The real reason is…. regulation, or lack thereof. The Affordable Care Act, in my opinion, is Obama’s attempt at trying to mitigate the rising cost of healthcare. I’m guessing he was hoping that with more people insured, the insurance companies may work more effectively with care providers like hospitals and doctors to cut down the costs. The reality though is the exact opposite is happening. Insurance companies are gaining more power, while providing less benefits. How can this be?
No matter what industry you look at, at the end of the day, it’s a business. While hospital organizations and big Pharma look to make a profit, they dump most of their money back into their projects and R&D. Insurance and third party payers however don’t really provide any other service than insurance. They only seek to expand their profits. Therefore, they are in the business to gain as much profit while spending as little as possible. Unlike other healthcare provider services, they don’t care about the best treatment for the patient, they care about the baseline.
What I mean by that is they are completely evidence based. Unlike doctors who are willing to risk a new experimental therapy because they believe the benefit outweighs the risk, the insurance company does not inherently like risk. For the insurance company, they run statistical models on therapies and medications to see what the effectiveness of said therapy will be across the wide range of patients. I often get frustrated patients asking me why their medication isn’t covered and to run it through the insurance thinking that the roadblock to their therapy is me. When I tell them the truth sometimes it’s almost like an epiphany to them. So what is the difference is between pharmacies and insurance companies? The difference is doctors, pharmacists, nurses, anyone that actually sees you face to face to help you with your health and well being will treat you as an individual. The insurance company does not. In essence, what I mean is that to the insurance company, you are not a person, you are a number. Sure we can get you that therapy we’ve been wanting to give you all along, but that takes stacks of extra paperwork, many phone calls, as well as time waiting for some supposed “clinician” to assess the situation and make a decision. What that really means is they have to check to see if you’ve followed their step therapy procedure and have done all previous therapies so that there is no choice but for them to cover this therapy. By the time we have finished this process, the patient has had to wait weeks to months without their treatment or medication.
So how did we get here? The point where, before explaining the situation patients automatically thought everything was covered and that we, as healthcare professionals, are the bad guys, when really the situation is reversed? Well in my opinion it’s two reasons. The first is people don’t read the fine print anymore, and the second is that the insurance companies have effective marketing, which is so effective because of the first reason. I’ve noticed the vast majority of people do not read the fine print on their insurance plans. This is most evident during the time of Medicare open enrollment. Part of the reason that Walgreens offers Medicare D price comparisons is that we know people need someone to explain the plans to them. I can tell you personally that over 80% of all the patients I have counseled on Medicare D prescription plans had absolutely no idea about the beginning deductible or the coverage gap. The biggest reasons for that are because they either trusted the Medicare representative over the phone that they had nothing to worry about, or had someone enroll them in the plan without spending time looking at the details, or just didn’t read the plan specifics themselves. The other problem is the patients see our faces on a daily basis and not that of the insurance, so naturally they will assume we are at fault for their insurance problems since we are the only face they see. Insurance companies are back end if you will while we are front end. We, the healthcare providers know there is a problem, yet we can do very little without the help of the patients. The truth is that we healthcare professionals care about YOU, the patient. The insurance companies only care about how little they need to spend on you. They claim they have the patient’s best interests at heart, but how is that true when they don’t consider you an individual, and only want you to get the “standard” treatment?
Is there a solution to this crisis? Possibly, but the path is long and difficult, as there will no doubt be lobbying upon lobbying by the insurance companies. I’m not a proponent for governmental regulation, as I believe personally the government is about as effective as using gas to put out a fire, but what can potentially make a difference is to evolve the healthcare system in a manner that adapts to the third party payer system. What I mean specifically is to increase the number of studies and trials on new medication in order to generate that evidence based medicine. With this method, we can challenge their decision making process by providing clinical documentation that the newer or riskier therapies can generate a more significant result. To take it one step further, with the advancements in gene therapy as well as biotech companies, we may potentially develop the ability to sample patients genetics and test their cells in-vitro first to see if the therapy will yield a positive result. In this way we can both individualize care, as well as provide to the third party payers irrefutable evidence that this patient should indeed receive the newer therapy.
Also, once we’ve fixed the issue with third-party payers, we can then reduce the charges to the patient as well as the third-party payers. For years medical organizations have charged seemingly high prices to the insurance, and the insurance re-negotiating to a smaller sum, due largely to the fact that insurance companies were refusing to reimburse for treatment. If we can offer more data to show that this treatment is the best suited for the patient, the insurance company will cover it, the hospital can reduce the costs since the insurance is willing to cover the treatment, and the patients can get the most effective treatment while having reduced expenses.