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Insurance frustration is dangerous to your health
The healthcare debate is so frustrating and confusing with so many special interest groups blaming each other for the exorbitant costs.
On the national level it will be interesting to see if the CEO's of Amazon, Berkshire Hathaway and JP Morgan can find a way to lower costs and improve quality for their employees by contracting directly with health providers. Needing to hold insurance companies accountable for the service they claim to provide, there is a bill in the Oregon Legislature, HB 4156, which attempts to prevent insurance carriers from making changes in prescription drug coverage after someone has already signed a contract for the year.
Such a provision, which seems common sense to those who serve patients and seek their best interests, has been progressively undermined by an insurance industry that continues to achieve record profit year after year. Although insurers blame lifesaving innovations for rising out-of-pocket costs, the big five for-profit insurers in America saw their net revenue exceed $4.5 billion for the first three months of last year. This revenue comes straight from the pockets of those whom insurers are in business to support.
My staff and I spend hours contending with insurance companies who want to deny care to our patients. The patients most deeply affected by slash-and-cut insurance programs are those with chronic health conditions. Although a cornerstone of the Affordable Care Act ("Obamacare") was to ban the practice of denying coverage to patients with pre-existing conditions, insurance companies have already found creative ways to punish our sickest patients.
One such practice is through denials to providers. Rather than support proven treatment plans as recommended by their physicians, insurers force patients to cheaper but less effective treatments.
Patients paying out-of-pocket costs less than $100 are seven times more likely to fill prescriptions than those paying more than $250, resulting in a 17 percent increase in emergency room visits because they could not afford the medication.
Insurance companies now design their benefit plans by listing specialty drugs for those with deadly and debilitating diseases on the highest-price tier.
They hope to drive "high utilizer" people with chronic illnesses and sicker patients out of insurers' plans.
Take for instance the pioneering cancer drug Neulasta, which can be costly but provides great savings to consumers in the long run.
Patients in clinical studies saw significantly reduced hospitalization rates due to low white blood cell counts and associated infections which occur commonly after sessions of chemotherapy.
This innovation is not free, of course, which is why it's not fair for insurance companies to shift these costs to patients, especially chronically ill patients.
Yet insurers resist paying for these medicines and try to shift costs to patients and make the drug makers out as the bad guy. Is it not the purpose of insurance to spread risk around, so that everyone has access to the most effective medical treatment? If insurers are passing through the costs of medicine to each patient individually, then why is the patient purchasing insurance at all?
It is hard to believe that insurers spend $471 billion a year on billing and insurance related administrative costs; much of it focused on denying claims for the lives that they insure.
A 2011 study by the California Nurses Association estimated that insurers deny 26 percent of all claims in the state and the Government Accounting Office projects that half of all denials are reversed on appeal.
But patients are forced to go through the process unnecessarily.
They are doing this while piling up massive reserves, and instead of paying claims, they pay exorbitant sums to slap their names on sports arenas. Yet, the outcry has been limited and insurers continue to come to the state seeking double digit rate increases while paying for these extravagant "marketing" expenses and showering CEO's with multimillion dollar bonuses.
Certainly, insurance policies are not the only factor in our healthcare costs, and pharmaceutical companies need accountability. Situations like the EpiPen price increases are unconscionable and should be prohibited.
We have to do something about our rising healthcare costs. For the leading business minds in our country, the first step is holding insurance companies accountable, and affirming that quality care starts and ends between a patient and a provider. The insurance you buy should pay for the medicine you need. It's that simple.
I encourage all Oregonians to join me in support of HB 4156, and contact your state representative to tell them you want accountability for insurance companies in our state.
Dr. Gregory Knopf, the founding physician of Gresham Troutdale Family Medical Center, has been practicing medicine for more than 30 years. He is a graduate and Clinical Associate Professor of Family Medicine at Oregon Health and Sciences University.
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