Why Insurance Companies Win and Patients Lose The Health Care Game

Health Insurance in America is not really about delivering health CARE. It seems to me that it is most often about obstructing access to care when it is most needed. This is primarily because health insurance in America is a for profit business. Therefore the entire system is designed to benefit the insurance companies’ bottom lines…profit, not patients well being, not making possible for care providers to make the best decisions for their patients….but insurance company profits…Only when insurance companies are NOT FOR PROFIT will we have real reform.

We all NEED health care  at some point in our lives and we all have a right to access to health care.  That  is a basic human right in any compassionate society. (In my opinion US fails miserably on the compassion scale.) Where has altruism gone?

I often ask insurance adjusters who are denying care to a patient..What if this was your mom, your sister, your grandmother?  What kind of care would you want her to have?”   Sometimes, the person on the other end of the phone actually opens their heart and not just their rule book and I actually get real CARE for my patient. I consider that a miracle when it should just be routine and not take that much effort.

Health Care is still owned and run by Health Insurance companies…one of the biggest and most well funded lobbies focused on influencing the votes of our legislators. Deep pockets.Health Insurance companies hold us all hostage. And unfortunately some of the very best, most humane, most caring doctors who love to spend time with their patients (not the typical 7.5 minute visit) are leaving medicine because they are just fed up and burnt out from dealing with the insurance system. This is a loss for all of us.

Here is a  blog post that gives a clear example of the problems created by the insurance industry and all the special interests that go into the “business” of medicine in which the patient’s needs and the best medical advice of their doctor is often ignored for mercenary reasons.


excerpted from an article by  NOVEMBER 2, 2013 found at http://www.kevinmd.com/blog/post-author/david-mokotoff

If you are like millions of Americans, at some point in your adult life, your doctor will order you to have a CT or MRI scan. Quick, easy, and painless, these invaluable imaging tests provide a vast amount and array of diagnostic information about illnesses, and direct treatment paths.However, the real pain usually begins when you receive the bill. It is not uncommon for the charges, including radiological interpretation, to run into the thousands of dollars. However, as those of us in the medical field know, “charges” do not equal “costs.” So what exactly is the cost of these tests? Good question.

It is not uncommon for a MRI to cost $2,000-$5,000, depending upon where it is done. So how about charging just $275 for the test? Sound like a myth or joke? It isn’t, if you go to a site like Affordable Medical Imaging. So here’s the catch: they do not accept insurance or fill out insurance forms. Neither do they wait for payment. The patient pays the bill at the time of service, and the company gives the interpretation results and billing information to the patient. The patient may then submit it to his or her insurance company for payment.

How can they do that and still make money? The answer is easy. Without having to bill insurance companies and wait for authorizations and payments, the supplier to consumer short cut saves thousands of dollars in overhead costs. It may come as a shock to many, but health insurance is in large part the problem, and not the solution, to not only skyrocketing health care costs, but also access to care in this country.

Insurance sets the rates of payment, including Medicare, and thereby increases overhead for hospitals and doctors. Since Medicare “rules the roost” over how providers get paid, and how much, they have no competition. One of the immutable laws of economics is that no competition equals increased costs. This is true whether you are selling hamburgers or imaging tests……
…..Every time insurance is excluded form the equation in medicine, prices go down — think LASIK and plastic surgery. Insurance, by its very nature, is meant to cover episodic large, often unpredictable, events, not everyday minor problems…..
…….To be sure, not everyone can afford high deductible health insurance plans. Although the Affordable Care Act will reduce premiums for some, it will raise them for many more. Yet, if the truly free market were permitted to grow in health care, prices could only come down for everyone. Imaging is the easiest place to have price competition as the Affordable Medical Imaging example demonstrates. But there is absolutely no reason why it couldn’t be done in other medical and surgical fields as well.

Medicare changes reimbursements for often arbitrary and political reasons. Up until a few years ago, there were hundreds of freestanding cardiac catheterization labs across the US.  That was until Medicare decided to reduce payments to these labs below the actual level of costs. No matter that most labs could do a heart cath, charge between $1,000-2,000, (including facility fees and professional charges), and still make a profit.

Instead, and due solely to favored payments, outpatient heart caths went back to the hospitals where charges for the same procedure are typically between $5,000-$10,000. That is an example of how preferential pricing can be a major driver of health care costs.

The roadblocks are substantial. The medical insurance and hospital industries have vested interests in keeping costs high. And as long as we view the holy grail of medical care being equated with having similar insurance for all, costs will never become significantly lower, and access will be come more two-tiered. Sometimes the simplest solutions are the best ones.

David Mokotoff is a cardiologist who blogs at Cardio Author Doc. He is the author of The Moose’s Children: A Memoir of Betrayal, Death, and Survival.