Fact: Yesterday my friend, the surgical oncologist I write about from time to time called me. He was almost speechless. He had a desperately ill patient with breast cancer. She required a particular type of chemotherapy (forgive me, I don't know exactly which drug or cocktail). But she needed what she needed. And she wasn't going to get it!
My friend had just ended a 45 minute conversation with an insurance company bean counter who was denying, denying, denying. I listened. All I could think: this is America?
Before we ended our conversation, this good doctor asked me whether he should come to Kos Yearly. Perhaps he could describe in very graphic terms how harrowing health care has become in America in 2006.
You might want to think about this diary the next time you visit your beleaguered doctor for your five minute drive-thru appointment. The next time your insurance company denies a test, a drug, anything.
In America, medical care is big business. It's not about you and me and our health. It's about meeting Wall Street expectations.
It's about the bottom line.
It's about stock options.
United Health Group, whose chief executive has racked up $1.6 billion in stock options, said yesterday it may have to slice as much as $286 million from its past three years of earnings because of the way it ac counted for options.
The nation's second-largest health insurer also acknowledged it is the subject of an "informal inquiry" by the Securities and Exchange Commission, and it could lose tax de ductions for options grants it previ ously thought were deductible.
http://www.nj.com/...
What in the world do stock options and pigs-at-the-trough CEO's have to do with five-minute doctor visits and denied chemotherapy?
This is the story from Nebraska. But it's happening in New York, Connecticut, California, Wyoming. It's happening everywhere. This is the ugly face of health care in America.
While UnitedHealth Group profits were soaring and its CEO was collecting more than a billion dollars in stock options, Nebraska doctors, hospitals and patients were experiencing frustrating claim payment problems, according to Department of Insurance records.
. . .The problems with United Healthcare give credence to worries about the potential power of large health insurance companies with large market shares, Wagner said.
. . ."It's just a continual floating craps game. "It's gone from horrible to better. But this is still the worst company (for payment) we have," Keetle said.
Filipi said he knows that a few doctors in Omaha and Lincoln refused to take patients with United coverage because of the claims problems.
. . .The company's stock price climbed more than 200 percent in the past five years.
But its claims-paying problems in Nebraska were also rising.
. . .The fine, one of the largest for a health insurance company in Nebraska, stemmed from three cases where the company did not pay claims for anesthesiology services for children's dental work until the state insurance department intervened. In one case a claim was reprocessed at least five times over eight months.
. . .Wagner said he had conversations with United Healthcare officials about the disparity between company leaders' compensation and the company's performance in Nebraska.
"I understand good performance," said Wagner. "But good performance ought to have some standards besides profitability."
Representatives for Nebraska hospitals and physicians agree: United Healthcare has been a difficult company to deal with.
"It's amazing that a company with these resources can't figure out how to pay a claim," said Keetle of the state hospital association.
"It's a company that has been highly profitable, and there is a reason why. They do a nice job of dealing with businesses. They have a tremendous Web site. They do a tremendous job of talking about quality. But their own administrative policy is a disaster," said Keetle.
[emphasis added]
http://www.journalstar.com/...
The claims actually paid by insurance companies are known as medical loss ratios. These payments adversely impact the bottom line. Spending less is a good thing--for them. Spending more is a good thing--for you.
Medical loss ratios indicate the proportion of total operating revenue spent for health care. I described this business reality in a diary I wrote a month or so ago called Ins. Co's. medical-loss ratios plunge, harming/killing Americans which you can read here:
http://www.dailykos.com/....
If a insurance company bean counter (making medical decisions, by the way) approves the chemotherapy my friend the oncologist is pleading for it goes against the medical loss ratio. Insurance companies monitor these ratios carefully to keep them from surpassing predetermined targets.
Let's look at the five-minute doctor visit for a moment. This is another Wall Street mandated reality. Since physician reimbursement is being strangled, most doctors must see more patients simply to stay in business. So, don't only blame your beleaguered doctor, blame this pornographic system we accept as normal in the United States.
One word on the Bush solution. The absurd Bush "reforms". We're being told "consumer driven (Health Savings Accounts)" health care is the answer.
Bullshit.
One of the major reasons why Health Savings Accounts (HSA) require that participants use high-deductible health plans (HDHP) is to lessen the incidence of moral hazard. When an individual is insured against medical expenses, they are not liable for the full cost of medical services and thus are more prone to use more services than they would have if they faced the full cost.
Allow me to translate this. If you pay for medical care using your own money so the theory goes, you use less. You delay and deny yourself health care and little problems become big problems.
Our system is so broken.
Every day the travesty implodes a bit more under the weight of its own unworkable and immoral underpinnings.