How insurance companies operate

[Guest guest]

Sorry, but you turned on my soap box. You said " I guess he spends 'too much

time' with his patients

and it costs the insurance carriers too much money " . Here's an example of how

insurance companies operate: My (former) employer pays $277/mo to my HMO. My

HMO uses capitation, in which it pays providers a certain set-in-stone amount

per patient, an average based on actuarial stats. There are several different

groups of fees, depending on age & sex (but not on existing conditions -- yet).

I'm sure you won't believe this, but 10 years ago I had the following fact

confirmed for me by two sources at two different medical centers (one was UC

Med Ctr) and also by a book written by a physician for physicians -- the

cap fee for a woman of childbearing age was at that time $12/mo. Let's says

it's tripled since then, which is unlikely, because we're talking about what the

insurance company pays out, and they are the only ones with bargaining clout

(and incidentally they've been illegally colluding on this since they started it

in about 1990 -- you may notice that our elected representatives, who do not

have HMOs -- they have PPOs and are 100% covered for everything, all over the

US). Anyway, let's just be generous in our opinion of HMO insurance companies

and say that they're now paying triple what they were paying in 1993, which

would be $36/mo for a woman of childbearing age. Also take note that the $36 is

it. They don't pay more for, say, surgeries, because that's all figured into

the statistics. If your doctor is affiliated with a small clinic, any referrals

to outside specialists come out of her pocket and you're likely to get the " Oh

you don't need that " response like I did in 1994 after I had hurt my back & was

in constant excruciating pain. OK, so what does the rest of the $277 go for?

Operating expenses? Depends on what you call an operating expense. $13M

bonuses for HMO CEO's? Big beautiful buildings all over the country with solid

walnut wainscoting and the best furniture and accessories, like marble

countertops in the executive restrooms? Perhaps investments in real estate

(after all, they're not non-profit any more)? They do all of these, and call

them operating expenses. Meanwhile, people are denied service because the AMA

hasn't got the same clout that the insurance companies have. It took the AMA

TEN YEARS to come out of the coma it went into when the insurance companies

started this. They've just begun to organize, and it doesn't look to me like

they've gotten very far. If this sort of insurance is foreign to any of you,

either you must not live in the US, or you have a PPO you can afford, or

capitation hasn't reached your state yet (they started out in California and two

other states. My understanding is that it's pretty nationwide by now, although

I know people in the eastern states who have PPOs that are affordable. I could

have a PPO too -- but I'd have to pay $213/mo (for just me), I'd have a $500/yr

deductible and a 10% copayment, with a $20 copayment for office visits. I can't

afford that. (Actually this plan used to be worse -- it had a $2000/yr

deductible -- they must have lost all their subscribers.)

<fume, fume>

Ann

Re: One Vote Against Exploratory

Arthroscopy

Mark:

Yep. I've heard that many doctors are paid by the insurance

companies to " keep costs down. " In fact, we had a pretty lively

discussion of this subject a while back.

It certainly explains the " take some Aleve and go away "

prescriptions that some of these guys give.

It is so pervasive (and I'm so paranoid) that I almost think it is

wiser to go to a doctor that isn't affiliated with too many

insurance carriers. My doc in Connecticut is only in one or two

insurance networks. I had to see him " out-of-network " and pay 30%

out-of-pocket. I guess he spends " too much time " with his patients

and it costs the insurance carriers too much money.

Like you said, imagine that...

- Doug

> Just another quick comment about the comp doctors is to remember

that they get paid by saving the carrier money.

> I know one doctor who is a friend of mine who told that the comps

won't send him any more patients because he sided with the employee.

He was told that he was costing them too much money.

> Imagine that.

>

> Mark

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