If you’re wondering why insurance companies deny necessary care and get away with it, it’s not only that the insurers are pulling all the strings and have become too big to fail. It’s that different doctors often have different opinions about what is medically necessary. A new report from the Center for Improving Value in Health Care focuses on the health care that people get that the Center says is not medically necessary, driving up health care spending, reports Markian Hawryluk for KFF Health News.
The amount spent on unnecessary care or “low value” care in Colorado, as reported–$134 million in 2022–seems relatively small. The Center says it is the tip of the iceberg. But who is to judge what is low-value care? The health insurance companies should not be the judge when they profit from denying care.
There is tremendous risk in turning authority over treatment decisions from physicians to insurance companies, as Medicare has done through the Medicare Advantage program. Where is the value in handing buckets of money to health insurance corporations who can deny coverage for low, medium and high value care without justification, in secret, largely with impunity, in order to maximize profits?
And, we continue to hear horror stories of the health insurers denying needed care through AI algorithms and staff physicians who earn bonuses when they don’t refer patients for costly specialty care. Why would we trust the insurance companies and their staff to get coverage decisions right when they have no understanding of particular patient conditions and an incentive to deny care? Read this post on how UnitedHealth is using AI to deny rehab care to vulnerable older adults without regard to their particular conditions and weep.
Of course, there is no perfect payment system. The Center for Improving Value in Health Care appears to like the idea of giving insurers buckets of money to cover care. But, rather than giving insurers the discretion over these treatments, isn’t the fix to have national policies, publicly vetted, about what is covered and not covered? If opiates, antipsychotics and screenings for Vitamin D deficiency are really unnecessary in most cases, why are insurers covering them?
A capitated payment system–one in which the insurers are handed money upfront to “manage” care–simply changes the incentives, disregarding physician opinions, working against patients, and rewarding insurance companies for giving less care or for denying care inappropriately. And, corporate health insurers operate in a proprietary or secret system. Researchers can’t even learn whether what insurers are doing when they deny care is endangering people’s lives or helping them. How does that add value?
What’s crystal clear is that if we are going to improve the health care system, we need to collect and review patient data. We need to know what is working and not working. We need to know in real-time what’s happening to protect people from insurance companies that put their profits first. And, we need to be doing what other wealthy nations do: Dictating all the terms of coverage, removing discretion over coverage decisions from insurance companies, so that people can count on getting the care they need without delay and are not forced to gamble with their health.
Here’s more from Just Care:
- Underpayments lead hospitals and specialists to cancel Medicare Advantage contracts
- 2023: Five things to think about when choosing between traditional Medicare and a Medicare Advantage plan
- What are your Medicare premiums in 2024?
- The choice between traditional Medicare and Medicare Advantage: It’s a sham
- If you want easy health care access and good quality care, you probably want traditional Medicare
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