Health Insurance Reform Won't Work Without Insurers, but Significant Administrative Improvements Needed

Is there any way to lower health insurance costs and improve quality of care besides reigning in over-utilization of services, cutting back on covered services and increasing patient responsibility?  The answer is an yes.  Let's look inside the health insurance industry and reduce the administrative burdens that keep providers and consumers from ensuring that the best and most appropriate, necessary care is provided.  I believe as much as anyone that the insurance industry is vital to Connecticut's economy and future, but it's time to pull out the calculators and health experts to scrutinize health insurance practices to drum up some additional savings.  Insurers have made many statements about the need to find savings in healthcare; I'm ready for them to contribute some of their own savings.

Where have we been in terms of looking at the bottom line--that insurance is a contract, a obligation on the part of insurers and consumers to follow rules that will allow those consumers access to coverage of medically necessary services?  Why have we allowed these administrative burdens to prevent access to care, to make it difficult to appeal a denial, to force providers to have to argue for days to justify treatment that they, much more so than any medical director of an insurance company, know is the best treatment.

This is not hypothetical.  In the last fiscal year, OHA recovered $11 million for consumers.  That's $11 million in wrongfully denied claims based on medical necessity, coding errors, and billing mistakes.  That $11 million represents people who went without needed cancer treatments or mental health services because the insurance company denied the care initially.  That's $11 million that should have been properly spent on medically necessary care that could have forestalled additional healthcare costs down the road.  That's $11 million of state residents' insurance premiums that without our intervention would have stayed in the pockets of the insurers.  And finally, that $11 million is a fraction of what could be recovered if all consumers knew how to appeal denials successfully.

It is not coincidence that there isn't more recovered for consumers. Only five percent of people appealed denials related to medical necessity last year  That is not a coincidence either.  The process is not easy to go through on one's own.  That means there is likely a substantial sum of our premium dollars that is going unspent on needed medical services that, if received, might actually lower future healthcare costs.

Every day I hear from providers whose services are routinely denied, only to be overturned after going through the burden of appealing.  Each insurer has its own provider guidelines--one plan's guidelines or practice requirements may completely contradict another's.  These burdens only serve to impede access to care and strike at providers' resolve to fight via an appeal.  These administrative burdens, imposed by insurers, add significant costs to the healthcare system.

As we move toward the healthcare reform, we need to revisit our mindset.  What is our focus?  Healthy individuals, cost containment, efficiencies, health information technology?  Surely all of these things play a role, and surely, the insurance industry is vital to providing insurance coverage, but it is the insurers who have yet to open the books and offer more than their products.  They must come to the table with their own solutions for streamlining processes, reducing administrative burdens and preventing improper initial denials of coverage.  They must prove to me and other advocates that the premium dollar is going to its intended purpose and not being used to thwart legitimate access to services through burdensome and inconsistent processes. 

I don't blame the insurers for wanting to hold their partners accountable, but we need to hold the insurers accountable too.  I believe we need a strong insurance industry in Connecticut. Accountability is not anathema to a strong insurance industry in Connecticut. It is essential to it.

A Model of Governmental Efficiency

There's no question that Connecticut is in lean budget times.  Looking for efficiencies in state government is undoubtedly a priority.  Look no further than the Office of the Healthcare Advocate to find a lean operation that produces five to six fold of its budget in taxpayer savings each year.  In fact, for calendar year 2010, OHA produced $5.7 million in savings for consumers on its $1 million budget.  While being efficient, OHA managed to assist consumers with the most difficult situations in securing medically necessary treatment or services, earning high praise and the respect of its consumers.

There is probably no entity in state government that provides the level of services that OHA provides to consumers.  There's a reason for that. OHA was established specifically to assist health insurance consumers who have problems accessing or receiving the medically necessary care they need.  The legislature recognized that a unique agency with expertise in handling consumer issues with plan selection and complaints would hold insurers accountable and get consumers the care they needed.  OHA's independent status allows it not only to advocate for individual consumers, but to bring systemic issues to the attention of the legislature and Governor for further action.

OHA is unique.  Its consumer assistance staff consists of clinical expert-advocates who can not only understand the clinical issues at hand, but also advocate for the care the consumers' providers request.  OHA is so unique in state government, that it was one of the models used to establish consumer assistance programs under the the Patient Protection and Affordable Care Act (ACA).  That uniqueness resulted in a $396,400 grant to OHA from the federal government--only one grant was awarded per state--to continue its effective advocacy model.

Housing OHA in state government is the ideal model.  Giving the force of government to OHA's advocacy is important, while allowing it the independent status of a watchdog, brings accountability.  OHA has brought legislation to the table to support consumer access to medically necessary care.  OHA's personal, real-time consumer assistance is unmatched, which is why referrals from legislators and people who have used our services continues to rise.  Our consumers report that they would come to us again 96% of the time. 

The reasons that OHA was established in the 1999 managed care accountability act still exist today.

What other entity in state government can show such efficiency with its budget, a nearly six to one rate of return, and such high satisfaction rates from state taxpayers?  Anytime, but especially in lean times, OHA is a model state agency.

Speaking out for SustiNet

Today I did a local access cable TV show out in Eastern CT about SustiNet.  It's important to get the accurate word about SustiNet out into the community.  Lately, I've noticed some negative and uninformed talk about the possible alleged costs of SustiNet and misportrayals of SustiNet as a large scale government run program.  I've decided that as the state's Acting Healthcare Advocate, speaking truth about SustiNet and refuting the continued mistatements is not only something that I want to do, but something I owe the healthcare consumers of Connecticut.

Well, let's start first with the fact that CT currently spends about $8 billion on healthcare.  Within that $8 billion, there is almost certainly some wiggle room, some areas in which we can squeeze out efficiences.  That's where SustiNet starts--with the assumption that we can find savings and control healthcare costs while improving healthcare quality.  How would SustiNet accomplish this?  Not by asking for initial funding from the general assembly, but by adopting long overdue strategies to save taxpayers money.  Things like patient-centered medical homes to coordinate care, ensure prevention of illnesses and protect against the over-utilization of medical services.  Things like interoperable elctronic health records that increase efficiency and reduce medical error.  Things like evidence based medicine that ensure appropriate delivery and healthcare and prevent payment for unsupportable procedures.  Things like payment reforms to ensure that we aren't creating perverse incentives for providers to have to see a hundred patients a day to make ends meet, and to improve the quality of service delivery.

All of these measures are no cost measures that will reduce cost and improve the quality of care for SustiNet populations.  These are common sense innovations that will create a better-operating state employee health plan, Medicaid plan.  Those that question the cost of SustiNet do not seem to understand that these strategies and the purchasing power of the combined lives of the state employee plan and the HUSKY and Medicaid plansARE the SustiNet plan. 

Why then shouldn't these innovations be extended to municipalities so that they can save money to cover their employees while ensuring them high quality care, and why at some later point shouldn't these cost savings and quality improvement strategies be exteneded to small employers and individuals?

This is what SustiNet is:  For the first time, there will be a concentrated effort to employ tactics to simultaneously improve health care quality and access, yet save costs.

So, now you have the facts about SustiNet.

Snow day projects

While you're inside staying toasty and out of the cold, you could take on the project of organizing your health insurance data. 

First, make sure that you keep your health insurance card in an accessible place.  (Remember not to share your insurance identification number with anyone other than a provider, an insurer or a reputable consumer advocacy organization like the Office of the Healthcare Advocate.)

Second, find those documents you've received from your insurer, called an "Explanation of Benefits" that explain how your insurance benefits were calculated.  You may find an error on one of those documents and need to appeal, so keep them in one spot.  A good rule of thumb for saving these documents is to keep them for seven years.  Medical disputes can arise well after your medical treatment.

Third, find and organize your medical bills by date.  You should be able to match up your medical bills to the EOBs you're received from an insurer.  It's wise to hang onto medical bills just like you hang onto EOBs.  A dispute may arise, or you may discover an error on a bill.

Doing these little projects on a day like today may take you an hour or so, but they'll prevent potential headaches down the line.

If you have any questions on your medical bills or EOBs, call OHA at 1-866-HMO-4446.  OHA is a free service of the state of Connecticut.