Today, hundreds of corporate health insurers offer thousands of health plans and treat much of their data on the care they cover and patient outcomes as proprietary. They have a powerful incentive to deny care as it increases their revenues and the ability to do so with near impunity. Effective oversight is largely not possible and tremendously costly. Enrollees gamble with their health and their lives when they choose a health plan, as there is no guarantee that their insurers will cover the benefits to which they are entitled.
What makes matters worse is that insurers are not willing or able to control health care costs. Increasingly, cost is a barrier to care for enrollees. High deductibles and copays mean tens of millions of Americans are underinsured and cannot get care, even with health insurance.
Additionally, insurers can delay and downgrade hospital and physician claims, and it is in their financial interest to do so.
If value is a function of quality and cost, insurers are providing low- or no-value health care. Costs are out of control, and quality is impossible to ascertain.
While there is no way to fix our broken for-profit health care system, some improvements would help ensure people get the care they need and providers are paid in a timely fashion for their services. These reforms are urgent and critical.
- Prohibit health insurers from offering more than three different health plans.
- It would simplify people’s choice and make it a little easier to distinguish among health plans.
- Still, it would not help people know whether a health plan would meet their needs.
- Establish an independent agency to standardize prior authorization rules and process claims.
- Members of the agency would have no financial incentive to establish rules that are not evidence-based.
- Members of the agency would be accountable for their rules, which would be transparent.
- Standardize prior authorization and claims processing.
- Standardization ensures that, no matter which health plan people choose, prior authorization rules are based on clinical evidence.
- Standardization would make prior authorization rules transparent.
- Standardization would reduce inappropriate delays and denials of care.
- Standardization ensures prior authorization rules are consistent across plans. Without standardization, each health plan uses different rules when deciding whether to cover services
- Standardization could allow enrollees to compare plans on how well they manage and coordinate care and costs.
- Standardization would help ensure patients get the care they need. It could allow patients to avoid bad actor health plans.
- Grant the independent agency authority to pay claims.
- Centralized claims processing ensures providers are consistently paid in a timely manner.
- Centralized claims processing allows the collection of complete, accurate and timely patient encounter data needed to oversee health insurers and understand emerging and persisting health care issues.
- Centralized claims processing could improve public health. It would make it easier to see what’s working and not working in our health care system and drive improvements.
- Establish meaningful network adequacy standards to ensure enrollees have access to needed care.
- Prevent insurers from establishing different networks for different enrollees in a given area, be they in employer-sponsored plans, retiree plans or ACA plans.
- Impose meaningful automatic non-discretionary penalties on insurers that misrepresent their network providers or that have inadequate networks.
- Establish meaningful prescription drug coverage rules.
- Require insurers to cover generic alternatives to all brand name drugs.
- Transfer step therapy decisions away from insurers into the hands of an independent agency.
- Require insurers to compete exclusively on network design, care coordination and cost.
Here’s more from Just Care:
- The wrong choice of Medicare Advantage plan could kill you
- The choice between traditional Medicare and Medicare Advantage: It’s a sham
- 2026: Five things to think about when choosing between Traditional Medicare and a Medicare Advantage plan
- OIG finds widespread inappropriate care denials in Medicare Advantage
- Medicare Advantage networks can be narrow and harmful
