Do you have health insurance? Or are you looking to get one? Having insurance like this is a great asset in case of an emergency or a major surgery. However, there is one aspect of how these insurance companies operate that we don't talk about much, but that we all need to know. Did you know that sometimes, your own insurance company's policies can prevent you from getting the treatment you need?
What can we learn from what happened in America?
To understand this story, let's take an example from a true incident that happened in America in the distant past. There is a very large health insurance company called Aetna. In 1998, the government of the state of Texas filed a lawsuit against this company. The accusation is that this insurance company is financially pressuring doctors and inciting them to cut back on the treatment needed by patients .
Think about how serious this accusation is. Isn't it very dangerous that the doctor you trust is being influenced from somewhere else to think about cutting costs rather than giving you the best treatment?
In the end, the company voluntarily agreed to settle the case without admitting any wrongdoing, changing many of its policies. But the issue didn't end there. Several other states, including New York and Connecticut, continued to investigate the company's actions. This incident illustrates the potential conflict between health insurance companies' profits and patients' health.
What is the reason for this conflict? Let's talk about 'Managed Care'
The main reason for this problem is the ``Managed Care`` approach that insurance companies use. In simple terms, the insurance company "manages" your healthcare. That means they decide which doctors and hospitals you can go to, what tests you can have, and even the treatments you receive. One of the most popular types of this is the ``Health Maintenance Organization (HMO)``.
This system may look good from the outside. They say things like it will control costs and reduce unnecessary tests. But the problem starts with the way doctors are paid.
The most important thing is that a doctor should have the freedom to decide the best treatment for you, based on his or her medical opinion, without any financial influence.
The dangerous method called 'Capitation'
We usually think that a doctor gets paid after he treats a patient and submits the relevant bill, right? But that's not the case under systems like ``(HMO)``. Most of the time, they use a system called Capitation .
Simply put, in this, the insurance company pays a small amount of money per month (per head) for each patient registered with a doctor. The doctor receives this amount regardless of whether the patient visits the doctor that month or not, or whether he or she is sick or not.
Now look where the problem lies:
- Imagine a doctor has 100 patients. The insurance company pays the doctor 1000 rupees per patient, or 100,000 rupees per month.
- Now, when one of these 100 patients comes in sick, the doctor has to cover all the expenses for the tests and medications that person needs from the one hundred thousand he received earlier.
- What happens if a patient has to undergo a costly test like an MRI scan? The doctor loses out.
- Then, there is a great temptation and pressure on the doctor to reduce costs as much as possible, not to do tests, and to give cheap medicine, right?
This is what even the US Attorney Generals questioned. They said that because of this system, the patient's health risk is placed on the shoulders of the doctor.
| payment method | The impact on the doctor | Possible risk to the patient |
|---|---|---|
| Traditional method (Fee-for-Service) (Payment for services rendered) | There is an incentive to provide whatever treatment the patient needs. There is no direct financial impact. | There is little chance of unnecessary tests and treatments occurring. |
| Capitation method (Prepayment of a fixed amount per patient) | There is strong pressure and incentive to avoid costly tests and treatments. Profits depend on providing fewer services. | There is a high risk of not receiving even essential treatment, delayed diagnosis, and worsening of health conditions. |
What should we do?
The health insurance system in Sri Lanka may not be as complex as the US, but it is very important to be aware of this when choosing insurance and receiving services from it.
1. Read your insurance policy carefully: Before you buy insurance, make sure you understand the terms and conditions. Make sure you understand what is covered, what is not covered, and how to get approval for certain treatments.
2. Don't be afraid to ask questions: If your doctor recommends a treatment or test and the insurance company denies it, ask for the exact reason. Talk to your doctor about this as well.
3. Stand up for your rights: If your doctor says a certain treatment is medically necessary for you, but your insurance company says it can't be covered, find out if there are ways to appeal it.
Ultimately, the relationship between doctor and patient is a sacred one. It must be based on complete trust. It is essential for a healthy society that we all be aware of the potential for that trust to be undermined by external financial influences.
Take-Home Message
- Health insurance companies are for-profit businesses, so sometimes there can be a conflict between their profits and the health of the patient.
- Before you purchase health insurance, read and understand its terms, coverage, and limitations carefully.
- Remember that payment methods such as ``Capitation'' may put pressure on doctors to avoid providing you with the treatment you need.
- If your insurance company denies a treatment your doctor recommends, ask why. Talk openly with your doctor and discuss the best solution.
- The final decision should be based on your doctor's medical opinion, not an insurance company's financial policy. Stand up for your health.
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