Role of Health Insurance companies with non traditional treatment Assignment | Get Homework Help

Role of Health Insurance Companies With Non-Traditional Treatment

Introduction

Hefty Healthcare cost is one of the most persistent problems in American healthcare delivery system. With the shortage of job opportunities in the labor market, most citizens struggle to meet their medical bills every month. Most insurance companies usually cover traditional medical necessities, while they have grown reluctant in purchasing plans associated with non-traditional technologies. Additionally, the health insurance premiums are very expensive, and the insurers are continuously limiting the cost of medical care considered experimental procedures. Healthcare being a primary necessity, the insurance companies should prioritize the health of their consumers while deciding on the coverage of their consumers’ medical necessities. This paper’s primary objective is to discuss the role of insurance companies in coverage of different medical procedures, illustrate what can and can not be covered by the insurer, and illustrate why they do not cover the non-traditional care methods.

Background

Initially, the Prepaid doctor group played a big role in health insurance. They offered inexpensive healthcare services as the doctors acted as the insurers (Chapin, 2016). Just like any other insurance, the patients paid monthly premiums directly to the group. The group consists of doctors of varying specialties. Whenever tasked with complicated cases, the doctors met to consult one another; therefore, this system allowed the patients to enjoy one-stop medical care. The prepaid group, health care system, attracted attention from several healthcare reformers, including President Truman, with the hope of developing a medical economy around it (Chapin, 2016). The fear of the prepaid groups evolving into healthcare corporations led to the rejection by the AMA, who then pressured the doctors through threats. After they defeated the prepaid doctors group, the leaders at AMA created the Insurance Company Model as a way to fight the health care reform from the government.

The Insurance model stated that for every service supplied by the doctors, they were to be paid. The model prevented insurance companies from monitoring the doctors’ billed work and prevented all of the insurance companies from being able to finance a multi-specialty doctor groups. The insurance model’s major limitation was that it allowed physicians and hospitals to order unwarranted tests and procedures for insured patients. Throughout the 1950s, excessive medical services such as unwarranted surgeries and hospital admission for insured patients grew into a national crisis (Chapin, 2016). The health care prices skyrocketed, so it lead to the insurers establishing and adopting cost-containment measures. For instance, previously the AMA’s initial insurance model forbid the insurers from supervising the doctor, now the doctors seek permission from the insurers before performing any medical services and procedures as an attempt to lower or eliminate the unwarranted procedures and admissions.

Supporting Arguments

The insurance coverage rendered the consumers ignored, with zero say in what services they are covered by the insurer, the type of service the doctors can render them, and the amount they will be paying. In most cases, when the doctors perform experimental or non-traditional procedures, the insurer may only pay a portion or nothing, leaving the patients solely responsible for paying the bills (Chapin, 2016). Health insurance policies primarily cover most doctor and hospital visits, prescription drugs, wellness care, and medical devices. These medical care services are considered traditional and are necessities. Cosmetic procedures, beauty treatments, like, Botox or any type of fillers.  Also, off-label drug use, or new technologies are considered unwarranted necessities; therefore, most insurance companies do not cover them. Over the years, health insurance companies have acted as the healthcare supervisor to restore healthcare cost transparency (Chapin, 2016). Therefore, it is essential that the affordable care act is grounded in the insurance company model.

In addition to the private insurance companies, the government has established the Medicare system. “Medicare system is a federally run healthcare system granted primarily to U.S. citizens age 65 and older” (‘Services That Health Insurers Often Decline’, 2020). Similarly, the Medicare system does not cover most new technologies in healthcare service delivery. For example, most health insurance covers the bare-metal stents in heart procedures rather than cover the eluting-drug stents. Obtaining coverage for traditional healthcare procedures is a lot easier than obtaining healthcare coverage for non-traditional and experimental procedures. The healthcare insurance models were mainly created to relieve the American citizens of the burden of paying for the hefty hospital and doctor’s office bills.

Since the primary goal of health care systems is to deliver quality services while keeping the cost of healthcare affordable, the insurance companies acted as the guards to ensure the patients are not taken advantage of. Therefore, the routine coverage of most insurance companies is founded on traditional healthcare procedures and tests. Although the insurance coverage plan varies among the insurers and significantly depends on the state regulations since each stated has its policies, and the needs of the patients. For example, when the patients suffer from a severe illness, the treatment may require a co-pay as a measure for paying the bill. Co-payment is a fixed amount of money paid by a patient to the doctor whenever the doctor rendered their services and each copay would depend on the patient’s insurance plan (‘Insurance 101 | Health Services’, 2020). Some of the medical procedures and test that are not covered by most insurance healthcare models are; Cosmetic procedures are not considered as primary Medical necessity, but a personal choice since the consumers choose to have these procedures. Medical necessity is a medical procedure, test to be performed following a doctor’s diagnosis and will help the patient’s health (‘How Insurance Covers Medical Necessity Procedures’, 2020). Most cosmetic procedures are optional and are wanted, not needed, by the patient. Since this is a personal choice of the patients who want to improve their physical appearance through some dermatological procedures and plastic surgery, the insurers do not cover this; therefore, the patients are solely responsible for the bills since insurance wouldn’t be able to cover any part of the procedure. Although in rare cases, the insures may cover plastic surgery only if it is deemed to be medically necessary by a medical doctor. I have seen some cases where an insurance company would cover a cosmetic procedure, if the patient was born with a defect.

Most insurance healthcare plans cover prescription drugs that are approved for specific disorders, such as autoimmune disease. The insurers may fail to cover these prescription drugs when prescribed for other disorders of the listed labelsthe right prescription name can make the biggest difference in the coverage of the medications.

Since offering quality healthcare services is one of the main goals of medical organizations, they are always finding different ways to improve drugs, tests, and services renders to provide the consumers with the best care. ‘Historically, most indemnity insurers have included language in their contracts indicating that experimental or investigational services are not covered” (‘Services That Health Insurers Often Decline’, 2020). This implies that most healthcare plans do not cover the services that are not time-proven and would only cover them when you have proper diagnosis and a detailed explanation from the doctor performing the actual procedure on its effectiveness.

Since the medical and healthcare pricing is significantly high, every patient is responsible for knowing if the medical procedure to be rendered to them are covered within their existing healthcare plan. As a patient, it is your responsibly to do the research that is needed for yourself or you will end up with a very large bill when insurance doesn’t cover it. Consequently, the consumers should ensure the procedure is diagnosed by a medical doctor and is considered necessary treatment. Consumers should always analyze the health insurance policies to understand the kind of coverage offered for specific procedures (‘How Insurance Covers Medical Necessity Procedures’, 2020). For example, a patient going into a treatment blind, can have great financial consequences. Furthermore, analyzing the insurance policy will help the consumer understand the procedures covered in the healthcare plan or understand what plan they are choosing when open enrollment time comes around.

When making decisions regarding the health interests of their consumers, the insurers may specify specific care centers that offer the best quality of service. The health insurance policies have made it available to patient to make sure to visit a provider that is in their network. Whenever a consumer goes to a healthcare facility outside the specified health network, this sometimes excludes them from the medical coverage plan. To control the increasing cost of healthcare, the insurers may make decisions on behalf of their consumers. For instance, the insurers do not allow patients to overstay longer than the approved length of stay in the health plan when admitted in a hospital. Additionally, just like any typical business organization, insurance companies prefer to spend less; therefore, they will not allow the patients to get treatment in hospital facilities that charge higher amounts, when there are organizations that offer the same quality of case for less.

Opposing Arguments

Most insurers argue that one of the reasons why they have limited the coverage of the use of new and experimental technology is due to the uncertainty of the patient’s safety. The experimental technologies are unproven, with zero data on their effectiveness (‘The Reasons Why Insurance Companies Refuse to Cover Natural Medicine’, 2020). Therefore, insurance companies fail to cover non-traditional technology to discourage the majority of employees from accessing them, which maintains the consumer’s safety (SteinbergKeeping the patients safe is the insurance and any medical organization’s main goal at all times. Additionally, new technologies are associated with increased healthcare costs. Which, the insurers are justified to limit their coverage as a measure of control healthcare costs. The barriers to insurance coverage of non-traditional technology is not necessarily a bad event since the side effects, and the aftermaths related to the use of the new drug is unknown (‘The Reasons Why Insurance Companies Refuse to Cover Natural Medicine’, 2020). The unproven drug may be ineffective and costly, resulting in a loss for both the insurer and the patients. Mandated by the AMA as a price transparency watch guard, the healthcare insurance plan should encourage their consumers to see clarification on the coverage plan to help reduce the out of the pocket spending. Additionally, the healthcare insurance plan may fail to cover the use of new technology when the doctors do not establish medical necessity, therefore, may be considered unnecessary.

Although there are some issues when developing an appropriate healthcare plan for paying for the non-traditional medical technologies often come from the need to balance several legal but opposing objectives (‘Paying for Complementary and Integrative Health Approaches’, 2016). Since most of the insurers need more justification when it comes to covering new treatment. They would need to know the effectiveness of the new technology is one of the main reasons to no longer see them as experimental. There are some benefits associated with access to experimental technology, which, the insurance company should consider incorporating these technologies in the health care plan (Steinberg et al., 1995). In case of a life-threatening disorder and lack of suitable and effective traditional treatments, patients are usually compelled with the desire to have access to any treatments that can work. In this case, the health insurers should consider the coverage of the use of the experimental drugs; therefore, help by paying off the bills or at least part of the bills.

Additionally, the coverage of non-traditional procedures and new technology in the healthcare plan by the insurer help support the high rates of technological advancement and innovation (Steinberg et al., 1995). When the insurers cover the uses of new technology, promising and effective technologies will help to improve the quality of service rendered to their consumers, help establish their safety within the healthcare systems and improve the rate of service delivery. With the rise of the required levels of safety and effectiveness of the new technology is met, the availability of reimbursement for their use will be certain for the consumers. Furthermore, the desire to promote such innovations are shared by patients, doctors, medical product manufacturers, and society at large (Steinberg et al., 1995).

“Employers are the largest single providers and purchaser of health insurance in the United States, covering over 150 million workers and their dependents” (‘To Control Health Care Costs, U.S. Employers Should Form Purchasing Alliances’, 2018). Although the employers have enjoyed the controlled healthcare cost over the years, the increasing out-of-pocket costs among workers has led to the problem largely driven by the lack of coverage of non-traditional procedures. The increased out-of-pocket copays are due to the increased cost of healthcare for some drugs and tests. It has consequently impacted the long-term health of the workers and their productivity as they skip healthcare services that are critical to maintain good health (Valles, 2019). The employers have pushed the premium and deductible as far as they can, but seeming the insurers are failing to cover some procedures that are deemed critical (‘To Control Health Care Costs, U.S. Employers Should Form Purchasing Alliances’, 2018). Since the healthcare premiums and deductibles have greatly increased over the years, most employers should consider settling their employees’ medical bills of their books of accounts. For instance, companies like Boeing have experimented reshaping the healthcare services for their employees by directly purchasing healthcare services rendered to their employees (‘To Control Health Care Costs, U.S. Employers Should Form Purchasing Alliances’, 2018). Through this, the employers will be able to secure better prices, eliminate the administrative costs of the insurers, and, eventually, lower their expenses on high elective procedures while receiving high quality care.

The state government should play a bigger role when it comes to private insurers. The government should focus on limiting total healthcare spending rather than focusing mainly on their spending on Medicare, which leads to the growing gap between the government and private insurers costs on the same service. Focusing on the total healthcare spending by the regulatory bodies will prevent the providers and payers from implementing activities likely to increase spending (Stuart Altman et al., 2018). With success witnessed in Massachusetts, regulatory programs will greatly limit the total healthcare spending across the nation. Additionally, the government should consider price regulations with the healthcare plan and price based on the quality of services, and the effectiveness of the treatment. Furthermore, the prices on healthcare spending can be limited through the price ceiling plan. The price ceiling plan will allow the regulators to enforce the limits on the prices of medical services.

Lastly, changing consumer behavior is essential in reducing the cost of healthcare services. Changing the consumer’s behavior is one of the most challenging measures, especially when the consumers want affordable medical care but struggle with restrictions on access to services and providers (Stuart Altman et al., 2018). Consumers are responsible for helping reduce the continued growing healthcare premiums and deductibles. According to Valles (2019), the consumers can also resort to alternative and less costly medical healthcare plan that offers the same medical care services at an affordable price.

Conclusion

In conclusion, although the cost of insurance healthcare plan can be very expensive, when it could be a lifesaving situation, the insurers should consider the coverage of the use of non-traditional care if it is an appropriate alternative for the patient. Insurers are slowing starting to adapt to new treatment and alternative ways of treating patients.  Since most of the new technology is experimental, with the continuous use of it, insurance will see the positive effects that it brings and start covering it for patients. The employers, the government, and the consumers are critical to determining the cost of healthcare; therefore, they should create different ways for reducing the rising premium and general cost of healthcare. Creating effective plans, with lower deductibles and lower copays would make a tremendous difference to all of the employees and consumers. Preventative care is essential to lowering overall healthcare cost, ensuring that patients go see their doctors at least once a year and allowing coverage to receive non-traditional care would save spending in the long run for everyone. Additionally, the use of technology and experimental devices significantly encourages technological development, making it easier and improved healthcare service delivery.  And this would be beneficial for everyone that needs care and consumers would lead healthier lives.

References

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Chapin, C. F. (2016, October 4). Why insurance companies control your medical care. The             Conversation. https://theconversation.com/why-insurance-companies-control-your- medical-care-62540

How Insurance Covers Medical Necessity Procedures. (2020, May 5). The Balance.             https://www.thebalance.com/what-s-medical-necessity-how-does-it-affect-insurance-        4172148

Insurance 101 | Health Services. (n.d.). Insurance 101 Health Services. Retrieved June 27,            2020, from https://healthypack.dasa.ncsu.edu/insurance-and-billing/insurance-101/

Paying for Complementary and Integrative Health Approaches. (2016). NIH.             https://www.nccih.nih.gov/health/paying-for-complementary-and-integrative-health-          approaches

Services That Health Insurers Often Decline. (n.d.). Investopedia. Retrieved June 27, 2020,           from https://www.investopedia.com/articles/insurance/09/services-health-insurers-do-     not-cover.asp

Steinberg, Tunis, Shapiro, E., ST, DC. (1995). Insurance Coverage for Experimental          Technologies. Health Affairs.      https://www.healthaffairs.org/doi/full/10.1377/hlthaff.14.4.143

Stuart Altman, Robert Mechanic, S., RM. (2018, July 13). Healthcare Cost Control: Where           Do We Go From Here? Health Affairs.   https://www.healthaffairs.org/do/10.1377/hblog20180705.24704/full/

To Control Health Care Costs, U.S. Employers Should Form Purchasing Alliances. (2018,            November 2). Harvard Business Review. https://hbr.org/2018/11/to-control-health-      care-costs-u-s-employers-should-form-purchasing-alliances

Valles, M. (2019, July 15). Alternative Medicine and Your Health Insurance. The Simple    Dollar. https://www.thesimpledollar.com/insurance/health/alternative-medicine/