Pissed at the current health care system? Yeah, me too

I remember growing up on masshealth and being so grateful for that assistance. In undergraduate school, I broke my leg pretty severely. I was able to have 4 surgeries, physical therapy, and prescriptions covered at no cost to me. If I hadn't had state insurance, I wouldn't have been able to go to graduate school. Pretty great right? To not have a complete accidental injury impact your entire future path. Fortunately, I grew up in a the progressive state of Massachusetts, first state to enact a public health care insurance outside of Medicare - unfortunately, this is not the health support most people receive. And even less so now.

I'm going to start with a few scenarios and do a deeper dive in the current state of affairs. I admit that this is my perspective, but in having worked directly with insurance companies in my role as a clinical director and prior to that for the past 8 years - I have had a lot of insight and since the system can't be transparent, well I guess I'll just light that torch and do it for them.

A 15 year old client of mine, mostly stable on his current medication regimen with some residual anxiety, was upped on his medication of Lexapro from 20mg to 30mg. In laymans terms, this monthly prescription was written for 1.5 tabs of the 20mg equalling 45 pills for the month. Oh no, cue insurance barriers. The insurance uses a standardized measure of what they will allow for a certain prescription, following FDA allowances in a pretty little cookie cutter way. You know what's not cookie cutter? Your life and your health treatment. But yes, just please check a box, explain your reason for upping the dose. Well the prescriber did, and the insurance company responded back with "we don't see a reason why this dose needs to be given," despite all of the evidence and explanations written on that form. This client was without his medication for a week while we figured this out. If you've ever been consistently on an antidepressant and then abruptly stopped, you know how negatively impacted your life can be. All things can go haywire. The prescriber then submitted two prescriptions - one for 30 pills of Lexapro 20mg and one for 30 pills of Lexapro 10mg. Same dose, different way of prescribing it. Voila! Success. No push back from insurance companies - they let it go through without even questioning it. Like what? And why? But again, standardized forms - standardized procedures. I still don't understand why this happened, but I'm happy for him that we were able to get it resolved.

Second scenario - a 10 year old client stable on ADHD medication when masshealth decided mayyyybe they didn't need this specific medication anymore. Instead, they wanted this client to try something else. Two months of a new regimen, so many negative consequences at school for dysregulated behavior. Issues at home because of this as well. But after two months of us "proving" the original medication was necessary, they decided okay. We'll cover it. Mind you, these people deciding this at the insurance companies have zero contact with the person they are making the decisions for. I'm not going to even get into the ADHD medication supply issue right now.

What do these scenarios show? Someone who has found something that worked for them and the system disrupting that care. You know who suffers? The person who is being helped. You know who benefits? Just the system really. The providers do not benefit - you as a consumer and patient do not benefit. But hey, at least reduction of health care costs are happening? Ha.

Within my 5 years as clinical director, I've seen insurance companies partner with or be absorbed by bigger and bigger health care systems, so many times that it's honestly dizzying. I can only speak to behavioral health since that's what I work in. Optum taking over most state insurances. MBHP and Beacon being bought by BCBS now Carelon. I can list name after name and you won't keep up, so I won't do that here. But what each change comes a disruption in billing process, disruption in what prescriptions they will cover, disruption in what care they allow.

What's most important is the thread. Most of these behavioral health care insurance companies are owned by United Behavior Health. All of them are getting absorbed by one specific company. Medicare and Medicaid as well. And this is the most important thing. I know a lot of people were angry about the Affordable Health Care act, but really what you should be more angry about is the fact that your government is mismanaging your health care by giving that responsibility to private companies.

Do you pay monthly premiums but still have to pay an insane amount of money for basic procedures? Don't be angry at the person who needs help with their insurance costs. Be angry at the system that is taking your money, making you pay more, and then giving the CEO a higher salary. United Health Group's, who owns United Behavior Health, CEO made $18.4 million in total compensation in 2021. But you have to scrape the cash the pay for a biopsy that might determine whether or not you have cancer - despite paying $400 a month.

Are you on state insurance? Well, bad news for you too. Recently, in Massachusetts and I'm sure other states but I can only speak to MA, the government started contracting with these giant corporate health insurance companies to manage their public health insurance programs. What does that mean for legit everyone? Well, you pay your taxes, the government takes those taxes, writes a check to these giant health care insurance companies, these companies put more effort into reducing costs, and hey, the CEO gets another vacation home. So, success?

Next topic relates to that, but I'm going to prompt it with: access to care. Provider availability, Mental health providers that accept your insurance. I've attended a string of listening sessions in Massachusetts focusing on addressing behavior health care reform. Each one focused on increasing access to care, talking about how there are so few providers, but very little of that conversation was addressing the third party payer system - the insurance companies. But instead, corporate mental health companies, which are unfortunately becoming more and more of a thing since independent community mental health centers cannot financially sustain themselves without a hospital system backing them up, placed the burden of low payments from insurance companies, "lost" claims, on the providers themselves. With increased productivity standards, a high need caseload of people really struggling with mental health issues, increase in documentation requirements, all at the measly annual salary of $52,000 a year, with a masters and being independently licensed by the state. What do providers do instead? They leave. They go into private practice and only accept self pay clients at $125 an hour. THIS is why you're having such a hard time finding care, appropriate care, consistent care. You know what the state did instead of holding the current system accountable? Required that all providers provide their information to the state. From what I read recently, they might also require that all mental health providers actually contract with state insurance. This seems a little less like the "free" country we say we're in and more so a "free" economy for giant corporations to do whatever they want at our expense, despite the fact that they only exist because of us.

So if you're tired of this situation, and I'm sure you are, you can file a complaint with the Division of Insurance. Each state has one. You can write letters to your governor, your senator. Make noise. Don't make this about anyone else besides the people making decisions for you, with your money.