On 10/1/06, Robert Donovan <[EMAIL PROTECTED]> wrote:
3) As healthcare costs continue to rise, insurers are forced to become gatekeepers to keep the cost of any one area of insured health benefits from swamping the others. This causes onerous oversite of doctors and slower payments of claims in portions as each cost is approved, which doctors respond to by increasing prices to get bigger portions paid to them. This additional bureaucracy require the hiring of additional clerical workers to make sure the payments are approved the cost of which is passed on in the form of higher healthcare prices to insurers, and insurance premiums to employers.
This is one that I've really been witness to. I've been on both sides of the claim form: on the insurance company side taking the claim form and on the provider side submitting it. The provider side tends to be the less bureaucratic (at least it is at the places I've been, and the reason may be simple economics; providers are smaller organizations). The provider hires a couple three hot shot coders (medical coders...) who look at exactly what procedures were performed on the patient, why, and what the results were, and then assigns codes accordingly. The coder tries to assign the most profitable codes, obviously, and there is often room for leeway. Codes that the insurance companies notoriously get sticky about are avoided if possible. And the doctor is playing his part, too. The doctor is fluent in the codes for his profession and will tailor his actions to steer towards the more profitable areas. To send the coder a signal, in a way. The provider must play to the insurance company's game: hitting the high paying codes, combining codes where possible, reclassifying incidental findings as central to the procedure after the fact, etc. There's a lot of strategy. On the insurance company side, the claims get submitted and there is a claims processor that reviews each one and nitpicks where he/she can, and passes on the ones that are standard. Did they pay the co-pay? Was it the standard co-pay or the higher one for special procedures? Is this a covered procedure in the first place? Was it necessary? Home plan or out of network? Pre-authorization? Timely filing? And on and on. On both sides it makes sense that they're trying to maximize income. No income, no company, no health care. But you know... My auto insurance isn't that complicated. It's pretty clear what my auto insurance policy covers and what it doesn't, and it's usually pretty clear whether any given incident falls under the covered category. Why can't health insurance be like that?
This is why companies are now spending money to prevent illness to keep insurance costs down that were run up in the first place by the very system they're trying to prevent the over use of. What this all amounts to is the creation of a massive incentive for employers, doctors, and insurers to underserve, deliver less service, to the customer rather than to deliver more.
This rings of truth.
The biggest problem I see with nationalizing healthcare is that instead of a system of doctors hospitals and patients competing for insurance money, you wind up with a system of doctors, hospitals, insurance companies, and patients competing for tax money. If that happens, take all the problems above and consider how much worse they would be if they were institutionalized into the federal government.
I'd certainly rather argue with an insurance company about what I'm owed than with the government. Government always seems to get the last word, regardless of who's right in the end. I'm not knowledgable enough to comment on your other points. Your theory sounds great on the surface, and we certainly need some kind of massive reform.
Robert Donovan.
Pleased to meet you. -todd -- [email protected] http://www.kernel-panic.org/cgi-bin/mailman/listinfo/kplug-list
