Can I Draw a Single Card?

In all the rancor over the Affordable Care Act (Obamacare), I think we have forgotten what the problems with our health care system actually are. While we have been embroiled in discussions of important issues (the HHS contraception mandate) and hysteria over chimeras (“death panels”), we have forgotten the main problem. And that is that our system is frustrating for everyone, cruel to some, and pointlessly wasteful.

That was borne in upon me recently as I tried to order three-month refills of my various prescriptions. I now go the pharmacy every month for each my refills, and, since they cannot arrange for them all to be refilled on the same date, I get a series of robo-calls reminding me to pick up pills throughout the month and stop off at the drugstore at least once a week. So I very much want to get everything filled through the mail and delivered in three-month batches.

My health insurance will not allow me just to ask my pharmacist to set this up for me. Nor will it do it itself. I must first take my number from them and get in touch with the company they have contracted with to handle prescriptions. That company gives me a new number, and refers me to a third company, which they have hired to handle the mail-order prescriptions while they focus on paying the brick-and-mortar drugstores. The third company has me set up a new account with them, which is then linked to my account with the pharmacy manager, which is linked with the account at the health insurance company—which is linked to my checking account, but that’s another story. So, to get my pills I have to have three accounts, three account numbers, as well as various User ID’s, passcodes, and group numbers. I have spelled my name and reported my birthdate so often that I feel like a POW who gives only name, rank, and serial number. (Rank is the one bit of information that need not be offered up repeatedly, since we are all buck privates in the Army of Wellness.) I now hate the sound of my birthdate, both because it has become part of a Kafkaesque drone and because on its next anniversary my provider will change and I will have to do this all over again.

Why do I need so many identities? Whoever is administering the benefits, wouldn’t one number for me be sufficient? With that and a bank account or credit card number, they should have everything they need to keep track of my records and make sure they get paid.

Instead, I have many numbers and passwords and codes to keep track of. And many of them come with cards. At one point, when I had more complete coverage, I had five different cards for my health benefits, all with different logos, account numbers, and customer service numbers. I had the medical insurance card, which I was to use for hospitals, doctor visits, and some forms of mental health care. It was a nice stiff plastic, the sort you can use to open any door that does not have a deadbolt, and a slick logo. Almost matching it was the prescription card, which was just as impressive, and could be used at drugstores. Then there were two cards for care that didn’t involve M.D.’s; to mark the lower status of the D.M.D.s and the D.O.’s, those cards were uncoated paper. The dental card was at least on card stock and came with crisp, nicely rounded corners, but the vision care card had to be torn out of a badly perforated piece of paper and so had slightly ragged edges. Humblest of all was the “Employee Assistance Program” card, which had a cheery, childish logo and looked nothing like the prescription card, perhaps because you were to present it when you checked into drug rehab, needed to talk to a therapist, or enrolled in an anger-management course.

None of the cards provided any information on my health conditions—you had to go to my driver’s license if you wanted to harvest my organs and a card with no official standing if you wondered if I was allergic to Penicillin or Sulfa or wanted to know my blood type. In fact all any of the cards said was, “This person is covered by the State of Illinois, which will pay for your services, though you’ll have to wait for your money.” A sticker on my driver’s license saying “IL Med” would have served the same purpose, left room in my wallet, and saved the money wasted creating and mailing the cards and keeping track of the various different numbers that meant the same thing. Why didn’t the state, which needed the money, insist on at least a single card instead of cooperating in all this waste and trouble?

The only answer that comes to mind is that five cards meant five corporations doing business with the state, each offering its own set of campaign contributions from both management and union. (I will not even suggest any money was passed under the table: why bother when so much slides right across the top?) The redundancy and complication is bad for the patient, who is confused by the complexity and wastes his precious time figuring it out, and for the provider, who must either add an M.B.A. to his medical degree to keep track of things or hire staff who never help patients to untangle the mess of payments. But it is gravy for the insurance companies and the politicians upon whom they shower their largesse.

When the Clintons made their attempt to improve American health care, one of their targets was this burdensome system. To solve what I think of as the “Five-Card” or “Full Poker Hand” problem, they proposed a single card and they matched it with a single form to take the place of the endless variety of forms the providers had to master use if they wanted to be paid. Perhaps the forms providers deal with have been simplified somewhat, but this drive for simplicity certainly did not animate the Affordable Care Act. It is more than a thousand pages long, and many people are unsure what is really in it. That is because the insurance companies were allowed to write the various systems from which they profit into the law. While I am glad we have made some progress toward universal coverage, I do not see how we are reducing costs in the areas where they can be cut without hurting patients or actual providers. The physicians I talk to don’t see the burden of complex forms used to delay payment being lifted from them.

To return to prescriptions, years ago I had an experience that showed most clearly what the complexity of our system is really intended to do. At that time, those in my medical plan had to fill out a form for every prescription, pay for the prescription, have the pharmacist sign the form, mail it in, and wait for either payment or requests for more information. The form was lengthy, with plenty of room for errors. I was sure, though, that I had completed one satisfactorily, with every date, price, drug name, and prescription number in place and all the appropriate receipts included with it, and was surprised when it came back unpaid. I had failed to give the address and phone number of the patient. I had filled out all that information correctly for the “insured, ” and carefully checked “self” as the relationship to “insured” under “Patient #1” before listing my prescription details. But I had not filled in Patient #1’s address and phone, which were, after all, right there on the page and obviously mine since my checking “Self” meant: “Guys, that’s me. I live with myself. I use the same phone. I take the same pills. It’s all the same.” In the eyes of the insurance company, however, my claim was incomplete until I wrote in all that information again two and a half inches below. They were clearly not confused, and if the info had to be on those lines, too, for some reason, they could have copied it into them. Their end was clearly just to delay payment, even if it meant wasting my time and stamps as well as theirs. The interest on a state’s worth of prescriptions comes to real money in the time it takes to process, reject, reprocess, and approve a form.

Illinois stopped doing such obvious things many years ago. Now it just withholds payment until long after the dentists start getting testy with the patients it covers. Our entire health care system, however, seems to be devoted to perpetuating this sort of skimming by people who don’t provide any real service.

The hours with the cards, the web sites, the customer services representatives and the three companies who are involved in getting me pills through the mail make me wonder again, what value do the insurance companies add to our health care system? For the most part we are not talking about spreading risk, which is what insurance does. We are talking about providing the care that everyone needs and that has to be paid for. Does keeping the insurance companies involved in the system further the efficient accomplishment of that end? I don’t think it does.

We have not yet had a chance to see how things will work under the Affordable Care Act. But I don’t see any reason to think there will be less of the waste, frustration, and, most importantly, skimming of resources by those who do not provide care that I have been describing. I would want not a state-run system of healthcare, like Britain’s NHS. I do think I would like a single source of coverage that would foster rational competition among service providers without skimming a lot for itself. And I definitely want to carry a single card, access a single website, and go by a single number—or even just by my name and birthdate.