Quoting The Commonwealth Fund: The United States spends more per person on health care than any other wealthy nation, and so do American families. How can we ensure that health care is affordable for individuals, families, and government? https://www.commonwealthfund.org/
Our American, for-profit health insurance system encourages health care carriers to deny payment for care our doctors recommend. We cannot effectively self-educate to find the best care by ourselves due to the medical system’s complexity. Even our medical providers are overwhelmed by the blockades erected by our 3rd party insurance system.
Our medical payment system is a role based, 3rd party insurance system. The first role or party, the insured, has entered into a contract with an insurance provider, the second party, who pays the 3rd party, the health care provider. The alternative to a 3rd party insurance system, whether administered or funded by an insurance carrier or the federal government, is one where individuals are self-insured, and able to pay for all health care costs themselves.
Inherently, there is nothing wrong with a 3rd party insurance system, except that in the USA, most insurance carriers are for-profit companies with shareholders. The insurance carriers make decisions about paying our health care claims through cost-benefit analyses and the question becomes – who benefits – the patient or the shareholder in that for-profit company? Too often, it is to the insurance company’s benefit to deny claims, benefiting shareholder value rather than paying for the care a medical provider recommends.
So, who should make the decision on your health care? The cost of care will always be a factor in the equation, but with our present system, shareholder value will often stand in the way of patient care. The simple case of a doctor presenting information and options to a patient according to the current scientific research is subject, in my opinion, to a for-profit system, with little interest in the patient’s health. Even with major scientific breakthroughs in research through clinical studies, trials, drug development and product release, assuming equity in access to these developments, the availability of new options will always be controlled by for-profit companies.
To break through this wall, it is my belief that the optimal solution is to break the relationship between profit and health care. But this has been deemed too simplistic to be resolved simplistically, so to fight this concept politically, it has been labeled … socialism.
Not only 3rd parties. Insurance companies also contract with additional companies to conduct utilization management, i.e. to make those decisions whether to approve or deny coverage. Like a lot of things in our modern economy, there are many, many middle entities reaching out with sticky fingers to snag some of the dollars flowing between individuals and companies that have any kind of financial ties (employment, mortgages, insurance of all kinds, and surely more). But in healthcare the stakes can be so much higher.
This is absolutely correct. In my case, it was the contract oncology company used by Cigna that denied authorization of payment for most of the claims for treatment. The most egregious example was the denial of Denosumab treatments to alleviate the bone metastasis. The irony was that I had received Denosumab for the previous encounter with cancer in the form of Prolia, but was denied authorization for Xgeva, which is exactly the same drug, Denosumab, but in a different amount. I took the cowards way out and started on Medicare instead of continuing to fight Cigna.
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