The philosophy of insurance companies

[MooseMom]

http://www.chicagotribune.com/business/ct-biz-1004-health-insurance-politics20101004,0,6752608.story

In my former life, I worked as a reinsurance broker for oil and gas/energy underwriters at Lloyd's of London, so insurance as a concept always interested me.  I know this will probably devolve into a political debate, which is fine, but I hope it will be something more than "I hate Obama" vs "I hate Republicans."  I'd like to know what all of you think about the fundamental philosophy behind providing access to health care.  I am all for health care providers making money.  But it is not doctors who ultimately govern our access to care...it is insurance companies, and it is THEM that I'd like to have a reasoned discussion about.  Insurance companies do not provide care, rather, they provide ACCESS to it, which is something else entirely.  They do not manufacture drugs or make medical equipment or pour over clinical tests; they produce essentially nothing save a door through which you may or may not pass, depending upon either law or their profit margin.  My essential question to you is "What role should insurance play in your medical care?"

(I should perhaps at this point disclose that I had an insurance company cancel my policy retroactively and then refuse to pay any claims during a policy year in which I was hospitalized for a week.  They made up denials, including "pre-existing condition".  They finally settled upon the idea that I was an immigrant and thus not eligible for coverage.  I'm an American citizen, so they just made that up.  I eventually had to sue them.  Have any of you had such an experience?)

The whole idea behind insurance is to spread risk and to create a pool of insured people, thus enabling more people to be insured at a lower cost.  What do you think of the idea that we all MUST participate in this pool?  If one chooses not to participate, what do you think should happen to that person and his family should they need access to health care?  But even more fundamentally, do you think that any third party, whether it be the govt or a corporation, should be able to decide whether or not you get this or that procedure or this or that medication, and should this third party be able to make a profit?

After you've read this article, I'd really like to know a few things.  First of all, we are taught to hate lobbyists; how do you feel about the fact that insurance companies are trying to purchase influence over government policy (like many other industries)?  Do you feel that insurance companies should continue to be able to cancel policies when you get sick?  Should insurance companies be legally bound to cover children?  Should there be lifetime caps on what your policy will pay?  Should the federal government continue to subsidize insurance companies' involvment in Medicare Advantage Plans, or do you think the govt should cut back, as planned in the new health care laws, in an effort to cut spending?  Again, I am interested in hearing your philosophical views on this issue.  I know these are politically divisive times, but what I am really looking for is a discussion about the whole comcept of health insurance and how it fits into our lives.

Thank you all so much for your replies.

[okarol]

Some random thoughts: I often wonder what would happen if we got rid of insurance for most things, such as Viagra, or regular check ups, or an occasional visit for a cold or flu. The amount we pay every year for insurance coverage is huge, yet they often deny coverage or reduce the bill to their randomly determined fee. If we all just paid for catastrophic insurance, covering things such as cancer, ESRD, heart surgery, or severe physical injury, would we pay about the same? I pay $40 co-pay at the pediatrician, the office visit is $80 and the insurance reduces it so they end up paying a small amount. They have thousands of employees and layer upon layer of administrators, that doesn't come cheap. I doubt we'd ever get back to paying as you go type of medical care, but it is so complicated now, you never know what they will cover until it's too late.

[MooseMom]

Okarol, it's hard to know how much such non-catastrophic items cost because it seems to be some sort of state secret.  When I was going through all of that palaver with my ins. co denying my claims, I finally had to sue them, and they had to pay all costs.  Shortly thereafter, I contacted the hospital to make sure they had been paid.  They told me that they had received payment and that my account was clear.  Interestingly, the insurance company paid them $3,000, which was odd because my bill was $20,000, which led me to wonder what the hell happened to the other $17,000.  We patients very rarely are told how much things actually cost, which is another way in which insurance companies come between patients and their doctors. 

[Jean]

Ya know MM, I have never had a fight with an insurance company and still, I hate them. The fact that I have to wait an extra week or longer to have a procedure done, when they dont think its an emergency, makes me angry. To be admitted to the hospital for a procedure is one thing, but to be admitted early, oh thats another approval altogether. They just seem as you said to have layers and layers of people to go thru. Besides that, I doubt if any of them are medically trained and still they get to make the decisions for us. Unfair!!!! The Dr's word should be enough, but no. I really think they are out of control.

[MooseMom]

Jean, when I was going through the pretransplant evaluation/tests, several of the procedures required me to get referrals.  OMG, the red tape was incredible.  I was trying to get a referral for a stress test, and the referral I got didn't have the correct code numbers according to the cardiologist's office.  So I had to get a new one, but the wording was incorrect.  Oh, it just went on and on, and I couldn't help but wonder how many people were getting paid to make up code numbers and to make it all as difficult as possible.  When they talk about cutting costs, maybe they should start with cutting back on the paperwork and the people who generate it.