February 7, 2016
The administration of the current system of “utilization review” and pre-authorization would cease, saving billions. Delays in treatment caused by the current system would disappear, eliminating the complications and increased costs that currently result from such delays. The money currently wasted by delaying care and the litigation costs resulting from denying care would be eliminated.
People would live longer less sick lives, allowing them to pay into the system longer and resulting in the payments to expense ratio to increase, making the cost per year lived less.
If insurance companies follow the suggestions in the Post, “How insurance companies could control costs if the Act becomes Law?” and the legislature enacts the suggestions in the Post, “How the Legislature Can Reduce Costs of Health Care”, costs should dramatically decrease. People who have to pay for some portion of each diagnostic test, and who are encouraged to ask, “How will this test benefit me?” or “What are the odds of my treatment being any different if this test is performed?” or “Why not see if treatment works before ordering this test?”, won’t request or authorize doctors to do tests that are unnecessary. Now, most testing is done because doctors get paid to do them whether they are necessary or not. They get more money per patient by charging to review or interpret test results. False positive tests result in more unnecessary and actually detrimental treatment of diseases and conditions that don’t even exist! The USA has twice the medical cost per patient than any other country. In other countries, fewer tests are performed per treatment. Doctors are not sued for not performing tests, so fewer false positive test results have resulted in less treatment of illnesses that do not exist.
If an insurance company’s medical committees determine that certain treatments are more cost effective than others for any particular diagnosis, or certain tests seldom add useful information, they can, without violating the letter or spirit of this act, offer that information to the patient. There is nothing in this act that prevents any insurer from requiring patients to have a second opinion prior to undergoing any treatment or surgery or even after a patient commences a treatment regimen. That second opinion is the opportunity for insurance companies to tell the patients about more cost effective and less risky treatment. It is also the chance for an insurance company to present why a test is not necessary. Insurers could require a wait period prior to elective tests or surgeries so the second opinion could be scheduled. The second opinion could be from a doctor who offers the treatments the insurance company favors. At that visit, the advantages of the suggested treatment could be explained the known risks of each treatment could be discussed, and the patient would be empowered to make a safer, and thus less costly to everyone, decision. While waiting for the test, the patients could have treatments based upon the clinical judgment of their doctor. If they get better during that time, they’ll know the test is unnecessary! Money won’t be wasted ordering unnecessary tests.
Based upon the diagnosis and proposed treatment presented with a bill to insurance companies, companies could send an email, make a phone call, or otherwise contact a patient to suggest alternatives to what the patient’s doctor has commenced. Knowing that a patient may get such calls, doctors would be motivated to provide the most cost effective treatment, not the surgery or other course of treatment that will get them the most money per patient.
Under our current system, insurance carriers, managed care organizations, and employers are perceived as a hindrance to getting well. Under the provisions of this act, insurers would be motivated to educate and inform, thus proving themselves to be allies to their insureds. Patients would be informed of the odds for improvement, and the risks of treatment by those wanting to keep the costs down by improving those odds of improvement and reducing the risks of treatment. Surgeons would be encouraged to disclose not just the risk of what their hands do, but the risks of infection from being in the hospital, the cost of rehabilitation, and risk of dying from anesthesia and comparing the sum of all those risks to the risks of non-surgical treatment for the same condition. This one change would result in far fewer surgeries. Neck disc surgeries are orders of magnitude more costly than non-surgical treatments and far more dangerous to the patient than physical therapy, chiropractic, or acupuncture for cervical disc disorders; yet not more effective than any of these alternatives. Urologists, knowing insurance companies could call their patients and explain why a trans urethral procedure is less dangerous, less likely to result in impotence and just as effective than the older and more costly procedures would stop offering the more costly more dangerous older procedures! Given exposure to this knowledge, patients will choose the safer, less costly alternatives. These are just two examples of how informing patients would result in huge cost savings, better outcomes, and longer living happier patients.
Insurance companies have the data from the bills for post-operative complications, to be able to tell which hospitals have more post surgical infections. So they could inform a patient which hospital is safer. Patients would be grateful for a call from an insurance company that informs them that they could go to a different hospital and have a much higher chance of not getting a post-surgical infection. Knowing such calls could happen, hospitals would be more diligent in preventing post surgical infections.
If patients were informed of the symptoms of the complications of statins by their insurer in addition to their doctor, they would be far more likely to remember and recognize them. They would then cease Statin treatment as soon as complications manifest, thus avoiding damage to muscles, impotence, diabetes, and other severe complications from the therapy. Better yet, if insurers offered an alternative, such as nutritional counseling and coaching, the perceived “need” for statins could be eliminated altogether, resulting in a much healthier population. Doctors knowing that the alternatives to statins could be presented by insurance companies would offer those alternatives themselves, thus reducing costs and morbidity. Statin therapy alternatives are published in medical journals. This is just one example of how better informing patients by insurers would reduce health care costs. Many advances in medical care that lead to reduced cost are published every year, but that knowledge seldom influences daily practice. If insurers were to keep up on these medical journals and make that information available to their insureds the gap between medical knowledge and medical practice would close. People would be healthier, and costs would go down.
Costs savings from these changes combined with dismantling of the current punitive system of pre-authorization should be dramatic!