It's Thursday, July 28, 2022 and it is still hot in Portland, Oregon.
Just one thread today, I think:
When you use health insurance in the U.S., you have to find a doctor or provider who's in your network coverage. After that, you've got to find a provider who's actually got the capacity to see you and is taking new patients. All well and good, apart from when it doesn't work, like when the provider directories are out of date: you go see someone, and if they're available, if they're free, you see them, they're out of network and then you're screwed. See: Even Well-Intended Laws Can’t Protect Us From Inaccurate Provider Directories1.
It's your regular story of inaccurate data that's outdated, a patchwork system of data collection, inconsistent data quality and data cleanliness, and of course the opportunistic business model of third parties:
a whole industry has sprung up around collecting provider updates through a centralized portal and selling the information to health plans. The inaccuracy problem remains, however.
My asking-dumb-questions take on this is, well duh, what's the enforcement and deterrence plan here? What's the consequence for a health insurer for publishing inaccurate data? There's the regular administrative burden: you've got to go around chasing and researching and calling to see if anyone's available and then calling your health insurer because you can't trust that the provider directory is accurate. But then, how can you trust that whoever you speak to at customer support is also telling the truth that a provider is in network? The thing is, you can't, and even if they were in network, it wouldn't matter anyway.
It wouldn't matter because network status could change. It wouldn't matter because the billing code might be wrong, or because one person thinks something shouldn't be covered when it should be, or it might be because the person who does know it's supposed to be covered is, I don't know, out of the office and unavailable that day.
It might be that you spoke to your provider and they assured you that they're in network and you go ahead and they submit a claim and it turns out oops! You're not! Because you're in a tiny sliver of a plan that has slightly different providers and you'll have to go file an appeal.
This sort of thing, this problem, gets described as systemic when it's big enough, when there are enough actors, when the environments multiply and when the incentives and disincentives are sufficiently dispersed. One answer to "why can't this be better" is "because it's complicated", but that doesn't mean it's impossible to fix, it just means that it's hard to fix. (Get me, just saying that it's "just hard). There are, though, no things that are really hard in that way, there are just things that aren't important enough to be worth spending the time, money, or effort on.
I buy the argument that health insurance is sufficiently complicated as to require a whole bunch of billing codes and there's ambiguity in those codes, yes, yes. But it strikes me that one of the reasons why it's so complicated is because we want to measure everything and we can never really measure things perfectly. I would have to go and do research about how, say, the NHS is funded and how individual NHS trusts and providers put together their budgets and how they get paid, but I have the sneaking suspicion that single payer models -- even ones that have had competition enforced upon them as a way to introduce efficiency -- have simpler accounting and tracking systems than the U.S. ones, primarily because as soon as money is involved, you want to start accounting for it in finer and finer detail.
You know, you could do accounting for other reasons, like tracking effectiveness of outcome. I guess what I'm saying here is a repetition of what I learned many years ago: that the electronic health records systems in the U.S. (now exported around the world), and the databases they were built on, were originally designed for billing.
So two more points:
At what point is it worth my while to employ someone to wrangle my health insurer on my behalf? It takes a lot of time and form filling -- yay administrative burdens -- for me to deal with things like claim denials, and claim denials or miscategorizations are the difference between a $20 charge per visit and $150. Over, say, six visits, if I'm ostensibly being charged $900 versus a potential $120, that's a lot of money I could pay someone to save me!
Of course this is an absolutely idiotic way to deal with the situation and a peculiarly American one. It's like the U.S. Consulate taking down online booking for, say, passport appointments because they kept getting booked by bots that would then resell the appointments for money, so now you have to call up for an appointment. Which makes sense! And also is sad. Sure in the short term it might make sense for me to pay someone to deal with an insurer for me, but a) that costs me money, b) that doesn't help anyone else, c) it's a giant waste of time for everyone involved and "navigating health insurance bureaucracy" is not the kind of economic activity I would really count as contributing toward GDP. It's more like "here's something that looks like it's productive but it's only moving money around when we could be spending that money on, I don't know, housing or schools or education". It is also, I would contend, a shitty job.
Which brings me to the next thing, well, not quite, but that again U.S. health insurers are supposed to reimburse you for the cost of buying COVID tests and isn't it completely unsurprising that being reimbursed for a COVID test isn't something that's easy to do? Yes I get that the process might be more complicated for medical reimbursement (see: above), but that doesn't mean the process for being reimbursed can't be highlighted. It's not like insurers didn't have a way to highlight COVID information during the earlier stages of the pandemic.
The lack of this type of functionality or design is just another signal reinforcing the belief that the whole point of an insurer is to not pay out, and that it's not in their interests to pay out. And yet you'd be forgiven for believing that the U.S. government committed to reimbursing insurers for those tests anyway!
Again, it feels like not trying is a signal.
Okay, that's it for today. I'm out tomorrow, back on Monday. Have a good weekend, and if you're somewhere melty, I hope you do not melt.
Even Well-Intended Laws Can’t Protect Us From Inaccurate Provider Directories, Bernard J. Wolfson, Kaiser Health News, 26 July, 2022 ↩