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Insurance: Physician's Perspective




Hi.  My name is Emily Dalton. I am a local pediatrician and  I have had the misfortune of dealing with the health insurance system from 3 different perspectives:   that of a patient who uses an insurance plan, that of a small business owner who purchases insurance for a group of employees, and that of a physician who contracts with and gets paid by various insurance companies.  Our system is profoundly dysfunctional, and we need to completely rethink how we deliver healthcare to the nation’s population.  Previously I spoke about my experiences as a patient and an employer.  Today I will share my opinion as a physician.  
I have had no end of problems dealing with the 9 different insurance companies with which our office contracts.  After one of our doctors has seen a patient, we submit a claim to that patient’s insurance plan requesting payment.  Three full time employees work to make sure the claims we submit get paid correctly.  It seems that any reason is good enough for an insurer to underpay or deny payment and if we don’t catch the mistakes, we lose out.  I pay my staff their hourly wage as they beg, bicker and bargain with insurance companies so we can get reimbursed. If we hit a dead end, we sometimes get help from the California Medical Association,  but we don’t reach out to the governmental agencies in charge of overseeing the insurance industry because they are understaffed and overwhelmed.  I also pay my staff to overcome other barriers the insurance industry has created like “prior authorizations” that are required before patients can get their medications, consults or procedures.  If the insurance companies would stop trying to underpay us and stop blocking the tests, procedures and referrals that we order, I could run my office with fewer employees, and the cost of medical care would decrease.
Insurance companies take every opportunity to try and pay us less for our work.  When the Affordable Care Act  was rolled out, our office was offered a very low reimbursement rate to see Anthem’s Blue Cross’ Covered California patients, so we declined the contract.  However, Anthem gave patients deceptive insurance cards that looked identical to those of our contracted patients, and we were also falsely promoted as contracted providers on their website.  Our office and our patients did not find out who had Covered California status and who had regular status until bills were denied, and it fell upon my staff to inform parents that their insurance had not covered their costs and that they owed us money.  Dumbfounded and dismayed, families wept and raged at our medical billers.  My newest employee quit because she felt she could not continue in a job that was so hurtful to young families.  After sending out patient after patient in tears, she decided the bad karma invoked by performing her duties could not be justified, and moved on to a happier job.  When things reach a point where your employees feel like they will face eternal damnation just for doing their job then THE SYSTEM IS BROKEN.  
Do you know what the the insurance industry calls the money they spend on your medical care?  They call it the Medical Loss Ratio.  In their eyes, money spent on providing your health care is considered a loss.  The health insurance system is focused on minimizing loss and maximizing profit.  Every time your insurer refuses to pay for a procedure, consult or medication, they get to keep the money!   Every time your insurer “forgets” to pay a claim, they keep the money!  Every time an insurance company suckers some poor clinic into accepting low rates, they keep the money.   The less they pay to the doctors who are actually doing the work, the more money they keep.  The more healthcare they deny, the more money they make.   Are we crazy to tolerate such a system?

The Affordable Care Act, despite the best of intentions, has fortified a monster.  By mandating that everyone purchase insurance, the industry feels emboldened to take advantage of patients and healthcare providers.   Exponentially larger and more powerful than the agencies assigned to oversee it, the health insurance industry finds ways to circumvent and resist restrictions.   This leech has gotten firmly latched on to the lifeblood of American medicine, and is sucking out money and energy that could be put towards actually providing medical care.   How long are we going to stand for this?

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