The Insurance Intelligencer
6/25/09
What is the matter with health insurance?
I can put it in three words: Insurance. Drives. Care. A private, for-profit corporation gets to decide whether or not they will pay for lifesaving treatments, which are always astronomically expensive.
Make no mistake about it -- health insurers are for-profit businesses, no matter what they call themselves. It is the job of a business to minimize operating expenses, and to maximize profits. That is what a business does.
We would not expect any other business to care about our lives, or about our quality of life. We would not agonize over the fairness or unfairness of any other business's decisions. Why are we so shocked and disappointed when we discover that Acme Insurance is not the least bit moved when we tell them, "But, without this treatment, I will die"?
Because of the propaganda.
I am not outraged that a bureaucracy makes unfair decisions, or that a business doesn't value lives above profits. That's life in the free-market economy. What does rile me up is the vast body of propaganda, designed to make us believe that they do.
The website with photos of happy, healthy insured people. Riding their bicycles, gazing up at the name of the insurance company: Neighborhood Healthy Choice United. You know, the insurance company that will refuse to pay for your child's brain surgery. The same insurance company that, if you need out-of-network treatment for breast cancer, will bill you for an extra $200,000 beyond what they consider to be "reasonable and customary." Some choice.
We have lived under this insurance-driven system for forty years -- so long that we accept it without question. We cannot imagine any other way.
In what world is it acceptable for a health insurer to pay for a lifesaving treatment for a hundred cancer patients, then to turn around the next day, and deny the same treatment as "Experimental"?
In what world is it acceptable for a health insurer to have the sole, unfettered power to decide how much they will pay for medical treatments? To keep this payment information secret. And to generate the numbers themselves.
In what world is it accepatable for a health insurer to deny a cancer patient the one treatment proven to prolong his life -- a treatment which costs $50,000 -- while spending $1.5 million on routine in-network treatments and surgeries, with no scientific proof that they will prolong his life, or give him any clinical benefit whatsoever?
Not in my world.
Let's see a few of the ways in which insurance drives medical decisions.
Your doctor: The gatekeeper
Your Primary Care Physician looks like a doctor. He wears a white coat. He asks the questions that doctors ask.
As you sit in his office describing your symptoms, you assume that Dr. PCP's job is to discover what is wrong with you, find the best treatment for your condition, and order the treatment for you.
Think again. The Primary Care Physician's job is to be the gatekeeper. In other words, to control access to medical services. A job which fulfills the primary goal of a business, which is to control operating expenses. Sounds like an insurance job, not a medical job.
If the best treatment for you does not happen to be offered in the insurer's network, it is not his job to find it, to offer it, or even to know about it.
This is one of the deeper problems of insurance-driven treatment.
I have a late-stage cancer. There is one out-of-network treatment that could rid me of the cancer, and give me a 70% chance of non-recurrence. This treatment has been performed, studied, proven for thirty years. In what world is it acceptable for the Chief of Oncology to say to me:- There is no treatment for your disease.
- If there were a treatment, they wouldn't pay for it.
- If you had this treatment, you would be disabled.
- I wouldn't send my mother for this treatment.
Ignorance? Acceptable. Because, in the insurance-driven world, if we don't have it in-network, it doesn't exist.
Lies? Acceptable. If he champions an out-of-network treatment for me, it will be a monumental hassle for him, and they won't pay in the end. My current local doctor is smart, diligent, respectful, and hard-working. However, even he is infected with insurance-think. Whenever I bring him new material to read about the treatment which saved my life in 2005, he says, "Of course, your cancer is so rare ... we won't see any more cases of it."
The horrifying presumption is that it is our job as insurance medical providers to treat the lowest common denominator of diseases and conditions. Why would we go out of our way to learn about a "rare" disease?
I belong to a very small HMO. I am not privy to medical records. I personally know of ten members of the HMO who have been diagnosed with my type of cancer. One of them was the wife of an HMO doctor. She was mistreated there for three years, until a friend happened to tell her about me. I talked to the patient, and to her husband the rheumatologist. They called my expert surgeon, but it was too late -- her disease was too advanced. She has most likely died by now.
This disease -- appendix cancer -- may have been rare back in 1962, but it is not rare now. However, my doctor will always see it as rare. Why? Because there is no treatment available in the network.
Even if you have the most common cancers, the best, most effective, most cutting-edge treatments may not be available in-network. As a matter of fact, they probably won't be, as insurance companies are very slow to approve new treatments. Like thirty years slow. Will your doctor know about them? Will he tell you about them?
What treatments your doctor offers are driven by insurance.
Denials and reimbursement strategies: How they shape medical care
We know that denials allow the insurer to not pay for that treatment, in that particular case. Of all people who receive insurance denials, only one-half of one percent ever appeal the decision.
If the patient is ambitious enough to appeal, and get the denial reversed -- still no problem for the insurance company. They will simply reduce reimbursement on the other end. Once the lifesaving treatment has been performed, Acme Insurance will delete codes, bundle codes -- whatever it takes to reduce reimbursement to pennies on the dollar.
Don't worry about Acme Insurance. Even if you make them pay for non-routine payments, they won't pay much.
We see that the insurer has many ways of reducing their operating expenses: Delay, deny. And, when you have to pay, don't pay much. Reducing expenditures is a perfectly natural practice for a for-profit business.
However, there are larger implications. Insurance drives care.
There is a perfectly good treatment for liver tumors called Y90 radioembolization. It involves introducing radioactive microspheres directly into the liver, via the hepatic artery. This treatment improves symptoms and prolongs life for people with primary liver cancer, and liver metastases from breast cancer, colon cancer, ocular melanoma, and neuroendocrine tumors.
Recently, a large medical facility had to stop offering this treatment for most cancers. Insurers vigorously denied it, or paid so little for it that the provider was losing about $10,000 per treatment. They couldn't even cover the cost of the microspheres.
Consequently, people won't be getting this treatment anymore at this medical center. Soon, other medical centers with have to stop offering it, too. Unless, of course, they bill Medicare enough to make up for the appalling shortfall from private insurance.
Is this acceptable to you? What if your mother needs this treatment, or she will die? If she is denied, I can write an appeal for her. However, if the treatment is no longer available, there is nothing that I can do.
What would the Insurance Warrior do?
I usually refrain from pontificating about the larger insurance issues. However, more and more people are asking, "What would you say, if Barak Obama asked you what to do about health insurance?"
First, Barak Obama should ask me about health insurance. Not only have I thought deeply about these issues, but I see up close and personal how insurance company decisions play out in the lives of real doctors and patients -- including myself.
As it stands now, the insurance company gets to decide whether or not we will get the astronomically expensive lifesaving treatments that the insurance company is going to have to pay for. This is insane.
Peer-to-peer reviews are performed by the same Medical Director of the insurance company who denied the treatment in the first place. He is not a peer, and it is not a review. The last independent review that I got mixed up with was for a technologically complex cancer surgery. The "independent review organization" was a chiropractor with a post office box in Lubbock, Texas. With an independent review, there is no accountability, no input, no recourse, and no oversight. They could uphold 100% of insurance denials, and nobody would ever know.
No matter how much you pretty it up, and try to give the illusion of due process -- this is the world's worst conflict of interest.
I would take both the research about which treatments to offer, and the decision on when to approve them -- out of the hands of the insurance company. Most of the treatments denied by insurance companies have more scientific proof of their efficacy than the treatments routinely offered by the insurance companies. They have no track record in making good decisions about treatments, it needs to be taken out of their hands.
A truly independent entity would be tasked with finding the treatments most likely to give a good outcome -- regardless of whether the doctor or facilty was contracted with anybody's insurance company.
Then, so that all doctors don't quit the profession, and all medical facilities don't go broke -- I would task my independent entity with setting fair reimbursements for medical services. I would also outlaw fraudulent and deceptive practices designed to unfairly reduce reimbursement.
We don't expect insurance companies to operate at a loss. Why should we expect the medical providers who are saving our lives to do so?
Give Barak Obama a call. I am eager to talk to him about health insurance.
Happy and peaceful Insurance Warrior-ing,
Laurie Todd
********
My new book is here! It's a CD!
It answers all of your questions about how to write an appeal!
It includes a sample appeal for you to edit and use!
"The Sample Appeal: More Insurance Warrior Wisdom"
SAVE $5 on the book/CD set.
|