Private health care insurers

There is a lot of concern in America today that the Affordable Care Act, known "affectionately" as Obamacare, will negatively effect the entire range of the heath care industry.  Depending on the particular grind of the speaker, everything from patient care, to doctor-patient relationships, to access to health care providers to the actual cost of health care will be changed for the worse.  This is especially troubling when the speaker holds the widely held but not as easily proven assumption that health care in the United States is the best in the world.

It does not take rocket science to conclude that the health care provider network in America is as good as it gets.  And while it is convenient to ignore the United States' world rank in infant mortality, life expectancy, and access to health care services, the fact that those with the most money invariably seek treatment here illustrates the point.  

In essence, when an elected politician claims America has the best health care delivery system in the world as Speaker Boehner did on Sunday, July 1st, 2012 in an interview on CBS's "Face the Nation", he can be said to be speaking the truth, in his experience.  After all, he has an incredible government provided health insurance plan.

But if you are one of the tens of millions of Americans without health care coverage, or have an insurance plan that severely limits which providers you can see, features only a basic list of covered benefits, and/or includes prohibitive co-payments for the more serious or less frequently occurring maladies, you might grade the United States differently. 

And, if you are the World Health Organization (WHO) your ranking of the US falls somewhat below #1.  Their calculation uses the five factors listed below, and produced a ranking of 37 out of 191 countries for the American health care system.

• Health level, as defined by a measure of life expectancy, which shows how healthy a country's population is. This factor gets a 25 percent weight.

• Responsiveness, which includes factors such as speed of health services, privacy protections, choice of doctors and quality of amenities. This factor gets a 12.5 percent weight.

• Financial fairness, which measures how progressive or regressive the financing of a country's health care system is — that is, whether or not the financial burdens are borne by those who are economically better off. This factor receives a 25 percent weight.

• Health distribution, which measures how equally a nation's health care resources are allocated among the population. This factor receives a 25 percent weight.

• Responsiveness distribution, which measures how equally a nation's health care responsiveness (which we defined above) is spread through society. This factor gets a 12.5 percent weight.

I am of the opinion that both the good aspects and the problems with our health care system, the reason behind why we are ranked only 37th by the WHO, and why individual experiences and opinions of our health care system vary so widely among Americans, is the private health care insurance industry, emphasis on private.

As I have stated in the past, I am a firm believer that all discussions of health care must include disclosure of ones own health care insurance status.  I think this disclosure will render some opinions mute, or at least provide the listener with a reference point to conclude when hypocrisy is at play.  In my case, as an employee of the state of Pennsylvania, I have a very good health insurance plan with good access and below market co-pays.

That being said, I just spent some time arranging a physical therapy visit for my daughter who recently had knee surgery.  I first went on line to the health insurance company's website to find a physical therapist.  There were literally dozens within 10 miles of my home.  But what appeared to be easy access, turned more difficult when I called the nearest provider.  They didn't except the HMO version of my plan.  So even though they were a listed provider, we couldn't use them.  During the conversation, I was also told that there might be some limits due to "capitation" and that I might want to call my daughter's pediatrician and/or knee surgeon to find out which therapists might be capitated to them.

If you haven't heard this term before, here is the Webster definition;

a payment method for health care services. The physician, hospital, or other health care provider is paid a contracted rate for each member assigned, referred to as "per-member-per-month" rate, regardless of the number or nature of services provided. The contractual rates are usually adjusted for age, gender, illness, and regional differences.


Interesting.  Fortunately, my daughter reminded me that she had required physical therapy a few years ago.  Checking the list, we found that provider, and when I called the office for an appointment they reminded me that we would need a referral.    All in all, not particularly cumbersome despite the roadblocks due to the capitation issue.  Still, when someone rants about how Obamacare will limit which providers you can see, remember that it is already the case in most health care plans.     You see, health care insurance companies still seek profit.  That profit is decried when it appears that it exists, or is increased, by sacrificing the health of those paying the premiums, or those denied coverage in the first place.  That profit is defended by those who believe that by maximizing efficiency, establishing fee based services that providers can live with, and reducing risk exposure by the health insurance providers, the entire system stays afloat providing health care insurance for the majority of us.   And that is the rub.  As long as we believe that without the profit motive we can't have a strong health care insurance industry, therefore a strong health care delivery system, then we will need to tolerate decisions by the insurance industry which deny benefits for certain procedures, force health care providers to see more patients for less money, and influence the doctor-patient relationship through the filter of what is good for the health insurance provider.  Strangely, it is a similar list to why some decry Obamacare in the first place.   Which brings us to a recent decision by the Highmark Group, one of the top ten largest health care insurance companies in the United States as ranked by http://health.usnews.com/health-plans/national-insurance-companies.   Unless something has changed since I was informed of this situation, as of September 1, Highmark will institute its Physical Medicine Management Program.  This system, developed by a software development specialist in the health care industry, will use computer algorithms to predict outcomes, thereby influencing doctor decisions.  In other words, a computer will help determine procedures and therapies based on its analysis of past results with patients with similar problems.  This, from a health insurance company that was questioned in 2002 by the Pennsylvania Insurance Department about their then-excessive $2.4 billion reserves which, as of 2011 had ballooned to $3.7 billion, an astounding 38% increase in nine years.   While it may be naive to think that huge conglomerates such as Highmark operate as a company committed to a "social mission to provide affordable health care to the community", shouldn't we at least expect them to operate without creating the impression that they are raking in profits via the pocketbooks of their providers and members?

"Don't let a bureaucrat tell your doctor how to treat you", is a rallying cry for those against the Affordable Care Act.  Unfortunately, there are already non-medical influences effecting how your doctor chooses to treat you, and could soon be computer print outs in every doctor's office "predicting" your course of treatment as well. 

Clearly, we don't want to replace one flawed system with another.  Obamacare is not perfect and needs some real discussion about what to keep and what to replace.  But a free market based system, profit driven, will never improve the United States ranking in the WHO calculation because sick and old people cost money and a profit driven system will always resist insuring those people and/or paying for the necessary benefits they need.

The health care insurance industry is not evil, as you might believe I think or as you may hear others claim.  But it is overly concerned with profit, as all huge corporations are.  Perhaps some nudging on the part of the government, the providers and us, the clients, might lead the health care insurance industry to

conclude that a reasonable profit is better than the perception that huge profits come from dead Americans     
reevaluate its fee for service model, under which doctors are compensated for the quantity rather than quality of their care and move to an alternative which gives doctors a flat salary with bonuses for improved patient outcomes

And perhaps with a group of elected officials less beholding to large health care insurance firms, pharmaceutical companies, trial lawyer lobbyists and the countless other factors that cause the United States to spend thousands of dollars more per person with limited return, we can

reform malpractice laws so that doctors don’t prescribe tests and treatments simply to avoid lawsuits.

provide better evaluations of the efficacy of all medical tests and treatments, so doctors don’t prescribe—and, equally important, patients don’t demand—unnecessary and even harmful procedures