Insurance Companies: A Major Problem in America's Health Care

Having gone through proton therapy and been on an expensive medication myself during the last year, I know first hand the problems most Americans face when seeking medical treatment.  One of the biggest is the effort by insurance companies to deny coverage and/or restrict permitted medications for the simple purpose of reducing payouts. The companies that happily take your premium payments simply do not want to have to pay out claims when their insureds need medical care or expensive medications.  In my own case, everything was eventually covered after protracted confrontations with my prescription insurance carrier.  Many are not so lucky and the reality is that most of us find non-medical personnel trying to dictate our medical care.  An op-ed in the Washington Post looks at this problem which, to me, is the reason a private for profit health insurance system without a significant challenge of a public option will never best serve individuals' and families' needs.  Here are column excerpts:

We know how important it is to have insurance so that we can get health care. As a physician, parent and patient, I cannot overemphasize that having insurance is not enough.

As a gastroenterologist, I often prescribe expensive medications or tests for my patients. But for insurance companies to cover those treatments, I must submit a “prior authorization” to the companies, and it can take days or weeks to hear back.

Because it ends up with the desired outcome, you might think this is reasonable. It’s not. On most occasions the “peer” reviewer is unqualified to make an assessment about the specific services. They usually have minimal or incorrect information about the patient. Not one has examined or spoken with the patient, as I have. None of them have a long-term relationship with the patient and family, as I have.

The insurance company will say this system makes sure patients get the right medications. It doesn’t. It exists so that many patients will fail to get the medications they need.

I’ve dealt with this system from the patient side, as well. My daughter has a rare genetic disorder . . . She receives applied behavior analysis therapy, an approach often used for autism, and which has been wildly successful in improving her skills and communication. But recently, our health insurer reduced the amount of therapy they thought she needed.

I probably have better access than almost anyone else can get, yet the ability of my daughter’s providers to mitigate denials for services they deem appropriate is slow and often ineffective.

My daughter can languish for months or years not receiving care that every highly qualified person who treats her agrees she needs. While we wait, the window to give her a little bit more function, a little bit less suffering and a little better life gets smaller.

Consumers have a right to appeal denials for health-care services, but regulations still largely focus on the process, not the content. For instance, insurers are required to notify you in writing of a denial, and patients have the right to an internal appeal; if that fails, some states also allow for an external review.

Insurance companies know that many patients don’t bother to appeal at all. A smaller fraction ask for an internal review, and still fewer seek or even know about external review options available in most states. Of the cases that do end up under external review, almost a third of all insurer denials are overturned. This is clear proof that whatever process insurers have to determine medical necessity is often not in line with medical opinion. A study of emergency room visits found that when one insurance company denied visits as being “not emergencies,” more than 85 percent of them met a “prudent layperson” standard for coverage.

This is a system that saves insurance companies money by reflexively denying medical care that has been determined necessary by a physician. And it should come as no surprise that denials have a disproportionate effect on vulnerable patient populations, such as sexual-minority youths and cancer patients.

When an insurance company reflexively denies care and then makes it difficult to appeal that denial, it is making health-care decisions for patients. In other words, insurance officials are practicing medicine without accepting the professional, personal or legal liability that comes with the territory.

We don’t have to put up with this. Health care in the United States is shockingly opaque; it’s time to take insurance companies out of our decision-making process.

Phony Health Care Reform

Two op-ed pieces - one in the New York Times and one in the Washington Post look at the captiulation of Obama and many Congressional Democrats to the health insurance companies and pharmaceutical companies as average citizens in dire need of health care reform are sold down the river. As John Aravosis stated at America Blog, maybe Hillary Clinton was right during the primary campaign of accusing Obama of not being tough enough to get the job done. So far he looks like slick talking gutless wonder when it comes to delivering REAL and MEANINGFUL health care reform and/or civil rights for LGBT Americans. I am increasingly feeling that I should have supported Hillary - at least she had some balls. First, here are highlights from Bob Herbert's piece in the NYT:

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It’s never a contest when the interests of big business are pitted against the public interest. So if we manage to get health care “reform” this time around it will be the kind of reform that benefits the very people who have given us a failed system, and thus made reform so necessary.

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Forget about a crackdown on price-gouging drug companies and predatory insurance firms. That’s not happening. With the public pretty well confused about what is going on, we’re headed — at best — toward changes that will result in a lot more people getting covered, but that will not control exploding health care costs and will leave industry leaders feeling like they’ve hit the jackpot.

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The hope of a government-run insurance option is all but gone. So there will be no effective alternative for consumers in the market for health coverage, which means no competitive pressure for private insurers to rein in premiums and other charges.

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Giving consumers the choice of an efficient, nonprofit, government-run insurance plan would have moved us toward real cost control, but that option has gone a-glimmering. The public deserves better. The drug companies, the insurance industry and the rest of the corporate high-rollers have their tentacles all over this so-called reform effort, squeezing it for all it’s worth.

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So much for real change. Eugene Robinson in the Washington Post likewise laments Obama's selling out the public for the benefit of those already reaping fortunes. It is a truly disgusting situation - no wonder Virginia is likely to return to red this fall if this is all that a Democratic majority in Congress and a Democrat in the White House can accomplish. One would think the GOP had drafted this "plan." Here are highlights from Robinson's column:

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It's true that politics is the art of the possible, but it's also true that great leaders expand the scope of possibility. Barack Obama took office pledging to be a transformational president. The fate of a government-run public health insurance option will be an early test of his ability to end the way Washington's big-money, special-interest politics suffocates true reform.

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Giving up the public option would send many of Obama's progressive supporters into apoplexy, yet the administration has sent clear signals that this is the path of less resistance it's prepared to take. . . . Where, if anywhere, does Obama draw a line in the sand? For reform to be meaningful, there must be some components that a final package absolutely should include. What on Earth might they be?

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Clearly, the White House feels itself on the defensive. But why? Consider the political landscape. Democrats control the White House and both houses of Congress. No matter how disciplined Republicans are in opposing any reforms -- even if Republican objections are accommodated -- they don't have the votes to kill a final bill. If conservative "Blue Dog" Democrats are successful in nixing a public health insurance option and watering down other reforms, progressive voters have a right to ask why they went to such trouble to elect Democratic majorities and a Democratic president.

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What the president hasn't done is the obvious: Tell Congress and the American public, clearly and forcefully, what has to be done and why. Take control of the debate. Consult less and insist more. Remind the Blue Dogs who's president and who's not. Giving up on the public option might be expedient. But we didn't elect Obama to be an expedient president. We elected him to be a great one.

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Candidly, unless Obama makes some changes in course almost immediately, I am beginning to greatly fear that he is well on the road to a failed presidency. Yes, it is early in his term, but if this mess is the best he can do with commanding advantages, then all those who wanted to believe that he would deliver real change will likely feel that there is no need to support him or the Democrats going forward if they are so eager to sell out the public. Indeed, should the GOP somehow nominate a non-nutcase - a long shot I know given the way the GOP base controls nominations - Obama might well see himself not re-elected in 2012.