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Life Health > Health Insurance > Health Insurance

On the Third Hand: The Patient Rate Race

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UnitedHealth Group Inc. made itself look good today by stating that it will continue to abide by many patient relationship provisions in the Patient Protection and Affordable Care Act of 2010 (PPACA).

To me, it seems as if all big health insurers should be agreeing to implement many of the PPACA patient relationship provisions for enlightened self-interest.

UnitedHealth didn’t say anything about adopting what might be considered the core PPACA rules — that it provide coverage on a guaranteed-issue basis, without considering the applicant’s health status when offering coverage or setting rates.

But, at least for consumers who can show that they’ve had “creditable health coverage” all or most of their lives, maybe the big carriers should figure out some voluntary, free-market way to stick with those provisions, too.

Otherwise, how can doctors and carriers get wellness programs to work?

The United States can cut health care costs by providing less care, regardless of whether the care is necessary or not; getting providers to accept lower pay for the care provided; or reducing the amount of care used by helping people live healthier lives.

Most people would probably agreed that reducing the amount of health care needed would be the nicest way to reduce health care costs. But doctors, hospitals, insurers, wellness companies, employers and the patients themselves probably need to work together better to make much progress at reducing the need for care.

The current system gives patients who have any clue about how the insurance system works every possible incentive to get the kind of sporadic, no-records kind of health care that James Bond might get if he were on the run and he thought everyone, including M and Her Majesty’s Secret Service, was out to get him.

If I let my plan know that I had high blood pressure, it might pay for great care and enroll me in all sorts of wonderful wellness programs that could help me control my high blood pressure, improve my quality of life and extend my life expectancy.

But, given the rules as they are now, letting my insurer know that I had high blood pressure might greatly reduce the likelihood that I could get health insurance that would protect me against a the flu or bad case of food poisoning, let alone cancer or a broken elbow, if I ever moved to a state like California that allows medical underwriting.

The mere act of going in for checkup is terrifying from the perspective of anyone who wants to look healthy on paper, because (as I’ve now learned from first-hand experience) primary care doctors now have a huge incentive to make ordinary, healthy checkup getters look like goners on the claim forms to jack up fee revenue. Even if I go in to a doctor with fine blood pressure readings, how do I know the doctor won’t look at his mortgage statement and frame me as being someone with high blood pressure just to make the monthly mortgage payment?

To me, it seems as if the most rational strategy from the point of view of a patient who’s more interested in maximizing access to coverage and benefits payouts than in the finer points of ethics is to avoid getting any preventive care or sick care that produce permanent records about physical imperfections; to get any unavoidable sick care at walk-in clinics, and pay cash; and to start using health insurance and communicating honestly with providers and insurers only after I have a serious, incapacitating illness that’s so difficult and expensive to treat that I obviously need health insurance.

Meanwhile, if a health insurer is insuring a patient through a high-deductible plan, the insurer may have no leverage whatsoever to get wellness program information from the provider or the patient. If the insurer will not be sending either the provider or the patient a reimbursement check, why would the provider or the patient bother to fill out the insurer’s carefully and thoughtfully designed condition management survey?

Right now, health insurers and doctors are, essentially, encouraging patients to show up as $50,000 or $200,000 cases out of the blue. 

The only force protecting insurers against patients clean sheeting themselves is consumer ignorance. Most consumers go to primary care doctors, take what the doctors say at face value, file routine claims and let information go to the insurance company because they don’t know any better.

If health insurers really have to ignore health status information when issuing coverage starting in 2014 because of PPACA, they might end up with more new enrollees who have cancer or heart problems — but maybe they’ll also find out about all of the current enrollees who’ve been hiding conditions such as cancer of heart problems. Maybe they’ll suddenly get an unexpected chance to manage the treatment of those conditions while there’s some hope of holding the cost down, or at least some chance that they can do a better job of budgeting for the incurred but not  disclosed health problems that will be leading to claims in over the next few years.


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