Okay, the health insurance companies are evil too

So, one of the things you learn when you really delve into health care policy is how much of the greed and the absurd costs in America are driving by the providers, especially large for-profit hospital corporations and medical practices.  (Again, I cannot recommend Elisabeth Rosenthal’s book enough).  Often times, the insurance companies are just the middle-men who get blamed.

But, damnit, sometimes they are pretty bad actors themselves.  Very disturbing story in Vox on how Anthem health has started denying coverage for emergency room visits for what turned out to be non-emergency situations.  They are doing it strictly off the diagnosis code upon leaving the ER.  What this obviously fails to take into account, though, is the presenting symptoms at the ER.  Have the basic symptoms of a ruptured appendix that turns out to be ovarian cysts, sorry you are out $12,000.  Have extreme chest pain that turns out to not be a heart attack.  Tough luck.

Of course, this expects people to be able to accurately diagnose themselves before visiting the ER.  And, it discourages appropriate (and potentially life-saving) ER use by instilling fear you’ll receive exorbitant charges.  No, you shouldn’t go to the ER for the flu or a sprained ankle.  And, yes, insurance companies have a right to disincentive that, but this damn sure ain’t the solution.  And Sarah Kliff’s terrific article does not get into what happens in other advanced democracies, but something tells me this is not happening in pretty much anywhere else with more rational health care policies.

About Steve Greene
Professor of Political Science at NC State http://faculty.chass.ncsu.edu/shgreene

6 Responses to Okay, the health insurance companies are evil too

  1. Mika says:

    We took our daughter to ER the other night because her stomach had been on and off sore for about three days. When we decided to take her to see a doctor it was late in the evening so the public ER was only place that was open.

    We got there, saw a nurse who evaluated if she needed medical care. She decided yes from what we told her and took us to waiting room. We waited for about 1/2 hour and then came other nurse who took us to an examination room. She asked more questions, took some blood for testing, measured temperature and asked us to wait until the tests get ready and doctor has time to see us. While we waited for the doctor our daughter delivered urine sample.

    Then the doctor came and did medical examination. Since the test were ok and the medical examination was ok too she figured that it might be some sort of a virus based thingy. “Come back if her temperature rises.” We were glad we took her to doctor so we all could stop thinking if it is something serious, for example inflamed appendix. We haven’t got the bill yet but I think it is something like 25€. She has a voluntary health insurance which covers it.

    We thought a lot about going to doctor. We didn’t have to worry about how much it might cost. That never crossed our minds. What we thought about was: is it necessary? What if she gets better after a good nights sleep (which happened)? They surely take blood and she doesn’t like that. What if we have to wait long? Is she more comfortable at home? First world problems.

  2. Nicole K says:

    I think it is pretty evil for an insurance company to take the only effective drug for narcolepsy off formulary with no notice to those who currently take it. I was lucky enough to to get this resolved quickly and approved until 2039, but I have been through 4-5 prior authorization battles for this drug already and I threatened to appeal to state regulators. I feel sorry for newly diagnosed narcolepsy patients who are now facing an even more difficult process with more roadblocks to gain approval.

    I get that the drug manufacturer is even more evil. They sell a drug that has been well understood since the 1960s (although it was found effective for narcolepsy in the early 2000s) and costs almost nothing to make for $15,000 a month. They have continued to impose biannual price increases every year since it was introduced. It has had an 871% price increase since introduced in 2007. They also do not negotiate with insurance companies about the price.

    They do almost completely remove the effects of high prices for patients because they subsidize all copays over $35. But their pricing strategy is making gaining insurance approval for their drug very difficult. It also makes patients unemployable at organizations not large enough to absorb a $150,000 annual hit on their insurance. So it’s not as helpful as they like to say it is. In fact the UK denies almost all narcolepsy patients access to the only effective treatment for the sleep deprivation associated with narcolepsy because it is deemed too expensive even with their price controls. Only the small number of patients who acquired narcolepsy as a result of the h1n1 vaccine are approved there.

    But the problem is really with the laws that have been put in place to encourage companies to supply orphan drugs for rare chronic diseases. These drugs are for very small populations and they wouldn’t be profitable if they were priced reasonably, so our government has given them extra exclusivity and other incentives that allow them to be profitable based on pricing rather than volume.

    I don’t understand why the government is not the provider of drugs that falls into this category. It’s such a small population served by these drugs (mine is prescribed to around 11,000 people in total) that it would cost little for government to assume this responsibility. That would make a ton more sense than turning people with rare chronic diseases into tools that a drug company can use to extort insurance companies. However, it would require actually admitting that health care is not a free market, which one political party will admit when hell freezes over.

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