I work in health care. I will try to brief, but I need to outline and unpack some things so, please understand. I have worked for 95% of my career running health care providers, going on 35 years. I have worked in senior/executive management and understand all too well everything being said here. I have mainly worked in post-Acute care (those service after a Hopsital stay or services): psych, chemical dependency, home health, hospice, home infusion, durable medical equipment, etc. I have worked within systems and have run independent organizations. Most of my work is in non-profit, that is not to say they do not make profits, as they do. Health systems are ruthless. I could do on and on, but just want to express that many that work in the field feel it’s broken too.
I was proud that the organizations I ran did many things within the community. Through philanthropy, we built hospice residences to house indigent hospice patients, we built low income senior housing, we purchased an office building and property in an economically depressed area of the city to facilitate revitalization. I say this only to lend perspective that organizations can do many things. We treated people in our area for 125 years and still going strong. We were the original health system, as home medical care was all there was in 1890. It was mainly helping with child birth and maternal care, along with an increase in activity around the 1918 flu and our work to immunize every one. We were a Community Chest (yes that was not just Monopoly, it really existed) organization that was the fabric of our community. I am very proud of the work we did and continue to do. I no longer run that organization, but now do consulting in health care.
Insurance gets a bad rap because they work at it. They are paid to take money from one and give it another. Really add no value. They make money by denial of claims and for delayed payment of claims. Like a blank, it is amazing how much money you can make by simply holding money in interest barring accounts for 15 days longer than you should. The reimbursement, especially with Medicare, is not done to promote health, but treatment. More treatments more dollars. Not really how this should work. Population health is all the buzz, but if a health system does things to keep people healthy, they will stay out of their system, they lower their revenue. Not how it should be. Our root causes of our health problems go all the way to the food system and mass production of food that is cheap to make, addicts us to the wrong things like, salt, sugar and fat. I will not derail this here, just making a point.
I also want to point out that even though Medicare is better than most, there is a concerted effort from CMS to move everything to Medicare Advantage (MA) which is managed care for Medicare beneficiaries. My point is the insurance companies will be a major part of Medicare as we move forward. Today 46% of all beneficiaries are in an MA plan. The goal is by 2040 for 70% of all payment to be through an MA plan, this will mean about 85% of all beneficiaries. Remember that the 15% not in MA are the high cost patients and would make up most of that 30%, as actually probable 5% of beneficiaries would be that much of the spend.
I have given you much to digest. I have inside knowledge to the system. If anyone of you need any help with understanding how the system works and what programs can be accessed, please reach out, as I helped many over the years.
OP, I understand what you are going through. The first thing that happened in the 80’s was the removal of all psychiatric benefits to reduce costs for the employers. Until then, it was standard to have substantial mental health benefits along with the ability to get addiction treatment in your employee benefits. This is when I worked in these areas. We have left mental health to the states and they have failed miserably. We seem to care more about an extra $5 in our paycheck than in helping or paying for people that need this care. This is also directly related to the political situation we have today, as we have a nation that pays attention to only price and ignores any other attribute like quality or local economics. We have suffered for that.
My rant is over, but please let me know if you have specific questions and I will do my best to help you and answer the question. I have extensive knowledge of the payer and provider markets in health care. I will confess much of what has been said is really on point. As an example, I have paid for health insurance my entire working life. I have had two surgeries which have cost multiple $100,000 in paid fees. This is much more than I have ever put into the system over those 35 years, which is another reason why this is such a difficult subject.