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Stanley Feld M.D., FACP, MACE

A major defect in our healthcare system is that the healthcare insurance industry controls the entire healthcare dollar. In California, Nevada and Hawaii the healthcare Medicare vendor has held back physician reimbursement and restricted access to care.

Private healthcare insurance companies have done the same.

Government funded healthcare programs such as Medicare and Medicaid outsource their administrative services to the healthcare insurance industry. The federal government provides Medicaid funds to state governments. State governments outsource their administration services to the healthcare insurance industry. The healthcare insurance industry controls these dollars.

A recent headline in the Dallas Morning News read, “Is Texas looking out for you? Health-care Outsourcing is rolling on, but many patients suffer from silent treatment.”

Evercare of Texas, a unit of the giant UnitedHealth Group, is the Medicaid administrative services vendor for more than 80,000 elderly, blind or disabled North Texans.

“We help make it easier to get the care you deserve,” the company promises on its Web site.”

The state has received hundreds of complains about its administrative services vendor. Evercare’s excuse is the same as Palmetto’s excuse in California

“Evercare said it experienced the normal start-up problems associated with a program that serves tens of thousands of people.” “It was a massive undertaking,” said Beth Mandell, regional executive director of Evercare of Texas.

Evercare has been servicing Texas for a while now. It was fined 1 million dollars in 2007 and $400,000 in 2008.

A few horror stories can be expanded to many. The healthcare insurance industry controls the healthcare dollar. They are in the business of making money. It would be much easier and less costly if patients controlled their healthcare dollar.

“Willis Stewart, a 61-year-old carpet layer who had his teeth pulled during treatment for mouth cancer, said he has waited three months for Evercare to approve the dentures that will allow him to eat solid food again.”

“ Steven McGee, a 55-year-old truck driver disabled by multiple sclerosis, said he phoned the company for seven months without reaching a medical coordinator.”

“Mary Hunt, a 72-year-old widow, said she has waited months for dental care. “They ought to call them ‘Nevercare,’ “ said Hunt, among the hundreds of people who have complained about denied or delayed medical care.”

Physicians have experienced the same difficulties with reimbursement that patients have experienced with receiving care.

“North Dallas doctor William Walton says caregivers must be vigilant in working with UnitedHealth, parent company of Evercare of Texas.”They’re dishonest, and they’re sneaky,’ Walton said.”

The state’s recourse is to fine Evercare. However the fines are insignificant compared to the money made by Evercare while exercising this behavior.

“UnitedHealth caught the front end of the Texas outsourcing wave launched by Gov. Bush. Since 2003, the state has paid the company’s Evercare and United Healthcare units more than $1.2 billion to provide managed care to more than 255,000 Texans under four programs.”

Fines are not high enough to be a deterrent to the abuse of patients, physicians and other vendors.

“The state has fined Evercare, more than $1 million in the last year, ordering it to increase staff and fix other problems. The most recent fines, totaling nearly $400,000, were in reaction to the mounting complaints about the North Texas program.”

The healthcare insurance industry does this all over the country. No one seems to connect the dots. The only recourse governments have exercised is to fine these companies. The fine is usually minimal compared to the healthcare insurance company’s financial gain.

President-elect Obama and HHS secretary Tom Daschle plan to provide universal healthcare coverage. Federal universal healthcare coverage in the present healthcare system will result in an expansion of outsourced administrative services. The state of Massachusetts has expanded outsourcing of administrative services. It has experienced massive cost overruns with little evidence of improvement in the delivery of care.

I fear that if and when the present Obama/Daschle plan provides universal healthcare to our entire population, Americans will suffer the same abuse with massive cost overrun and without appropriate recourse.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

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