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We are social animals. Rules, laws, codes, and mores are the natural consequence of that shared life. We establish governments to organize and formalize those rules. The fundamental purpose of governments is to improve and protect the lives of the governed. Those of a libertarian bent decry government as being intrusive upon their freedoms. Yet, the very purpose of laws is to limit any individual’s freedom to do harm to society. For humans, anarchy tends to devolve into chaos. For arch Libertarians, every law (or at least every law they dislike, today) is pejoratively defined as “Socialism,” and that supposedly ends the argument. They opt for “small government” which tends to translate into, less taxing of the rich and fewer benefits for the poor. But Socialism, like most “isms,” neither is bad nor good, in of itself. The assessment depends on conditions and how the “ism” is applied. When Ronald Reagan famously declared, “Government is the problem,” he was President of one of the more successful governments on this planet — successful in the sense that it oversaw one of the freest, wealthiest, most powerful nations in history. Clearly, Reagen was not a Libertarian when he uttered those words, which in any event have been misconstrued and twisted over time. And as it turned out, Reagan was not a small-business President. Today’s Libertarianism leans heavily toward a form of Conservatism that favors the rich over the poor, to the point where virtually any benefit for the poor is denounced as encroaching on “our” (meaning the rich’s) freedoms. Despite the “Socialism!” howls of today’s Republicans, and the “Big Government!” screams of the Libertarians, some things truly are better left to the federal government. Three of these things are discussed at: The military, the nation’s banks, and healthcare.
Major Insurers Running Billions of Dollars Behind on Payments to Hospitals and Doctors Posted on October 10, 2021 by Lambert Strether: “We should bail them out. Obviously.” Jay Hancock, of Kaiser Health News. Anthem Blue Cross, the country’s second-biggest health insurance company, is behind on billions of dollars in payments owed to hospitals and doctorsbecause of onerous new reimbursement rules, computer problems and mishandled claims, say hospital officials in multiple states. Anthem, like other big insurers, is using the covid-19 crisis as cover to institute “egregious” policies that harm patients and pinch hospital finances, said Molly Smith, group vice president at the American Hospital Association. Hospitals are also dealing with a spike in retroactive claims denials by UnitedHealthcare, the biggest health insurer, for emergency department care, AHA says.What is the underlying problem? Money, or more specifically, the profit motive.
While the primary mission of Medicare and Medicaid is to pay for medical expenses, the primary mission of private-sector health care insurance companies is to make a profit.
A government agency can be inefficient, uncaring, and downright ignorant. So can private insurance companies. The single biggest difference is the profit motive, or the lack thereof.Disputes between insurers and hospitals are nothing new. But this fight sticks more patients in the middle, worried they’ll have to pay unresolved claims. Hospitals say it is hurting their finances as many cope with covid surges — even after the industry has received tens of billions of dollars in emergency assistance from the federal government. “We recognize there have been some challenges” to prompt payments caused by claims-processing changes and “a new set of dynamics” amid the pandemic, Anthem spokesperson Colin Manning said in an email. “We apologize for any delays or inconvenience this may have caused.”“Any delays or inconvenience” sounds benign, but it is a serious, often existential problem. Nurses rely on their salaries. Doctors, too. Hospitals have creditors who rely on repayment. And patients suffer emotionally and medically from those delays and inconveniences. When an insurer reneges on its payment responsibilities, a falling domino effect occurs, where thousands of people are injured, some permanently.
Virginia law requires insurers to pay claims within 40 days. In a Sept. 24 letter to state insurance regulators, VCU Health, a system that operates a large teaching hospital in Richmond associated with Virginia Commonwealth University, said Anthem owes it $385 million. More than 40% of the claims are more than 90 days old, VCU said. For all Virginia hospitals, Anthem’s late, unpaid claims amount to “hundreds of millions of dollars,” the Virginia Hospital and Healthcare Association said in a June 23 letter to state regulators.Clearly, Anthem values its own finances above the finances and health of many thousands of people.
Nationwide, the payment delays “are creating an untenable situation,” the American Hospital Association said in a Sept. 9 letter to Anthem CEO Gail Boudreaux. “Patients are facing greater hurdles to accessing care; clinicians are burning out on unnecessary administrative tasks; and the system is straining to finance the personnel and supplies” needed to fight covid. Complaints about Anthem extend “from sea to shining sea, from New Hampshire to California,” AHA CEO Rick Pollack told KHN. Substantial payment delays can be seen on Anthem’s books. On June 30, 2019, before the pandemic, 43% of the insurer’s medical bills for that quarter were unpaid, according to regulatory filings. Two years later that figure had risen to 53% — a difference of $2.5 billion. Anthem profits were $4.6 billion in 2020 and $3.5 billion in the first half of 2021.While Anthem thrives, everyone else suffers. The villain all of this is not just Anthem, but the profit motive. That is where the problem begins. If Anthem were like the federal government and wasn’t concerned about profits, everyone would have been paid, and those payment dollars would have benefitted the entire economy.
Alexis Thurber, who lives near Seattle, was insured by Anthem when she got an $18,192 hospital bill in May for radiation therapy that doctors said was essential to treat her breast cancer. The treatments were “experimental” and “not medically necessary,” Anthem said, according to Thurber. She spent much of the summer trying to get the insurer to pay up — placing two dozen phone calls, spending hours on hold, sending multiple emails and enduring unmeasurable stress and worry. It finally covered the claim months later.Apparently, the claim was a good one. Anthem paid it, not out of the goodness of their hearts, but because the claim should have been paid. The delay was unwarranted. The fundamental purpose of the delay was the profit motive.
“It’s so egregious. It’s a game they’re playing,” said Thurber, 51, whose cancer was diagnosed in November. “Trying to get true help was impossible.” Privacy rules prevent Anthem from commenting on Thurber’s case, said Anthem spokesperson Colin Manning. When insurers fail to promptly pay medical bills, patients are left in the lurch. They might first get a notice saying payment is pending or denied. A hospital might bill them for treatment they thought would be covered. Hospitals and doctors often sue patients whose insurance didn’t pay up.Yes, there are times when Medicare refuses to pay, but those have to do with disagreements about the rules and coverages. The federal bureaucrats making those decisions are not constrained by profits or affordability. They simply interpret the rules. They have no m oneyreason to lean away from the creditor.
Hospitals point to a variety of Anthem practices contributing to payment delays or denials, including new layers of document requirements, prior-authorization hurdles for routine procedures and requirements that doctors themselves— not support staffers — speak to insurance gatekeepers. “This requires providers to literally leave the patient[’s] bedside to get on the phone with Anthem,” AHA said in its letter.Ah, the old “prior authorization” insurance scam. How many millions of patients have been tripped up by that one? A frightened, inexperienced patient is told he/she needs a procedure. In a panic about her health, her personal life, and the future, she neglects to tell the insurance company in advance. Payment is denied, not because the procedure isn’t proper, but simply because she didn’t go through the formality of prior authorization. Gotcha! Medicare seldom requires prior authorization.
Anthem often hinders coverage for outpatient surgery, specialty pharmacy and other services in health systems listed as in-network, amounting to a “bait and switch” on Anthem members, AHA officials said. “Demanding that patients be treated outside of the hospital setting, against the advice of the patient’s in-network treating physician, appears to be motivated by a desire to drive up Empire’s profits,” the Greater New York Hospital Association wrote in an April letter to Empire Blue Cross, which is owned by Anthem.Original Medicare aMedicare and Medigap do not use provider networks. With Original Medicare and Medigap you can use any healthcare provider that accepts Medicare-assignment. With Original Medicare, you do not have to wander through the “in-network, out-of-network” jungle.
Anthem officials pushed back in a recent letter to the AHA, saying the insurer’s changing rules are intended partly to control excessive prices charged by hospitals for specialty drugs and nonemergency surgery, screening and diagnostic procedures.A for-profit organization has to worry about “excessive prices. For the government, “excessive” prices merely mean that the federal agency will pump more stimulus dollars into the economy.
Claims have gotten lost in Anthem’s computers, and in some cases VCU Health has had to print medical records and mail them to get paid, VCU said in its letter. The cash slowdown imposes “an unmanageable disruption that threatens to undermine our financial footing,” VCU said.“Lost” is the way a for-profit organization increases its profits.
United denied $31,557 in claims for Emily Long’s care after she was struck in June by a motorcycle in New York City. She needed surgery to repair a fractured cheekbone. United said there was a lack of documentation for “medical necessity” — an “incredibly aggravating” response on top of the distress of the accident, Long said. The Brooklyn hospital that treated Long was “paid appropriately under her plan and within the required time frame,” said United spokesperson Maria Gordon Shydlo. “The facility has the right to appeal the decision.” United’s unpaid claims came to 54% as of June 30, about the same level as two years previously.When more than half of all claims are not paid, something is terribly wrong. There simply cannot be that many false claims.
When Erin Conlisk initially had trouble gaining approval for a piece of medical equipment for her elderly father this summer, United employees told her the insurer’s entire prior-authorization database had gone down for weeks, said Conlisk, who lives in California. “There was a brief issue with our prior-authorization process in mid-July, which was resolved quickly,” Gordon Shydlo said.“Brief issue” is private insurance-speak for “the longer you have to wait, the more money we make. Maybe you’ll just give up, altogether.”
When asked by Wall Street analysts about the payment backups, Anthem executives said it partly reflects their decision to increase financial reserves amid the health crisis.“Decision to increase financial reserves” is insurance-speak for “decision to make more profits.”
“Really a ton of uncertainty associated with this environment,” John Gallina, the company’s chief financial officer, said on a conference call in July. “We’ve tried to be extremely prudent and conservative in our approach.”Translation: “To be really prudent and conservative, we’ve decided not to pay claims. You’d be amazed at how that reduces our costs. But you better send in your premiums on time.”
Several health systems declined to comment about claims-payment delays or didn’t respond to a reporter’s queries. Among individual hospitals “there is a deep fear of talking on the record about your largest business partner,” AHA’s Smith said.“Business partner” is a synonym for “the guy who is squeezing my reproductive organs in his fist.”
Alexis Thurber worried she might have to pay her $18,192 radiation bill herself, and she’s not confident her Anthem policy will do a better job next time of covering the cost of her care. “It makes me not want to go to the doctor anymore,” she said. “I’m scared to get another mammogram because you can’t rely on it.”And that is exactly what your insurance company wants. Plenty of premiums with no costs. An excellent business model. That is where the profit motive can devolve in the health care business. Health should be a recognized basic human right. In a Monetarily Sovereign nation, federal support of healthcare costs taxpayers nothing. Comprehensive, no-deductible Medicare for All is the correct solution. But, until the public realizes it, it won’t happen. The politicians are too well-bribed by the insurance industry. Rodger Malcolm Mitchell Monetary Sovereignty Twitter: @rodgermitchell Search #monetarysovereignty Facebook: Rodger Malcolm Mitchell
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THE SOLE PURPOSE OF GOVERNMENT IS TO IMPROVE AND PROTECT THE LIVES OF THE PEOPLE.
The most important problems in economics involve:- Monetary Sovereignty describes money creation and destruction.
- Gap Psychology describes the common desire to distance oneself from those “below” in any socio-economic ranking, and to come nearer those “above.” The socio-economic distance is referred to as “The Gap.”
- Eliminate FICA
- Federally funded Medicare — parts A, B & D, plus long-term care — for everyone
- Social Security for all
- Free education (including post-grad) for everyone
- Salary for attending school
- Eliminate federal taxes on business
- Increase the standard income tax deduction, annually.
- Tax the very rich (the “.1%”) more, with higher progressive tax rates on all forms of income.
- Federal ownership of all banks
- Increase federal spending on the myriad initiatives that benefit America’s 99.9%
MONETARY SOVEREIGNTY
