Friday, June 15, 2012

A Perfect Storm - the second ingredient

And that would be The Games Health Insurance Companies Play.  Again, my previous blogposts have covered this landscape with examples and details.  However, and this is just anectodal to me, the ways these games have been played have gotten worse recently...maybe because they see the writing on the wall with healthcare reform not necessarily going their way (yet...).

First, to preface, I have no problem with what insurance companies are.  If they are for-profit entities and they are beholden to their stockholders, their mission and their existence is clear.  What is NOT clear is the ROLE that they play in the HEALTHCARE SYSTEM IN ITS ENTIRETY.  What is clear to me is they have wedged themselves been the doctor and the patient and holding the money that is the transfer of payment for services rendered by the physician.  Aside from the payment formula disparities and lack of prioritization (See Ingredient #1), the doctors are beholden to what an insurance company will pay them for any services rendered to a patient.  These are what I refer to as the Games Health Insurance Companies Play.  There are several games I'd like to highlight that us physicians, whether we know it or not, are unwilling participants and ultimately the perennial losers in these games.

1.  The "We won't pay you because we don't know if your patient is on our insurance or not, and oh...we don't have that information yet..and we won't pay you anyways" game.  There's always a disclaimer when you hear the voice messaging system when you call the health insurance companies that they cannot guarantee payment of services based on the information they're going to tell you about eligibility for a patient.  Ever wonder why?  Because at any moment's notice, something may inexplicably change, without knowledge of the patient or to the physician or to the employer (if it's employer based) and we're at the mercy of whether the insurance company ACKNOWLEDGES that a patient is eligible.  This is even worse when it comes to secondary insurance; then it's another game of....

2.  The "The OTHER insurance company is paying it first" game.  And it goes back and forth, back and forth.  Payment, anyone?

3.  The "I want my money back" game.  Because of the first game, or the second game, or for some other lame reasons because they didn't know their own rules.  It's a total time waster, and a waste of resources.

And for the patient's point of view...the following are games that I'm very upset about.

4.  The "We're gonna make your doctor's life hell so the doctor will never want to order another test again" game.  I understand that some procedures and tests are very expensive and will need a review.  But by making the whole process to get authorization a total time waster for the doctor only so that the doctor will never want to deal with them and think twice about ordering an MRI (for instance) for where there are already standards and guidelines that we're taught over and over again.  I do not find it useful for an insurance company to have me wait 30-60 minutes on a phone to get a human person to tell me that I followed the guidelines and they're going to grant it anyways, and to also personally denigrate you on the phone after you've already met the guidelines and then tell you that your an incompetent doctor because I care about my patients and actually listen to them (by the way, that truly and shocking did happen to me).  I keep doing it anyways, but knowing that I lost 30-60 minutes of my time doing this.  When you start adding it up, it starts becoming a reality that they don't care about my time.  They only care about their profits (which I guess they are entitled to) but this is exactly where the SYSTEM is all wrong.  Take the profit motive out of it and we'll already be in a much better place.

While on this note, I will say that I understand that the government (and rightly so) wants to crack down on fraud and unnecessary testing.  Of course, the government is beholden to the people.  The motives of insurance companies are not so clear cut, and at its worst, greed and maliciousness are part of it.  But I can say that if we fixed ingredient #1 and made it less of an incentive to commit fraud for expensive procedures, hospitalizations, etc; we wouldn't necessarily be in this mess to begin with.

5.  The "You have to pay more for health care services and we keep more of it anyways" game.  Not too long ago, people only had to pay a small copay for their visits.  Now we're dealing with hundreds and thousands of dollars of yearly deductibles before an insurance company is paying a penny for services.  What's the point of having insurance if you can't pay for these deductibles anyway and you're still paying the insurance company money to have "health" insurance.  So many of my patients can barely afford to pay the deductible amounts.  And then to lose your job, you're really stuck, even with COBRA coverage.

All these games, to me, are an insult to what should have been a simple, common sense transaction for services between the patient and the physician.  What is a viable alternative?  A single-payer system where everybody's in and nobody's out coupled with priority of services to preventative care and fair pay for primary care providers.  None of these games are played in other countries with single payer program or universal health insurance.  When I tell some of my peers in other countries about my experience, they laugh, take pity on me and they think we're a bunch of suckers.

Alas, that is where this second ingredient did me in...I saw no hope in the next decade that this was ever going to change given the political climate we're in.  Worse yet for me is this simple fact...THE HEALTH OF OUR PEOPLE IS NOT A GAME.


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