Even though physicians, hospitals, nurses and other medical providers give care to people every day, they have very little control over how that care is delivered. That control, unfortunately, rests with health insurers. Their policies dictate not only what is covered, but how care is delivered, and they say a great deal about what insurers really value.
Policymakers are sometimes forced to step in when insurers place profits over patients. Last year, for instance, the Kentucky legislature passed a law mandating insurers pay for smoking-cessation services provided at the same time as an exam.
Their failure to properly cover such services was shocking to legislators because smoking is the clear cause of so many of our health problems.
In Kentucky, most of the control over how care is delivered rests with Anthem. According to a recent American Medical Association study, Anthem controls nearly 60 percent of the commercial market, so the policies they adopt have an enormous impact on the delivery of health care in our state.
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Anthem’s share of the market might have been even greater had the proposed merger of Anthem and Cigna been completed last year. The merger fell apart, however, when the federal government opposed it on antitrust concerns and internal squabbling between the two companies went public.
Cigna is now suing Anthem for over $1 billion, which Anthem was apparently obligated to pay if the deal fell through.
At the same time the insurer may be forced to pay for its bad business decisions, it is instituting new policies that impact how people receive care. And these new policies send the clear message that in the desperate scramble for profit, your comfort and convenience as a patient are secondary.
For example, Anthem steers those who they find in need of an MRI to the MRI provider they choose. Whether or not that provider is one who might have access to your medical records or is convenient to you doesn’t seem to matter to the insurance giant.
Anthem also gets to decide whether an emergency room visit — precipitated by what is no doubt an extremely uncomfortable condition — is truly an emergency, after you have already received the care.
Most recently, the company has refused to abide by standard medical practice and properly pay for procedures that might be done at the same time as an exam, regardless of how convenient it might be for the patient to have them done that day, or the comfort provided by not waiting.
Anthem is using its overwhelming market power to reshape health-care delivery in Kentucky, no matter if patient comfort or convenience suffer. Comfort and convenience should be essential parts of the health care system. They should not be sacrificed at the altar of disastrous business decisions.
Patrick T. Padgett is executive vice president of the Kentucky Medical Association.