Fixing_Healthcare
New Member
- 1
Why do so many, including me, do this work? Most of us choose to spend their careers and lives in health care and health insurance because we are experienced, compassionate, dedicated, tenacious and uniquely situated to understand, assess, improve and ultimately address the gaps and challenges in the system – from the inside. Many of us didn't seek it out or spend our childhoods dreaming of being a healthcare leader. For me, I felt drawn to health care, got a job and started learning and gathering experience, and over a career felt called to use that experience and expertise to do more, to have more impact and to continue to serve, innovate and reform.
My colleagues in this work are physicians, pharmacists, nurses and home care specialists and they are heroes, but so are the technologists, data scientists, financial actuaries and business leaders that work alongside them. I have witnessed their heroic actions in support of our front line medical and clinical staff. My colleagues innovate, discover, care, serve and work together every day. The system is better because of them – in fact it wouldn't function without them…and those are the people that will reform the US health care system for future generations.
It is a complicated system. Maybe the better description is complex. That is not said to make excuses – it is just a description of a system built over years that requires deliberate and thoughtful reform. The answers are not easy, they require tradeoffs. Quick solutions could have unintended consequences and cost. Because access to quality care is non-negotiable, reform requires planful steps to change.
Yes, historic health insurance practices relied on reviews by medical professionals of requests for services to evaluate the quality and appropriateness of the request when considered against other available options. This practice is decades old and a long-standing part of the established system – requiring collaboration by all health system stakeholders to effect productive change.
The vast majority of claims are approved, and if denied, are denied for procedural reasons and after the service is performed – many times because service is not covered by the employer, the member is not eligible on the date of service, the claim is not billed correctly, or for fraud. Any requests denied for medical reasons can be revisited or re-reviewed as a process safegaurd. Employers, states and federal governments require health insurance companies to perform this review. If every request was approved, our health care would cost much more.
That is the historic, established system. But maybe most importantly, health insurers have been moving away from the practice of reviewing claims for medical necessity for several years – with momentum in the last 2-3 years. Today, many health insurers are shifting the responsibility to make decisions regarding what is right for the patient to the patient's treating physician. In accountable care models, the physician makes the treatment decisions. The insurance company still plays a vital role – providing all relevant patient eligibility and history, evidence-based care guidelines for consideration, plan design administration, provider network for referral, and claims processing.
The incredibly cruel, sad irony of all of this is that UnitedHealthcare is accelerating the shift to less prior authorizations (and denied claims) and having the treating physician make the best decision for their patients with all the available data and support, investing in the infrastructure necessary to empower physicians to make the right decisions for their patients without bankrupting their practices, the delivery system and the US economy.
They are investing in the infrastructure necessary to empower physicians to make the right decision for their patients without bankrupting their practices, the delivery system and the US economy. None of this is to minimize the daily frustrations about our system. People want high quality providers to see them quickly and conveniently and want their physicians to have the final say. Providers want to be paid or know why not quickly.
Colleagues of mine are constantly questioning the status quo because they believe they are doing their part to improve, reform and fix a broken health care system for their family members, friends and neighbors. These dedicated people choose to utilize their training, their experience and their talent to further this mission.
Before people prejudge the people that work for health insurers, consider that every company is just a collection of people, dedicated, talented and experienced people, working to make it better for all of us. These are humble people – they are my colleagues, and my friends. And I know that like me, every frustrated member, every sick patient, and every scared family member, breaks their heart, moves them and drives them to keep working to improve our healthcare system from the inside. The employees of this organization are the helpers in healthcare.
Scrutiny, discussion and debate is fine – but personal attacks, threats, and horrific violence against our fellow humans, is shameful – absolutely shameful. We must acknowledge the frustration but correct the misinformation if we are to have a productive, thoughtful reform of the health care system…and it will require all participants to change.
My colleagues in this work are physicians, pharmacists, nurses and home care specialists and they are heroes, but so are the technologists, data scientists, financial actuaries and business leaders that work alongside them. I have witnessed their heroic actions in support of our front line medical and clinical staff. My colleagues innovate, discover, care, serve and work together every day. The system is better because of them – in fact it wouldn't function without them…and those are the people that will reform the US health care system for future generations.
It is a complicated system. Maybe the better description is complex. That is not said to make excuses – it is just a description of a system built over years that requires deliberate and thoughtful reform. The answers are not easy, they require tradeoffs. Quick solutions could have unintended consequences and cost. Because access to quality care is non-negotiable, reform requires planful steps to change.
Yes, historic health insurance practices relied on reviews by medical professionals of requests for services to evaluate the quality and appropriateness of the request when considered against other available options. This practice is decades old and a long-standing part of the established system – requiring collaboration by all health system stakeholders to effect productive change.
The vast majority of claims are approved, and if denied, are denied for procedural reasons and after the service is performed – many times because service is not covered by the employer, the member is not eligible on the date of service, the claim is not billed correctly, or for fraud. Any requests denied for medical reasons can be revisited or re-reviewed as a process safegaurd. Employers, states and federal governments require health insurance companies to perform this review. If every request was approved, our health care would cost much more.
That is the historic, established system. But maybe most importantly, health insurers have been moving away from the practice of reviewing claims for medical necessity for several years – with momentum in the last 2-3 years. Today, many health insurers are shifting the responsibility to make decisions regarding what is right for the patient to the patient's treating physician. In accountable care models, the physician makes the treatment decisions. The insurance company still plays a vital role – providing all relevant patient eligibility and history, evidence-based care guidelines for consideration, plan design administration, provider network for referral, and claims processing.
The incredibly cruel, sad irony of all of this is that UnitedHealthcare is accelerating the shift to less prior authorizations (and denied claims) and having the treating physician make the best decision for their patients with all the available data and support, investing in the infrastructure necessary to empower physicians to make the right decisions for their patients without bankrupting their practices, the delivery system and the US economy.
They are investing in the infrastructure necessary to empower physicians to make the right decision for their patients without bankrupting their practices, the delivery system and the US economy. None of this is to minimize the daily frustrations about our system. People want high quality providers to see them quickly and conveniently and want their physicians to have the final say. Providers want to be paid or know why not quickly.
Colleagues of mine are constantly questioning the status quo because they believe they are doing their part to improve, reform and fix a broken health care system for their family members, friends and neighbors. These dedicated people choose to utilize their training, their experience and their talent to further this mission.
Before people prejudge the people that work for health insurers, consider that every company is just a collection of people, dedicated, talented and experienced people, working to make it better for all of us. These are humble people – they are my colleagues, and my friends. And I know that like me, every frustrated member, every sick patient, and every scared family member, breaks their heart, moves them and drives them to keep working to improve our healthcare system from the inside. The employees of this organization are the helpers in healthcare.
Scrutiny, discussion and debate is fine – but personal attacks, threats, and horrific violence against our fellow humans, is shameful – absolutely shameful. We must acknowledge the frustration but correct the misinformation if we are to have a productive, thoughtful reform of the health care system…and it will require all participants to change.
