Avoid having to check back and subscribe to Roll Away the Dew by email. It will take a whole pail of water just to cool you down!

Tuesday, April 7, 2009

Go ahead and shoot the messenger: Defending the US health insurance industry

The health insurance industry is not solely responsible and the source of all that is wrong with the US health care system. Posts like this are usually as welcome as unsedated colonoscopy but I am ready to post it. Even if all of the health insurance companies were merged into one gigantic non-profit organization, it would not solve fundamental issues in the health care system and probably not improve the situation.

I first became interested in working in the insurance industry while working in a psychiatric crisis center in Philadelphia. I would triage patients, work with the clinical team to develop the treatment plan and would submit this treatment plan to the insurance companies for authorization. They would decide the patients' fate. As a result, I decided that my career in health care should follow the money and that at one point, I would work for an insurance company. While this story make insurance companies look like the equivalent of Roman emperors deciding who lives or dies at the coliseum, the point is more to show that I came to work in health insurance through being a clinician and a clinician who worked with some very sick and desperate individuals. Readers can know there is at least one person in the insurance industry who had a heart at one point in their lives.

Best Data in the industry: When it comes to health care data, most think of academic medical centers and the research. However, their data comes from only their patients in their geographic area and only from their providers. Additionally, hospitals and physicians also do not have very good data systems beyond their billing systems. A provider also has to be very large for it to be economical to purchase a really robust data system attached to an Electronic Medical Record. Insurance companies have data from multiple geographies and multiple providers in claims systems that can search by diagnosis code, providers, geographies, etc. There can be comparisons between different hospitals, providers, age cohorts across a broad section. My best example of the data is that during the Anthrax scares in 2001, the government asked the large national insurance companies to review their databases for anyone who sought treatment for Anthrax.

This data is important because truly effective reform needs to be based on data-driven decisions and ultimately tracked. For example, this data can be used for development of evidence-based treatments or tracking patients with chronic diseases.

Only ones that say No: In every health care system there is some kind of rationing. We typically hear of long waits for certain elective surgeries in Canada or Great Britain which is a type of rationing. In the US we ration by not always providing health care for those without the ability to pay for it. Insurance companies ration by requiring people to pay more for the brand drug than the generic or limiting the number of days that someone can stay in a nursing facility. Insurance companies use their data to ration based on acceptable levels of care. Bad outcomes are always more expensive so insurance companies do have the financial incentive to ration based on effective medical care.

We all want to receive as much care as possible. However, there is not enough health care in the country for everyone. Doctors and hospitals do not typically refuse to provide health care services especially since they get paid to provide it and might get sued if they do not. Therefore, insurance companies are the only part of the health care industry to tell someone that the $10 generic is just as good as the $150 brand even though it didn't advertise on TV last night.

Here is one example where insurance companies rationing or saying no helped end a very invasive and effective jaw surgery. People who had jaw pain (or temporal mandibular joint disorder or TMJ) would get these extensive surgeries that would remove pain for a few years because the surgery killed all the nerves. When the nerves grew back, the pain returned. It was an ineffective, expensive surgery and is now excluded by most insurance companies.

The hard choice that will be made in health care reform is how to say no to giving someone the health care that they want. Health care is a limited resource and if we want to spread it across an entire population as equitably as possible, we need to learn to say no. Oregon's Medicaid reform in the early 90's was an example where services were ranked from top to bottom. Those on the top of the list were covered and when the money ran out, the rest were not covered.

Administration: Someone has to collect enrollment information, pay providers, pay providers the right amount when they should, and not pay when they should not. This information gets updated and revised daily. It's simple data storage and a commodity so it should be done by the cheapest vendor who can do it accurately. The insurance companies have the data systems and experience doing this. Would it make sense for anyone else to take over this function? When Medicare was created in the 60's, the federal government had Blue Cross Blue Shield handle all of these functions so the government has never done this. There is no other candidate than the insurance companies.

This is not an exciting part of health care reform. However, someone needs to pay the bills correctly. Traditional Medicare is so inefficient with paying bills that providers receive only 45 cents of every dollar billed. If providers get paid this ineffectively under a new system, it will undo the reform.

While I was working at the psychiatric facility, we were fairly good at knowing when someone really did not need an inpatient hospitalization. They weren't unable to cope at the time with their situation but rather they just didn't want to. However, when someone was hospitalized or needed treatment, we would want to keep them in treatment for much longer than they probably really needed. Kind of like you always want one more slice of pizza. That was my weakness when I worked on the clinical side and now I see that is an insurance company's strength.

No comments:

Related Posts with Thumbnails