UnitedHealth Group (UNH) had a banner quarter as their fourth-quarter earnings jumped to $ 1.7 billion. Is this good news for UNH but bad news for healthcare users? With total annual revenues approaching $ 200 billion, things are looking good for UNH executives and shareholders. But what does this mean for healthcare users?
For the last 12 years, as a business owner, I have paid 100% of all healthcare costs. This gives a pragmatic view of the industry, regardless of the rhetoric of political parties or political promises. In my view, the only constant is the increased premiums and the reduced benefits. That was true in the Bush years, and it hasn't changed since. All countries involved in our healthcare system, including hospitals, insurance carriers, pharmaceutical companies, and medical device manufacturers, seek to maximize profits. This includes many non-profit hospitals, which are actually extremely profitable, profits being reinvested in facilities, technology, research and of course compensation. Little has been done to ensure the patient's visibility into the rising costs. Then again, why should these parties work to reduce costs or increase patient visibility? Lower costs lead to reduced revenues and profits, and these healthcare businesses are motivated to earn compelling income for their shareholders and CEOs. The same motivation as any business.
How much does a radiography cost?
Let's look at an example of a real life problem. I had ankle pain and was referred by my primary care assistant ($ 50 Tufts copay) to an ankle specialist. The ankle specialist ($ 75 Tufts copay) directed me to do an X-ray. So I asked the receptionist at the ankle specialist a simple question, how much would an x-ray cost? They said, "Your insurance will cover it." Of course, this is no longer true, since deductions and payments are often applied, and even if my insurance covers it, do I not know what they are charged for? Then the doctor told me to ask the radiology department.
About 10 minutes later, I was in radiology and asked their planner the same question about the price. She had no idea and seemed surprised by the question, but said she would call the radiology billing department. The billing department told me (indirectly as she is talking on the phone with the planner) that it depends on my insurance company. I provided my Tufts insurance card and asked again how much the x-ray would cost. They then told me to speak directly to their billing specialist, who would help me determine the cost of the x-ray. After a 10-minute discussion and twice withholding, I was finally told what the carrier allowed me and the likely cost range, which she thought was about $ 100 to $ 150. It was a difficult journey to get to what it needed to be easily and instantly accessible from the hospital and insurance carrier, computer or smartphone application.
Many millions of x-rays are made in the United States each year and costs do not have to take on a mystical property. If we can quickly learn the cost of adding the smallest item to a new car (easily accessible online) or quickly determine the average price paid for each car model, new or used, in any given area of the country, why should medical procedures are different? The simple answer is to providers, such as hospitals, clinics, laboratories, etc. we don't want to know. Maintaining hidden rates helps to mitigate competition and limits the patient's view of their costs. If Hospital A pays $ 200 for an ankle radiography, and Hospital B, which is 5 miles away, charges $ 100, patients can choose the latter (provided they are on your network, which also needs to be checked ). Look at it differently, if you want to buy some groceries and they would cost $ 200 at the convenience store around the corner, but only $ 100 for five minutes, would you spend five minutes on the savings?
Fortunately, this is changing, though very slowly. Gradually, there are more online sources and services that help determine the best quality of available resources at the best price. This includes drugstore sites and applications (GoodRX) that compare the cost of drugstores in a particular area, doctor (PriceDoc) and hospital quality and costs (LeapFrogGroup or even medicare.gov/hospitalcompare), surgical costs, and so far there are many sites. Compare dental fees. This is potentially good news for consumers and the faster and more widespread the better.
It's all about profits
Now let's return specifically to UnitedHealth and to healthcare providers in general. What happens when health insurance companies focus primarily on profits? Our capitalist system is in many ways the most enviable model for the whole world. Usually efficient, often transparent and open to most people (anyone can start a business in America). It promotes innovation partly because of intrinsic competition. This is quite impressive. But as far as healthcare is concerned, the system seems to be falling apart.
You may remember that in 2016, UNH was withdrawing from certain markets related to Obamacare. Forbes reported that "UnitedHealth entered 2017 by selling individual coverage under the ACA in only a few countries after significantly reducing its footprint on Obamacare." However, UNH did see a promise to offer Medicaid coverage that was expanded to 31 states under the ACA. Why did they do that? Remember that their main priority is not profit, but care, and patient care. And if the $ 7 billion in profits is not enough for their shareholders, then UNH must go (or leave) and find a place where they can get even more return. It is allowed that healthcare companies really have to make money in the current climate, the question is what profit and how they profit.
The gains from car sales differ from the gains from saving (or not saving) life? Prior to Obamacare, insurance companies may reject people who consider it an unacceptable risk. For example, let's say that there was a 60-year-old man who we would call Mike the Mechanic who was changing jobs and moving to a new health plan. Mike had been healthy his entire adult life (almost 40 years from 18 to 58), but then had a heart attack on his 59th birthday. Before Obamacare (ACA), that would have been a prerequisite, and even though Mechanic Mike really needed health insurance and had been a net contributor for almost four decades, insurance companies could simply say no or impose drastically higher rates. This does not sound like a fair or fair deal and leaves insurance carriers to own all the cards.
The $ 110 million Mike Award for Steve Pay
But wait a minute, what happened to Mike's 40s hardly used bonuses? During that time, Mike's premiums went to pay for less healthy people and pay the profits of the health insurance company. Let's look at an example. Let's say UNH charged $ 10,000 a year when Mike was 50 and healthy and earned 10% off the average policy. Mike contributed $ 1,000 to his profits, while the remaining $ 9,000 would pay for his health care costs (which have been rated for 40 years) and others in need of more care than their premiums. Of course, profits can be a deceptive indicator as they are determined after executive compensation, fins and other expenses. And just in case you are wondering how big that can be, United Health Group CEO Steven Hemsley received total compensation of approximately $ 110 million in 2010 and $ 66 million in 2014. , General compensation may include salary, stock options rewards, which are often a big factor in compensation , deferred benefit benefits, expense accounts, health benefits, life insurance policies, and more. Whether you think it or not, some of these CEOs are paid too much, it seems that it must be different in terms of health and health insurance. When a health insurance company refuses someone with a pre-existing condition, they enrich themselves by refusing to pay for the most desperate. This makes sense in terms of profit, but not in terms of health.
Say No and hope the claim goes unpaid
About six years ago, my daughter traveled to Moscow for her "abroad fashion" program at the university she attended. She was a major in government, studying international politics and studying Russian. At the time, our insurance carrier was Blue Cross Blue Shield from Massachusetts. We contacted them to ask about her coverage in Russia and what our daughter should do if she becomes ill. They were very specific and offered three options for doctor's offices and clinics in Moscow that she could visit in case of illness.
A few months after her arrival, she came down with a conjunctivitis, visited one of the proposed clinics, received a written receipt for the visit, and sent the receipt to me. I filled out the correct BCBS form with a detailed explanation and sent the form and receipt to BCBS from Massachusetts. What happened to that statement? He was rejected! So I called the claims department and was directed to a supervisory authority who told me that the claim had been reviewed and found out that it was not part of our coverage. I said, "They didn't review it." The supervisor again said they did. We went back and forth several times when I said, "So how many of your processing claims are proficient in Russian?" The receipt was in Russian (Cyrillic letters), which is essentially unreadable for your average English speaker. I also told her that we were exactly following the BCBS protocol and that we had documented everything to ensure we had an audit trail. The surveillance held me back twice, and came back about five minutes later to say they would pay the claim. It was a lot of reclamation work that was about $ 150, but that seems to be the idea. Consumers are tired, do not understand the nuances or just throw in the towel when it comes to dealing with these types of problems.
It was extremely difficult to obtain cost estimates from insurance companies. Here is another example of real life. I was 50, which means the time for routine colonoscopy has come. I called Tufts Health to ask about the cost of the procedure and after a series of transfers and detentions, I finally got a line from a representative who told me that the procedure would be 100% covered as this is a preventative procedure care. A few months after the procedure, my EOB (Benefits Explanation) arrived with the patient responsible part costing me thousands of dollars. After another series of calls, Tufts agreed that there was a mistake and said it would be 100% covered. Another month went by and I received a new EOB, one for hundreds of dollars. Once again I made the necessary call to Tufts and they said that the new mistake would be corrected and I would owe nothing. And after many months and many calls, Tufts' health plan finally did what they had to do and paid for the procedure. But what happens to people who do not have the time, knowledge or patience to make all these conversations? Many give up, contributing to the profits of the insurance company. Does our captivating capitalist system work well with most types of businesses but fails to do so when it comes to healthcare?
ACA defended against the pursuit of profits
There are other protections that have been created with Obamacare. Before the ACA, many twenty-something children were not covered by their parenting policies after graduating from college. There were restrictions on annuals and life expectancies that were devastating to families who were facing a serious illness. And as mentioned before, the ability to opt out of people with pre-existing conditions has been a major problem for many healthcare users. These problems are exacerbated by the exorbitant "retail prices" charged by hospitals, pharmaceuticals and medical companies. For example, an ankle X-ray, which can be billed at $ 150 for an insurance patient, could be $ 500 or more for a patient with a private payment without insurance coverage.
One of the reasons for all of the above restrictions goes back to the profit motive of healthcare companies, including insurance carriers. Although profit opportunities usually deliver positive results in our highly competitive capitalist system, as companies work hard to reduce costs and improve efficiency, healthcare creates some unusual barriers to this paradigm. For example, when mechanic Mike suffered a heart attack, he was not concerned about the cost, he wanted the best care possible, regardless of cost. And that is a big part of the problem. As for the health of our loved ones, we are often not interested in what it costs. But not all problems are related to emergency care and in many cases patients can take the time to weigh the cost, quality and venue of the procedure if providers simply notify us.
Would UNH receive lower profits if they provide better coverage or less expensive plans? The simple answer seems to be yes. From what I have seen, there does not seem to be much competition as all major health carriers charge similar (and confusing) rates. When I compare the tariffs and coverage of carriers each year, including the dizzying array of seemingly similar plans, they all seem comparable. But this is not the case when comparing car and homeowners insurance – often there is a big discrepancy – probably because of competition and transparency. Is there really any real competition between health insurance carriers?
With all these healthcare players (insurers, hospitals, pharmaceuticals, medical companies, etc.) striving to maximize profits and lobby our politicians to allow them to do so, how costs will be limited and how fair coverage can be apply? Just imagine how many billions more UnitedHealth (or any health insurance carrier) can earn if they manage to deny anyone they consider an expensive potential asset. Or maybe they could win even more by refusing to cover people who are genetically predisposed to health. In fact, some of the carriers and large employers have tried to do this, as a result of which government law does not allow carriers and employers to refuse to insure people on the basis of genetic profiling. The Genetic Non-Discrimination Act of 2008 (GINA) prohibits discrimination on the basis of genetic information with respect to both health insurance and employment.
What if health insurance companies manage to lobby Congress to reduce these annoying annuals or life limits? Maybe they could really make those profits jump, with shareholders recording unexpected profits. Or maybe insurance companies could lobby to cover only healthy young people up to the age of 50, or impose 10 times higher prices for older people. These statements are at the heart of the paradox, the fair distribution of health insurance over the model based on the profits of our current healthcare system.
Health insurers are now operating under a law referred to as Rule 80/20 that is designed to help consumers by ensuring that at least 80% of insurance premiums are used to pay for health care costs. The remaining 20% goes to general administrative, overhead and marketing expenses. In some cases, such as group benefits or certain state requirements, the required cost level is 85% to 88%. This regulation may be helpful, but it is not helping enough. Стимулът за намаляване на разходите е смекчен, тъй като по-големият брой приходи в горната линия често води до по-големи печалби. Казано по-просто, застраховател с милиард долара ревизия може да спечели 200 милиона долара, докато застрахователят с половината от тези приходи може да спечели само 100 милиона долара печалба, въпреки че вършат по-добра работа, контролирайки премиите и разходите.
Несъвършено, но стъпка в правилната посока?
Obamacare е несъвършено решение, нека разгледаме причината за това. Обама трябваше да изгради консенсус със съществуващите играчи, за да се опита да усъвършенства съществуващата система. Опитът му да създаде опция за правителство се провали и в резултат на това и Конгреса, лобиращ специалните интереси, ACA не направи достатъчно, за да намали разходите. Освен това тя добави сложности и проблеми за спазването на много предприятия и създаде данък Cadillac, за да помогне за покриване на разходите по програмата. Това каза, че добави много важни защити и помогна за осигуряването на субсидирана застраховка за милиони неосигурени потребители в здравеопазването в САЩ. Макар и несъвършен, това изглеждаше като стъпка в правилната посока, застраховане на десетки милиони хора и ограничаване на потенциалните злоупотреби от застрахователните превозвачи.
Отмяна и замяна
Новият ни президент и контролираният от нас републикански Конгрес се опитват да отменят ACA. Тръмп обеща да разреши всички тези проблеми, да намали разходите и да запази ключовите предимства на Obamacare. На мен това ми се струваше трудно да повярвам. И наскоро POTUS изглежда разбра, че промените в нашата здравна система са трудни, „това е невероятно сложна тема, никой не знаеше, че здравеопазването може да бъде толкова сложно“. Не съм сигурен къде е бил, но е сложно толкова дълго, колкото мога да си спомням. Може би POTUS трябва да прекарва по-малко време в туитър и повече време за четене на книги като Америка "Горчиво хапче": пари, политика, закупуване на задни кутии и борба за поправяне на нашата разрушена система на здравеопазване , която подробно описва силно нюансираната политика и сложностите, свързани с нашата здравна система.
Ще бъде ли отменен ACA и заменен с „по-малко скъпа и много по-добра … застраховка за всички“, както заяви Тръмп? Американският закон за здравеопазването, изглежда, противоречи на високите и на пръв поглед нереалистични обещания на Тръмп. И въпреки че Тръмп каза, че всички ще бъдат застраховани, Службата за бюджет на Конгреса на САЩ заяви, че над 14 милиона души ще загубят здравноосигурителното си покритие, ако американският закон за здравеопазване някога бъде одобрен. Тъй като най-накрая се появяват повече подробности за републиканския план за замяна на ACA, се казва, че една от предложените промени позволява да се даде възможност на застрахователните компании да таксуват по-възрастните клиенти до пет пъти повече от по-младите клиенти. Звучи като лоша новина за механика Майк, ако това е позволено да се случи.
Все още за видимостта
Независимо от предложените промени, разходите никога няма да бъдат ограничени, ако потребителите не получат видимост в цените, за които всички сме таксувани. Не че видимостта е единственият отговор на този сложен въпрос. Но това е добро начало. Всички трябва да сме загрижени за разходите за рентгенография на глезена, включително и за лекарския кабинет, насочващ пациента за процедурата. Това струва ли 200 долара в сградата на медицинския кабинет, но 100 долара зад ъгъла? Практиката по радиология зад ъгъла в „мрежата“? Какви са оценките на пациентите за всеки от тези двама доставчици? Звучи сложно? Ако Yelp, TripAdvisor и Edmunds могат лесно да споделят изобилие от информация, включително специфични данни за ресторанти (коя храна да поръчате), хотели (най-добрите стаи за поискване) и автомобили (средна цена, платена във вашия пощенски код), isn & # 39; не е възможно да предложим достъп до милиардите, които прекарваме за здравеопазване?
Разбира се, би било чудесно, ако всички успеем да получим това, което обеща Тръмп, а именно „по-евтино и много по-добро“ здравно осигуряване. Но тъй като всички тези обещания звучат като празни обещания, аз няма да затаи дъх, защото това може да причини разкъсване на белите дробове и това вероятно е предшестващо състояние.