A good friend mentioned the other day that an operation to repair the rotator cuff in his shoulder cost about $25,000, which was paid mostly by Blue Cross.
Then Blue Cross sent him another check for $9,000. He called to ask if there was some mistake, and was told, "No, you're covered by two policies, so you actually make money on this operation."
This particular friend is unique among my friends in that he is so substantial that he doesn't need the money. He certainly isn't going to get his other shoulder operated on to make a $9,000 profit, even if, as I put it, "pain is just weakness leaving the body."
In theory, the insurance industry has always had something called "coordination of benefits" so that it is impossible to profit from the payments from double coverage -- which can happen when a husband and wife, for instance, are both covered under each others' policies through their jobs.
Compare this with my own recent annoying experience with Blue Cross. I had a regular EKG that looked suspicious, so my doctor recommended a stress EKG. That was great. I got to the level where I was effectively sprinting up a steep hill for three minutes. I did well as policemen to get that far, but this EKG indicated that I had no problem with only 60 percent certainty.
To know with 95 percent certainty that I had no problem, the doctor recommended that I come back for a sonogram EKG that actually shows your heart valves pumping away on a computer screen -- much like seeing your actual heart valve on TV. Based on this more sophisticated test, my heart was deemed to be just fine.
Where I almost had a heart attack was when Blue Cross informed me that they wouldn't be paying for that second EKG. Huh? I read the "contract" that had been presented to us as the summary of our coverage, and it looked like everything should have been covered beyond the deductible as long as I was "in the network."
I had been careful to be in the network. Everything that was being tested was part of the process of determining whether or not I had a heart problem that might need a stent. When I complained, Blue Cross effectively said, "Read your contract," and referred me to something called the Blue Cross Small Group Certificate.
This 84-page document was not part of any material presented to us originally when my company bought the plan, and even our broker had to go to Blue Cross to get a copy when we requested it.
Having read every word of it at this point, I don't see any indication as to why Blue Cross wouldn't have paid for whatever EKG was deemed necessary when my own physician, a member of the network, specifically sent me off within the network to get checked out. He thought there was some possibility that I was about to collapse, like Jim Fixx, the late marathon runner.
Meanwhile, one of our employees managed to get a formerly declined health claim paid by just calling Blue Cross and badgering it. Our anecdotal evidence indicates that the way to get the health insurance industry to pay the claims it promised is to just threaten it. Fly into a rage over the phone and tell them you'll see them in court.
It's analogous to the credit card industry that refuses to lower your interest rate until you actually send a letter canceling your card. Then, and only then, you start receiving calls from another division of the company offering you an interest-free year of credit card usage -- from the same card company.
It's a disgusting business practice.
Health insurance is too important for these cheap bait-and-switch tactics. Further distressing is that this is all happening against the backdrop of presidents such as Leonard Schaffer walking off with annual bonuses (in the case of Blue Cross) of as much as $300 million in a single year, while United Health's leader paid himself $1.6 billion (that's not a misprint) last year.
I'm not a fan of big government, but private industry has had its crack at delivering a cost-effective solution, and has turned it into a feeding trough for itself. The collateral damage has been extensive. It is destroying our automobile industry, for instance, when we compete with companies in countries that provide national health care.
The most recent argument against allowing us to negotiate with the drug industry for cheaper drug costs is that "it is a disguised approach to a government health care system."
Considering the alternative, which we do battle with today, a government health system might be far superior to the corporate welfare approach that is failing us.