:: Obstacles To Real Health Care Reform – A Sequel
Some time back I began a list of practical obstacles to improvement of the health care delivery system. (“The Real Obstacles To Health Care Reform”) The issues I cited are resistant to any reform proposal currently under consideration. This post is a continuation of the list.
Previously Noted
Here are the previous items:
#1 Lack of Accountability For Public Funds
Funding of health care constitutes an important issue to be sure. But spending-based initiatives, the definition of health care reform for many, fall short of providing a complete solution.
#2 Outpatient Treatment Centers and Physician Self-Referrals
According to a report by the McKinsey Global Institute, one of the significant cost drivers in the United States health care system can be found in the emergence of out-patient treatment centers. See, Accounting for the Cost of Health Care in the United States, McKinsey Global Institute (January 2007). The out-patient treatment include ambulatory surgery centers, diagnostic imaging centers, drug rehabilitation clinics, mental health clinics and “nonphysician†offices.
(The U.S. spends 37% more than would be predicted on the financial model used by the economists to compare the U.S. with other developed countries adjusted for wealth of populations. See, generally, Health Care Reform By The Numbers – Factoring In The Argument From Statistics)
Newly Listed
And the new items:
#3 The Role Of Phamaceutical Companies and PBM’s
Previous posts on this site have addressed these issues in specific instances (see, e.g., :: Reflecting On The Delaware Battle of the Titans – Are The Pharmarcy Benefit Managers Really Helping Health Plans?), but for comprehensive analysis, the The Health Care Blog is hard to beat. The Health Care Blog lays out the problems with Big Pharma and the PBM’s that are supposed to be negotiating with them for health plans.
Health care reform or not, the same intermediaries will have their claim on health care dollars. See, :: PBM Defeat In Medicaid Liability Dispute Has Financial Implications For Plan Sponsors and :: The Role of Medicare Fiscal Intermediaries After Healthcare Reform
#4 Cost-Shifting To Health Plans
- When workers’ compensation carriers refuse to pay legitimate occupational claims, the comp carriers routinely direct the claimants to file claims on their own group health plans.
- If suit is filed against a workers’ comp carrier, and the comp carrier settles, the comp carriers never inform the health plans. Those funds are therefore unreimbursed to the health plan though the claim is actually adjudged occupational. Since the health plan rarely discovers the reversal of the comp carrier’s position, the costs are effectively shifted from the comp carrier to the health plan.
- When Allstate takes an unreasonable stand against payment of claims against it by injured motorists, the injured party’s health insurance has to pay the difference.
- When a potentially liable third party, say Wal Mart, for example, refuses to pay a claim by a customer claiming injury on the premises,the customer’s health plan gets the bill.
- When a physician’s business office, discovering a pending liability claim, files a lien, receives payment from the personal injury settlement, but never refunds the health plan’s payment of the physician’s fees, who suffers the loss? The patient’s health plan.
- When health care providers commit malpractice, in more cases than not, their liability carriers do not compensate for the injuries caused, and the patient’s health insurance pays the medical bills that should have been assessed against the malpractice carrier.
As long as health insurance is viewed as the payer of first resort, and ultimately the default payer of claims for every accident, the cost of health care will always be inflated.
