The snowball effect has begun. Earlier this year, United Healthcare announced that they were unlikely to continue to participate in the Affordable Care Act (ACA) exchanges in 2017. As the largest Obamacare insurer, United’s announcement may be the harbinger of things to come—I predicted that others would follow. Many patients will likely will be left with even less choice and may be left with no insurance at all. Many of the insurers that remain in the Exchanges are not able to provide the services that they promise to their patients. Case in point–Blue Cross/Blue Shield of North Carolina.
This past month, Blue Cross/Blue Shield of North Carolina announced that they may leave the Affordable Care Act exchanges. BCBS is the state’s largest insurer and is the only company that has provided health insurance policies through the ACA in all 100 counties in North Carolina. The insurer has reported a second consecutive financial loss in spite of raising rates more than 35%. Rumor has it that BCBS may no longer provide insurance through the ACA exchanges unless it is granted yet another rate hike by the State’s insurance commissioner. IN addition to reporting financial losses, BCBS has struggled to provide basic services to its customers in North Carolina. Software “snafus” and a lack of staffing in call centers has resulted in many insured patients reporting to hospitals and physician offices and finding that they have either no insurance (via a computer database) or not the same insurance they signed up for. Some patients report that they have been charged twice for coverage and others have been charged incorrect amounts. When customers have turned to BCBS for answers, they have been unable to speak with customer service representatives without extended wait times lasting hours at a time. IN response, BCBS of North Carolina’s CEO made several public apologies via television and print media and promised to “get it right” in the future. However, lapses in service continue to plague North Carolina customers. For example, since January the customers have experienced the following issues:
-Nearly 7% of 25K customers were put into the wrong plans
-3200 customers had their bank accounts drafted for the wrong amounts (most were over-drafted)
-Many customers never received their insurance cards or received them late
-The company’s phone lines backed up. They have the capacity to deal with 20K calls a day, but received nearly 100K on certain days in January, 2016
Why is this Happening? Why Can’t BCBS Do more?
The simple answer: Follow the Money. BCBS–and others like it–are designed as a for-profit entity. It probably does not surprise anyone that these insurers are NOT providing insurance services in order to make the world a better place. Rather, insurers are taking a calculated actuarial risk on a patient population that they insure in order to “play the odds” and make a profit. Ideally, insurers want to insure large populations and provide few costly services.
I spend a great deal of my time arguing with BCBS and other insurers as to the appropriateness of medications, tests or procedures that my patients may need. Even though I have trained for nearly a decade and have multiple board certifications, awards and honors, insurers have their own way of looking at prescribed treatments–often it involves cost rather than efficacy as a bottom line for decision making. Every single week I must deal with insurance “denials” and even though I am the expert in cardiovascular disease, I must speak with a “physician representative” on the phone in order to argue that an indicated medical test be approved. Many of the insurance “physician representatives” have no training in cardiovascular disease and are simply reading a script or checklist in order to determine an approval or disapproval status for a particular patient. They do not routinely examine the individual case–unless a clinician, like myself, appeals the denial and takes the time to argue the case specifics. In my opinion, insurers today are looking for higher premiums and work diligently to avoid as many “payouts” as possible. Unfortunately, it is our patients who suffer the most. It is hard to both prevent chronic disease and treat acute events when patients are afraid to come to the doctor for evaluation due to high costs passed on by insurers.
The “Buck” does NOT stop here….
As you might imagine, the “buck” is quickly passed when BCBS of North Carolina is asked about the reasons for the recent avalanche of errors and poor customer service. CEO Brad Wilson is quick to place the blame firmly on everyone BUT his own organization—the Affordable Care Act, software companies from other states, billing errors by third party companies—you name it. BCBS claims that they recently implemented a new customer service record system and that a third party company (hired by BCBS to handle billing) is responsible for the errors in billing that many patients have experienced. In addition, a whistleblower claims that BCBS leadership knew about the potential for errors when implementing the new systems but declined to address these concerns prior to the roll out. BCBS vehemently denies the whistleblower’s claims.
While Mr Wilson has issued multiple public apologies on behalf of his organization, little has been done at this point to correct the problems.
And the problems continue…
More recently, BCBS released privileged health information from one customer and their family to another customer by mistake. Last month, a family went online to check their information on the “secure” BCBS patient/customer website and found another family’s names, medical histories, social security numbers and other sensitive information listed on their account in addition to their own. When the customer tried to contact BCBS to report the error and data breach, she was placed on hold for hours—ultimately she was told that it was due to an error made by another third party vendor from Utah. When she contacted the company in Utah, they blamed BCBS of North Carolina. Bottom line…no accountability….AND these folks want to raise your rates? Really?
What is Next?
While there are no easy answers, we must hold insurers accountable for their actions. They must accept responsibility for lapses in coverage, breaches of sensitive data and they MUST provide the services for which they are contracted. Insurers must be held to the same high standards that all healthcare professionals are held to when it comes to working with customers and patients. While cost controls are a reality of modern healthcare, we must put patients first. Insurers must be forced to approve tests, medications and procedures that are deemed appropriate by the preponderance of the data—less focus on cost, more focus on quality.
These changes in insurance will not come without legislative action. The ACA has provided for significant regulations on physicians, hospitals and other healthcare providers. However, nothing is being done to ensure that insurers provide affordable, quality healthcare and allow patients Access to the institutions and therapies that they deserve. While the ACA was designed to provide access and affordable quality healthcare for all Americans, it has fallen far short of this lofty goal. It is my hope that the next administration will focus on the patient—and require insurers to become more accountable. As voters and as medical professional, we must reach out to our representatives in Congress and demand action.
As for North Carolina BCBS, the story is not yet over. The State Attorney General is now involved and has sent a formal letter to BCBS leadership. I fear that BCBS will likely follow the lead of United Healthcare and withdraw from the exchanges in 2017. If this happens, hundreds of thousands of North Carolinians will be without viable healthcare. In a state with a high prevalence of heart disease, obesity, diabetes and other chronic diseases, patients will suffer and I fear that preventable deaths from treatable illnesses will only increase.