This blog is primarily a personal one. I don’t usually write about political events or issues. That is not because I am not interested in politics and world events, but rather because I don’t feel that I can add much to the excellent discussions of blogs like Darlene’s Hodge-podge and Time Goes By.
I am making an exception here, partly because I do have something personal to add to the topic of health care reform.
I live in the Pacific Northwest, near the city of Bellingham, which is about 90 miles north of Seattle. Many people in this area are insured by a company called Group Health. My husband Jerry insured his late wife, Susy, with Group Health. He himself had Medicare, but she was too young.
Group Health is being held up as an example of a model for a “cooperative” health care plan that would be a “compromise” solution to the Republicans’ objection to a government health plan. There is an article in today’s New York Times discussing Group Health. Toward the end of the article it states that “Technically, Group Health was misnamed. . . . . Structured as a not-for-profit corporation, its revenues (2.6 billion last year) are reinvested rather than redistributed among members. But it is governed like a cooperative – and calls itself one – because its board consists of and is elected by members.” In fact, according to the article, only seven-tenths of 1 percent of enrollees voted in the last board election.
In fact, Group Health is an insurance company. Apparently its fees are slightly lower than other insurance companies, supposedly because its records are computerized and its doctors are paid a salary (not fee for service). Salaries are based on “performance.” The article does not say who evaluates performance, or what criteria are used in the evaluation. But I’d be willing to bet my bottom dollar that keeping cost down is a biggie!
At Group Health, according to the Times article, patients are assigned a team of primary care practitioners who are responsible for their health. Notice that they are assigned practitioners. What that means is that you don’t choose your own doctor, and you don’t even choose whether or not you see a doctor. You may see a nurse, and you don’t have a say in which it is.
Suppose you were a doctor working for Group Health and your salary was based on your performance. Your performance would be measured by the administrators running the insurance company (Group Health). These administrators would be very interested in keeping costs down, and probably secondarily, in keeping patients healthy (or perhaps in keeping healthy patients). You would be disinclined to order tests for patients, especially expensive tests. You would prefer not to treat the really sick ones.
The Times article states further: “Medical practices, and insurance coverage decisions, are driven by the company’s own research into which drugs and procedures are most effective.”
Don’t let them fool you. It’s an insurance company, pure and simple.
Here’s what happened to Jerry’s wife. Some years after he took out the insurance she discovered that she had metastasized breast cancer, the same thing Elizabeth Edwards has. It would eventually kill her, but there were treatments which could significantly prolong her life. She was given chemotherapy and the cancer went into remission. The tumors were not gone, but they were no longer growing. After another year they came back. Jerry got a letter from Group Health saying they would no longer cover Susy’s cancer. He read the policy, which had been sold to him by an insurance broker (because Group Health is an insurance company) and it had a lot of language in it that was difficult to understand, but which did seem to indicate that the insurance company could terminate coverage under various conditions.
Is anyone surprised by this story? Isn’t this standard insurance company practice? Don’t get really sick because the doctors will get paid less and the insurance company will get less money.
Jerry made a fuss. The original broker got involved. (“This is outrageous!” is what he said to Jerry.) Eventually he got coverage reinstated, and Susy lived another 5 years.
Jerry and I both have Medicare. He wouldn’t be paid to have Group Health. Medicare isn’t perfect, but it is the best health insurance I ever had. We supplement it with a medigap policy. That is not cheap, but it allows us to choose our own doctor and to decide when to go. We can see a specialist when we need to, and the insurance company has nothing to do with the decision. We decide, with the recommendation of our doctor, which specialists to see.
President Obama said that if we like the insurance we have we can keep it. I sure hope he keeps that promise, because I really don’t want to be forced into something like Group Health.