The most realistic path to ‘Medicare for All’ says a former Insurance CEO

I said back in 2010 to a healthcare consulting colleague, we will eventually need to consider national health insurance, but it won’t happen. When he asked why, I responded the “Healthcare industrial complex is too powerful.” People forget the reason we have the Affordable Care Act is CFOs were tired of rising healthcare costs to their bottom line.

Healthcare is a complex topic and the ACA added to that complexity. It has since gotten better, but we need to shore it up to stabilize it more, rather continue to allow it to be diminished as its opponents have down for several years.

But, national health care under the banner of “Medicare for All” is worthy of consideration with data and analysis. This retired actuary, benefits consultant and benefits manager supports data driven analysis to improve what we have and consider more substantive changes. JB Silvers, a former health insurance CEO and professor of health care finance at Case Western University, penned an article called “The most realistic path to ‘Medicare for All'” in The New York Times earlier this month. Here are excerpts from the article:

“Much to the dismay of single-payer advocates, our current health insurance system is likely to end with a whimper, not a bang. The average person simply prefers what we know versus the bureaucracy we fear.

But for entirely practical reasons, we might yet end up with a form of Medicare for All. Private health insurance is failing in slow motion, and all signs are that it will continue. It was for similar reasons that we got Medicare in 1965. Private insurance, under the crushing weight of chronic conditions and technologic breakthroughs (especially genetics), will increasingly be a losing proposition.

As a former health insurance company C.E.O., I know how insurance is supposed to work: It has to be reasonably priced, spread risks across a pool of policyholders and pay claims when needed. When companies can’t do those fundamental tasks and make a decent profit is when we will get single payer.

It’s already a tough business to be in. Right now the payment system for health care is just a mess. For every dollar of premium, administrative costs absorb up to 20 percent. That’s just too high, and it’s not the only reason for dissatisfaction.

Patients hate paying for cost-sharing in the form of deductibles and copays. Furthermore, narrow networks with a limited number of doctors and hospitals are good for insurers, because it gives them bargaining power, but patients are often left frustrated and hit with surprise bills.

As bad as these problems are, most people are afraid of losing coverage through their employers in favor of a government-run plan. Thus inertia wins — for now.

But there’s a reason Medicare for All is even a possibility: Most people like Medicare. It works reasonably well. And what could drive changes to our current arrangement is a disruption — like the collapse of private insurance.

There are two things insurers hate to do — take risks and pay claims. Before Affordable Care Act regulations, insurance companies cherry-picked for lower-risk customers and charged excessive rates for some enrollees…”

There is only one solution: pooling and financing many of the risks related to chronic and acute health care issues. A study by my former company noted generally 15% of participants drive 80% of the claims costs in any given year. It may not be the same 15%, but with major chronic issues, some could continue to be in the mix. The principle of insurance is to pool those risks, so that good risks can moderate the higher risks.

The ACA uses the private insurance system, exchanges and expanded Medicaid. Unfortunately, there are about 15 states who still have not expanded Medicaid. Medicare for All would consolidate the risk into one place, eliminating the profit load and reducing the relative administration cost of insurance companies. I have suggested for several years to do a pilot and expanded Medicare eligibility from age 65 to age 62, or even lower. This would let us measure the impact of such a change.

Yet, what we don’t need is this to become political. What people do not realize is the ACA has been sabotaged on several occasions by my former party which drove some insurers out of the market and increased premiums for everyone else more so than they otherwise would have been.

So, let’s cut to the chase and study options. And, politicians should let people who know what they are doing do the analysis. The ACA was made too complex and the exchange roll out was botched. On the flip side, what the GOP did in 2017 was sloppy and poorly staffed, so what was voted on woulf have been harmful to many.

Medical errors are a problem – here are some thoughts on how to reduce them

Earlier this week, a US health news piece entitled “In a review of 337,000 patient cases, this was the no 1 most common preventative medical error” by Meera Jagannathan was made available on msn.com. This article echoes the findings of two pieces I have referenced previously, the first, a book called “Internal Bleeding: the truth behind American medicine’s terrible epidemic of medical mistakes,” written in 2004 by two internists Dr. Robert Wachter and Dr. Kaveh Shojania. The second was the Leapfrog Study which looked at deaths caused by medical errors toward the turn of the century. A link to the recent article is below.

The article reveals the results of four medical studies that analyzed medical death rates from 2000 – 2008. Of the just over 251,000 medical deaths, 9.5% of the deaths could be attributed to medical error. In other words, 1 out of 10 deaths could have been avoided as they resulted from a medical error.

The article focuses on nine things that should be done to reduce medical mistakes. I will just list them, but please click on the article link below.

  1. Make sure you fully understand the procedure and why it is necessary.
  2. Brief the doctors on your allergies, health conditions and medicines.
  3. Don’t assume every provider has access to your records.
  4. Bring a friend or family member if the patient is not good with asking questions about what is happening.
  5. Keep close track of your medicines and results.
  6. Make sure the doctors and nurses wash their hands.
  7. Research wisely.
  8. Don’t be afraid to speak.
  9.  Ask providers what they are doing to prevent  mistakes.

The Leapfrog study noted three things to reduce deaths due to medical errors.

  1. Have complex surgeries performed in centers of excellence where they have done multiple hundreds or thousands of the procedure.
  2. While dated, poor handwriting of prescriptions or instructions caused mistakes. Most hospitals now have electronic orders, but be sure you understand what is being asked or prescribed.
  3. Make sure there are doctors on site and not just residents in intensive care units.

I wrote earlier about the book “Internal Bleeding,” so I provided a link below. Reviewing that summary and comparing to the above, here are a few more thoughts from that post as well as a few others thrown in.

  • write a summary of your and your family medical history
  • write down what your symptoms are – people see the white coat and forget.
  • if you are not sick or injured, the hospital is the last place you should be; some hospitals incent ER doctors to admit patients; ask questions about this.
  • know your environment; if you have bladder or some other cancer it may be environmental not familial. Bladder cancer is a bellweather environmental caused cancer.
  • ask for other pain medications beside opioids; they should be only used for severe pain and for short durations.
  • introduce yourself to all providers; make sure they know who you are.
  • Complete the prescription regimen and don’t stop when you are feeling better.

Medical professionals do not want medical errors either. So, help them help you. And, if you have trouble advocating for yourself, take a trusted person with you.

https://www.msn.com/en-us/health/health-news/in-a-review-of-337000-patient-cases-this-was-the-no-1-most-common-preventable-medical-error/ar-AAEGPVF?ocid=spartandhp

https://musingsofanoldfart.wordpress.com/2012/07/28/internal-bleeding-be-your-own-health-care-advocate/

Navigating medical customer service

Before I share a few observations and experiences, let me first note that too many Customer Service Representatives (CSRs) are likely understaffed and undertrained to do the jobs they are asked to do. The healthcare system in the US is complex with a lot of moving parts, including consolidated entities on the provider side and insurer side. In other words, there are plenty of opportunities for the system to fail the customer, provider and insurer.

Through all of this, the patient has to be the navigator of his or her customer service experience. Otherwise, the patients may not realize they are not being treated fairly. As evidence that I am not personalizing this more than I am, let me mention two things.

First, I have a friend who runs a successful business advocating for insured patients. Her firm is hired by companies to help their employees and retirees navigate the healthcare insurance system. In essence, they advocate to get the insurers to pay for what they say they will in plan documents. No more, no less.

Second, as a retired benefits manager and consultant, I am familiar with the complexities, but there are people who know them far better than I. So, what concerns me is people who get maltreated  by the system and don’t know they can push back or don’t feel comfortable in so doing. The various acronyms, footnotes, poor communications, entities and touch points are confusing.

Rather than lament issues, let me offer a few tips to help in the navigation.

– If you need a pre-authorization for a surgery or procedure, start at least a week before or as soon as you can. Ask what they need and make sure they know who to call. An increasing number of providers are putting the burden more on patients to get the process started.

– On any call or reach-out, save emails or notifications, write down notes, names, dates and phone numbers – there are many, especially with centralized functions for smaller doctor offices. Recently, I was given multiple numbers to call (and addresses) from each party.

– Read your EOBs – Explanation of Benefits – including the footnotes as to why something was unpaid or pending. There may be an action needed on your part. If have a non-ACA, non-Medicare or non-employer plan, there may be a need for medical information to confirm this is not a pre-existing conditon.

– If you feel uncomfortable with asking questions of your doctor or insurer, write the questions down or include someone to advocate for you. Don’t be afraid to ask what someone said as it can be confusing or the person may not be the best communicator. And, if it is a major surgery or procedure, it is more than OK to seek a second-opinion.

– Follow-up. This is critical. Hand-offs are made to do things and the receiving entity may not confirm it has the ball. As a result, while you are waiting, nothing is happening. If medical records need to be there in 30 or 60 days, follow-up 10 – 15 days before those deadlines.

– Finally, be as diplomatic and polite as you can, but sometimes it is hard. So, be prepared to say something like, “I am sorry to be a pain, but this is frustrating.” Also, if urgency is needed, please share that need. Some readlng this may note there are websites to facilitate this process, but too often, the website does not do what you think it is doing. It may just be recording a query and not codifying an action. You may be surprised how frequentIy I have to read to the CSR what another part of the company sent me.

Again, there are many fine people in these positions who want to get things right for the patient. It is often said, good people make up for a bad structure.  Yet, it should not be as hard as it is. Until it is made easier, you must be the navigator of your customer service.

Please feel free to share your ideas and reactions.