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Monday, March 2, 2015

The Frustrating Thing(s) About the US Health Insurance Marketplace - Part 3

This is part 3 of a 3 part series. Click to read Part 1 and Part 2 for background on the story.

In parts 1 and 2, my friend Eva tries and eventually succeeds in getting an appointment so she can get treated for what turns out to be severe laryngitis and walking pneumonia, and how the market-based insurance system foils her attempts.


At the end of the last post, I asked the question "What would have happened to Eva if I (or someone else with health system insider knowledge) hadn't been there to help her get connected to people who could see her that day?

Scenario 1: She gets frustrated with not being able to find a primary care practice who can see her that day and so decides to go to the local public hospital emergency department (ED) --because they will take her insurance.  She goes to the ED and spends hours waiting to be seen because her case is considered non-urgent.  Eventually she is seen in the overcrowded ED and gets sent home in the middle of the night (or next morning even) with the same prescription.  It cost her insurance $500 as soon as she registered as a patient in the ED and her copay for an ED visit is $50.

If she'd been seen in primary care, it would have cost the insurance company $125 (by local market standards) and her copay would have been $25.

Scenario 2: Despite being young and healthy (she's 35), walking pneumonia is nothing to mess with and it can get worse.  Since she wouldn't have known she had it, she probably would have put off trying to get seen because it was too complicated.  Knowing full well how long she'd wait in the ED (public or private) and because urgent care wasn't an option because they didn't take her insurance either, trying to ride out the illness using over the counter prescriptions was the next option.

Walking pneumonia can turn into regular pneumonia and if it gets really bad, she could have ended up hospitalized. Even if the infection didn't end up hospitalizing her, she would have hit a point where she would have needed to go be seen by someone.  People delay seeking care all the time for lots of reasons that often defy rational thinking, and in her case her rationale choice might have been to avoid paying for the most expensive option.

In addition, since trying to find someone who would take her insurance would have been even more difficult if she was feeling awful and still wanted to avoid the ED, then urgent care and paying out of pocket becomes her only option.  Sure, she could charge it to a credit card, but then the illness would cost her money for months ahead as she pays it and the interest off.  Remember: She's only consulting at the moment and her income isn't regular.  It all becomes an unnecessarily complicated mess.

If all providers were required to take all insurance, she would have had no problem getting seen without the help of someone like me.

If she lived in a country with a single payor system, she might have had to wait but she still would have been seen the same day.

If Eva was poor and/or less educated, the scenario would have been far worse and more costly.  Poverty is costly to your health.

What's the take home message?

From this story, you can see in the system inefficiencies that are private sector driven that the incentives are not designed to benefit the consumer.  The insurance companies benefit in one way by consumers not using their insurance.  They can work off of the 23-35% administrative overhead built into private insurance costs because people skip care or they deny access. That helps their bottom line and ensures that executives still get their six figure bonuses (yes, really, many do).

Physicians benefit because they can choose to accept the insurances that reimburse at the highest rates or require the least amount of paperwork. If the state where they practice or the insurance plan doesn't allow nurse practitioners to be designated as primary care providers, they have less competition for the patient market and incomes (supposedly) are higher.

So that's the "perks" of a market driven system.  There's choice!  Sort of.  There's more efficiency! Not so much.

And it is important to note that these same inefficiencies existed PRIOR to ACA implementation.

Overall, it is by far better to have health insurance as the annually increasing ACA enrollments and dropping uninsured rates demonstrate.

But even if you have insurance, it shouldn't be so hard to access the system --especially now.

Friday, February 27, 2015

New Twitter Handle

Based on the advice from a good friend whose a journalist, I've updated my Twitter handle. If you're interested in following me there, here it is: @ASquiresPhDRN

The Frustrating Thing(s) About the US Health Insurance Marketplace - Part 2

This post continues from Part 1.  Click here to read it.

This is the story of my friend Eva trying to get seen in primary care and how the insurance system foils multiple attempts and delays care. We left off with Eva's first attempt to getting an appointment failing.  Eva is a friend of mine from graduate school with a PhD and a good job she was able to take because it was easier for her to buy private insurance after the Affordable Care Act and work as a consultant.

Eva still needs to be seen. She's traveling for consulting work three days later --kind of important when you need to pay your bills while waiting to hear about full time work.  She doesn't travel, she doesn't get paid.

I dive into the bag of tricks most nurses develop when they've dealt with their health system after about a year.  I email a colleague I know who runs a nurse managed clinic (staffed by nurse practitioners) to see if she can get her in.  In 5 minutes, she gets back to me and connects her to the clinic's admin to get an appointment arranged. By this time, I've gone to work and Eva is waiting to hear from me by email.  Again, feeling triumphant that we'd finally be able to get her the care she needed and I'd once again figured out how to work around the system, I sat down at my computer and began to prepare to teach my class later in the day.

Several emails fly through the inbox and my triumphant feeling evaporates.  While my colleague's practice would have been able to see her, they didn't take her insurance either (even though the insurance company's website said they did).

They didn't take it for a different reason though.

Turns out, her particular insurance plan does not allow nurse practitioners to be designated as primary care providers, so my colleague's practice cannot take the insurance even though they would have been happy to see my friend the same day and treat her.  Many insurance companies and states in the US restrict nurse practitioner practice and require physician supervision.  Change that and physician incomes get affected.  Do you see why it  hasn't changed yet?

#systemfail number 2

Nonetheless, the nurse practitioner practice knew another group that would take the insurance and was a comprehensive, non-profit community health care center.  They were able to see her the same day.  As it happens, she had severe laryngitis and walking pneumonia. She got an antibiotic (appropriately prescribed) and was so pleased with the experience, she signed up for her first full physical health exam in two years.  She was able to travel, but postponed the social part of her visit (she was going a few days early to the city where her consulting was to visit friends) that would happen before her work started so she could rest and let the medicine do its work.

So what if I (or someone else) hadn't been there to help work the system to get her the care she needed?

To be continued...