Late last year while playing tennis I reached up to serve and I felt a painful pop in my shoulder. The inflammation got worse over the next few months. Now anytime I try to put my arm above my head, pain shoots up my arm. I often wake up at night with an agonizing throb in my shoulder.
So I finally and reluctantly went to the orthopedic surgeon and he said that I had a rotator cuff tear and I probably would need surgery. Ugh. He scheduled me for an MRI but the day I was set to go, the hospital called to tell me my insurance company declined to pay for the scans. The insurance company, CIGNA, tersely sent me a note: “You will need to complete six weeks of conservative treatment, such as physical therapy and anti-inflammatory medication. Once that has been completed and you have been re-evaluated, we can try to have the MRI re-authorized.” Gee, thanks. You guys are the best.
What’s that about? I’ve been doing therapy for many months already with not much improvement. The doctor explained that the insurance companies want to make sure that physicians aren’t padding bills with unnecessary procedures. Incidentally, I’ve paid for health insurance for 30 years and have almost never used the medical care system. I calculate the insurers have made well over $100,000 off of me.
But I am lost inside the bureaucratic maze. They don’t want to pay for the MRI because they don’t want to have to reimburse for rotator cuff surgery. So their hope is that I will just go away. Studies show these delay tactics and bureaucratic runarounds work to reduce insurance payouts.
I’m starting to feel just like Helen Hunt in the movie “As Good As It Gets,” during the memorable scene when she finds out her health coverage won’t pay for the proper treatment for her son’s asthma condition and out of frustration she yells: “F*&#ing HMO bastard pieces of @#*@.”
Everyone has horror stories of insurance companies denying coverage for valid procedures. As an analysis in the Baltimore Sun recently put it: “Among insurance professionals, it is common knowledge that health insurers are denying claims for coverage with increasing frequency.” This is what the health industry calls “cost control.”
Look, I get it that the insurance companies are trying to root out the fraud and abuse of excessive procedures, which drive up costs for everyone. But the insurance companies are becoming barriers to care even when it is for legitimate and necessary procedures.
What’s the root of the problem here?
First, the excess of health insurance actually drives up cost. The more insurance for a procedure, the more expensive it is. Health inflation and premiums has been rising for at least the last decade by nearly double the CPI. This is also why there are so many frivolous procedures performed. Patients have been removed from the decision-making process.
Second, Obamacare has increased demand for health care and is driving up costs, so insurers appear to be cutting their expenses by denying claims more often. By the way, the insurance lobby should take note that this sleazy practice only plays into the hands of the likes of Bernie Sanders who wants a single payer government system to take over the health insurance system.
That will make medical care worse — and more expensive. Studies on Medicaid patients find little or no improvement in health outcomes compared to the uninsured population — because the level of care is so lousy. Government health care will be Medicaid-type coverage for all. It will be “fair” because we will all get equally subpar medical care — and I would never get my shoulder surgery under that system.
The health insurance scandal in America today argues not for a vast expansion of government-run health care, but the medical savings account approach, where people put money tax-free into an IRA account and draw it down to pay for their first few thousand dollars of coverage. That way it isn’t an insurance company who makes the call as to whether I should get an MRI. I make the call with my own money. Is the pain so bad in my shoulder that I want to shell out $1,200 to have a scan? Right now, CIGNA says I don’t get to make that choice. So it’s “free” but I don’t get it. Wonderful.
The only people who really know whether my shoulder is in such bad shape that I need surgery is not the faceless bean-counting claims adjusters living in Toledo, Ohio, but me and my doctor.
• Stephen Moore is an economic consultant with Freedom Works and a Fox News contributor.