The news cycle is moving on, but the killing of Brian Thompson was awful, no matter how one feels about the shortcomings of the American health care system. In a recent New York Times opinion piece, Andrew Witty, president of the UnitedHealth Group, wrote that no one would set out to design the system we now have. We can all agree on that. Our goal in participatory medicine is for “patients to shift from being mere passengers to responsible drivers of their health, and in which health care professionals encourage and value them as full partners,” using Gilles Frydman’s words. But the patient/clinician relationship happens in the institutional contexts of health systems and health insurance companies, to name a few, that exert force on that relationship. To be participatory, I think it’s important to be both health and health insurance literate.
Complexity and a lack of transparency dog the US health system, and institutional interrelationships can be a barrier to being participatory. Referrals out of a health system may not be made because of the health system’s desire not to have patient utilization ”leak” into other systems, even though the patient’s insurance policy permits using other health systems. An insurer’s “step therapy” policies can result in getting suboptimal drugs, when it is clear to the clinician that the drugs being used aren’t achieving the clinically needed result.
Improvement of the health system won’t happen overnight, so I work to be literate about both my health and my health insurance and understand who is responsible for what. That doesn’t solve all problems, but it can help. I choose my clinicians and my insurer based on their respective satisfaction and performance ratings. I work to understand health system’s and health insurer’s referral policies. I use both my health system’s and health insurer’s patient/customer service to gather the most information I can. I learn the basic concepts of insurance, reading my policy and talking with customer service to know what to expect about how coverage might be administered, and when my clinicians are knowledgeable, talking with them about whether the care they recommend might be covered. Most of all, I need my insurance carrier to be 100% transparent about their policies and the logic behind them. It shouldn’t be this complex, but it is. Until it isn’t I want to be both health and health insurance literate.
Mary Hennings is board chair for SPM. Her professional background is as a senior healthcare executive with 35+ years of broad health care experience. She has expertise in formulating product strategy and new products, and developing and implementing organizational innovations that are aimed at supporting better care, coverage, and customer experiences. She has held leadership roles in both integrated health care delivery and health insurance settings.
Mary, of course the murder was terrible, but I don’t think you’re being realistic in your expectations. As a retired Blue Cross executive yourself, I’m sure you’re *enormously* more equipped to comprehend plan terms than most consumers, and I’m sure you’re shocked by the thought of a consumer killing someone like you. But your employer was not guilty of the rate of heartless denials that UHC is!
Getting back to your post – you propose that patients get better at knowing the fine print in their policies, as you yourself have done. Let me ask: as board chair, can you propose a campaign that the Society for Participatory Medicine could conduct, or design, or something, to HELP patients understand their insurance plans? “Clarity is power,” as this blog has said since 2011. We’ve long helped patients to find answers to their medical questions, and we’ve long railed against complexity and smoke screens that made it hard for patients to know what’s going on. Can SPM today mount similar efforts on insurance clarity?
Nonetheless, nobody’s saying Thompson was murdered because the plans he sold were too complicated. The bullets were not inscribed with words like “obfuscate” and “confuse.”
Anyway, is it possible for SPM to do anything along the lines you propose?
To be clear: this example posted tonight on Facebook has nothing to do with whether patients understand their insurance policies.
Zachary D Levy MD 🇲🇦 🇨🇮
@ZLevyMD
@UHC just denied a claim on one of my patients in the ICU with:
— a brain hemorrhage
— in a coma
— on a ventilator
— in heart failure
…because I haven’t proven to them that caring for her in the hospital was “medically necessary”.
[Original source on BlueSky]
But yes, it would be great if we CAN propose a way to help people understand their benefits.
Is this something generative AI could do? Upload someone’s entire insurance policy and then ask it questions? THAT would be empowering.
I wish I could say I was enormously prepared to interpret insurance policies–it’s complicated. I have my own dissatisfying and health-impacting experiences with insurers.
I have seen loads of survey research data that demonstrate that people react very emotionally to health insurance coverage decisions, partly because the decisions are often confusing, opaque messes and partly because the health and well-being of both ourselves and our families are so important to us. The research shows that people can forget that the basic insurance concepts they understand with their car or house insurance also apply to health insurance. Applying insurance concepts I already know helps me a great deal.
The National Association of Insurance Commissioners [state insurance commissioners are the police for health insurers] have good information to help increase consumer understanding of health insurance. https://content.naic.org/consumer/health-insurance.htm
They also have a tool that lets you see how many complaints to state insurance commissions have been received for a particular insurer and what those were for. It’s not an easy tool to use, but with some work, you can compare insurers in your state. Here is a link. https://content.naic.org/cis_refined_results.htm There are tons of insurer reviews out there, and you can find a generally vilified carrier on lots of top 10 lists. Caveat emptor.
I have pasted policy language into AI engines to get clearer wording. It helps, but I confirm my results with customer service reps. BTW, all that obtuse language has to meet state regulations, at least in MA, which can be obtuse too.
Once you have a reasonable understanding of your policy, you then have to tackle how a claim is paid. I have used AI to understand my explanation of benefits [EOB in insurance parlance] as well. There are a lot of arcane things that can happen in claims processing, two brief examples follow that I have experienced.
1- Family member needs MRI; we pick an in-network provider and get the imaging; EOB comes back saying we owe $3k because the radiologist who read it was out-of-network; we had checked that the facility’s radiologists were in-network and were assured all was fine, but the day of the exam, they were using an out-of-network provider to do the reading due to a staffing issue the facility had. We were stuck.
2-Family member has an annual visit, with zero cost share but in the visit, the clinician asks if a medical problem addressed in a prior visit has been resolved. That lets the clinician put a modification code on the annual visit claim that makes it both an annual visit with no cost share and a sick visit, with a cost share and a deductible to meet. We had to pay the out-of-pocket amount, per our policy.
Those kinds of gotchas are infuriating. I offer these two examples because they illustrate how much the interactions of providers and insurers can impact claim outcomes. I haven’t asked an AI engine to compare a policy against an EOB, but I will, and let you know how that goes.
The example you gave of the United patient in the ICU who wasn’t medically qualified is heartbreaking. I can’t comment on what is happening in this instance but I know that Medicare and all health insurers only cover acute care intended to cure or restore a patient to their best stable state of health. If a patient is in a permanent vegetative state, for example, the patient no longer needs acute care according to the health insurance benefits descriptions I am aware of. The patient needs custodial/long-term care, not restorative/acute care. When those determinations were made by the insurer I worked for, they weren’t made quickly and involved lots of medical input from the treating clinician and the insurer’s medical directors. There aren’t enough facts offered in the post you shared to say what happened. I share how health insurance policies are generally interpreted regarding coverage of care that is no longer acute just as information.
Maybe SPM could develop some organized resources around health insurance literacy if that was of interest and help.
Thanks,
Mary
As an additional thought, I’d be happy to get interested Society members together to talk about what steps make sense to take regarding improving health insurance clarity. Please indicate if you are interested in thinking about how to have the best impact.