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I have often made the point that a major flaw in the health care  status quo – I balk at using the word “system” – is that no single entity accepts full responsibility.  With very few exceptions, everyone is trying to find someone else to pay the bill or the rest of the bill.

And too often the consumer is the rope in this tug of war.

I received a call from a member.  He wanted to drop his employment based insurance.  Why?  His wife had insurance.  Not an uncommon request in today’s market.  But some questioning revealed that it was a bit more complicated than that.

It seems the member had been admitted for emergency cardiac by-pass surgery.  After the surgery, he was referred to a rehab facility for cardiac rehabilitation.  But the rehab facility refused to admit him until they got clarification on which insurance was primary.

I have determined which insurance is primary.  I think I also understand a possible reason for the confusion.

I can not determine why a provider would deny care – or even suggest that care might be denied – when it was clear that one of the insurance companies would cover the services.

But that’s the way it is when everyone is looking for a way out.

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Approximately six months ago our office began receiving stacks of paper claims for prescription drugs.  The drugs originated in various Veterans’ Administration medical centers around the country.  They were for drugs that members in our Plan had received at VA medical centers. 

It was obvious that there had been some sort of new policy at the VA that required the VA to obtain payment from other payers when veterans had other coverage.  The problem in this case is that our Plan had just changed pharmacy benefit managers effective January 1, 2008. 

So think about this.  Until recently, a veteran who also happened to have other coverage went to a VA medical center and received care.  The VA paid for the service and somebody figured out how much it added to national health expenditures.  Our health plan did not pay for the services and therefore nothing was added to national health expenditures, other than the cost of keeping that Participant enrolled in our Plans.

Then someone in Congress got the idea that the VA could save money by finding someone else to pay for services.  Ignore the macro perspective that it increases the total cost to the system.   Now a layer of bureaucracy is added to find who is liable for payment and send the bill to that payer.  Remember the card game Old Maid?  Who is going to be left holding the poison card?  That’s what our health care financing system has come down to. 

But wait!  What happens when the payer information is no longer correct.  In the private sector, plan sponsors are constantly changing carriers and pharmacy benefit managers.  So now add an additional layer of administrative expense. 

In addition, these are paper claims.  Our vendors charge more to adjudicate paper claims.  The VA has an excellent reputation for its effective and efficient delivery system. (J. Kupersmith, et al.,Health Affairs, March/April 2007; 26(2)) It has not had a need for an efficient claims billing system.  Upgrading that system will add additional costs not only to the VA budget, but also to total national health expenditures.  And people think that Americans pay more for health care because we have better health care?

In our case it seemed that a central computer had the other party liability (that’s the technical term) information.  If they had the correct information, our office could be removed from this process, thus offering a small marginal efficiency to this additional administrative rabbit hole.  The local VA facility was not helpful.  I contacted my congressman and after several months and a lot of phone tag, I located someone who not only understood my problem, but also understood how it was also their problem.

But the more serious problem is that no one is looking at the big picture.  Making someone else pay the bill, may save the VA some money.  It does not save the American economy any money.