Thoughts on Health Insurance Companies

Thoughts on Health Insurance Companies

Moving to a universal healthcare system with everything run by the Federal government might not solve all the problems in our healthcare system, and it might not really reduce all of our healthcare costs, but at least it would give us someone to hold accountable for rising costs, challenges with accessing care, and questionable quality of care. People across the United States are frustrated by healthcare providers and systems that seem to always be raising their costs and charging outrageous fees for basic medical care. Younger people today seem to find the idea of profiting on medical care to be slightly unethical, and health insurance company practices do a lot to increase people’s discontent with the current system and actors. In short, a lot of people probably just want to move to universal coverage provided by the government just to simplify the process and cut out insurance companies, especially when the average consumer can’t understand what benefit the insurance company provides.

 

These thoughts about our discontent with our current system came to mind this morning after reading the following passage that I highlighted in Dave Chase’s book The Opioid Crisis Wake-Up Call. Chase writes, “If you’re a fully insured employer and have higher-than-expected claims in one year, your insurance carrier will work to get as much back as possible in subsequent years through larger premium increases.”

 

What Chase describes is something that not everyone is directly aware of or able to explain, but it is something many of us have a vague feeling of or intuitive expectation of. Rather than existing as organizations to help us be healthy, rather than trying to solve a problem, rather than caring about our health needs, many people simply see health insurance as stealing a few bucks from them, their employers, their providers, and from people who really need medical care. Insurance companies are seen as morally unethical, powerful government lobbiers, and as bureaucratic machines that treat everyone like numbers.

 

If you are not in favor of a public health insurance program, and if you think that private insurance is the way to go, ask yourself what the industry could do better to actually provide value to patients. If you are in a health insurance company and think you do provide value to your patients, ask yourself, why don’t people see it? Perhaps we only see the games that insurance plays to limit access to care, to increase premiums every year, and to squeeze hospitals and providers, causing us to misunderstand the benefits that insurance provides. If private health insurance really wants to survive in the future, the industry needs to do better at showing its value, and minimizing its greedy tricks, otherwise, you can’t blame the public for wanting to eliminate insurance companies and have an accountable government take on universal coverage.
Healthcare Stagnation

Healthcare Stagnation

We are facing a disastrous healthcare stagnation in the United States. Our hospitals are getting older, Medical providers are aging with too few young providers to replace them, and the quality of care that many of us experience is not getting much better. Despite this, the cost of healthcare has been soaring. Healthcare expenditures, including the costs of our deductibles, co-pays, and what our insurance pays out, has been going up at a rate reliably above inflation.

 

In The Opioid Crisis Wake-Up Call, Dave Chase writes the following about our healthcare stagnation, “Unlike virtually every other item in our economy, where the value proposition improves every year, the norm in health care for decades has been to pay more and get less. Also, unlike nearly every other industry, healthcare hasn’t had a productivity gain in 20 years.”

 

Productivity is how much we produce per unit of time spent on production. A factory that makes 5,000 widgets per hour is more productive than a factory that makes 1,000 widgets per hour. Automation and new technologies have helped factories and offices become more productive, but our healthcare stagnation is evidence that we are not seeing the same gains in healthcare. Technology has improved, but not in areas that seem to produce more healthy patients given the same amount of time and effort from our medical providers. We have some new technologies, but somehow those technologies have not translated into a healthcare system that supports the same number of people with fewer resources.

 

Chase continues, “In other words, for the last two decades, there has been a redistribution tax from the working and middle class and highly efficient industries to the least productive industry in America.” 

 

As your job has become more efficient and more productive, your healthcare costs have risen. Chase equates this healthcare stagnation price increase to a tax. Factories that can work with fewer employees, software engineers, and other employees form highly productive sectors are paying more in healthcare for services that haven’t kept the same pace as the industries of the patients they treat. This is the cost of healthcare stagnation that chase wants to push back against by demanding better systems and structures from healthcare providers, insurance companies, and benefits brokers. Chase believes we can find a way to improve our healthcare system and help people live healthier lives for less cost, if employers are willing to make real investments in their employees healthcare, and are willing to hold their brokers and insurance providers accountable for the value their products provide.
Harris Rosen's Program to Invest Locally

A Program that Invests Locally

Harris Rosen runs a hotel chain in Orlando Florida. He has eight hotels in total, and his company does something almost no other companies in the country do. They provide real, meaningful healthcare services to their employees. They save a ton of money on healthcare by actually providing more of it, and better quality services at that. With the money Rosen saves on healthcare, he has developed programs in a neighborhood called Tangelo Park in Orlando to ensure children can attend school, get support to graduate from high school, and attend college on scholarships provided by Rosen.

 

Dave Chase writes about his efforts in his book The Opioid Crisis Wake-Up Call, “The cost over 24 years of the Tangelo Park program has been $11 million – roughly the amount Rosen saves in one year on health care. … For Harris Rosen, the approach is simple: Get involved; care for your people.”

 

$11 million is not a small amount of money, but what Rosen’s example shows is that you don’t have to be billionaire to make a meaningful impact in your community. $11 million is not an unattainable sum for many companies, communities, and philanthropists who want to make real changes. Mayor Bloomberg spent $500 million on failed presidential election campaign, money that could have helped almost 50 Tangelo Park neighborhoods.

 

What is important to see here, is that we can actually provide people with more healthcare, better preventative services, and easier access to good healthcare to save money in the long run. Money that could be invested back into the communities where it can have the greatest impact. Reducing crime means more savings for local communities by reducing resource demands for policing and jails. Improving education achievement means more people have the tools they need to grow and pursue the American dream. Improved health for employees means they are more productive and live happier, healthier lives.

 

We don’t make these kinds of investments for lots of reasons in the United States, but Rosen shows that we can. We are spending the money that we could use for these programs, but we are spending it in the wrong areas. If we looked critically at where we put the money, and where it could go to actually improve lives, then we could really make a difference in our communities and our countries. It starts with caring for people, helping them to become their best, and encouraging our communities to build together.
Healthcare Price Transparency

Healthcare Price Transparancy

Have you ever tried to figure out what a healthcare procedure is going to cost you before you have the procedure? Almost no one can give you a straight answer, and it takes a long time to get a number at all because the doctor’s office has to check with your insurance to see what their agreement is, what you still have left with your deductible, and where you stand relative to your out of pocket maximum. The result is that consumers have very little insight into what they are actually going to pay or owe when they go to a check-up, when they need a new prescription drug, or when they have a knee operation at a local hospital.

 

In his book The Opioid Crisis Wake-Up Call, Dave Chase addresses the lack of transparency in healthcare pricing. Specifically looking at the ways that insurance companies hide claims data from employers, Chase writes, “They want to maintain the status quo. This means protecting pricing opacity at all costs. If you could see the prices you actually pay, you might begin to wonder why a hospital with a large market share but mediocre quality outcomes is paid exponentially more than a smaller, high quality provider in the same network.”

 

Healthcare price transparency reveals disparities in our healthcare system and shows that healthcare costs are often not connected with quality or health outcomes. Cost is somewhat arbitrary and usually negotiated without the person who will actually be receiving the service. If we could see the costs, then we would be more likely to shop around, either for different insurance or for different healthcare providers with more reasonably prices for services and treatments. I think our health spending is generally rather inelastic, but nevertheless, if we better understood pharmacy pricing, basic medical services, and major surgery costs, we could start to move toward options that offered higher value.
Health Insurance Company Games

Health Insurance Company Games

Dave Chase’s book The Opioid Crisis Wake-Up Call was an interesting read because Chase highlights many of the health insurance company games that add to the cost of healthcare in the United States without providing additional value. I’m skeptical of health insurance companies, and Chase’s book discusses some of the nitty-gritty details of misaligned incentives that lead to unending increases in healthcare premiums and costs.

 

An example that Chase highlights is early renewal discounts for companies that chose to stay with their current health insurance company or plan administrator. Throughout the book, Chase discusses how businesses are letting their employees down and allowing healthcare costs to skyrocket by accepting increasing healthcare costs from health insurance companies each year. Many companies don’t have someone who really understands healthcare or health insurance in charge of their benefits programs, and as a result those individuals are often more focused on not being yelled at by employees than on reducing costs and providing a valuable health insurance package. Insurance companies take advantage of this by pressuring businesses to accept increases in the cost of healthcare administration each year at rates far above inflation.

 

Insurance companies know that businesses don’t actually want to shop around for health insurance and they know that employees don’t want to have a change in insurance each year. Insurance companies will offer benefits for early renewals from companies, and as Chase writes, “Often these early renewals come with no-shop clauses. So, a 20 percent rate increase may only be a 15 percent if you sign today and agree not to shop the competition. This should be viewed as a red-flag, not a great deal on a premium reduction.”

 

Insurance companies position themselves as offering a good deal, but they are increasing the cost of the insurance plan by 15%. Busy employers with small HR staff often see this as a win because it reduces their effort and while employees see costs rise they don’t have to hassle with changing insurance and unknown insurance processes. This is part of why premiums in the United States are rising so fast. Insurance companies hide information and data, and make it difficult for overwhelmed staff to pick benefits that will truly help employees.
Pay and Chase

Pay and Chase

If you were working to set up a healthcare plan for your employers, you would want to make sure that payments by the insurance plan were quick so that your employees were not constantly bombarded by letters and phone calls from doctors offices asking when they would be paid by the insurance plan. You also would want the plan to have a system in place for catching fraudulent claims or errors in charges from hospitals and doctors offices. Both of these desires are reasonable, but in the real world, they have created a system of perverse incentives that Dave Chase calls “Pay and Chase” in his book The Opioid Crisis Wake-Up Call. Here is how Chase describes it in his book:

 

“Another fee opportunity is so-called pay and chase programs, in which the insurance carrier doing your claims administration gets paid 30-40 percent for recovering fraudulent or duplicative claims. Thus, there is a perverse incentive to tacitly allow fraudulent and duplicative claims to be paid, get paid as the plan administrator, then get paid a second time for recovering the originally paid claim.”

 

Insurance companies administering health insurance don’t actually have an incentive to create tools to proactively stop fraud. They actually benefit when there is fraud, because they get a bonus when they spot the fraud and recoup the already paid fraudulent amount. As an employer partnered with the insurance company, you might be happy that claims are paid quickly so that your employees don’t have negative interactions with doctors about payment, but the way that many plans currently operate, you will end up paying a lot more overall when your plan pays for fraudulent claims and billing errors. You will pay for the fraud itself, and if you get any money back, it won’t be for the full amount that your claim administrator originally paid in the fraud or error – they will keep a cut.

 

Chase continues, “Many of the fraud prevention tools used by claims administrators are laughably outdated and weak compared to what they are up against. Modern payment integrity solutions can stop fraud and duplicate claims, but aren’t being used by most self-insured companies’ claims administrators.”

 

Poor incentives and confusing systems have allowed this to occur. This is one example of how the systems around healthcare in the United States are not aligned with what we would all agree should be the number one focus: improving the health of Americans. Employers don’t want their employees to be angry, and plan administrators want to maximize profits. In the end, we all pay more as fraudsters find ways to get past the outdated fraud prevention systems of insurance companies and as those companies turn around and charge fees for catching the fraud and payment errors they didn’t prevent in the first place.
GoFundMe For Healthcare

GoFundMe for Healthcare

We all complain about our personal healthcare costs and we know that healthcare spending in the US is a huge percentage of GDP, but what isn’t clear is that the vast majority of spending and healthcare costs come from a small minority of patients. Cancer care, treatment for severe trauma, and therapy for rare diseases can be incredibly costly and unpredictable. For many people who face such substantial challenges, GoFundMe ends up being a huge support, and I think it is worth asking ourselves if that is a reasonable way for people to be able to afford medical care in the United States.

 

As Dave Chase writes in The Opioid Crisis Wake-Up Call, “In 2013, more than 1.5 million Americans lived in households that experienced a health-related bankruptcy. More than three-quarters of those people had insurance. Some say medical bills may also be the top cause of homelessness. Nearly half of all GoFundMe crowdfunding campaigns are to pay for medical-related expenses.”

 

Our health insurance, what we pay for and what our employers offer us to help ensure that if necessary, we can afford medical care, does not actually help us afford medical care in the case of an emergency or major diagnosis. Medical related bankruptcies are not a rare occurrence, even for those who have insurance, and if Chase’s quote is accurate that a large cause of homelessness is medical bills, then the cost of care that is supposed to help someone be healthy, likely pushes people into incredibly unhealthy living circumstances. The fact that people have to turn to crowdfunding moonshots for treatment is a clear indication that the healthcare system in America is failing those who need it most.

 

I would argue that much of the social unrest in our country is related to stagnated wages. Chase argues that wages have stagnated as businesses cope with increasing costs for providing healthcare to employees. Americans don’t see their wages increase, but do see the cost of healthcare rising, and many face bankruptcy and must turn to GoFundMe for healthcare related expenses. It is not hard to imagine how healthcare costs contribute to an unhappy populace that doesn’t trust public officials and elected leaders who have not been able to remedy the situation, or business leaders who have not provided real value in the health benefits they offer employees.
Healthcare Pricing Failures and Overtreatment

A Story of Healthcare Pricing Failures and Overtreatment

I don’t know anyone who would not agree if I said that there was a pricing failure with the way that healthcare operates in the United States. My personal favorite example of this was a story about a person who wanted some type of medical care, but couldn’t get it due to complications with payment between what he would pay and what his insurance provider would pay the provider. The individual one way or another found out what the charge was for someone who was uninsured, and asked if he could just pay that amount instead, but the provider couldn’t offer him the same rate because of the complications involving the private insurance, contracts, and all the confusing legal structures involved. The price of healthcare in the United States is not just high, it is completely opaque to even the people on the inside, it is apparently arbitrary in some instances. It is a pricing failure that is detached from the costs that anyone involved actually seems to face.

 

One of the worst parts of the pricing failure of healthcare, however, is that it isn’t even connected with the services we receive. Because no one knows what anything costs at a pure base level, consumers can’t easily shop around, and providers have no incentive to make sure they are actually providing value for the service they provide. I’ll use an example from my own life:

 

I had been getting vision checks and contact prescriptions done at Costco for several years, but thought I ought to actually get in for a full eye exam at an office a couple years back. Costco was cheap, it was easy, the service was quick, and the optometrist was a good communicator. In other words, the service and the value of the care I received were excellent. At the other office I paid substantially more for an eye exam, did a bunch of tests that seemed unnecessary and needed to be repeated, never got a great answer about why I was doing the tests, why I failed them, and if it was a problem with my eyes or the machine in use. The optometrist was less friendly, didn’t communicate as well, offered me fewer contacts to try on and conducted what felt like an unnecessary contact fit exam rather than letting me try out the contacts for a couple weeks before making a purchase. Where Costco gave me my prescription and sent me out the door, the office I went to had no intention of letting me have my actual prescription, in an effort to force me to purchase contacts through their office rather than someplace cheaper.

 

Dave Chase in his book The Opioid Crisis Wake-Up Call writes, “Broadly speaking, the two biggest problems in the U.S. healthcare system are pricing failure (no correlation between price and health outcomes) and overtreatment.”

 

I experienced both of these in the example above. I (and my insurer) were billed for unnecessary services at the more expensive office. The services provided were worse, less convenient, and didn’t seem to be related to my actual eye health outcomes.

 

There are a ton of challenges to addressing these problems. Policies to reward good health outcomes often end up rewarding providers who serve more affluent populations, who tend to just be more healthy in general. Equating patient satisfaction and quality of services also are not always related to actual health outcomes, so measuring the quality of services from a patient standpoint is not always helpful and often full of bias. Nevertheless, it is clear we need more transparency, and more market mechanisms in the U.S. healthcare system so that quality, outcomes, and price can be taken into consideration and more directly linked to the services and products that medical providers offer.
Medical Technologies

The Problem with Healthcare Technology

In my last post I wrote about hidden costs of the healthcare system in America. I wrote about tax breaks for employers who offer health benefits, and I wrote about third party insurance preventing the healthcare system from working like a pure market. This post introduces one consequence of the hidden costs of our system and the ways in which our system fails to act like a market: the high cost of medical technologies.

 

In The Opioid Crisis Wake-Up Call, Dave Chase writes, “We ended up focusing on a certain type of high-technology, acute medical care – which we financially reward far more than lower-level preventive and chronic care – without regard for the quality of the outcomes or value of the care.”

 

When I took a healthcare policy and administration class along with a healthcare economics class for my graduate studies, I was surprised to see a critique of advancing medical technologies as part of the problem of American healthcare costs. I live in Reno, under the sphere of influence of the Bay Area, where technological solutions to global problems are hailed as the cure-all, deus ex machina that we need for a peaceful and prosperous world. I always thought that better medical technology saved lives, made us healthier, and ultimately reduced cost by being more efficient and precise than older technologies.

 

As it turns out, new medical technologies are incredibly expensive, and often times the benefits that patients receive are only marginally better than what existing technology offers. In some instances those marginal improvements make the difference between life and death, but in many instances, the new technologies might only add a few months of life to a terminal diagnosis, a few additional months lived in pain and fear. In other instances, the new technologies might add a little more comfort or certainty in a patient’s procedure or diagnosis, but it is fair to question whether its really necessary and worth the additional cost.

 

The quote from Chase reveals that when we are shielded from the costs of care, and when we remove market aspects from the healthcare system, we adopte a mindset that healthcare equals expensive interventions with high cost technology. I had clearly bought into this narrative prior to my graduate studies. The alternative that Chase highlights in his book, which we have underdeveloped in the United States, is to move upstream, and take care of people at a preventative level before they are sick and before they need expensive technological interventions. Developing systems, structures, and norms for healthy lifestyles will do more to reduce costs than the development of new magical cures and technological fixes. Our priorities and the focus of our system is flawed, and a as a result we focus on high cost interventions within a system no one is happy with. Rather than develop a system that actually supports healthy living, we have fished around for quick, high-cost technological solutions to our health woes.
Hiding the Cost of Healthcare

Hiding the Cost of Healthcare

In the United States, our current system of healthcare coverage is hiding the cost of healthcare. Anyone who has to go to physical therapy, get an MRI, has a child that needs treatment for a disability, or ends up in an ER knows firsthand that healthcare is expensive, but many of them probably don’t realize just how costly our healthcare system truly is. For the most part, in our country we have a system that pulls a third party into every payment scenario for healthcare, and as a result, the cost of healthcare is not reflective of a true market.

 

Many argue that our current system creates too much of a moral hazard, with people living unhealthy lifestyles because they know they won’t face the full cost of care if they need it. Some argue that the current arrangement leads to unnecessary care or over-treatment because people don’t pay the full cost of care, so they seek more of it. At the same time, groups argue that insurance and healthcare coverage are still prohibitively expensive, and that the stress of possibly having to go to a doctor and spend thousands of dollars (even if one is insured) genuinely harms people’s health.

 

I think all of these are true in their own way, and I think they are relatable because they are things that people have seen first hand or can easily imagine, but there is still a deeper level of healthcare costs in America that we don’t discuss. Our system of taxes is also hiding the cost of healthcare. As Dave Chase writes in The Opioid Crisis Wake-Up Call, “Today, the tax break for employer-paid benefits is estimated at over $600 billion, making it the largest tax break in the tax code, the nation’s second largest entitlement after Medicare, and the primary wage suppression driver.”

 

During World War II, wages to employees were frozen to prevent rapid inflation in the United States during the war. To attract and retain qualified employees, businesses turned to employer-paid benefits, and congress created a law which would allow those benefits to be tax-deductible for employers. This was a way to effectively give employees a bonus without paying them more, keeping inflation down, but still giving them something that economically and socially benefited them. Today of course, you are taxed on anything of value you receive from your employer as if it was straight cash, so your healthcare benefit basically still counts as wages, but that tax break for the employers is still in place for the health benefits they provide.

 

This is where we are hiding the cost of healthcare in America when it comes to private insurance. Most Americans receive healthcare through their employer, and the US government loses out on $600 billion in taxes to allow employers to offer health insurance. So the plan you are on that you might lose if you are fired, the plan you have this year that might not be offered again next year if the insurer changes, the plan that still has a $1,500 deductible and $4,000 out of pocket annual max, costs you and U.S. tax payers $600 billion per year.

 

Because this is a hidden cost, it is not something we discuss very often. We are afraid of the cost of a nationwide healthcare system, but we don’t discuss how much money is not being collected in taxes and being sheltered by a tax break that maintains a system that very few people are actually happy about. We face high costs ourselves, even if we are covered by a plan that fits within this $600 billion tax break system, and the system has warped the way that care is payed for and provided to the point where we don’t even know what knobs and levers to try to pull to get the who thing to be more transparent, provide real value, and to be less costly. We need to be honest about the ways that our current system is hiding the cost of healthcare in America, or we will never be able to make real changes to improve the system.