The Health Insurance Monster

If you have read some of my previous blog posts, you may have noticed my disappointment and lack of faith in the field of healthcare to provide what its name implies, improved health for the patient. There are many healthcare professionals that truly want to do what is best for their patients but find themselves as unwilling cogs in the healthcare system. There are many factors in the failure of this system. I will only discuss one of them today, the misnomer that we call health insurance.

Health insurance is not real insurance. The definition of insurance is “an arrangement by which a company provides a guarantee of compensation for a specified loss”. An example of insurance is home insurance that will provide financial compensation for the loss of material goods should your home perish in a natural disaster. 

Health insurance may have started out as a way to prevent bankruptcy from the costs associated with an unexpected medical accident, but it has since morphed into its own monster. Health insurance has become a carrot that is dangled in front of prospective employees as a replacement of adequate financial compensation. Health insurance has become a political football that is thrown about during election speeches in hopes of dizzying the voters into ignoring real issues. Health insurance has become a promise of covering all possible health costs associated with being human rather than the costs of unexpected emergencies. The term health insurance has been warped and twisted into the idea that it equates to health care.

Health insurance does NOT equal health care. Take a moment to step back and think about this statement. Health insurance does NOT equal health care.

What exactly is health insurance in today’s terms?

Today’s health insurance is a contract between a patient and a company that requires the patient to pay monthly premiums in exchange for relinquishing their medical decision-making abilities. Ouch! Some of you may have bristled when hearing this tidbit of truth. The last few years have proven that people on both sides of the political spectrum believe in “my body, my choice” and yet we easily relinquish this right to large companies in exchange for what we perceive as health security.  

Just because you have a “good” health insurance plan doesn’t mean that you will receive proper care for your health issue. In fact, having health insurance can sometimes prevent you from receiving the care that you need. How many times have you been prevented or delayed from receiving the procedure, test or medication that you and your physician have agreed that you needed? Were these delays or problems due to a person reviewing your records and asking about the safety of the prescribed therapy given your individual combination of health issues? No. Instead, the prescribed therapy may cost the insurance company more than they want to pay. When this happens, they employ a common lawyer technique in hopes of saving money. Delay, Delay, Delay. When the bottom line is financial and not personal, the decision to delay is an easy one. By refusing payment or approval for a procedure, they are playing a game of chicken with the patient. Will the patient’s condition worsen to a point where the therapy is no longer needed? Will the patient die before receiving the treatment? Will the patient decide to give up the fight and simply live in pain or with a lower quality of life rather than continuing to fight the insurance company? In all of these scenarios, the insurance company wins. They save money.

Another game that the insurance company will play is the one of denial. They decide to deny compensation to the healthcare providers. They put the burden on the provider to prove that the service is beneficial by requiring complicated coding structures and delaying payment until they are satisfied with all the required paperwork. Most healthcare professionals trained to improve the patient's health, not code for proper payment. Some offices and facilities resorted to hiring staff for the sole purpose of filling out the daunting piles of paperwork required in order to receive payment from the insurance companies. This method eventually ran out the small, independent offices and facilities since their budget for hiring staff to play the insurance game was smaller than the larger institutions. The larger institutions started buying out the smaller ones, the independent physicians started working for companies or institutions in order to actually get paid, and small independent pharmacies are becoming obsolete. The healthcare professionals lose their autonomy to provide patient-specific health care because they must answer to the institution (their employer) rather than the patient. The result of this takeover of the small health business owners is a one-size-fits-all healthcare and the dying out of individualized medicine.

How does this work?

The health insurance companies make deals with institutions. Does an institution or healthcare facility want the business of the many patients serviced by a particular health insurance? Then that facility must play the game by following the rules set by the company. The deals are made in board rooms without consulting the health professionals providing the services nor the patients receiving the services.

Next, the real games begin. The facilities charge as much as they possibly can for every tiny bit of service for which they may be able to convince the insurance company to compensate them. They bill for services not necessarily needed and charge the largest conceivable amount for every service in hopes that the insurance will pay the bill. The insurance then lobs back the bill with all of their denials. The facility’s paid representative spends hours completing required paperwork and sitting on hold with insurance representatives in order to meet the requirements for payment. This process takes months and even years. Sometimes the facility wins by getting paid an amount that covers their costs of services. Sometimes the insurance company wins by refusing to pay a bill. If the insurance company is on the losing end and costs go up over a year, the insurance company increases their premiums, deductibles or decreases their covered services. If the facility loses and the bill isn’t paid, they pass the costs to the patient and/or decide to cut ties with the insurance company requiring the patient to find a different healthcare provider. In this game, the patient is rarely the winner. The problem with playing games like this one is that while the facilities and insurance companies are gambling their money, the patient is gambling his/her quality of life.

The government has even bought into the concept that health insurance equates to health care and now requires health insurance for all individuals. How is a patient to win in this game where he has the most to lose and the least amount of leverage to play? He isn’t. The patient is simply the byproduct of the billing, payment and political game.

The sky seems dark, the options are grim. Should we accept this as our fate and crawl under our desks to cry every time that we face an astronomical medical bill or refusal for care? Of course not. There are other, less popular options that are available to patients that are willing to put a bit more effort into finding them.

Various business models of physician offices are cropping up around the country. One example is a fee-for-service model where the physician refuses to accept insurance and the patient pays directly for each service provided by the physician. The patient may submit the bills to the insurance company if desired for reimbursement. Another model is the concierge service. In this model, the patient agrees to a monthly fee and that entitles him/her access to the physician’s services. Some physicians charge specific fees per type of visit. These business models vary by office, but the general idea is that by removing the insurance company, the patient/physician relationship is restored. Each entity saves money by not playing the game with the insurance companies. By dealing directly with each other, the patient becomes the customer instead of the insurance company.  

Another option is the increasingly popular use of health shares rather than insurance. Health shares are what health insurance tried be, but failed. There are a variety of them available, but for the most part, they are designed to cover unexpected medical expenses.

Why are these health shares a better option?

• They allow the patient to choose their provider without restrictions.
• Without paying for long-term conditions, it financially incentivizes patients to take better care of their overall health.
• The majority of the premium payments are going directly to other patients to pay for healthcare bills rather than for large administrative costs.
• By avoiding the games associated with billing the insurance companies, the providers can (and often will) provide discounts for self-pay patients.
• Often, the premiums are comparable to the ones paid to the health insurance companies.
• Health shares fit the government requirements for health insurance allowing you to avoid penalties.
• Health shares return the freedom of making medical decisions to the patient.

 What are the downsides to a health share?

• They require more patient participation. The patient doesn’t simply choose from a small list of approved providers but can utilize the provider that can best suits their needs.
• They require more paperwork for the patient. With a typical health insurance, the bill is sent from the facility to the insurance company. The insurance company eventually pays their portion and forwards the unpaid balance to the patient. With a health share option, the patient receives the bills directly from the facility. The patient is responsible for submitting the bills to the health share company. The bill is then shared with other members of the group (hence the term health share) and the individual members send payments to the patient for the bill. The patient uses the money received from other health share members to pay the facility. It’s a lengthier and more involved process for the patient.
• The patient must adjust their mindset to set aside payments for non-covered visits, like yearly physicals. I have discovered that the cost difference is minimal when you factor in the facility discount and the lack of meeting a yearly deductible.
• Each health share has their own restrictions. Some are religious based, and some are not. The patient must research the various options to find the best fit for them.

Should all patients dump their health insurance companies and search for alternative options? In my opinion, yes. The only way to take back our medical autonomy is to refuse to play the game for which we always lose. In the words of a smarter man than I, “we need to starve the beast”. Put your hard-earned money into systems that are actually providing the services for which they are promising. If enough people refuse to play this game, the monster will weaken and eventually die off. The effects of the monster's far-reaching tentacles will become less effective, and many other aspects of healthcare will have to adjust to the concept of answering to the patient instead of the insurance.

*Full disclosure: We switched from a health insurance plan to a health share plan about two years ago. I love the freedom to make our medical decisions without being "parented" by the insurance company's restrictions. We use Samaritan Ministries and find it to be a great fit for our family. If you are interested in this one, here's the link: Christian Health Care Sharing | Samaritan Ministries