home email us! sindicaci;ón

Thinking of Insurers as the Enemy Is Simplistic

by Scott MacStravic

The easiest and most common portrayal of health insurance companies is that of an “evil empire” constantly looking for ways to get out of paying for health care that their customers need, delaying and cutting payment, etc. in order to maximize their own profits and their shareholder value, which is, after all, the job of corporations, according to many economists. The book and film “The Rainmaker” portrayed insurers at their worst, systematically denying almost all claims and only paying a minority of them when complaints were filed, while letting patients die for lack of needed treatment.

Physicians seem to rank health insurers only a little better, with one survey in Texas finding that all the state’s insurers rated were rated poorly. Contrast this to the extraordinarily high consumer ratings given to USAA, the insurer that markets to military personnel and veterans, and made news when it forgave the auto insurance premiums of its clients when they went to war in Iraq.

But while it is probably natural that insurers tend toward very conservative definitions of what is necessary treatment and “experimental” vs. proven treatment, they also serve to control the already skyrocketing costs of health care, and thereby make it more affordable for both individuals and employees covered by their employers’ sponsored plans.

In a recent article, its authors suggested that; “It’s Not More Medical Tests We Should Be Fighting for, But More Information and Choice”. It cites the U.S. Preventive Services Task Force ratings of preventive tests and services, noting that ratings vary from “A” meaning a really good option that should definitely be covered, down to “D” meaning of dubious or mixed quality, compared to negative side effects or risks. It rates some as “inconclusive”, meaning that it is too soon to tell.

It cites examples of tests that tend to produce identification of what are deemed medical problems, even though the person affected by the “problem” has no pain or other symptoms or lost functioning. Many tests have extremely high rates of “false positives”, meaning a lot of people will be treated as if they are sick when they are not, creating risks from treatments, as well as adding significantly to the level of unnecessary care we all pay for.

The side variation in frequency of many treatments across the country, with no signs that the areas with higher frequency have healthier citizens as a result, has frequently been cited as evidence that we should probably get less care, in general, than we do now. [“Geographic Variation in Health Care Spending” Congressional Budget Office 2008] Total spending in 2—4, for example, varied from a low of <$4,000 per capita in Utah, to a high of >$6500 in Massachusetts. Even government-controlled Medicare spending varied from a low of $5600 per beneficiary in South Dakota to a high of $8700 in Louisiana.

The plight patients denied an expensive test that might have saved one or more of them always looks more dramatic and heart-rending than the possibility that had all who thought they needed the test been given it, the results might have caused enormous amounts of unnecessary, dangerous, and wasteful treatment of people who were not really sick. And organizations with financial interests in selling the test are likely to be in the forefront of those demanding its coverage, without mentioning the profits they expect to gain as a result.

The best we can probably hope for is that insurers and patients alike will look for information such as the U.S. Preventive Services Task Force ratings before they demand coverage for themselves, or join others making such demands. Insurers have already begun, though belatedly, the move to promoting wellness and reducing health risks, so that they, along with everyone who benefits more from good health than bad, can reduce the incidence and prevalence of disease in the first place. Conjecture over what good might have been done if a given test or treatment were covered should always be tempered by some insights into the full range of effects on entire population, good and bad, not just the positive possibilities in one case.

<a href="http://www.worldhealthcareblog.org/2008/02/24/thinking-of-insurers-as-the-enemy-is-simplistic/" rel="bookmark" title="Permanent link to Thinking of Insurers as the Enemy Is Simplistic" class="perm