Leap of Faith

Well, I finally did it. I left my job with the health insurance company. Yes, I took a pay cut but that is a small price to pay for peace of mind. I won’t miss the stress or worry- now I’m on the hospital side trying to get insurance companies to pay for needed and emergent care. I am well aware of what the bottom line is for the insurance companies and want to hold them accountable to their members.


If you are not affiliated with a hospital utilization review office and don’t work for a health insurance company, chances are you have never heard of Interqual. You lucky devil. It is one of the programs used to determine if someones health status and course of treatment warrant an inpatient admission. When it behooves an insurance company, they will deny an inpatient admission as the interqual criteria were not met. Then, talking out of the other side of their mouths, they insurance company many deny someone who met the interqual criteria because, after all, they are just “guidelines”. I am not a huge fan of interqual as it takes certain factors out of the equation, reducing hospital admissions to black and white. As a nurse who has been in healthcare 25+ years I know there are several shades of gray. However there is no one to hold these insurance companies accountable, allowing them to call the shots when it comes to our healthcare. And have you ever noticed that when something is denied and you try to talk with your insurance company the process is so lengthy and tedious you want to just give up? Yeah, insurance companies bank on that, literally.

How much do you know about your health insurance

I can’t help but feel the general public would be more up in arms over the current state of healthcare if they knew jobs like mine existed. Most people probably sign up for health insurance through their employer thinking that means if they need to go to a hospital they are covered. NOT TRUE!!! Health insurance plans hire staff to pour over medical records and give a synopsis of what is going on medically to the insurance MD, who, applying criteria ( we don’t all fit into a box), decides if your hospital visit is warranted. And they play by their own rules. If someone ” meets” said criteria, the physician of the MCO, at his discretion, can still decide not to approve a full admission. WHAT!!! We need to take the power of our health out of the hands of people who are not looking out for our best interest. I think a generalized agreement on basic health care ( which should be a right) needs to be obtained and all citizens should be covered. Those that so desire ( and can afford) private insurance should have that right.

single payer vs. two tier

I’ve been pondering a few hiccups in the single payer healthcare system- the first being MD salaries and that if they significantly decreased, would as many people go into that profession? Of course that could also be seen as a positive, as then only people passionate about the work would enter that profession. The second hiccup is in the area of medical research- would as much money be allocated for needed research if corporations were not involved.

This has caused me to investigate the healthcare system in Ireland-where there is a public health option funded by the government as well as a private health care service. 100% of residents have state coverage, while roughly 40% have chosen private insurance. Most GP’s are technically part of the private system, which is why they charge a fee. If individuals with a higher income want to buy more generous coverage- they should be allowed to- but not with government subsidized dollars. The United States needs to define a universally accepted minimum that all citizens should receive . If individuals choose to purchase above that minimum, the government should not subsidize these purchases.


Here are some little known facts-the government pays commercial health insurance companies nearly $200 billion a year to provide medicare benefits to the 20 million people enrolled in medicare advantage plans. These advantage plans have an incentive to spend as little as possible on their members as what they don’t spend they get to keep. Could this be related to the increasing number of denials from medicare advantage plans?? Surely I am not suggesting a large for profit corporation would have anything but the member’s best interest at heart! Also, these plans often operate in a ” cloud of secrecy” making it difficult for CMS to accurately detect improper payments- but a rough estimate is 20 billion annually. It usually takes a whistleblower working at one of these companies to expose the fraud- meet said whistleblower.

There is no “advantage” to medicare advantage plans

I wish all elderly kept their red, white, and blue medicare card. Sure these advantage plans pull out the bells and whistles- the exercise groups, the no 3 day qualifying stay in a hospital before going to a nursing home. But sometimes these people don’t realize what they are giving up- now someone behind a desk decides if you get to go to that nursing home- it’s no longer a matter of your best interest. With an advantage plan owned by one of the big names in insurance- the bottom line takes precedence. And while traditional medicare pays the first 20 days at 100%, these advantage plans rarely approve more than 7 days at a time. And this is the most fragile of our population- they deserve to trust we are looking out for them. Corporations should not have a say in the care medical professionals feel people need.

two-tier healthcare

Why don’t we take our example from Australia or Ireland where they have a two-tier healthcare system. The government provides basic care and if people so choose and can afford, private health insurance is an option. This sounds a lot like our current medicaid system to me. I’ve paid into everyone’s healthcare lots over the years, and I wouldn’t mind reaping the benefits. Now is our turn to be ” everyone.”


When I say #medicareforall I in no way mean to imply that medicare as it stands now is a perfect system. Maybe I really mean #healthcareforall. Healthcare where you aren’t saddled with a bill of $147.00/ day for skilled nursing care as medicare only pays 80% of the bill after 20 days. Healthcare where seniors don’t have to get supplemental insurance for things medicare doesn’t cover. Healthcare where diagnostic tests don’t cost twice as much because hospitals know insurance will only pay a fraction of the cost. I am tired of hearing how we can’t afford healthcare for all. Let’s start talking about how we CAN afford it. Imagine if all managed care organization salaries nationwide were nonexistent. Imagine not having to worry if insurance was going to cover the surgery that could improve your standard of living. Imagine that the only people involved in your healthcare are the people doing that job because that is their passion.


People talk a lot about death with Dignity. How about life with dignity? Not being scared to go to the doctor because a medical problem may be found that you can’t afford?? Actually caring for one another. None of us are getting out of here alive. I know thinking about our own mortality is uncomfortable for some. But wouldn’t it be nice to have the financial burden eased so each of us could become the best versions of ourselves?