Monday, August 15, 2016

If I Were in Charge.....

What is the big deal about single payer medical insurance that makes so many people angry and upset?  Actually, I think it's the insurance industry that promotes activity against single payer medical insurance even though they have already made inroads into Medicare by offering supplemental medical insurance as well as Medicare-approved plans.  Maybe it's time to take a hard look at what Americans need vs. what they currently receive in terms of medical insurance, i.e. if I were in charge....

We need medical insurance that doesn't make us sick or make it necessary to hire someone to deal with it for us (Patient Advocates).

Here's an example of this: last spring I received a letter from a company I'd never heard of telling me that they'd assessed my medical need for a medication I was taking, and they'd approved coverage for that medication by my insurance through October. My first reaction was "Oh, no! Who are these people? Why are they assessing my medical need for a medication? They know absolutely nothing about me!" I was in a panic that my insurance would eventually decide not to cover this medication that I need, I'd have to go off it because I couldn't afford to pay for it (unless the drug company would be able to help me), I'd become quite ill again, end up in surgery and cost the insurance company tens of thousands of dollars more than if they'd covered the medication. Not to mention the stress and the devastation of illness.

I sent my doctor's office a note asking if the prior authorization had been revoked. I thought that we'd gotten a prior authorization for a year from my insurance company. So why did I get this letter from a company I'd never heard of? They assured me that they'd gotten the prior authorization, and sometimes medical insurance companies run medical necessity assessments on a quarterly basis, especially for expensive drugs. What?  They think my necessity will change every three months? Wrong.

Of course, this incident upset me and angered my medical team. It created work for me that took me away from my livelihood. Does my medical insurance care? No. I spend so much time on issues like this with my insurance, I sometimes think it could be a full time job. I'm in relative good health right now (thanks to that medication) but I don't know how someone who's very ill can cope with this work. I have learned that there are people you can hire to do it for you if you don't have a family member adept at maneuvering through the insurance mazes. My insurance company even hires an outside company to do their medical necessity assessments.

Doctors decide medical necessity, i.e. the patient's doctors not doctors who have never even met or seen the patient that work for a company that works for the patient's medical insurance. Wouldn't life be a lot simpler if that were truly the case? It used to be the case years ago.


We need medical insurance that's easy to understand.

When I began dealing with medical insurance after my chronic illness diagnosis 15 years ago, I struggled to read through my policy. I still need help with understanding how the medical insurance industry works. Does anyone else get the feeling that they make their policies and procedures difficult to fathom in order to catch patients or to protect themselves from paying out too much on claims? Policies and procedures need to be written in plain English that anyone can understand, and need to be simple to do, fast, and supported by the company.

For example, I have a prescription for injectable B12 that I must do every 3 weeks. In my insurance policy, it says that coverage is for a one month supply of a medication. OK. Sometimes, because of the every-3-week schedule, I need to inject the B12 twice in one month. I thought that getting 2 vials per month rather than 1 would solve the problem. So, I talked with my doctor. She called the pharmacy with her approval, but would not write a new prescription because my dosage was once every 3 weeks. But the pharmacy couldn't do the 2 vials per month because of the terms of my insurance. I finally asked the pharmacist how I was supposed to follow my doctor's dosage instructions. She told me that I could get my prescription refilled every 3 weeks and my insurance would cover it because of the doctor's prescription.  Who knew that the one month supply restriction stated so clearly in my policy would not apply to my B12 prescription?

Supporting bureaucratic language and procedures wastes time and money for everyone. Patients don't have the time or resources to be constantly checking on the rules medical insurance companies do not publish in their policies.



We need medical insurance that isn't more expensive than the medical expenses that we have.

If the insurance coverage pool consisted of every American, i.e. approximately 400 million people, that would be the biggest risk pool any insurance company could ever wish for. That in and of itself could bring down costs for both insurers and the insured. I don't buy that insurance companies are non-profits, that they use their surplus each year to cover shortfalls.  There was a gigantic insurance company in the last year who tried to claim a loss in my state when they had a surplus pool many times the amount of their alleged loss, and they were supposed to use that surplus to cover that loss.  The reason they were trying to claim a loss was to charge people more for their premiums and coverage.


Insurance companies are in the business of making money, pure and simple. In that respect, they are for-profit entities. We need to take out the whole notion of making money from medical insurance.

We need medical insurance that applies to everyone, without any kind of discrimination, no matter what age or health status.

We now have the situation in the U.S. that several big medical insurance companies have pulled out of participating in the ACA (because they are allegedly losing money), and therefore, their policies are no longer eligible for the tax credit subsidy offered under the ACA for people who have problems affording sky high premiums. This move by these companies has shrunken the number of policies available to patients and the amount of coverage.

I think that it should not be a choice for insurance companies, but a requirement on the state and federal level that they participate in the ACA. When they don't participate, that means that they can return to their practices that led to the ACA years ago, like discriminating against people with chronic illnesses, for example, and older adults.  And charging so much in premiums and out-of-pocket expenses that people cannot afford to buy coverage. We are already seeing this happening.

We need medical insurance that will cover everyone equally, that is reasonably priced, that has streamlined procedures for administration. Some have suggested Medicare for all as a solution, but Medicare needs cleaning up itself.  However, Medicare is single-payer medical insurance -- yes, the U.S. already has single-payer medical insurance for everyone 65+ years old. Why not channel all the energy being spent on insurance companies and the ACA into cleaning up Medicare, making it more efficient and less prone to fraud, and phasing it in over the next 10 years as a single-payer medical insurance for every person no matter what age he or she is in the U.S.?

And we need to make the insurance industry want single payer medical insurance.  

Guess who screams the loudest against a single-payer medical insurance system available to all? Of course. The medical insurance companies. They haven't the imagination to figure out that they could still play a role, and therefore not lose their business, in a single-payer system. But no one who has supported a change to single-payer insurance has ever explained how it would be in the best interests of the insurance industry to make that change.

First, most medical insurance companies already offer Medicare-approved plans for seniors. Second, those plans can be the foundation for phasing in Medicare for all, and the insurance companies can contract (as they already do) with Medicare to be regional centers for processing Medicare claims. What then happens is that as Medicare phases in for all ages, the insurance companies become independent contractors working for Medicare, i.e. the government. They can be a part of streamlining Medicare's business processes so that everyone saves money and time. And Medicare will then have the clout to negotiate with drug companies and pharmacies for lower drug prices for patients, and will be able to continue to establish pricing for hospitals, clinics and private practice physicians.



And so.....
I often tell people that medical insurance companies are not our friends. They really don't care if we live or die. All they care about is whether or not they must pay out on claims. They don't want to pay out. Instead, they want to accumulate as much money as possible, ostensibly to pay out on claims, but I wonder just how much of that money goes to executive pay, perks, and non-business expenses. The insurance industry, like the pharmaceutical industry, could benefit in the long term from financial transparency and being more responsive to the market. And from transforming into a single-payer system under Medicare.

2 comments:

cheryl (clee') said...

Aaack! You can add my story to your font of patient-knowledge. At my last dentist appointment, I asked if they accepted my new (assisted) insurance. They did not. I had been paying cash for several years because I was not insured or employed. Now, I was told they did NOT accept cash if I had insurance! So I was not even able to see my dentist and walked out. What the???? My brother had a similar experience with trying to find a dentist who would accept his assisted-insurance. He was very unhappy with the one he had found, couldn't find another, and couldn't afford cash even if they would have accepted it.

Gina said...

Dentists, I suspect, somehow get away with far more than other medical professionals, and I have no evidence to prove it. I'm sorry to hear about your experience with the dentist. I recently learned that when one has state-assisted insurance like Medicaid, it's possible to lose that insurance if one tries to pay cash, especially if the service or medication is covered already. I suppose the thinking is that if you can afford to pay cash for anything, you don't need the state-assisted insurance. I'm in the process of searching for a new dentist because the one I'd been going to for about 20 years doesn't accept state-assisted insurance and are "out of network" for all dental insurance. A former dentist referred to me the last practice she worked for before retirement but it's been a HUGE challenge to get in because they accept only 10 new patients on state-assisted insurance per month, and last month when I called and called and called for the first 2 minutes they were open on the first day of the month, I still didn't get through in time to make the first 10. I'll try again for September (this has been going on since April) but if it doesn't work this time, I may look elsewhere. Too bad, too. I don't plan to be on state-assisted insurance forever! Thanks for sharing your experiences!