick and the insurance company, by creating barriers, chalks up a few more dollars for executive salaries.
Wednesday, September 23, 2009
Fundamental Right, Yes or No
In T.R. Reid's great new book The Healing of America he talks about the fact that the U.S. hasn't taken the critical first step in reforming healthcare and until we do we are just spinning our wheels. First, we as a nation have to make what is fundamentally a moral decision: Do we believe that everyone in the U.S. has the right to quality healthcare (NOT health insurance)? Yes or No. Period.
If yes, then we can proceed to decide what the most appropriate, cost effective way is to achieve that goal, and it will be a work in progress as we learn what does and doesn't work. This is a decision the rest of the developed world has already made, and they have taken steps to make it happen, more or less successfully, using a variety of models. But the goal is clear, to get everyone the medical care they need.
If no, then we have to decide exactly what it is we DO believe, and proceed from there.
If yes, then we can proceed to decide what the most appropriate, cost effective way is to achieve that goal, and it will be a work in progress as we learn what does and doesn't work. This is a decision the rest of the developed world has already made, and they have taken steps to make it happen, more or less successfully, using a variety of models. But the goal is clear, to get everyone the medical care they need.
If no, then we have to decide exactly what it is we DO believe, and proceed from there.
Public Option Paranoia
I have been so appalled by the furor over the concept of a public plan, as if such a thing had never been contemplated before. Does Medicare ring a bell? How about the VA?
Aside from the insurance companies, who clearly want to avoid any competition (although most likely they would also be bidding for these contracts) I don't understand the concern. Medicare patients LOVE Medicare, and are lining up to march on Washington if a hair on it's head is touched.
People say they don't want government bureaucrats in charge of their healthcare. Perhaps they don't understand that right now private sector bureaucrats (with a profit motive and a strong disinclination to spend premium dollars on healthcare) are in charge of their healthcare. At least with a public option, the public has the opportunity to weigh in and participate in the development of the benefits. Right now, we have no say.
I think one thing that would reassure people about the quality and coverage available in a public option would be for all local, state and federal employees, including members of Congress, to be assigned to that plan. It is very different to design a plan for "them" as opposed to designing one for "us." If the public were assured that Congress had some skin in the game, it might alter the perception. Although the insurance companies will still be lobbying against the evils of "socialized" medicine.
Aside from the insurance companies, who clearly want to avoid any competition (although most likely they would also be bidding for these contracts) I don't understand the concern. Medicare patients LOVE Medicare, and are lining up to march on Washington if a hair on it's head is touched.
People say they don't want government bureaucrats in charge of their healthcare. Perhaps they don't understand that right now private sector bureaucrats (with a profit motive and a strong disinclination to spend premium dollars on healthcare) are in charge of their healthcare. At least with a public option, the public has the opportunity to weigh in and participate in the development of the benefits. Right now, we have no say.
I think one thing that would reassure people about the quality and coverage available in a public option would be for all local, state and federal employees, including members of Congress, to be assigned to that plan. It is very different to design a plan for "them" as opposed to designing one for "us." If the public were assured that Congress had some skin in the game, it might alter the perception. Although the insurance companies will still be lobbying against the evils of "socialized" medicine.
Thursday, August 27, 2009
Transparent as Mud
I just got off the phone with a supervisor at Blue Cross CA who was trying to sell me on why Blue Cross wouldn't give me pricing information for a particular service. Since being able to call your insurance company to find out the cost of a procedure you are considering is pretty much the cornerstone of the whole "consumer directed healthcare" model, it was quite a surprise (ok, not really, nothing surprises me anymore) to find out that Blue Cross will not give you that information.
If the provider you are using is not in their network, Blue Cross calculates an allowed amount for the service (based on zip code) and then applies your benefits to that. The difference between their allowed amount and the provider's charges is 100% patient responsibility, so you can see why you might want to know what their allowed amount is. In order to get that amount, Blue Cross says they have send a written request to the provider for demographic information and anticipated coding (all of which you already have and could give them) and once they get that back from the provider (assuming they do), then they will prepare a written quote and mail it to you.
When the provider does participate in their network, if you call Blue Cross to get the rate, they will tell you to ask the provider what his contract rate with Blue Cross is. Blue Cross will not tell you. Your provider probably doesn't know, and most likely wouldn't tell you either.
In both cases, Blue Cross has the information at their fingertips in their database, but they will not give it to you. I asked the supervisor (a pleasant, patient man, but clearly heavily indoctrinated into the Blue Cross way) if he didn't think it was contrary to the concept of transparency, but he didn't see it that way. The information is available, just now from them, or not in your lifetime. I pointed out that if a patient was using an in-network provider and wanted to get an out-of-pocket estimate, he had to make multiple phone calls to do so, because the patient would need to talk to the doctor to get the rate and then call Blue Cross to find out what benefits apply, which didn't seem very customer service oriented. The supervisor said the patient should know his benefits, deductible and out-of-pocket levels, etc but could consult the plan website or call Blue Cross if necessary. He didn't see this as a customer service failure, more a patient failure.
So much for shopping!
If the provider you are using is not in their network, Blue Cross calculates an allowed amount for the service (based on zip code) and then applies your benefits to that. The difference between their allowed amount and the provider's charges is 100% patient responsibility, so you can see why you might want to know what their allowed amount is. In order to get that amount, Blue Cross says they have send a written request to the provider for demographic information and anticipated coding (all of which you already have and could give them) and once they get that back from the provider (assuming they do), then they will prepare a written quote and mail it to you.
When the provider does participate in their network, if you call Blue Cross to get the rate, they will tell you to ask the provider what his contract rate with Blue Cross is. Blue Cross will not tell you. Your provider probably doesn't know, and most likely wouldn't tell you either.
In both cases, Blue Cross has the information at their fingertips in their database, but they will not give it to you. I asked the supervisor (a pleasant, patient man, but clearly heavily indoctrinated into the Blue Cross way) if he didn't think it was contrary to the concept of transparency, but he didn't see it that way. The information is available, just now from them, or not in your lifetime. I pointed out that if a patient was using an in-network provider and wanted to get an out-of-pocket estimate, he had to make multiple phone calls to do so, because the patient would need to talk to the doctor to get the rate and then call Blue Cross to find out what benefits apply, which didn't seem very customer service oriented. The supervisor said the patient should know his benefits, deductible and out-of-pocket levels, etc but could consult the plan website or call Blue Cross if necessary. He didn't see this as a customer service failure, more a patient failure.
So much for shopping!
Friday, June 12, 2009
Health Insurance vs Health Care
I'm noticing that as the debate heats up about healthcare reform that the focus is always on insurance rather than healthcare. The goal shouldn't be to make sure that everyone has some sort of insurance, but to make sure everyone has access to quality healthcare. Somehow the two seem to have confused.
Health insurance is hardly a cure-all. Most of the clients I help actually have health insurance. The majority of the people in bankruptcy due to medical expenses had health insurance. Doctors are refusing to participate in health insurance networks because they are fed up with the bureacracy, the paperwork, and the cash flow hassles.
Health insurance is hardly a cure-all. Most of the clients I help actually have health insurance. The majority of the people in bankruptcy due to medical expenses had health insurance. Doctors are refusing to participate in health insurance networks because they are fed up with the bureacracy, the paperwork, and the cash flow hassles.
Making sure everyone has health insurace will certainly ensure access to high profits for the insurance industry, but it won't ensure access to high quality, cost effective care for the U.S.
We don't have a health insurance crisis, we have a health care crisis. Lets fix that problem.Thursday, May 28, 2009
Is Preventive Care Financially Prudent?
The current debate over how best to give everyone access to healthcare without going broke reminded me of a fascinating article I read last year about the costs versus benefits of preventive care. According to the article (David Brown, Washington Post, 4/8/08), back in 1986 a health economist published a study showing that prevention activities can actually cost more than they save. Since then other studies have demonstrated the same thing.
The most obvious reason is that healthy people live longer, and generally the older you are the more healthcare dollars you'll consume. If you die off before you get into those expensive golden years, you save society money.
Another reason is that, when the odds of getting a particular disease are relatively low, the dollars spent preventing the disease for the entire at-risk population are greater than the dollars spent on the fraction of the patients who actually get sick. One example the author provides is that of a 50 year old female smoker with high cholesterol and moderate hypertension. Her odds of having a heart attack in the next 10 years are apparently 11%. The rest of the people in her situation will escape a heart attack without doing anything. But we prescribe statins for all of them, because we don't know who the unlucky 11% are, and that is very expensive. Even consumer education can be expensive in terms of the actual lives it saves, particularly because it is often ineffective in changing behavior.
Clearly there are societal benefits to a healthy population, and most people would rather do things like take statins than trust to their luck ("do YOU feel lucky today, do ya?"), but at a time when we have to decide exactly how to get the most bang for our healthcare buck, it adds a really interesting dimension to the debate.
The most obvious reason is that healthy people live longer, and generally the older you are the more healthcare dollars you'll consume. If you die off before you get into those expensive golden years, you save society money.
Another reason is that, when the odds of getting a particular disease are relatively low, the dollars spent preventing the disease for the entire at-risk population are greater than the dollars spent on the fraction of the patients who actually get sick. One example the author provides is that of a 50 year old female smoker with high cholesterol and moderate hypertension. Her odds of having a heart attack in the next 10 years are apparently 11%. The rest of the people in her situation will escape a heart attack without doing anything. But we prescribe statins for all of them, because we don't know who the unlucky 11% are, and that is very expensive. Even consumer education can be expensive in terms of the actual lives it saves, particularly because it is often ineffective in changing behavior.
Clearly there are societal benefits to a healthy population, and most people would rather do things like take statins than trust to their luck ("do YOU feel lucky today, do ya?"), but at a time when we have to decide exactly how to get the most bang for our healthcare buck, it adds a really interesting dimension to the debate.
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