Demand Openness from Health Insurance Industry

November 6, 2009

One of the things I liked about Obama’s campaign was his seemingly relentless pursuit of opening government up to the people. It wasn’t hard to sell that point. It’s clear that under Bush, the people were kept in the dark so some light was more than needed with a new president.

Obama has made strides in his efforts to bring “transparency” to government by bringing in smart tech people and creating sites like data.gov. Though not perfect, it is a step in the right direction. People have more access to raw government data than before, which helps educate the public. We should count our blessings we not only elected a leader who believes in an educated public, but also takes such visible steps to help educate the public.

As health care continues to dominate headlines and debates both in Congress, at local hang outs and even around the dinner table, one thing is missing: health care transparency.

Open standards for electronic medical records: OK. Coverage for more Americans: on the table. Eliminating “pre-existing” conditions as grounds for denial: on the table. Giving Americans more choice/control over their health care: on the table.

Except how can we make informed choices without access to the data that determines those choices? How can we make informed decisions on anything related to health care if the data remains obscured by government and health insurance bureaucracy?

Simple answer: we can’t. But, as we’ve all come to realize, any issue around health care is anything but simple.

A start would be to provide standard definitions for “pre-existing” conditions and for what constitutes a “history,” and make those definitions universal. If one incident, even if not repeated, constitutes a “history,” then say so. If the “pre-existing” condition list is so expansive as to include any trip to the doctor that resulted in “recommended treatment,” even for the common cold, then say so.

By leaving such things undefined, or rather leaving it up to insurance companies to define, creates wide-spread confusion and denial of coverage in one state but approval in another. People will be more likely to gravitate towards the states where they are more likely to get coverage, sucking states dominated by money-hungry insurance companies dry. Loss of population leads to loss of tax revenue. Loss of population means companies have a smaller pool to help shore up their work force, so they will look to move where there are people. Small businesses will gravitate towards states that are more kind to them. An imbalance will be created that will only exacerbate existing budget falls.

Requiring health care companies to show where exactly premium dollars are spent is another starting point. How much goes towards claims? How much goes towards advertising? Payroll? They are run like companies, so all the money goes somewhere. It comes out of our pocket and goes into someone else’s, and we should be allowed to know who.

So if the government is truly set on health care reform, and truly wants Americans to be able to make their own health care decisions, then demand insurance companies become more transparent than the government. Clearly no one can rely on studies conducted by groups, even if the groups claim to be “neutral.” Americans must be given access to the very information used to decided whether or not they can receive coverage, whether or not a particular procedure or visit is covered and whether or not their health is really that important.

Health care reform may force insurance companies to cover more people than they’d like (despite their claims that they will have access to a broader base, which they already do but choose to deny), but until Americans are given more than a cursory view of how the system works, health care reform won’t do much good in the long run.

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Health Coverage Frustration

October 26, 2009

OK. I’ve done my best to stave off a rant on health care coverage, especially since I’m sick and tired of hearing people, ahem, politicians, health insurance companies and the like, put forth the same arguments for and against health care reform. They all take a rather narrow-minded view of health insurance reform, and are completely ignoring something basic: the health insurance application process.

If you want everyone to have coverage, then you must simplify the application process. Case in point: me.

Just to recap: I got laid off in April 2008, making me ineligible for extended benefits, or what I’ve referred to as inadvertently being ahead of the pack. Knowing my COBRA insurance would run out after 18 months, the maximum length of time for coverage, and would not be extended under new legislation since I was laid off well before the masses, I applied for individual coverage. I’m a fairly health individual, take 0 prescription drugs but like to have a plan in case of the unexpected, especially after getting hit by a CTA bus. I came away from that unscathed, but with a profound sense that accidents happen (the bus hit me, not the other way round) and I may not always be as fortunate.

I did some initial research, and I found that I still liked my current carrier and that an individual plan would save me roughly $300 a month over COBRA. I momentarily kicked myself for not switching earlier, but there had been the chance of gainful employment that brings with it health insurance coverage. Plus, it is the 3rd time I’ve had this particular health insurance carrier so my records are already with them. In triplicate, actually, which I find rather silly but didn’t know exactly how ridiculous this was until I applied for individual coverage.

Logic dictates that since I am already insured by said carrier, indeed have been insured by said carrier, switching from an employer to an individual plan should not be equivalent to walking through a mine field shackled and blind folded. They have my information, they have my records, they have what is needed. When I called to inquire about switching, I asked if they can just transfer my records from an employer account to the individual account I wanted to set up. The person laughed. Nope. Doesn’t work that way. I have to re-apply and re-submit my medical records. All of them.

Now keep in mind I am not changing carriers; I am using the same carrier. They have my records. The records have to be submitted for claims, and there have been a few claims since I have been insured by said carrier. Bottom line: they have the records.

Apparently, though, no division communicates with any other division. They cannot simply move my records from the “employer” division to the “individual” division, and then check for discrepancies and make records requests for incomplete information. No. I have to go through a completely separate, wonderfully detailed application process. The majority of the questions, by the way, would have been answered if they had been able to move my records. And they clearly have access to my claims history because they read it back to me over the phone, and inquired about each one. My answered verified what they had on their screen.

So this is where my frustration has started to…OK…has boiled over. If they can pull up my claim information, why can’t they then review my records? Why is it that I had to sign 4 records releases? 4! And here we are, more than a month later, and I am still waiting for the underwriter to approve or deny my application.

Yes. That’s right. Approve or Deny. Without employer coverage, there is the possibility of being denied coverage. If I’m denied coverage, I’d hate to see what happens to people who have submitted 0 claims and also take 0 prescriptions.

That’s not what annoys me, though. What annoys me is the silos. How on earth can there be any kind of meaningful health care reform if health care insurance companies cannot even share information within their own walls? And if they can’t even do that, how can they possibly field requests for information from out-of-state hospitals? Seriously. What happens if I am in a serious accident or have to be hospitalized in Arizona, Florida, Maine or *gulp* overseas? If it takes more than a month simply to request records and “process” an application, how long does it take to send my information to a hospital somewhere else?

I talked about this whole medical records transfer issue in a previous post on electronic medical record portability, but this lack of internal communication makes me think the problem runs much deeper than anyone, myself, Congress, anyone, originally conceived.

My point, though, is that if health care coverage is to be granted to everyone, then Congress must force the health care insurance industry to simplify its process. So if a person like me, who is KEEPING THE SAME INSURANCE CARRIER, applies for individual coverage, the process should happen much more quickly than if I were to change carriers.

Otherwise, shelve health care reform and focus on creating jobs as that will be the only way the rest of us will be able to obtain health care coverage.