Insurance Coverage Denials: Private versus Public
The people behind the coming denials:
[Centers for Medicare and Medicaid Services] has fewer than twenty physicians on its coverage staff and fewer than forty total clinicians once pharmacists, nurses, and other health care providers are counted. While this isn’t a precise surrogate for sound decision-making, it gives insight into how well the agency informs its decisions. Most of its physicians are generalists. It doesn’t have a single oncologist on its staff, and has just one nephrologist despite the fact that it pays for the vast majority of dialysis performed in the U.S. To give a basis for comparison, private health plans—which exercise far fewer authorities to set prices or coverage rules—have more clinicians by order of magnitude on their staffs. Aetna has more than 140 physicians and about 3,300 nurses, pharmacists and other clinicians. Wellpoint has 4,000 clinicians across its different businesses, including 125 doctors and 3,180 nurses. United Healthcare employs about 600 doctors and 12,000 clinicians across its health care business.
This is from Scott Gottlieb’s chapter on medical innovation. See previous posts here and here.
I get the message. You don’t need a large staff if your purpose in life is to deny claims.
Why the distinction? The big insurers are going to get in bed with the government and they are going to deny claims as one big happy family.
Pundits talk about how efficient Medicare is. They also passionately assert the need for better care coordination among private payers. Yet Medicare doesn’t coordinate or manage anything. Its contractors mainly just pay claims. When considering the low overhead associated with Medicare, the unknown costs should be taken into account. These include fraud and, as the Wall Street Journal highlights in today’s paper, surgeries of questionable efficacy.
@ Bruce
“The big insurers are going to get in bed with the government”
Bruce, what do you mean “are going”? They already ARE.
I think the future holds a lot of denials in store for us.
Don’t most Medicare recipients have a secondary private policy administered by a private insurer? If that’s the case, then the government might be piggy-backing off of the private carriers who want to control costs. I’m not sure how approvals work. Beyond coverage for nursing homes, I not very knowledgeable about Medicare.