Unraveling Universal Healthcare, and a Good Place to Start
I started reading TR Reid’s The Healing of America in which he analyzes the main components of universal healthcare systems in developed countries around the world, and then compares them to each other, and to the U.S.’s system.
I’ve gotten as far as France, Germany, Japan, and the UK. Each one is slightly different in whether insurance is private or government funded. How much citizens have to pay (if anything at all). How much providers, physicians and hospitals make. How they maintain patient records (France maintains all patient records on a card similar to a credit card. When you visit the doctor or a hospital they simply swipe your card and all of your information pops up, and the provider can update your chart. Imagine never having to complete a new patient intake form again!).
There are a lot of small differences.
But the one thing thus far that is universal to them all is that no insurance, whether it’s private or government run, can deny a claim. If a physician, hospital, or provider, submits a claim for a procedure, test, or medication, insurance must approve it, pay it, and the patient must get the service.
The one slight caveat to this is in the UK, where a government run organization called the National Institute for Health and Clinical Excellence, NICE for short, conducts research and studies to decide what gets approved. The difference though between NICE and insurers in America is that NICE publicizes its decisions. While private insurers in the U.S. make their decisions in private.
Another difference is that NICE only has a set amount of money to fund healthcare for the whole country, so they need to be strategic. But denying a service doesn’t result in extra profits in the UK like it does in the U.S. Rather, rationing some services, like experimental treatments, means that someone else can receive the care they need.
It’s been shocking to learn because it is so contrary to the way we provide healthcare in America.
In America the insurance carrier decides what procedures, tests, and medications are approved. Not the doctor. In America, the clinic’s office staff frequently has to fight with the insurer to get approval and payment. They have to go through a lengthy appeals process, and very often the doctors themselves have to take time out of their day to get on the phone with the insurer!
It’s so engrained in us that I had a hard time accepting it. My American brain, programmed from spending 10 years working in the American healthcare system, kept saying “That doesn’t make sense. Of course they should be able to deny claims.”
I told my brother, who’s an operating room nurse manager in the largest hospital network in the northeast, about it, and he too was confused. His response was, “wow, really?”
Corollary to that thought, my next one was, “Their claims, testing, and procedures, must be through the roof. And costs as a result.”
But that’s not really the case. It is true that in most of those countries utilization rates are higher when compared to the U.S., but still the overall cost of healthcare is cheaper. One of the main ways they manage that is by having a drastically lower fee schedule when compared to the U.S.
A $200+ office consult in America might cost $20-$30, while a $1,500 MRI might be $105.
And the evidence actually says the inability to deny claims makes it cheaper by putting less strain on the system. Providers in those countries aren’t required to employ additional administrative staff to bill claims, file appeals, and fight denied claims. A huge expense, and huge time suck. I know because it’s one of the main responsibilities I had at my company.
Which made me think, “Why do we allow insurers to deny claims here?”
The answer. It’s just what we do.
I was talking to a gentleman at the airport who works for Firestone Agriculture as a farm consultant. He was a big heavy set Texas man with a handle bar mustache.
I asked him what he does in his role. He said he tries to save farmers money by implementing more efficient practices. He said the main thing he does was advise them on what tire pressure to maintain on their tractors. The correct pressure can save 1 percent on annual fuel bill of $250,000. That’s $2,500. A lot of money for farmers who typically run at a loss.
But he said despite telling them that, he often meets resistance. They don’t want to check their tire pressure and most farmers keep their tires at around 24 psi. The correct pressure is 12 psi.
When he asks farmers why they chose 24 psi, they respond by saying, “Because that’s why I’ve always done.”
It seems to me that we have a long road ahead if we’re ever going to get to a real universal healthcare system in this country. But maybe a smart approach is to start tackling it piece by piece.
It seems like, especially given recent events around healthcare and its executives, that a good place to start might be outlawing the practice of denying claims. If we can’t yet wrap our heads around universal coverage, maybe we can accept that anyone with coverage needs to be covered.