Health care debate really about control

When you think about whether or not you want the insurance companies or the government making decisions about the health care you receive, you probably quickly answer neither. But unfortunately, that's not an option unless you can afford to pay for all your health choices out of pocket without carrying a health care insurance policy.

Since we're looking at what could be the demise of the national health care package now being held up in Congress, we'll likely continue to be solely under the control of the insurance companies. Knowing that they're going to be in control, insurance companies are flexing their muscles and making it harder for you to get the care you need.Take for example the current battle between Continuum Health Partners and UnitedHealthcare. United Healthcare wants Continuum to sign a contract that demands that the insurance company be notified within 24 hours after a patient's admission. If notification is not received on time, United Healthcare will cut reimbursements in half.

United Healthcare is putting that clause in contracts with other hospitals nationwide as well. More than 25 million people nationwide are covered by United Healthcare health insurance policies.

Hospitals contend that a 50% cut is too much and are seeking help from their state insurance regulators. In fact, the Greater New York Hospital Association, a trade group, told the state attorney general that the 50% penalty was "confiscatory" and the attorney general is reviewing the matter.

A spokesperson for WellPoint, which manages Blue Cross Blue Shield in more than a dozen states and has the most subscribers nationwide, said they are not enforcing a similar penalty. A spokeswoman for the American Hospital Association also told The New York Times they are not aware of any other insurer imposing this type of penalty. But if United Healthcare succeeds in imposing this contract clause, won't the other insurers follow their lead?

So I asked Emory University health policy professor David Howard why United Healthcare was taking such a drastic step. He said insurance companies are not necessarily taking steps to "reduce quality, but steer patients toward lower cost treatment options."

I asked whether that means United Healthcare may try to limit testing or take some other tact to lower costs by controlling treatment. Howard said that, while he doesn't know the specific terms of United Healthcare's contracts, hospitals don't usually get paid by insurers according to the tests. Instead, they pay based on a flat rate per admission or a flat rate per day. While he does say insurers may try to steer patients to "lower cost treatment options prior to a hospital admission," he doesn't think the 24-hour notification rule will affect care once a patient gets into the hospital.

He believes the 24-hour rule likely has more to do with case planning after the patient leaves the hospital, but it will also probably affect how many days a patient is permitted by the insurance company to stay in the hospital. United Healthcare is likely trying to move the patients "out of the hospital to lower cost type of care" as quickly as possible.

United Healthcare case managers will start taking information as soon as they are notified about an admission to determine a patient's options for care after the hospital stay. For example, they will ask: Do they have someone to care for them in the home? Do they need home care, or will they need to move to a skilled nursing facility?

Collecting this type of information is important, and it's good that insurers do look at post hospital care more closely, but is a severe 24-hour notification penalty such as the one United Healthcare wants to impose truly necessary to reach that goal?

Insurers are realizing that pushing someone out of the hospital without proper care results in costly re-admissions, Howard notes. Without proper home care after a hospitalization, insurers realize they can be stuck paying for costly re-admissions.

He says hospitals are legitimately concerned that notification can slip through the cracks, especially with an emergency admission to the hospital. Yet, he reminded me that hospitals are very good about making sure they collect your insurance information within 24 hours of admission, so he's not sure why they have such a problem notifying insurance companies within the same time period.

The key here is who is controlling your health care: you, your doctor or or insurer? Right now unless you pay the bill yourself, your health insurer often controls your options by steering you and your doctor toward cheaper treatment options. We hear stories frequently about people being denied treatments because their insurance companies refuse to pay the bill.

And who do you want to control your health care: you, your doctor, your insurer or the government? Without a health care bill that includes a choice for a government option, your choices will continue to be as limited as they are today. Your insurer, who pays the bill, will continue to push care toward the options it will cover.

Lita Epstein has written more than 25 books including "Working After Retirement for Dummies" and "Surviving a Layoff: A Week-by-Week Guide to Getting Your Life Back Together."
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