Not too much of a surprise, given how Kaiser is arranged. It is quite obvious to participants which providers are in or out of network, and paying physicians by salary instead of fee for service reduces incentives for physicians to add questionable services.
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This is the number one reason that Kaiser and Mayo both outperform. Itâs a closed system that incentives outcomes not production.
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When I had cancer I was on Kaiser insurance. My husband had a coworker whose wife was also being treated for breast cancer at the same time but they were on something else, maybe HealthNet. Anyway, I just showed up, paid my small copay, and got whatever the doctor ordered. She had so many denials and billing issues to deal with on top of cancer treatment. I know that what the doctor ordered may have been limited by Kaiser. But it certainly was much less hassle for me and I got the âstandard of careâ for my illness. This was 15 years ago though. I remember thinking that if single-payer universal health care could be like Kaiser, Iâd take it in an instant. Not that people donât have issues with Kaiser, they do. But knowing that when I left the doctor I would be able to get what was ordered was a good thing.
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But I think you are missing the point which is that the person posting was trying to gather information to make an informed decision and the people who are supposed to have that information didnât. It is a reasonable request to ask that a health insurance companyâs customer service know the business well enough to answer customer questions. Donât you agree?
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My worry is that if the age to collect social security benefits rises, at some point so will the age to qualify for Medicaid.
I think you mean Medicare?
When Medicare began the average life expectancy was quite a bit lower than it is today, longer average life expectancy is obviously contributing to the issue that Medicare outflows >>>> inflows. Lots of similarities with Social Security.
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Op-Ed from the CEO of United HealthGroup
âWe know the health system does not work as well as it should, and we understand peopleâs frustrations with it. No one would design a system like the one we have. And no one did. Itâs a patchwork built over decades. Our mission is to help make it work better.â
Gift link
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Read the comments. Hereâs one:
âMr. Wittyâ
Please start by listening to the physicians who provide care in your system. They are beyond frustrated that they cannot prescribe the care their patients need because your company will deny it.
You say that youâre âstruggling to make senseâ of Mr. Thompsonâs murder. Yes, the killing was wrong. But why is it so hard to understand that many of your customers are miserable?
Iâve been reduced to tears multiple times on calls to customer service. Why canât you change the structure of impersonal phone trees that donât provide an option for questions or that connect with a human being who can only read from a bloodless script or that run in maddening circles and dump the caller with an insolent hang up by a computerized voice intoning âGood-bye!â?
I canât count the times that I felt sheer rage after interacting with impersonal healthcare systems.
Someone must tell an IT designer, âMake it very hard to reach a real person. We donât want to spend money on live reps.â
Someone must say, âMake the system hang up on the caller if he or she asks for ârepresentativeâ or dials zero.â
Someone must say, âHave all patients discharged from rehabilitation facilities within 2 weeks even if they are still as physically compromised as they were on the day that they arrived and even if their doctor pleads for more time.â
Please take a long look in the mirror and ask yourself why you deserve 23.5 million dollars a year to oversee a system that is so broken?â
BTW, my father died because of policies described in the penultimate paragraph of the commenter.
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Absolutely and said so further down the thread 
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Iâm so sorry about your dad. My dad is always discharged after two weeks in rehab, too. Maybe thatâs why he keeps ending up in the ER repeatedly? Thatâs really cost effective!
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Iâm counting my blessings that two of my medicines that I take monthly are $3500 and $900 apiece. My copay is $0 and $25/month after insurer and any coupons! My insurer has not made a fuss at all! My lung docâs office had to get pre-approval for the $3500 Rx but it was approved promptly.
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They should start by making sure that the first person you speak with a) speaks English as their first language (or is more than just âfluentâ) and b) has the authority to correct obvious issues.
An example from an experience I had about 6 or 7 years agoâŠ
We had switched insurance to be through my employer, rather than my husbandâs employer - that year, it was basically the same plan, same insurance company, but cheaper through my employer. Someone in my family needed the new insurance card, but it hadnât arrived in the mail (everyone else in the office had received their card at home). So, no problem you think, because you can login online and print a card.
So I went to create a login, which required birthdate, last four of SS# and home zip code. It would not let me create a login, would not let me continue, so I called the help line.
The first two reps I spoke with had heavy accents and were tough to understand. From what I could understand, they were just telling me to enter those three pieces of information (which I had done, repeatedly, and I knew they were correct). The third person also had an accent, but had a better command of the language - I think that people can be fluent in a language, but not familiar enough that they understand unusual situations or words people do not use frequently (in the prior example, someone might be considered fluent in a language, but not be familiar with the words toric and astigmatism).
The third person was able to identify my issue - it was my zip code. I entered it correctly, though this was the reason I could not log in, and the reason my card had not arrived in the mail. The rep told me that he would get that changed, and that now I could log in. I asked âSo now I just use my correct zip code?â and the answer was âNo.â He said it would take 5 to 7 days to be updated, so use the wrong zip code to log in.
I then went to our benefits person, to review the paperwork from the sign up for healthcare benefits. It was a paper sign up - no option to sign up online - and I had written everything very clearly (my handwriting is not good, but I knew to write clearly in a form like this).
So the insurer must employ people to do data entry, which is something that, at that point in time, most people could have done online (I think this would save money). Then, when they entered a mismatch between city and zip code, why did their software allow them to continue? Anything I have filled out online at least alerts you of the mismatch, and many times, will not let you continue.
None of this was a denial, this was just a very simple problem which must have cost the insurer much more than it should have. So make sure that the help line folks a) speak English as a first language or equivalent ability (or whatever language the caller has as a first language) and b) have the ability to change obvious problems - that it doesnât take a week or need to be authorized by folks several rungs up the ladder.
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Medically, The best thing that happened to me was when I could enroll in Medicare. When I lived in Boston, I was a staff member of a big hospital for a dozen years ,where I had surgery and treatment for cancer. Everything was covered without a question. Then I moved to a different state and had to find my own insurance. I was paying a lot, but it covered so little ; mammogram colonoscopy- everything was self paid. Having a pre-existing condition and not Being able to be insured through a job, Made everything so difficult
As a sidenote, EpiPen are covered now.
As a warning to those with Medicare advantage plans, it has been my experience as a provider that they do not pay for mental health sessions. Well, I did get $14 but Iâve spent months and months with people where I got zero reimbursement.
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I just had a similar issue signing up with our new insurance. Every person I talked to was a native English speaker, it wasnât outsourced, unless one would call Texas a different country. Which it isnât.
Took me 7 different representatives, hours of my and their time to do something that should have been taken care of on the first.
Iâm not going to blame people who donât speak English as their first language. But that customer service is hard. I donât even think it was the representatives, I think when itâs not common, itâs hard to fix.
Ugh! Mental health is so important and so dismissive in the American healthcare system!
I have no idea how it is in other industrialized countries but know that it 
here
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I know from working in financial aid that the key to good customer service is for the CSR to ask questions. When people call with questions and/or issues, they often only tell part of the story or ask questions that donât really address their issues. CSRs must have critical thinking skills and be able to find out what the customer really needs. Unfortunately, this would involve paying more and allowing CSRs more time per call. If call centers were reworked to have multiple steps that allowed moving a customer to the next level immediately, it might help.
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Iâm not blaming the customer service reps who donât speak English as a first language. I blame those who hired them. If I wanted to speak to a rep in another language, I would expect that was either their first language or that they have native fluency.
I suppose companies - insurers and other companies - find that a lot of people call customer service for a question that is answered by the FAQs. However, I - and I suspect most of the people on this thread - do not call with such questions. Only after I have tried to figure it out myself, and cannot find the answer/solution, do I call for help.
If the people at customer service can understand the situation and have the authority to fix the situation, you wouldnât need so many reps. However, perhaps the current model is one that companies find to be the most cost efficient (for them), as a lot of people just give up.
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I totally agree, and I think what you say is applicable well beyond healthcare (itâs just that our American healthcare system has refined it to an art) - the constant recorded suggestions that you look at the website or get lost instead of wanting to talk to a person. I almost got PTSD reading the comment above from someone who was told âgoodbyeâ when they pressed zero.
You are also absolutely right that the current model is designed to get people to give up. Heck, maybe the companies like UHC will get lucky and the patient will even die in the meantime, saving more money for executive compensation.
I needed a specific procedure (which I got, in 2010), but received the runaround including a doctor in another specialty giving his paid opinion in a letter solicited by the insurance company. It wasnât this exactly, but analogous to - patient needs cardiac microsurgery, and pediatrician in a small town suggests he could do it cheaper with a paper cutter.
(No offense to 99.9% of pediatricians in small towns who would not participate in such foolishness as being paid shills to deny care from insurance companies.)
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I have stuck with local BCBS because you talk to someone in our state and if youâre very upset can go to their office and speak to someone in person. They even validate parking. I know I might be able to get a slightly better deal if we were to switch to a mainland national BCBS but have been pretty satisfied for most of my life with the local company and am sticking with them. Knock wood they are so far using local customer service agents that speak English as native speakers and try to help.
I admit Iâm not a fan of the menu of options but at least you can get an agent.
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Iâm not sure how BCBS operates exactly but they seem to be more autonomous by state than other companies. I wonder if they donât have to operate under the same financial goals.
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