:: The Role of Medicare Fiscal Intermediaries After Healthcare Reform
Barbara Calder lives in nearly constant pain. Her limbs dislocate at the slightest movement, even when she turns over in bed at night. She wears her hair short because brushing it hurts too much.
Mrs. Calder suffers from Ehlers-Danlos Syndrome, a rare genetic disorder in which the connective tissue that binds the body together gradually falls apart. But, although she began suspecting she had the disease 16 months ago and had health insurance, she spent a year battling numerous roadblocks just to see a specialist who could diagnose her condition. Now Mrs. Calder says she is left wondering whether she’s going to die suddenly because she can’t get the test that would tell her whether she has the fatal form of the disease . . .
Mr. Calder, whose father was a doctor and mother was a nurse, grew up believing the U.S. health-care system was the best in the world. But he says his wife’s struggle has eroded that faith. “I’ve actually turned around to where I’m thinking, ‘Yeah, Europe may not be a bad thing.’ ” “How U.S. Health System Can Fail Even the Insured”, Wall Street Journal (November 16, 2007)
The Wall Street Journal editorial staff has evidently bought into the idea that universal health care translates to universal coverage. The adjudicative record of Medicare fiscal intermediaries does not bear this out.
For example, the article describing the bureaucratic maze faced by Ms. Caulder features Anthem Blue Cross and Blue Shield, a unit of WellPoint Inc. Now Anthem, and of course, Blue Cross, are major players in the Medicare fiscal intermediary market.
When the author decries the runaround given Ms. Calder, the author evidently does not understand that a universal health care system will entail claims payment decisions by entities like the very ones complained of in the WSJ article. In the “Medicare For All” initiatives, the lost details are that the fiscal intermediaries for public welfare are really not so friendly as their supporters wistfully suppose.
From the Caulder case, consider Anthem’s “customer service”:
Mrs. Calder tried to get her Celebrex prescription filled at a local drugstore. Anthem refused to cover the drug, telling the pharmacist she needed to try over-the-counter painkillers first. When Mrs. Calder called the insurer to protest that she had tried other painkillers, an Anthem representative told her that only her doctor could get the drug approved by calling the insurer on her behalf.
An Anthem spokesman, James Kappel, says it considers Celebrex a “step-therapy” drug and doesn’t cover it unless other, cheaper treatments have been tried first.
Mrs. Calder says she called Anthem back a week later to inquire whether her policy covered genetic tests. And once again she was stymied by a misunderstanding.
Mrs. Calder says a representative told her that Anthem doesn’t usually cover tests for diseases that aren’t treatable. Mr. Kappel says Anthem has no record of that call and that skin biopsies were in fact covered by Mrs. Calder’s plan. “If we had received a call about a skin biopsy, we would have approved it,” he says.
Bottom line – the claims adjudication process in a publicly financed system, such as Medicare, will be handed off to the large fiscal intermediaries such as Anthem. Any notion that their claims adjudication processes will evolve into more accommodating claims practices should be measured against their past record. The facts in the WSJ article actually support the view that the European model is a bad thing if it means that health care decisions will be outsourced to the same entities that serve as Medicare fiscal intermediaries.
Postscript - The foregoing article was penned on November 16, 2007. Today, November 19, 2007, the WSJ reports that:
Democratic presidential candidates like to beat up on insurance companies, but there is a lot for the industry to like in their health-care plans — starting with plenty of new business.
“Here’s the potential for a whole new pool of lives for them to cover, with payment behind it,” said Benjamin Isgur, assistant director of PricewaterhouseCoopers’ Health Research Institute, which examined the presidential health plans’ impact on industry. The study, a comprehensive look at health-care plans offered by candidates in both parties, also concludes that doctors, hospitals and other health-care providers would likely benefit since more patients with insurance suggest more would seek care and be able to pay their bills. . . .
The study, to be released this week, also notes risks for insurers, the biggest of which might be a proposal offered by all the leading Democrats that would set up a Medicare-like health plan that would compete with private insurers. Health-Care Plans Aid Industry Wall Street Journal (November 19, 2007)
The big insurance carriers that serve as intermediaries for Medicare will benefit from the Medicare for all proposals. The legislation will crowd small competitors and eliminate any vestiges of free market competition.
The WSJ reports:
The early signals from the insurance industry, which played a major roll in killing health-care reform in 1994, are positive. The industry’s chief lobbyist, Karen Ignagni, president of America’s Health Insurance Plans, says she is encouraged by the debate so far and says her group is focused on trying to get universal insurance enacted rather than stopping it.
The outlook for the largest insurance companies under a reformed health care system is getting brighter all the time.
