Insurance Company Reform

[Spidey's mom]

Hi everyone - I'm interested in opinions from nurses regarding health insurance company reform. From the perspective of you all - nurse practitioners, DON's, managers, floor nurses, etc.

What are your burning issues?

What would you think about an insurance company actually asking employers, producers and providers what needs we have?

What would you tell them?

What is your image of insurance companies?

Thanks.

steph

[CCL"Babe", BSN, RN]

In network means that the facility/physician/providor (of services) has agreed or contracted with the insurance company for a set price for services.

Some providers outside a net work will charge up to 3 times the amount the want for services in hopes that they will get that additional amount.

When reveiwing cases, most insurance companies use standards/protocols that are nationally accepted. They take the information supplied and set in against benchmarks for Intensity of Service- what is being done for the patient and Severity of Illness- does this person really need to be in the hospital? The reviewers rely on the hospitals giving them the correct info.

HMOs are usually less expensive. Your Primary Care Physicain/PCP is the "gate keeper". They "manage" your care. In other words they decide if and when they will refer to another provider. When you are referred it is usually to someone with in the system.

PPO more expensive. You can go to who ever you want for want ever you want- within the system you pay less. No referrals are needed. Less restrictions. It is more expensive because people will self refer and often go outside the system.

POS - Point of Service. A new hybrid. It has the benefits of HMO- lower cost, PCP referrals at a lower cost. You can go outside the system and self refer - at a higher cost. Many companies are going with this option.

[Spidey's mom, ADN, BSN, RN]

In network means that the facility/physician/providor (of services) has agreed or contracted with the insurance company for a set price for services.

Some providers outside a net work will charge up to 3 times the amount the want for services in hopes that they will get that additional amount.

When reveiwing cases, most insurance companies use standards/protocols that are nationally accepted. They take the information supplied and set in against benchmarks for Intensity of Service- what is being done for the patient and Severity of Illness- does this person really need to be in the hospital? The reviewers rely on the hospitals giving them the correct info.

HMOs are usually less expensive. Your Primary Care Physicain/PCP is the "gate keeper". They "manage" your care. In other words they decide if and when they will refer to another provider. When you are referred it is usually to someone with in the system.

PPO more expensive. You can go to who ever you want for want ever you want- within the system you pay less. No referrals are needed. Less restrictions. It is more expensive because people will self refer and often go outside the system.

POS - Point of Service. A new hybrid. It has the benefits of HMO- lower cost, PCP referrals at a lower cost. You can go outside the system and self refer - at a higher cost. Many companies are going with this option.

Thank you.

steph

[Jolie, BSN]

I firmly believe that the only way costs will be brought under control is for the individual consumer to begin paying out of pocket for both insurance premiums and routine healthcare expenses. And I believe that this will happen sooner, rather than later. My hubby's company is approaching the point where I anticiapte that they will soon give each employee a set amount of money to spend on healthcare, rather than providing insurance. This money will be used to purchase insurance, pay co-pays, and out of pocket expenses. Those who desire "full" coverage may have to use some of their own money to purchase a full coverage policy. Those who do not want to pay high premiums will choose a catastrophic policy, and use the money for more routine expenses. Such a plan will make the individual responsible for their own expenses, encouraging them to think prior to making unnecessary appointments for minor illnesses, choosing an expensive brand-name drug when a suitable generic is available, etc.

Insurance was initially intended to protect consumers from CATASTROPHIC expenses, not routine, everyday costs. Over the years, it has expanded to the point that individuals have come to expect full payment for virtually everything, necessary or not. My MIL used to get 2 new pairs of glasses every year, "because her insurance paid for it". Not because it was necessary. She used to go to the doctor and request the latest medications she read about in the women's magazines, fill the prescriptions, and keep them on hand "just in case". I'm sure she wouldn't have done so if she'd had to pay for the office visit and Rx out of pocket.

Only when people are fully responsible for their own costs and payment will matters change.

[Spidey's mom, ADN, BSN, RN]

I firmly believe that the only way costs will be brought under control is for the individual consumer to begin paying out of pocket for both insurance premiums and routine healthcare expenses. And I believe that this will happen sooner, rather than later. My hubby's company is approaching the point where I anticiapte that they will soon give each employee a set amount of money to spend on healthcare, rather than providing insurance. This money will be used to purchase insurance, pay co-pays, and out of pocket expenses. Those who desire "full" coverage may have to use some of their own money to purchase a full coverage policy. Those who do not want to pay high premiums will choose a catastrophic policy, and use the money for more routine expenses. Such a plan will make the individual responsible for their own expenses, encouraging them to think prior to making unnecessary appointments for minor illnesses, choosing an expensive brand-name drug when a suitable generic is available, etc.

Insurance was initially intended to protect consumers from CATASTROPHIC expenses, not routine, everyday costs. Over the years, it has expanded to the point that individuals have come to expect full payment for virtually everything, necessary or not. My MIL used to get 2 new pairs of glasses every year, "because her insurance paid for it". Not because it was necessary. She used to go to the doctor and request the latest medications she read about in the women's magazines, fill the prescriptions, and keep them on hand "just in case". I'm sure she wouldn't have done so if she'd had to pay for the office visit and Rx out of pocket.

Only when people are fully responsible for their own costs and payment will matters change.

Excellent post and I agree.

steph

[grannynurse FNP student]

I had to take my 4 year old to a pediatric dentist - not in our "network" and the insurance only covers 50%. Even with the deductible.

I'm interested in the original questions in my post - have a friend working on some PR with an insurance company (does not work for the company) - I was fascinated by some things I learned.

I recently attended a conference on depression and one of the participants was an insurance company - they were amazingly compassionate about trying to help. Guess I just am interested in other's perceptions.

Thanks - steph

When I was a Rehab Counselor, I worked with many different insurance companys. For the most part, the adjusters agreed with my plans. I also spent time teaching them to think outside the box, to authorize treatment and service, sometimes not connected to the injury. My selling point was while it might cost them, in the long run it would be less expensive. I did run into a few hard nosed ones, to view everyone as a cheater. I would try to work with them but if it failed, I would ask to be taken off the case. In ten years I had about ten such cases.

When I suffered my own work related injury, the company was hard nosed. I thought it was because of my background and I knew what I needed. After seven years of fighting and deneid treatments they settled. There are many good adjuster but it is the bad one who make the name. Education of the adjusters and understanding of the client's needs is what is imortant.

Grannynurse:balloons:

[gr8rnpjt, RN]

In network means that the facility/physician/providor (of services) has agreed or contracted with the insurance company for a set price for services.

Your whole post was very well written CCL "Babe". What people also need to remember is when you are with an HMO you usually don't need to pay deductables and out of pockets like you would in PPO and POS plans. Some people like that in an HMO. I used to say, (before I made the career change into the insurance arena), " I love my HMO, I don't mind jumping through hoops to have no deductable or out of pocket. Most doctors I like are in the network, and so I don't mind doing what my PCP tells me to do".

I was never denied a service and never saw a claim form or had to pay anything myself. Some people feel restricted with an HMO. That is why we have choices, so most people will find something they like.

Nowadays, things have changed a little. We now pay copays for Dr visits adn ER visits. I think there is a small copay for some procedures also, but nothing I can't handle (nothing more than $35. The health plan I work for has the HMO, PPO, and POS plans, all have deductables and out of pockets, but you can have them waived if you fill out a questionairre about your health. It took all of 10 minutes on line at my health plan website, now I don't have to worry about this.

People also need to remember that most employers have a cap for your insurance.(usually $1 mill lifetime max) If you think that you will never reach that mark, hope you don't. But all you need is one catastrophic illness, or a 25week preemie (what we call million dollar babies) and there is a chance you will run out of funds. I bet most of you don't know that insurance companies buy insurance against these type of cases that can make or break a company (called reinsurance). We have people look very closely at all our high dollar cases, and when they get to a certain point, we call in the reinsurance company to manage the case. Illness can be very expensive, and we are not trying to be bad guys. Like the previous poster, your employer writes the plan. some companies are self -funded which means they can pretty much write their own plan. One company I was involved in, had written in their plan language that if they could prove that your heart disease was caused by your smoking, or if your AIDS was caused by risky behavior, they would not cover you the employee. Scary, huh?

[June55Baby]

Although I grumble at times about the changes in the insurance industry... I still say prayers of thanks EVERYDAY for my insurance!

[Daytonite, BSN, RN]

I think the only insurance company reform that is going to occur is that laws will probably be needed to force the insurance companies to start covering people that they would normally refuse insurance in order to get those people off the back of government assistance in the form of Medicaid, Medicare (disability) and declaration of bankruptcy for catastrophic medical events. This is what our capitalist system has evolved into since we are afraid to use the words "national health" like UK or Canada. And, it doesn't come cheap. I have been watching as insurance companies mimic what they will and won't pay based on a lot of the Medicare payment schedules. As Medicare reforms it's prospective payment system to include first hospitals (DRGs), nursing homes (MDS), and now ambulatory surgery, doctor's offices are next targets. The insurance companies fall right in line with what Medicare has decided to pay out. . .that is where payouts by insurance companies are headed. If providers don't get in line and accept these payouts they are going to lose customers (patients) as the patients will go to providers who will take these discounted payments. This is one of the big reasons why hospitals are dropping like flies and going out of business--they can't curtail their costs enough to exist on what Medicare and the insurance companies are forcing them to accept in payment for their services. I don't know why we just can't go to a national health system and have this done with because what is going on now is an over-and-under pseudo national health system game.

[Spidey's mom, ADN, BSN, RN]

I think the only insurance company reform that is going to occur is that laws will probably be needed to force the insurance companies to start covering people that they would normally refuse insurance in order to get those people off the back of government assistance in the form of Medicaid, Medicare (disability) and declaration of bankruptcy for catastrophic medical events. This is what our capitalist system has evolved into since we are afraid to use the words "national health" like UK or Canada. And, it doesn't come cheap. I have been watching as insurance companies mimic what they will and won't pay based on a lot of the Medicare payment schedules. As Medicare reforms it's prospective payment system to include first hospitals (DRGs), nursing homes (MDS), and now ambulatory surgery, doctor's offices are next targets. The insurance companies fall right in line with what Medicare has decided to pay out. . .that is where payouts by insurance companies are headed. If providers don't get in line and accept these payouts they are going to lose customers (patients) as the patients will go to providers who will take these discounted payments. This is one of the big reasons why hospitals are dropping like flies and going out of business--they can't curtail their costs enough to exist on what Medicare and the insurance companies are forcing them to accept in payment for their services. I don't know why we just can't go to a national health system and have this done with because what is going on now is an over-and-under pseudo national health system game.

Ah national healthcare - there is no utopia and I don't agree with the whole premise behind national healthcare.

We do have major problems but I think Jolie's post is the better answer.

steph