I'll go over some of these things again, as I have done a few times.
I agree that there needs to be more regulation in the healthcare system, not less, but only in some areas. But the focus needs to be in the relationship between the provider and insurer, because this is a two way street. Yes, insurance providers do have people looking at treatments and rejecting payment of those treatments to the provider, based on what they believe to be treatments that are unecessary. While its true that these people do not see the patient, the treatment is reviewed by a liscenced medical professional. The insurers pay good money to these people. In the case of an RN, he/she could make well more than they could working at a hospital. However, providers are more willing to do "more tests" for insured patients, than they will for uninsured patients. Because the insurance companies have the deep pockets. This back and forth fight between health insurer, and provider over what is necessary, is a HUGE part of the problem IMO. This is an area that needs regulation. However, it is my opinion that the regulation needs to come from the states and not the federal government. Insurance laws are written by state legislatures and are overseen and enforced by a commisioner of insurance in each state. Devising a national regulatory system would infringe on the ability for states to retain control over the health care providers and insurers under their rule.
The payment situation is absurd, and its because of the back and forth struggle between insurer and provider. I received a bill for $350 almost a year after my son was born, from my wifes anethesia. I called to find out why I was getting a bill for $350 dollars, since we hadn't been to the hospital for nearly a year. Supposedly there was a dispute between the two that had to be settled before they could bill us. Now thats not a huge bill in this case, but its an inconvience for sure.
If we were to remove the stipulation that pre-existing conditions have to be covered, then insurers will have to be allowed to charge additional premium because of pre-existing conditions. Insurance by definition is the transfer of risk. The greater the risk they assume, the greater the premium they charge. Thats the insurance market in a nutshell. The reason they do not cover pre-existing conditions, is because they are trying to keep the premiums lower. Anybody who seeks to reform this, had better be careful because if they try to be noble and force insurers to cover pre-existing, and deny them the ability to charge for it, will seriously screw everything up and insurance companies would either collapse(more unemployment for you to deal with Mr. President) or they would find a way to increase premium in an "unrelated" way, to cover costs.
Also I remember reading on Obama's website during the campaign season, that he would essentially remove the cap on insurance policies. I do not know if he still seeks that, but that would be a disaster of epic proportions. As I said before, insurance is a transfer of risk. If we tell insurance companies they must take on an infinite amount of risk, what do you think that will do to premiums? ALL insurance policies, regardless of what kind of insurance it is, has a policy limit. The higher the limit, the higher the premium. Insurance companies have deep pockets, but not that deep.
I can agree with much of what you say except two points:
1) Those that the insurance companies employ to review treatments are indeed trained professionals. It is still irrelevant. They do not see the patient. Reviewing files or hearing reports is completely different. As a provider, I see my own patients. If a colleague goes on vacation and asks me to cover, I am
very uncomfortable doing that. Though they may tell me about them, and I may read about the case, I will
NOT make any major treatment decisions, unless their is a major crisis. There are nuances that go along with working with a patient that don't go in the record. These people at insurance companies don't see these nuances. Further, it is not the job of these people to help provide the best care; it is the job of these people to save their company money. This aspect of insurance-provider care needs to be eliminated.
2) It needs to be in the hands of the federal government, not the states in order to provide conformity amongst policies, to head off confusion. I work in NJ, and my patients come from NJ. However, I deal with insurance companies from at least 10+ different states, as the companies these patients work for may have their home office in other states. Each of these states have different regulations, different paperwork requirements, etc... This is just another way for the system to break down and for payment to get denied. I once sent a request for service to an insurance company in Pennsylvania. After receiving no payment for 2 months (it takes that long or longer), they told me the home office was in Missouri. So, I sent it there. Same thing...2 months later, they told me that
this patient's divisional home office was in California. So I sent it there. Same thing...2 months later, they told me that Pennsylvania was wrong, that
that was where it was to be sent. This "round and round" process went on for 8 months. Further, each state had different regulations on how the paper work needed to be handled, requiring it to be sent back,
more times, especially when they gave me wrong information. And all the while guess what? I wasn't getting paid for treatment. If this was an isolated incident, I wouldn't be complaining. But it's not. This is why many people in the medical field no longer accept any insurance...and why many cannot afford health care.
More regulation on the federal level, taken out of the states' hands in order to avoid the kinds of manipulations that occur, and to avoid the lack of conformity in dealing with companies is what needs to happen.
