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Tag: Health insurance

Health Care, Disagree Better

BY KIM BELLARD

On one of the Sunday morning news programs Governors Spence Cox (UT) and Jared Polis (CO) promoted the National Governors Association initiative Disagree Better. The initiative urges that we practice more civility in our increasingly civilized political discourse. It’s hard to argue the point (although one can question why NGA thinks two almost indistinguishable, middle-aged white men should be the faces of the effort), but I found myself thinking, hmm, we really need to do that in healthcare too.  

No one seems happy with the U.S. healthcare system, and no one seems to have any real ideas about how to change that, so we spend a lot of time pointing fingers and deciding that certain parties are the “enemy.”  That might create convenient scapegoats and make good headlines, but it doesn’t do much to solve the very real problems that our healthcare system has. We need to figure out how to disagree better.

I’ll go through three cases in point:

Health Insurers versus Providers of Care

On one side, there are the health care professionals, institutions, organizations that are involved in delivering care to patients, and on the other side there are health insurers that pay them.  Both sides think that the other side is, essentially, trying to cheat them.

For example, prior authorizations have long been a source of complaint, with new reports coming out about its overuse in Medicaid, Medicare Advantage, and commercial insurance.  Claim denials seem equally as arbitrary and excessive.  Health insurers argue that such efforts are necessary to counter constantly rising costs and well documented, widespread unnecessary care. 

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The Simpson’s Explain Healthcare

By KIM BELLARD

Happy New Year!  We’re starting 2022 full of hope and renewed optimism. Oh, wait; not so much. We’re not only still in a pandemic, the Omicron variant is the most infectious one yet.  Daily cases are setting new records. Our hospitals are full again. Our beleaguered healthcare workers – the ones who haven’t already thrown in the towel – are at their breaking points.  Two years in, and we still don’t have enough tests. We’re in the greatest public health crisis in a century, yet our legislators are taking power away from public health officials, and their angry constituents are forcing many of those officials to quit. We have effective vaccines, but millions still refuse to take them. 

The Simpsons – especially, Homer — has the right word for this: D’oh!

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Health Insurance is a Stumbling Block in Many Patients’ Thinking

By HANS DUVEFELT

I have a patient with no health insurance but a brand new Mercedes. He says he can’t afford health insurance. He cringes at the cost of his medications and our office visit charges. His car cost a lot of money and I know that authorized Mercedes dealers charge around $140/hour for their technicians’ (not mere mechanics) time. A routine service costs several hundred dollars, which he seems more okay with than the cost of his own healthcare visits.

His new Mercedes is under warranty, but his body is not. He is risking financial disaster if he gets seriously ill with no insurance coverage.

I have another patient who needed a muscle relaxer for a short period of time. His insurance wouldn’t cover it without a prior authorization. The cash cost was about $14. We suggested he pay for the medication and told him his condition would have resolved by the time a prior auth might have been granted. He elected to go without.

The brutal truth is that a primary care doctor’s opportunity cost, how much revenue we can potentially generate by seeing patients, is around $400/hour or $7/minute. There is no way I could request a prior authorization in under two minutes. So it would have been more cost effective to pay for his medication than to do the unreimbursed paperwork (or computer work, or phone work) on his behalf. But, of course, we can’t do that.

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Biden Should Extend a “Public Option” as a Message to “Health Care Royalists”

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By MIKE MAGEE

In this world of political theatrics, with Democratic legislators from Texas forced into exodus to preserve voters’ rights, and Tucker Carlson rantings about Rep. Eric Swalwell riding shirtless on a camel in Qatar streaming relentlessly, Americans can be excused if they missed a substantive and historic news event last week.

On Friday, July 9th, President Biden signed a far-reaching executive order intended to fuel social and economic reform, and in the process created a potential super-highway sized corridor for programs like universal healthcare. In the President’s view, the enemy of the common man in pursuit of a “fair deal” is not lack of competition but “favoritism.”

To understand the far-reaching implications of this subtle shift in emphasis, let’s review a bit of history. It is easy to forget that this nation was the byproduct of British induced tyranny and economic favoritism. In 1773, citizens of Boston decided they had had enough, and dumped a shipment of tea, owned by the British East India Company, into the Boston Harbor. This action was more an act of practical necessity than politics. The company was simply one of many “favorites” (organizations and individuals) that “got along by going along” with their British controllers.  In lacking a free hand to compete in a free market, the horizons for our budding patriots and their families were indefinitely curtailed.

Large power differentials not only threatened them as individuals but also the proper functioning of the new representative government that would emerge after the American Revolution. Let’s recall that only white male property owners over 21(excluding Catholics and Jews) had the right to vote at our nation’s inception.

Over the following two centuries, power imbalances have taken on a number of forms. For example, during the industrial revolution, corporate mega-powers earned the designation “trusts”, and the enmity of legislators like Senator John Sherman of Ohio, who as Chairman of the Senate Republican Conference, led the enactment of the Sherman Antitrust Act of 1890.

He defined a “trust” as a group of businesses that collude or merge to form a monopoly. To Sen. Sherman, J.D. Rockefeller, the head of Standard Oil, was no better than a monarch. “If we will not endure a king as political power, we should not endure a king over the production, transportation and sale of any of the necessities of life”, he said.   The law itself stated “[e]very contract, combination in the form of trust or otherwise, or conspiracy, in restraint of trade or commerce among the several States, or with foreign nations, is declared to be illegal.”

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Election Issue Spotlight: “Junk” Insurance Makes a Pandemic Even Worse

By ROSEMARIE DAY and NIKO LEHMAN-WHITE

One of the most important responsibilities of the American government is to protect its citizens from harmful industry practices, from lead poisoning to dangerous pharmaceuticals to financial meltdowns. Its record is far from perfect, but government regulators usually act in good faith and in turn earn the trust of those they protect. As we head into Tuesday’s election, it’s important to shine a spotlight on the fact that the Trump administration has betrayed that trust yet again. They have allowed low-quality, unregulated forms of insurance called Short-Term Limited Duration Insurance (STLDI) to prey upon those who lost their jobs during this pandemic. Also known as “junk” insurance, this issue has gotten far less attention than the need to protect people with pre-existing conditions. But the consequences of its inadequate coverage can be just as devastating.

Only 57% of STLDI plans cover mental health care, only 29% cover prescription drugs, and virtually none cover pregnancy. These plans are also allowed to discriminate against the sick, which most do in order to save money. STLDI managed to penetrate the market through a combination of cheap prices, lucrative broker incentives, and deceptive marketing.

Consumers get very little back for their money with these plans. Plans on the Affordable Care Act’s exchanges must spend 80 cents out of every premium dollar collected on care. In 2018, the top five STLDI insurers spent only 43 cents.

Originally envisioned as short-term solutions to gaps caused by unexpected coverage loss, the Trump administration extended their maximum length from three to 12 months and allowed renewals that can essentially extend them to three years, thus drawing consumers away from the individual markets established under Obamacare. This was essentially a kick in the gut for the law, after the current administration was unable to win any legislative or court battles against it.

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Health Insurers Ride High for Now, But Watch What’s Coming Next

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By KEN TERRY

In the strangest healthcare business story of 2020, the major health insurance companies are thriving despite—or because of—the pandemic. As the second quarter reports of United, Anthem, Cigna and other insurers reveal, their COVID-19-related costs were outweighed by the sharp drop in claims for other healthcare services.

As a result, the second quarter operating gain for Anthem, one of the largest national carriers, jumped 65% from the prior-year period, while the portion of its premiums spent on member benefits dropped to 78%. The earnings of UnitedHealth, similarly, vaulted 98% as the percentage of its premiums spent on health care fell to 70.3%. Such a low “medical loss ratio” has probably not been seen since the 1990s.

At the same time, the big insurers’ membership has been rising, but not among workers covered by employer-sponsored plans. Commercial insurance members served by United, for example, fell by 270,000 to 26.8 million, following a drop of 720,000 in Q1. In contrast, the number of people in United’s Medicaid managed care plans rose by 330,000.

These trends track with the short-time fallout of the pandemic. Families USA reported that 5.4 million workers who lost their jobs from February to May also lost their health insurance. Another study predicted that by the end of 2020, 10.1 million people will lose employer-based insurance tied to someone in their household.

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Health Insurance Needs to Grow Up

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By KIM BELLARD

I’ve been covered by private insurance my entire life.  Even more telling, I worked in the health insurance industry for — gasp! — some thirty years.  It’s not just paid for my healthcare, it’s financed my life.

Today, though, for the first time in my life, I’m covered by public insurance — and I couldn’t be more relieved.  

Now, I’m not going to go all Wendell Potter.  I know many people have their health insurance horror stories, but, sadly, people have them about pretty much every part of the healthcare industry.  I believe most people working in health insurance, like most people working in healthcare generally, sympathize with the people they serve and are just trying to do a good job.  

The problem is that the health insurance model has outgrown the times.  I’ll try to explain some ways how.

Premiums

Once upon a time, most people had employer coverage, and those employers paid all or most of its cost.  Those days are gone.  Employer coverage is still the predominant form of private health insurance, and employers still pay the majority of its cost, but percentage of people with employer coverage continues to drop and the amount they pay for it continues to increase.  

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Health Plans Need to Go Farther To Get Us Through the COVID-19 Crisis. Employers Can Encourage Their Cooperation.

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Brian Klepper
Jeffrey Hogan

By JEFFREY HOGAN and BRIAN KLEPPER

Among its less appreciated but more worrisome impacts, COVID-19 threatens to destabilize America’s health care provider infrastructure. Patients have largely been relegated to sheltering at home and, to avoid infection, are avoiding in-person clinical visits. The revenues associated with traditional physician office visits have been curtailed. Telehealth capabilities are gradually coming online, but are often still immature. The concern is that many practices will be financially unable to keep the doors open, compromising access and healthy physician-patient relationships.

Health plans have become health care’s bankers, controlling the funding that fuels larger care processes. Health insurance companies and health plan administrators rely on networks of doctors and hospitals to deliver health care services. They also rely on premium payments from employers to administer and pay for health care. In conventional fee-for-service, pay as you go arrangements, providers are paid after they have delivered care services. The stability of this approach, of course, assumes an unhindered flow of patients receiving care.

When the stability of that flow is disrupted, as it has been with COVID-19, physician practices become vulnerable. Solving that vulnerability would give members access to critical services – primary care, specialty care, urgent care and pharmacy coordination – during this epidemic. Without these resources, members will be forced to turn to overburdened hospitals, where they risk increased COVID-19 exposure.

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The Digital-First Health Insurance Startup Changing Healthcare in Nigeria | Femi Kuti, RelianceHMO

By JESSICA DaMASSA, WTF HEALTH

RelianceHMO is a Nigerian-based health insurance startup that aims to turn the traditional health insurance world upside-down. CEO Femi Kuti delves into how his company is using mobile phones, telemedicine, data science, and even underwriting (!) to make health insurance cheaper — and more accessible. With more than 1800 hospital partners across Nigeria, RelianceHMO is making a name for itself, but how does it plan to scale throughout Africa? And, what can payers around the world learn from their approach as they seek to make health insurance easy and affordable for Nigeria’s 190M uninsured? We love talking about disrupting payment models in healthcare and after hearing Femi’s story, you’ll understand why.

Filmed at Bayer G4A Signing Day in Berlin, Germany, October 2019.

Asinine, Backasswards Colonoscopy Insurance Rules Make Patients Decline Medically Necessary Testing

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By HANS DUVEFELT, MD

I’ve had several telephone calls in the last two weeks from a 40-year-old woman with abdominal pain and changed bowel habits. She obviously needs a colonoscopy, which is what I told her when I saw her.

If she needed an MRI to rule out a brain tumor I think she would accept that there would be co-pays or deductibles, because the seriousness of our concern for her symptoms would make her want the testing.

But because in the inscrutable wisdom of the Obama Affordable Care Act, it was decided that screening colonoscopies done on people with no symptoms whatsoever are a freebie, whereas colonoscopies done when patients have symptoms of colon cancer are subject to severe financial penalties.

So, because there’s so much talk about free screening colonoscopies, patients who have symptoms and need a diagnostic colonoscopy are often frustrated, confused and downright angry that they have to pay out-of-pocket to get what other people get for free when they don’t even represent a high risk for life-threatening disease.

But, a free screening colonoscopy turns into an expensive diagnostic one if it shows you have a polyp and the doctor does a biopsy – that’s how the law was written. If that polyp turns out to be benign, or hyperplastic, there is no increased cancer risk associated with it, but you still have to pay your part of a diagnostic colonoscopy bill because they found something.

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