Insurers are in the cat-bird seat for now
In the debate about health care reform, it was emphazized that to cover the under- and uninsured, the healthy escape from the risk pool; this raises the per capita cost of coverage of those who are left. Rate increases are bubbling up all over the country; people are being pressured into buying increasingly expensive health insurance that there is good reason to believe wouldn't be there when it is really needed.
To paraphrase a colleague said, "Mmmmm.... maybe we can learn something from the way pods of hungry whales hunt herring—surround their prey with "bubbles"* ["Humpback Whale: Hunting Technique," YouTube] so they panic into a swirling, confused unprotected ball of fish and the predator takes a larger bite?
* The "bubbles" are the threats of being unable to afford the healthcare you need from job loss, cost sharing/out-of-pocket expenses, bureaucratic interference, denials, delays, contract exclusions, preexisting conditions like having a uterus, and rate increases.
Predicating this tirade of mine is the fact that advocates of single-payer are often excluded from high-level discussions. Nevertheless, at the same time, we know that:
- Employment base coverage isn't universal.
- There are huge gaps in vital coverage in our current approach (e.g., doughnut holes).
- As much as 3/5ths of the spending in the U.S. is already publically administered. [Health Affairs, July 2002. Woolhandler, Steffi]
- Insurers say regulating premium increases "won't do anything to reduce the soaring costs of medical care." So, we sit on our hands, seemingly afraid to stop transferring our money to private insurers--$2.2 Trillion was spent on Health Care in the US in 2007. Insurance companies absorbed over 25% of that meaning that we're paying over $500 Billion per year to the wealthy people who own and run the insurance companies even as 2.7 million lose coverage [Feb. 2010].
- Insurance companies are afraid that regulation is coming and they might not be able to raise rates too much later. Fredrick adds: "I suspect that the insurance companies are raising rates now for the same reason that bailed-out bankers are taking outrageous bonuses."
- Doing nothing is not an option.
"The Costs of Failure: Economic Consequences of Failure to Enact ... Health Reforms," The Commonwealth Fund Blog.
See Also "A Roadmap to High-value Healthcare Delivery," by Denis A. Cortese, MD and Robert K. Smoldt, MBA where they discuss some of the concepts of and options for improving health care delivery; the authors "zero in on the need to change existing healthcare provider financial incentives toward ‘pay for value’* as a key stepping stone toward high-value healthcare delivery."
* "Value" is defined as "patient outcomes divided by total cost per patient over time."
So let's see - Insurers create bureacracies and bureaucratic hurdles. In daily medical practice, that drives me nuts! They do case management and try to reduce readmissions; that is good, but they have a conflict-of-interestdon't they—They see profits before patients' needs.
How to Play the Insurer Game Well
You are a practitioners, frustrated by insurers who 'have the best interest of patients at heart.' Before you hire even more staff just to wait on the phone for "prior" auths, get a med the patient has been on for 30 some odd years approved, or worse, get yourself an ulcer, be sure to review local coverage policies (usually available online), precedents and the Farmer's Almanac while you are at it. It is also important to know the players. Dr. Elston writes in an editorial, "In the past, payers mostly were the insurance companies who assumed the risk for providing health care coverage and established the policies for those plans. Now many payers act as health benefits administrators for employers who self-insure" and who are focusing on the cost of care. These Human Resources or Benefit Manager types would love to see cost-benefit and efficiency analysis if they had the time (but they don't.)" Unfortunately, they have to take "appropriateness," and "medical necessity" as a given.
Dr. Elson continues: "The health benefits administrator is accountable to the employer who pays the bills but does not set a policy regarding what is or what is not covered by the plan. In this scenario, the insurance company does not set a policy but merely carries out the policies of the employer.” I really cannot agree....the employer will decide how much to spend on what, but s/he should not be making those decisions in a vacuum. Imagine one of your employees having emergency surgery and finding out, before or worse, after the fact, that the anesthesiologists aren't part of the deal??
If You've Been Denied a Reasonable Request, There's the Inevitable Appeals Process
• Demeanor: When appealing a denial, know who you are dealing with; the roles and authority people are and are not entitled to play. Always be professional and cooperative. Remember, you are "representing your specialty as well as the patient"...so be "professional and persistent if you are in the right."
• Differentiate "contractual exclusions from medical necessity determinations" in any appeal. A medical necessity denial is supposed to come from a fellow doc who, in this case is not practicing medicine. In fact, remember, insurance companies are not practicing medicine, either. Let it be known (Yes, I am talking about a threat*), if your patient is harmed by a denial of a covered benefit, there will be accountability (Unless ERISA pre-empts state law - more on that another time). *See Nataline Sarkisyan.
• Distinguish insurers from benefits administrators. (An "insurer sets a policy and a health benefits administrator follows a policy")
• Deliberate with peer-reviewed, published evidence-based medicine references in hand that can be used to "support your recommendations: case reports carry little weight, but higher levels of evidence can effectively be used to help your patient."
• Designated Hitter: declare your medical and/or specialty society will be kept abreast of these discussions and proceedings "if you feel you are not getting anywhere and the decisions have broad implications."
Dirk M. Elston, MD. “Using Evidence-Based Medicine to Appeal Medical Coverage Decisions.” Cutis.com 2012;90:11
[Especially, see Table 2: "Standard Terminology Used for Levels of Evidence in Evidence-Based Medicine.]
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