In 1961 I started working for a large employer. My first job (after starting as a mail boy) was processing health benefit claims. I have been involved in designing and managing all forms of health care and other benefits since then. That included being on the boards of directors of four HMOs back in the 1980s and chairman of two.
Over all those years I interacted with thousands of employees and their spouses when they had problems with their benefits, the plan administrator and sometimes a hospital or physician. I feel like over nearly fifty years I heard every complaint, conflict and screwup possible.
Problems were caused by the insurance company (in the role of self-insured plan administrator), HMOs, the health care provider, the PBM and often the patient/employee.
A clerk made a mistake, a coding error caused a claim to be denied or processes incorrectly. Someone misinterpreted a plan provision, a Rx was lost in the mail, a patient was told the generic was not equivalent, a physician tried to interpret a plan provision when knowing nothing about our plan (and the employee believed them). A claim was denied upon appeal and we sought independent review.
Patients routinely equated high cost with high quality and wanted unrestrained access to any physician or hospital at in-network cost, patients were convinced HMOs provided lower quality care or avoided care altogether and on and on and on.
Politicians rhetoric adds fuel to the fire of misinformation and exaggeration.
According to Elizabeth Warren, “Families pay every time an insurance company says, ‘Sorry, you can’t see that specialist.’ Every time an insurance company says, ‘Sorry, that doctor is out of network. Sorry, we are not covering that prescription. Families are paying every time they don’t get a prescription filled because they can’t pay for it. They don’t have a lump checked out because they can’t afford the co-pay.”
Why does any of this matter? Simply because health care horror stories tend to be accepted on face value while often you are not hearing all the facts and circumstances. Good press sometimes comes before common sense and facts.
Frequently upon investigation I found I was not told the whole story, I was mislead or simply lied to by the employee or spouse. The physician’s staff gave incorrect information. And, of course, whatever the employee was required to pay, was unaffordable.
None of this applies only to private coverage. Medicare has an extensive claim appeal process. There are appeal five steps for basic Medicare.
There are two takeaways from this. First, don’t accept every tale of horror with health care on face value.
Second, don’t assume anything will be different under a universal program promising total coverage free of patient direct cost. If anything the conflicts and controls and controversy will be greater.