Written by Andrew Malekoff Friday, 25 June 2010 00:00
We are all familiar with stories about the ineptitude of government officials and regulators in protecting the public. At the SEC, they fell asleep at the wheel as Bernie Madoff made off with billions. In its eagerness to put more low-income families into their own homes, HUD failed to rein in Freddie Mac and Fanny Mae from saddling borrowers with mortgages they could not afford. So, it comes as no surprise to me that I cannot get a straight answer about who regulates the commercial insurance industry in New York State.
New York State is on the verge of implementing a plan for restructuring the financing of community-based mental health clinics. The plan discriminates against the underinsured middle class and working poor and is scheduled to commence on October 1. It represents a dramatic shift away from universal mental health care and towards care for families with Medicaid insurance only.
Those who have Medicaid are able to easily access community-based mental health services. Otherwise, you will soon be out of luck. When a family cannot get essential community-based mental health services, that is what is known, in insurance industry parlance, as an inadequate network of care. Network adequacy has to be monitored and enforced.
In an attempt to get some straight answers, I contacted nuclear power plant safety inspector Homer Simpson, who was recently quoted as saying, “America’s health care system is second only to Japan, Canada, Sweden, Great Britain; well, all of Europe. But you can thank your lucky stars we don’t live in Paraguay!”
Andrew Malekoff: It is great to see you Mr. Simpson. You are looking dapper as ever.
Homer Simpson: D’OH!
AM: I know, I know, enough small talk. So, let’s get down to business. As someone with quality assurance experience, do you have any insights into who is overseeing the commercial insurance industry in New York State?
AM: Are you expressing astonishment at my question, or are your referring to the D.O.H. - the New York State Department of Health?
AM: A state official told me that this was the State Insurance Department’s (SID) jurisdiction.
AM: Okay, okay, take it easy. I contacted a senior examiner at SID and she told me that they (SID) had regulatory authority over all licensed insurance companies and that they did enforce the insurance laws and all policy provisions but, she was quick to add, “We do not get involved in the network adequacy issue.” She said that that was the Department of Health’s job. I take it that you concur?
AM: As I am sure you know, the commercial insurance industry uses managed-care companies to hold down costs. They decide, usually from hundreds of miles away, who gets what kind of mental health care, for how long and at what rate of reimbursement. In other words, they don’t really manage care, they manage cost and sometimes they even mangle care - at a nice profit.
AM: According to Patrick Gauthier from Advocates for Human Potential Healthcare Solutions, “Despite the deepest and most enduring recession in 70 years…the five largest health-insurance companies in the nation disclosed combined profits of $12.2 billion last year — a 56 percent increase over the previous recessionary year. They managed this feat even though they experienced a combined loss of nearly two-million members to unemployment.”
AM: My sentiments exactly! I am not sure that families know what to do if they cannot find a provider in the advertised network of care available to them via their health plan. May I ask you one final question, Mr. Simpson?
AM: It will be quick. I promise. I raised the issue of network adequacy with the network manager for a well-known insurance company. She said to me, “We have a large volume of therapists within a five-mile radius of your agency that see young children which supports that our network needs are being met. What brings clients to your agency rather than an individual clinician’s office?” How do you think I should answer her?
HS: First of all, Marge and I want to thank the Guidance Center for helping our family. Here is what I recommend you say in response to the network manager’s question: “The kind of comprehensive service that a community-based provider offers cannot be duplicated by any private practitioner in your network. For example, at North Shore Child and Family Guidance Center, the wrap-around services, for which they are not reimbursed by you or any commercial insurer, are by no means unnecessary frills or perks. They are essential services for working with a growing population of families in emergent crisis and in need of a community-based agency approach that is designed for this population, versus an individual private practitioner with limited availability, time and resources.” That should set her straight. Now I have to leave before happy-hour is over at Moe’s.
To learn more about your rights as a health care consumer go to the following website: http://www.ins.state.ny.us/hrights.htm.