Unlike most twenty-three-year-old sorority alumnae, I receive my monthly subscription of Cosmo with a side of insurance rejections: such is the life of a coed who lost the genetic lottery. Thankfully, I earned an undergraduate degree in Health Administration and specialize in reminding health care organizations of their contractual obligations. Unfortunately the majority of Americans have not had this training while the red tape surrounding the insurance system is dense and misleading (1). But that’s to be expected; even the laws put in place to protect patient rights are incomprehensible. A Journal of General Internal Medicine report found that legislation set to protect patient rights is comprehensible to people with a reading level equivalent to that of an Associate Degree (2). To put this in perspective, approximately 70% of the United States population over the age of 25 can’t understand the laws which protect their health care rights (3). This ambiguity has created a market of confused individuals who are easily melded into padding the bottom line for both insurance companies and for-profit health care advocates.
According to the California Nurses Association, 1 in 5 claims are rejected by private insurance companies each year (4). These rejections can occur before or after care is received and come in two classes: quantitative and subjective. The first genre consists of clerical errors and miscoding issues, both of which are easily corrected to the subscribers benefit (so long as the subscriber catches the error, knows their benefits, and appeals the rejection in a timely manner). The second groups of denials are difficult to negotiate as they result the insurance companies definition of preexisting conditions, medical necessity and experimental procedures (5).
Comedian Stephen Colbert illustrated the satirical nature of this licensure in his October 29, 2009 introduction in which he asked “What qualifies as a preexisting condition? … If you have to ask, you probably have one! (6)” Take for example Stephanie, a 24 year old from Oakland, California, who opted into a single-payer insurance policy while she was studying for her MCATs. She went to the doctor for an annual exam and was diagnosed with bronchitis. This diagnosis led her insurance company to do a five-year review of her medical records in which they found evidence of a past chest infection, providing them with grounds to refuse payment for her care. She never thought that her former chest cold could be a preexisting condition, yet due to her insurance company’s interpretation, she was forced to pay out of pocket (7). Obviously the insurance industry has to stack the deck in their favor; they are for-profit companies and deserve to be compensated for their sizeable gamble on individuals, but the high profits which result from rising premiums and unclear coverage denials is unethical (8).
This no-man’s land between insurers and individuals has led to a job market in patient advocacy. Many advocacy groups are either non-profit or governmental agencies; indeed, most states have patient advocacy bureaus to help their residents navigate the difficult legislature governing their care (9). Unfortunately these bureaus, like most social service sectors, are overworked and underpaid, forcing states to mandate who qualifies for advocacy (10). This urges patients with financial means to employ private, for-profit advocacy agencies to help them navigate the intricacies of the health care system, adding additional cost to their health care. Furthermore, the for-profit nature of these companies caters to healthy individuals, and some refuse to work for people with preexisting conditions, leaving those who desperately need support without recourse (11).
Einstein once said “make everything as simple as it has to be, but no simpler.” If this principle governed the success of Time’s “Person of the Century,” perhaps we should consider applying his wisdom to our current health care crisis (13). Simplicity is indeed the key to our success. Currently, health care reform bills have provisions to subsidize and reward the utilization of electronic medical records. Unfortunately, these electronic medical records are not currently at a developmental level which would supply security or uniformity. Yet these systems have great promise, indeed, if they are streamlined, continuity and accuracy of care would be vastly improved (14). A standardized record system would incite uniform regulations across insurers, helping to hold the insurance system accountable in a laissez-faire manner which increases its political viability. Furthermore, the clarity this system provides would help subscribers to understand the reasoning behind decisions which were formerly illogical. Unfortunately this goal is several years in the offing and we cannot wait to provide culturally relevant data to patients.
I recently attended a Comparative Effectiveness Research seminar in which Dr. Robert Epstein was panel member; I recognized his name, but couldn’t immediately place him (12). Halfway through the panel, it hit me - Epstein’s signature is affixed to letters I receive from Medco Health Solutions when my prescription drug coverage changes. In my world, Epstein is the prescription-drug-coverage-devil. But as I sat listening to his speech on personalized medicine, his congenial nature and “carpe diem” philosophy made me realize that the man behind the signature is human and truly cares for his subscriber’s futures.
Insurance companies are made up of educated people who, like Epstein, want what’s best for their subscribers. Admittedly, the more effective treatments are, the less they have to pay in the future. Yet these companies are woefully unsuccessful and demonized by the lay public in their attempts at efficiency. Likewise, the current push for health care reform is misunderstood and chaos abounds. If you want proof that a number of Americans do not understand the goals of health reform, look no further than “end of life counseling” being touted as “death panels.” Something has been lost in translation. If our goal is efficient, culturally competent care, the information delivery system must be clarified and translated via an appropriate advocate.
Note: For this piece I was recognized in NCHE's Annual Scholarship competition.
1. Kaiser Family Foundation. Confusing Insurance Jargon Prompts Call For Reform. Kaiser Health News. [Online] September 21, 2009. [Cited: October 31, 2009.] http://www.kaiserhealthnews.org/Daily-Reports/2009/September/21/2khnstory.aspx?referrer=search.
2. Gardner, Amanda. Patient's Bill of Rights Too Tough to Read. U.S. News & World Report. [Online] March 27, 2009. [Cited: October 31, 2009.] http://health.usnews.com/articles/health/healthday/2009/03/27/patients-bill-of-rights-too-tough-to-read.html.
3. United States Census Bureau. Educational Attainment: 2000. census.gov. [Online] August 2003. [Cited: October 2009, 30.] http://www.census.gov/prod/2003pubs/c2kbr-24.pdf.
4. California Nurses Association. California's Real Death Panels: Insurers Deny 21% of Claims. National Nurses Organizing Committee. [Online] September 2, 2009. [Cited: October 30, 2009.] http://www.calnurses.org/media-center/press-releases/2009/september/california-s-real-death-panels-insurers-deny-21-of-claims.html.
5. Vogin, Gary. Dealing With Rejection. MedicineNet.com. [Online] WebMD, March 22, 2002. [Cited: October 30, 2009.] http://www.medicinenet.com/script/main/art.asp?articlekey=51313.
6. Wednesday, October 28, 2009. Comedy Central, New York : Stephen Colbert, October 28, 2009.
7. X., Stephanie. Personal Interview. October 2009, 28.
8. FactCheck.org. Insurance Co. Profits: Good, But Not Breaking Records. FactCheck.org. [Online] August 5, 2009. [Cited: October 31, 2009.] http://www.factcheck.org/2009/08/insurance-co-profits-good-but-not-breaking-records/.
9. Patient Advocate Foundation. The National Financial Resources Guidebook for Patients. Patient Advocate Foundation. [Online] [Cited: October 30, 2009.] http://www.patientadvocate.org/report.php.
10. R, S. Personal Interview. June 2009. Mr. R is a CNA employed by Tenderloin Health in their case management and health advocacy departments.
11. HealthCare Advocates, Inc. The Consumer Price Plan. HealthCare Advocates, Inc. [Online] 2009. [Cited: October 31, 2009.] http://www.healthcareadvocates.com/priceplan.html.
12. Personalized Medicine Coalition/National Pharmaceutical Council. Comparative Effectiveness Research and Personalized Medicine: Policy, Science, and Business. Arlington, VA : Personalized Medicine Coalition/National Pharmaceutical Council, October 28, 2009.
13. Golden, Frederic. Person of the Century: Albert Einstein. Time. [Online] Time, Inc. , January 3, 2000. [Cited: October 31, 2009.] http://www.time.com/time/time100/poc/magazine/albert_einstein5a.html.
14. Huslin, Anita. Online Health Data in Remission. The Washington Post. [Online] February 16, 2009. [Cited: October 30, 2009.] http://www.washingtonpost.com/wp-dyn/content/article/2009/02/15/AR2009021501284.html.