RE: [Winona] It's the Insurance Companies

[terri hyle]

[Winona Online Democracy]

I always thought that one reason employers offered good health insurance 
options as part of the menu of benefits (retirement, vacation, personal 
days, holidays, etc.) was to attract and retain good employees (aside from 
legal requirements if you employ above a certain number of employees).  In 
fact, good health insurance coverage was an important factor when my husband 
chose to accept employment in Winona.  I believe that employers who provide 
health insurance coverage for employees are able to claim their portion of 
premiums as a business expense, a benefit to the employer which would be 
lost under a single payer or everyone for him/herself scheme.

This thread is entitled It's the insurance comapnies, yet it does not focus 
specifically on insurance companies.  I'd like to turn some attention in 
that direction.

Steve Kranz made some good points about the limitations of MCHA and 
MinnesotaCare and Medical Assistance.  In addition, for Medcial Assistance 
and MinnesotaCare, are intended for low income families who meet strict  
income limits unless there is a serious medical condition for which the 
child is not covered under other medical insurance.  In the case of 
MinnesotaCare, if premiums are even a day late (as easily can happen for 
families struggling financially), the coverage lapses and you cannot reapply 
for some period of time (I forget how long).  There is a large burden placed 
on the medical provider to ensure that the provider is the one identified in 
the policy, except in some emergencies.  If a physician provides medical 
services to a patient who is not in his/her network, the provider is unable 
to recover the cost of the treatment.  There are other limitations as well.

Some links for MinnesotaCare:

http://www.house.leg.state.mn.us/hrd/pubs/mncare.pdf
http://www.cchconline.org/publications/lawlinks.php3
survey:  
http://www.mhdi.org/quality/health-plan-projects/95survey/sta/mn.html

One of the biggest reasons that insurance premiums are so expensive is 
because of the paperwork and the personnel that a medical provider must 
employ to ensure that all insurance regulations (and they differ between 
Medicare, Medicaid, MinnesotaCare, MCHA, and all of the various policies 
offered by all of the different insurance companies) are complied with, and 
that claims are filed with appropriate and necessary documentation, etc. 
These regulations/rules/levels of coverage change frequently, in the case of 
government insurance programs and annually for private insurance companies.  
For government insurance (Medicare, etc.), the responsibility lies with the 
medical provider (doctor) to know all of the regulations (which are not the 
same thing as knowing the appropriate diagnosis/treatment options) and to 
stay within the limitations of the regulations, even if they run counter to 
what the physician believes is best for the patient.

Some insurance companies routinely deny all claims on the first filing in 
order to discourage additional claims from being made:  if it is 
sufficiently difficult to be reimbursed for an office visit or a strep test, 
people are less likely to file legitimate claims for covered services.  With 
each filing of a claim, a cost is incurred to the provider and also to the 
insurance company.  These costs are passed along to the insured through 
higher premiums and higher fees for services.

Insurance companies hire non-medically trained personnel, or medical 
personnel who may be providing opinions about treatment options that lay 
outside their area of expertise  to review claims and to determine whether 
or not a treatment the physician feels would best meet the needs of the 
patient will be covered.  In my opinion, that is akin to practicing medicine 
without a license.  Medical providers enter into contracts with insurance 
providers to establish the parameters of fees and payments.  Included in 
these parameters are limitations on the numbers and kinds of referrals a 
physician or clinic can make, with financial incentives to stay within these 
parameters.

I have had some experience with Indiana's version of MCHA (far too expensive 
for most people, even with a large deductible) and with Medicare  while 
helping to manage my mother's health care.  Neither are models of what I 
would like to see for the U.S. or Minnesota.  Medicare determines what 
services will be paid based on statistics, not on the best interests of the 
individual patient, and on the premise that medical providers try to defraud 
the government.

Paul suggested 7.5% (I assume of annual income) as the limit of out of 
pocket expenses individuals would be expected to pay for their health care.  
I assure you that for many families, that 7.5% would mean the difference 
between having a roof over the head and food on the table and not.  This is 
a cruel choice that even today many seniors and others with chronic 
illnesses are facing when they purchase medications.  If we should switch to 
this scheme today, many of us would see an immediate decrease in our income 
of up to 7.5%.

So what is the solution?  I think Rich had some good ideas, especially about 
expanding the definition of 'group' to include all of MN, or even the US. I 
think that insurance companies must be made to play by a more fair set of 
rules and guidelines--and I think that physicians and other medically 
trained persons must play an important role in establishing what these rules 
and guidelines are.  Might I suggest that they include establishing the 
right of a physician and patient to determine the best course of treatment 
and a universal set of claims processing procedures?



Terri Hyle

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