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Hanging By a Thread: If the Public Ever Found Out About the American Health Insurance Industry

Below: If the public ever found out what % of doctors’ preventive, medical, surgical or palliative decisions are denied by the health insurers..

Make no doubt about it, the very existence of the multi-payer high-earning American Health Insurance Industry is hanging by a thread.

Yes, the endomorphic corpus of American Health Insurers and their wholly owned PBM’s is a model of extremely good fiscal health. What keeps these demon gatekeepers of medical care access up at night in the most developed and democratic nation in the world is not the possibility of poor fiscal health or diminished profits, lack of political control and indemnification, lack of Americans healthcare access, a lack of concern for the health of the living or an inability to manipulate regional markets or multiple cost centers for enhanced earnings. The sole concern of collapse and irrelevance for the health insurance industry and their vertically integrated axis of subsidiaries is based on the possibility of Americans receiving and understanding transparent revelation and quantification of the workflow, human and medical costs and consequences of delayed, changed or abandoned medical care due to insurance industry prior authorization rationing, physical rationing or high out of pocket costs.

We can all agree that the past three decades have seen the highest portion of $3.6 Trillion a year in healthcare resources redistributed from medical care at the bedside to the insurance boardroom.

 

Red=Everything Other Than Healthcare Providers

 

This redistribution of healthcare resources has massively rewarded insurer shareholders, bondholders, executives and their patron politicians. These enormous business gains have been enabled due to creation of the most expensive and most segregated and rationed multipayer healthcare system of any developed nation or democracy in the world. American healthcare is horribly segregated and rationed according to age, illness, location, race, sex, job, net worth and military status (see illustration below).  Tens of millions of Americans have no health insurance hindering access to quality affordable medical care, and many more Americans are underinsured, holding a health insurance card but one illness from fiscal bankruptcy and physical or family ruin. The recent Covid Pandemic confirmed Americas health insurance grift.

 

 

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The foundation upon which the private health insurance industry’s subsidized, successful and risk-less segregating and rationing of health care is built will remain solid and intact only if the American public is kept unaware of the true costs and consequences of fiscal and physical rationing of access to preventive, medical, surgical and palliative care. Continued ignorance and blocking of the exact fiscal and medical price Americans pay for rationed and segregated healthcare enables the health insurance companies to make unsubstantiated and false claims that they are providing great access to improved preventive, medical, surgical and palliative outcomes and ‘providers’ for more patients at lower costs. Industry-bought and owned politicians will continue to falsely boast that America has the best access to the best healthcare value in the world without providing any real evidence which quantifies or reveals the increases in morbidity or mortality of highly rationed and segregated healthcare which is created by our multiplayer insurance system’s labyrinth of diagnostic and treatment authorizations and denials of medical care. Many in Congress may be heard uttering ‘So what if Americans are dying and sicker and physicians are burning out due to crappy access to quality affordable healthcare, I’ve got a Cigna office employing 200 people in my gerrymandered Congressional district and receive $ and my family members are on their payroll.”

The data demonstrating the damage to patients and their physicians by prior authorization rationing, physical rationing and high out of pocket costs is collected by health insurance companies from 3rd Party Prior Authorization Override Corporations, Pharmacies, EHR’s and practice management computer systems. For 3 decades health insurers and their wholly owned patient data subsidiaries such as United’s Optum Inc. capture, document, track and assess every single piece of personal health information, social determinations, costs, demographics and medical chart data, tests and images on every one of their contracted patients. Every health insurance company has the data to inform the public what percentage of their patients’ diagnostics, palliative, medical, surgical and palliative treatments are delayed, changed or abandoned, and the consequences of that insurance rationing or high out of pocket costs for the patient and their physician. Of course, the medical care consuming American Citizens will never see that insurer obfuscated prior authorization rationing or cost data. There is however, an incredibly simple and efficient method, which I’ll discuss below, of obtaining and spreading sunshine on the consequences of insurance company rationing and costs prior to the data being locked up in the impenetrable servers of insurers or their health and medical data confederates such as SaaS, Oracle, IBM, Salesforce, Epic, Cerner, Modernizing Medicine, Flatiron Health, Mayo Clinics, Google and many others illustrated in the medical data bourse diagram below. Keep in mind, while companies have been peering through your medical chart data for decades to increase tens of billion$ in yearly earnings, there has been little or no demonstrable improvement in access to quality affordable healthcare or clinical outcomes or costs returned to patients and physicians in America.

 

 

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In America, there is only one corporation which publishes and sells medical diagnostic and treatment CPT codes used by private insurers (Current Procedural Terminology). Sales of these CPT codes enable and provide the lifeblood of the symbiotic medical data industry described above. The American Medical Association Corporation is the sole developer, maintainer and copyrighter of Medical CPT codes. As the practice of health care changes, new codes are developed for new services, current codes may be revised, and old, unused codes discarded. Thousands of codes are in use and updated annually. There are several categories of CPT codes delineating procedures, services, devices, drugs, performance measures, quality of care, services, procedures, technologies and lab tests. Health insurance companies and their partners utilize analysis of these codes to enhance earnings and guide profitability actions against physicians and their patients. Physicians, using their in-office or institutional practice management computers may easily recall all these measures for many charted variables on all their patients to assess diseases and practice efficacy.  Its simple to see that CPT codes could easily be created by the AMA which would document performance measures, quality of care services, healthcare consequences and workflow burdens of delayed, changed or abandoned medical care due to prior authorization rationing, physical rationing or high out of pocket costs. Here are some examples of codes the AMA should issue which physicians or institutions could track with their own in-house practice management computer systems;

FU10.1 Diagnosis Delayed by Insurer, FU 10.2 Treatment Delayed by Insurer, FU10.3 0-10 Minutes Spent trying to Override Insurance Prior Authorization Rationing, FU 10.4 11-30 Minutes Spent trying to Override Insurance Prior Authorization Rationing, FU 10.5 >30 Minutes Spent trying to Override Insurance Prior Authorization Rationing, FU 10.6 Patient Medical Condition Deteriorated Due Delay in Trying to Override Prior Authorization Rationing of Diagnostic, FU 10.7 Patient Died while waiting for Insurance to Override Prior Authorization Rationing of Diagnostics or Treatments, FU 10.8 Preventive, Medical, Surgical or Palliative Care Delayed Due to Insurance Company Ratioining, FU 10.9 Patient had prolonged suffering due to Prior Authorization Rationing Delayed, Changed or Abandoned Treatment, FU.10.10 Treatment failed due to Prior Authorization Rationing Delays, FU 10.11 Patient unable to access palliative, medical, surgical or preventive care due to no available network physician or facility, FU 10.11 Patients diagnostics, preventive, medical, surgical or palliative care failed due to no contracted network or facility. FU10.12 Patient Chose not to diagnose or treat due to costs. FU10.13 abandonment of preventive, medical, surgical or palliative care due to cost to patient.

Readers, feel free to add your own codes defining the consequences of prior authorization rationing, physical rationing of networks or facilities or high costs passed onto patients from insurers refusals to accept risk to pay.

In December, 2019 the AMA conducted an internal poll of physicians to assess the deleterious consequences for patient’s health and on doctors workflow burdens of prior authorization rationing and high out of pocket costs.

 

 

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This poll was repeated a year later in December 2020 (see infogram below https://www.ama-assn.org/system/files/2021-04/prior-authorization-survey.pdf?utm_source=bambu&utm_medium=social&blaid=1605148 ). Both polls of physicians revealed an extraordinarily high level of dangerous and time consuming interference and obfuscation of medical care by the health insurance industry. The fact that the health insurer forcing the delay, change or abandonment of medical care never performs a patient history, physical exam and is not educated to formulate an assessment or plan does not matter. The reason why all this doesn’t matter to the insurance industry is because if a medical consequence, like debriding a post operative wound infection (CPT code 086.o) isn’t coded, IT NEVER HAPPENED. Clearly the lack of physicians ability to code the medical or workflow consequences of insurer rationing or high costs has made the problem disappear fiscally, publicly and politically. The suffering of patients and their physicians does not matter as long as insurers hit their earnings projections and their shareholders, bondholders, executives and patron politicians are paid off. In essence, there is no problem because the problem can’t be coded, documented and tracked by physicians.

 

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No one knows for sure why, despite recognizing the serious dangers of insurance company rationing for patients and associated workflow burdens for physicians from insurance rationing in their own internal polls, the AMA has never issued CPT codes for physicians such as those suggested above to document and track delayed, changed, or abandoned medical care due to insurer rationing or high costs. Perhaps its because the AMA has only a minority of American physicians as members. The AMA does however own a highly rationed Medicare Advantage HMO insurance company in Chicago and 3/11 AMA Coding Committee members are health insurers. While this obviously poses a conflict of interest on the issuance of AMA formulated codes to document and track insurer rationing, it is beyond the scope of this article or the authors understanding to speculate on the potential of Antitrust actions between the Insurers and the AMA.

If the public ever found out exactly what % of doctors’ preventive, medical, surgical or palliative decisions and orders are denied by the health insurers and the fiscal, medical and workflow consequences of those denials for insurers profit, the foundation of the highly profitable private health industry would collapse and the entire Government-Insurer Axis would become irrelevant allowing Americans to move onto more equitable less rationed and less segregated access to medical care for all.

It would be irresponsible of me, a practicing physician who adheres to the Hippocratic Oath and the moral commandments of other age-old scrolls to suggest the deconstruction of a fraudulent health insurance system without offering an alternative means of ensuring access to quality affordable private healthcare for patients and their families. With the demise of the insurer-political complex, it would be simple to install a proven Bismarck Healthcare system with some tweaking to offer higher subsidies for primary care physicians and internists who represent patients’ best advocates. The Bismarck Health Model (Below) successfully utilized by many democracies and developed nations essentially neutralizes and utilizes health insurers making private health insurance a utility instead of a luxury. The result of Bismarck Healthcare is it enables access to quality affordable private insured and private delivered preventive, medical, surgical and palliative medical care for-all with transparent access to healthcare data to improve the physical and fiscal health of the nation.

 

 

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