Joomla Sport Template

Have you ever wondered what really goes on inside our insurance companies? The media portrays them as the bad guys but in actuality, they are selling a product just as any other legal business. In this article, we will discuss health insurance because that is where my experience comes from. I was the Director of Medical Services for a large insurance company for eight years. As an RN with many years of medical expertise, I learned the business side of healthcare.

Employers purchase this product, called health insurance, for their employees. Several products are offered and the employer chooses what is affordable. It is very similar to purchasing a car insurance policy. The employer can choose a premium policy with a lot of bells and whistles or a lower coverage, lower cost option. The employer then decides how much of this cost is passed on to each employee.

The problem begins when the policy holders expect more than the policy coverage allows. When we purchase a car insurance policy, we don't expect more than what we purchase but somehow with health coverage we do? Medicare is very similar. There are limits to what Medicare will pay. That is the way the system works.

The insurance companies have contracts with willing healthcare providers at a discounted rate. Instead of paying eight dollars for the tube of toothpaste the hospital wants to charge, the contract allows the insurance company to pay, for example, a daily rate that includes all of the hospital services and charges for that patient. Since the hospital in this case has some financial liability for services offered on this day, it forces them to be efficient in the quality and services they offer, therefore, helping with wasting healthcare dollars and services.

Just as with car insurance, there is abuse of healthcare also. Some providers order medical testing to avoid lawsuits instead of what is medically necessary. Families want to leave their loved ones in the hospital longer than is necessary because they perhaps want someone else to care for their loved one for as long as possible. Consumers want sinus surgery and try to get plastic surgery on the nose at the same time. Companies are billing our Medicare insurance and getting paid for patients that don't exist. Patients insist that they are going to live forever and demand treatment that is useless. The list goes on and on.

Insurance companies collect data on their contracted providers to see which providers stand out from their peers. They research why these providers have such higher cost and utilization of services. The insurance quality department is required to analyze data for quality improvement. Requested surgeries are screened to make sure they are necessary according to National Guidelines for the medical industry. They have stringent state and federal rules that must be followed, including improving the quality of care.

The challenge for the requirement to improve quality and cost in insurance companies comes with the consumer changing companies. Why invest in a group to improve health when employees change to another company in a year? The HMO model was designed to be preventative which in turn improves quality and cost but when consumers change companies the cost savings goes out the window. The federal government even put into place a limit as to how long a Medicare client must keep an HMO before they are allowed to change.

The system is broken. It is not just the insurance companies that have caused the problem. We all have a responsibility to improve the system by limiting abuse, limiting frivolous lawsuits, being realistic in the medical testing and care we request, and realizing that we are not going to live forever.

Genetics plays a large role in the medical care we may need. Healthcare providers need to individualize healthcare and stop the fight to have patients live forever also. We tend to blame patients that are ill on lifestyle, work, environment or whatever else we can find to avoid looking within them as a human being that is uniquely designed. Help patients define quality of care for them and move to meet that goal. Statistics are great but that in healthcare practice is not always sensible. Your patient may be the outlier for that statistic so the goal will never be reached. Let's choose healthcare goals that are reasonable for our patients and patients need to be reasonable within the divinely designed body in which they have been given.

We must remember that there is abuse in any industry. That doesn't make the whole industry bad. We all play a role in that abuse. Every time a patient or provider requests a test, procedure, or surgery that is not going to improve the outcome the costs go up and the quality goes down. The family that insists that Grandma is going to live forever or Grandpas diabetes is going to go away is unrealistic. We let our emotions take over and forget about the quality of life.

Let's all take responsibility for our healthcare. Laws have to continually be changed and updated to keep up with the abusers. Why don't we just limit the abuse to begin with?

Louise Williams is the Director of Hospice of the Pines, located in Dewey-Humboldt, Arizona.