A Dysfunctional System Of Health Care

As one who has been working with Medicare, Medicaid and private health insurance since January 1973, I can understand the frustration that consumers have towards health insurance companies. At the heart of all this is the profit driven private health insurance companies. Polls and surveys consistently have shown widespread public approval of Medicare and Medicaid. Both are government programs, although far from perfect do a good job of covering those who are eligible.

However, I believe that many Americans are becoming upset with the obscene compensation being paid to executives and managers of health insurance companies. The CEO of United Health Care received $10 million dollar compensation which was the lowest among CEOs of major health insurance companies. The CEO of Elevance Health (which owns Anthem Blue Cross that is my insurer) receives more than double Brian Thompson’s compensation of over $21 million dollars this year.

Another thing that I have learned is that the popular drug Ozympic which is used to treat type 2 diabetes but is frequently prescribed for weight loss has a retail cost of over $1000 a month in the United States, but the cost for the same drug from the same manufacturer costs only $300 a month in Canada. So why is the cost in the United States for the same drug more than three times what it costs in Canada where the government negotiates drug prices for their single payer system that covers all Canadian citizens?

A lot of middlemen are getting filthy rich off the system of public and private health insurance system in the United States. United Health Care has the largest market share of the popular Medicare Advantage market in the United States. Yet all too often those health insurance companies will delay or deny coverage to people just based on saving money rather than medical necessity. I call those cases “bean counter decisions,” made mostly for financial reasons more than medical necessity.

Here is a case in point where I became personally involved with this system for a close friend. Several years ago, a longtime friend of mine spent ten days in the hospital and was sent to a facility for skilled care. Skilled care is rehabilitative care, and Medicare covers up to 100 days of skilled care. I was granted a temporary health care power of attorney for this friend since she had no close family living in the area. After ten days in skilled care, her Medicare Advantage plan said that they were stopping payment for skilled care. But the doctors and social workers all agreed that she needed more rehabilitation and was improving. We filed an appeal and submitted all the clinical information on her condition. It took just two days for the insurance company to deny the appeal and terminate skilled care.

We filed a second appeal and that only took one day for the insurance company to deny that appeal. Everyone involved with her care believed that they didn’t even look at the clinical information that was submitted. The third step was to request an administrative review by a third-party administrative company. This took a week for them to deny their appeal. The third-party administrative company was owned by the insurance company, a clear conflict of interest.

The final appeal was to God, in this case the Centers for Medicare and Medicaid Services (CMS) the government agency that administers Medicare and Medicaid. CMS is literally God when it comes to Medicare and Medicaid since they are all powerful and can do anything. This appeal to CMS was successful as they overruled the insurance company and approved the skilled care. By then full guardianship had been established for this friend and an attorney appointed by the Probate Court was now handling all her affairs, including heath care. She left skilled care after a little less than sixty days and went into assisted living.

But how many people know all those appeal steps or that after all appeals are exhausted, it can be taken up by CMS? I knew that and so did the lawyer who was assigned as her guardian. But how many similar “bean counter decisions” are made and never appealed? Or is the appeal process rigged like what I encountered with this large insurance company?

I can sum up the problems with the health care system in the United States with six words: too many pigs at the trough. Those top executives receiving seven and eight figure compensation are the biggest pigs at the health care trough. Then add in the obscene salaries of CEOs of hospitals, medical equipment companies, pharmaceutical companies and all the other private companies that are making a lot of money in health care throughout the United States. The United States has by far the highest health care costs in the world, yet based on actual statistics, our nation’s overall life expectancy is lower than most developed nations.

To put it mildly, we are not getting our money’s worth for all the health care dollars that we are spending. I am not surprised that finally a lot of Americans are simply fed up with this dysfunctional and rigged system of health care in the United States. Why are executives of health insurance companies making well over ten times what an experienced doctor makes? Why do medical practices and hospitals often employ many more people handling patient accounts and billing than they employ doctors, nurses and therapists who actually provide the health care to the patients? Those people do not work for free so that adds to the cost of health care for Americans.

What surprises me more is why has it taken the assassination of a health insurance CEO to bring all this to the attention of the country? I am certainly not advocating the assassination of health insurance executives. But I can understand why so many people in the United States are upset and frustrated.

We are spending a lot of money on health care and health insurance, yet private for-profit companies are making gobs of money and paying their top executives seven and eight figure compensation while necessary health care is denied or just not available because the patient lacks the ability to pay. Medical expenses are still the number one reason for personal bankruptcy in the United States. Yet “medical bankruptcy” is unknown in the other developed countries of the world.