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Brian Lehrer: Brian Lehrer, on WNYC. We talked on yesterday's show about the corporatization of medicine, as experienced by doctors. We'll talk now about the corporatization of medicine as experienced by patients, even when they're insured, with Karen Pollitz from the health policy organization KFF. She will share the results of a new KFF survey in which Americans described where their health insurance falls short.

KFF is the group formerly known as the Kaiser Family Foundation. Karen Pollitz is senior fellow and co-director of The Program on Patient and Consumer Protections in Health Insurance at KFF. Karen, thanks for joining us. Welcome to WNYC.

Karen Pollitz: Thank you. Good morning.

Brian Lehrer: What was this survey that you did? What were you trying to learn, and who were your respondents?

Karen Pollitz: We were trying to learn how health insurance actually works for people when they go to use it. We had a nationally representative sample of over 3,000 people, covered by all of the major types of insurance, Medicare, Medicaid, employer-sponsored coverage, and Obamacare policies that people buy on the marketplace. We found that most people rate their coverage favorably overall, about 8 in 10 say it's excellent or good.

Even so, most of them also report, about 60%, that when they actually go to use their coverage, they encounter problems, like denied claims, or problems finding a doctor who's in network. Among people who are sicker or who use mental health services, 75% experienced problems.

Brian Lehrer: Would you say, for example, the people who need healthcare most are being served by their insurance plans the worst, based on what you just said?

Karen Pollitz: Well, I would say they are encountering more problems. I think most people, when they use their insurance, they get the care they need, and insurance performs the function that it is supposed to provide. It's supposed to connect us to the care we need, and protect us from unaffordable expenses, but it's a complicated product. People have a lot of difficulty understanding it, and it is far from idiot-proof. It just doesn't work sometimes, and people don't always know why it works.

People tell us, about half the time, when they encounter problems, they can't fix them. About a third of people just throw up their hands, and just take no for an answer when insurance doesn't work for them. People don't know their rights, and they don't know who to call for help when they have trouble.

Brian Lehrer: Listeners, we invite your calls for Karen Pollitz, from KFF. How much are you experiencing obstacles to care, or financial coverage, even with insurance? This conversation is in the context of having insurance and still finding obstacles to care, and obstacles to reimbursement or coverage. 212-433-WNYC, 212-433-9692, or you can text a thought or a question to that phone number, as well.

Karen, before we dig into more of the specifics, just to take a step back. It's remarkable and incredibly frustrating, because so much of the policy debate in this country, for decades, has been on getting people insured. The metric we would look at for years and years and years is what is the rate of people, in any particular community, who don't have health insurance. Well, that insured rate has gone up because of Obamacare, to a large degree, but even with that, you're talking about--

Even with insurance, a majority of people, that is the majority of insured people, are saying that they're finding obstacles to coverage, having care denied, having bills that are higher than they think they should be, and things like that. A bottom line here is the imperfection of the insurance system to actually insure people, right?

Karen Pollitz: Well, yes. I think the bottom line is that we have to take a close look at how coverage actually works when people use it. It's like we want everyone to have affordable cars, but we also have lemon laws. People just, I think, tend to assume, or certainly shouldn't assume, that if you have a card in your wallet, that's it. That's the end of the game. Policymakers, I think, shouldn't assume that our only goal is to make sure that everyone has a card in their wallet.

We really have to pay attention to how the coverage works, and hold our insurance companies, our health plans, and programs accountable for delivering the coverage that they promise on paper.

Brian Lehrer: We'll talk about solutions as we go, but let's hear a story, I think, from Caroline, in Princeton. You're on WNYC. Hello, Caroline.

Caroline: Hi. Thank you so much, Brian. I just have a question. Most insurances seem to reimburse what they call customary and reasonable. Especially when it's out of network, maybe you get 60% of customary and reasonable reimbursed, except that no providers actually charge you the customary and reasonable amount. It seems like this is especially true when it comes to psychology and psychiatry, where the reimbursement rate will be, say, 60% on maybe $110, but you can't find a psychologist who charges under $250 an hour.

Is there any way to challenge an insurance company to provide a higher reimbursement rate, based on what your providers will actually accept? Thank you.

Brian Lehrer: Thank you. That's a great question. Maybe, also, Karen, to fact-check them on what they claim is the reasonable and customary charge in your area for a particular thing.

Karen Pollitz: It's always a good idea. If you make a claim for any coverage, certainly mental healthcare in this instance, and insurance doesn't reimburse an amount that you think is appropriate or fair, it's always, always, always good to at least ask questions. I think that's step one. Call your insurer, ask them to reconsider, ask them to provide you with a rationale for why they're only paying what they pay.

It may also be worthwhile to go back to your provider, and ask, also, some questions, and say, "Hi. Insurance will only pay this much. Can we talk about your rates, and is there some way to adjust those for me?" These questions can get very complicated very quickly. We generally don't have a rule regulating what insurance has to pay, or what doctors can charge, certainly outside of public programs anyway, like Medicare and Medicaid.

We mostly don't have those rules. That can definitely be part of the problems, or a type of problem that people encounter. I can't give you a step-by-step solution to it, because you're going to have to try to work it out with, probably, both your insurer and your mental health provider.

Brian Lehrer: She mentioned-- Caroline, thank you for your call. She mentioned reimbursement for psychotherapy as one particular example. I see the result from your survey, that around 3/4 of people receiving mental health treatment experienced problems obtaining care, or getting that care adequately covered. Can you elaborate on that?

Karen Pollitz: Yes. Mental health problems, and problems for people who consider themselves to be in poor mental health status, kept coming up. We found that 17% of all adults with insurance said there was a time in the past year when they thought they needed mental healthcare, but they didn't get it. Among those who said they are in fair or poor mental health, it was more than 4 in 10, it was 43%, said they didn't get mental healthcare that they thought they needed.

Much of the time, that was related to their insurance. The insurance wouldn't pay enough, so that they could afford. They couldn't find a provider in network, or the insurance just wouldn't cover the care or the medication that they needed. These mental health access problems we found were particularly prevalent among young adults versus older adults, and among women compared to men.

Brian Lehrer: Didn't Congress pass a law, a few years ago, that was supposed to guarantee parity? That word was in the law, I think, parity and coverage, between mental health treatments, and those for other kinds of conditions.

Karen Pollitz: They did. That law has been on the books for decades now. It's evolved a couple of times. I think federal agencies are just now beginning to take a new look at how it is that they would monitor compliance with mental health parity requirements, and whether, or what kind of data they should be requiring health insurance to report on how they cover mental health services.

Brian Lehrer: As we continue with Karen Pollitz, senior fellow and co-director of The Program on Patient and Consumer Protections in Health Insurance at KFF, formerly known as the Kaiser Family Foundation, they have this new survey out, finding that a majority of Americans with health insurance encounter obstacles to care, or affordability of care. Let's take another call. Mychal, in Nyack, you're on WNYC. Hello, Mychal.

Mychal: Hi, can you hear me?

Brian Lehrer: I can hear you.

Mychal: Oh, hi. Hi, thank you for taking my call. I worked at a very large health insurance company in California for 10 years. Most things that most people don't realize, when your claim is denied, in general, there's an unspoken rule that if you appeal three times, at that point, the insurance company is more inclined to pay your claim than to continue denying it. It costs more time and energy for them to continue denying it.

When I have friends and colleagues, they've had a claim denied, I say, "Make sure that you-- [sound cut]" Oftentimes, that does result in them getting their claim paid. Most people don't know that, but that was an insider tip that I learned from my many years there. The second thing is that-- It's quite interesting, the differences amongst state insurance-- [sound cut] You-- [sound cut] -small business where-- [sound cut] -in California, I was able--

Brian Lehrer: Unfortunately, your line is cutting in and out. Let me ask you, because of that, to go back to the tip you gave a minute ago, because I think the reveal got lost. When you said it cost the insurance company more to continue to deny your claim than to accept it, when you do what?

Mychal: I usually advise people to file an appeal three times, because, at that point, it [sound cut] cost-effective to continuing denying the claim. That's the reveal. [crosstalk]

Brian Lehrer: Did you say file an appeal a number of times, is that what you said?

Mychal: Three times. Yes.

Brian Lehrer: Three times.

Mychal: At least three times. At least three times.

Brian Lehrer: You can do that?

Mychal: Yes, because at some point, [sound cut] more than once. At some point, the time and effort it takes to keep denying your claim isn't worth it to the company.

Brian Lehrer: It's the other thing that you said, and again, your line was cutting in and out, so I apologize for making you repeat, but that different states have different standards of enforcement for this.

Mychal: Well, what I was starting to say was that in California, as I myself, I'm an independent business, just myself, I could purchase PPO as an individual, but in New York, you cannot. You can only purchase HMO, which was incredibly frustrating for me.

Brian Lehrer: What's PTO?

Mychal: PPO is when you do not need to have a referral to see any doctor, if you can choose your own. Whatever doctor you want to see, dermatologist, specialist, you do not need a referral in order to see that-- From the insurance company.

Brian Lehrer: Yes. You don't need the referral from the primary care as a requirement from the insurance company. Yes, I misheard the middle initial in there. You were saying PPO, Preferred Provider Organization. Mychal, those are great tips for people. Thank you very much. She might have just helped a whole bunch of people by putting those on the table. Yes, Karen?

Karen Pollitz: Definitely. We found, in our survey, that the vast majority of people who have insurance problems do not appeal. Only about 10% say they actually file a formal appeal. Three times that amount, 30%, say they don't do anything. They just take no for an answer.

Brian Lehrer: Obamacare is officially called the Affordable Care Act. It certainly helped make insurance affordable to buy for a lot more people, with the subsidies it offers, or tell me if you disagree. How would you say that law has or hasn't lived up to its name, the Affordable Care Act?

Karen Pollitz: Well, I think what we found in our survey is that the complexity and red tape, and prevalence of insurance problems, rivals affordability as a concern among people who want and need health insurance. Obamacare has absolutely connected millions of people to coverage that they didn't have before. The subsidies, recently, have been improved. I think outreach, consumer assistance to enroll, that's all been strengthened in recent years, but the oversight of these plans, and how they actually work--

Mychal had talked about the plans that have HMO networks, you can only get coverage if you see a doctor in the network. Who's looking at those networks? Who's checking to see, do they have enough doctors in them? Do they have enough doctors of the right specialties? How are the claims being appealed? It's good advice to keep appealing. I would agree. I'm certainly one of those pain-in-the-neck customers, that insurance-- I'm sure when they see me coming, they say, "Oh, just pay the claim," because I won't let go.

Lots of times, people can't do that. If you've made a claim for something, chances are, you're sick, and you just don't have the bandwidth. It's important to also keep an eye on how these plans are working. There's a law on the books, for more than a dozen years now, that requires the federal government to collect data from private health plans to find out, well, how reliably are you paying claims? How often are you denying them? Which claims are you denying? Which claims are you requiring prior authorization for?

How often are you giving it? That's largely been unimplemented. It's just authority lying around, waiting to be used. That oversight, I think, would really change how health plans are held accountable, and could relieve people of having to appeal denials if a pattern of improper or uncareful claims payment practices is detected and addressed.

Brian Lehrer: Here's another persistent story, I think, from Brian, in Westchester. Brian, you're on WNYC. Hello.

Brian: Hey, Brian. Hi, Karen. Well, this is outrageous to me, because sometimes, the insurance companies, or the doctors, can make a mistake, and they stick you with the bill. In this case, you is me. I switched health care providers. Last year, I went from my plan to my spouse's plan. All of a sudden, my claims on the new plan are getting denied, because, to them, there was some mistake, that I was still covered by my old insurance.

They wouldn't cover the claim because the first insurance company needed to cover it, or needed to talk to them beforehand, but I wasn't on that plan anymore, so they were denying my claim. In another case, I saw a doctor, and they coded it wrong. They said it was one type of visit when it was a different type of visit. I didn't know that, but the claim was denied. I had to go through so many phone calls, so many appeals, to get everything sorted out.

If I was actually sick, like you said, no way would I have had the bandwidth to do all this. Eventually, thankfully, gratefully, I got covered. They eventually paid it, but just WTF, what are you doing? I didn't do anything. I just saw the doctor, and they all made the mistake.

Brian Lehrer: Yes. It's a horror story wrapped in a success story, or a success story wrapped in a horror story. Brian, thank you for sharing it. As we start to run out of time, Karen, you mentioned a couple of policy recommendations. Anything else you would add as the bottom line of what we can do, as a country, about these findings in your KFF survey, about a majority of Americans finding obstacles to care, even when they're insured?

Karen Pollitz: We did ask for people's views on public policies that are meant to address these issues. We have laws on the books that say that the EOB, the statement that your insurance company sends you explaining why they did or didn't pay a claim, has to be written in a way that people can understand. That's an old rule, but it doesn't seem to be working all that well, because we have lots of people who tell us they don't understand. 30% of people tell us they don't understand what their EOB means.

We have laws on the books that say insurance has to report data on which claims they deny, how often, and for what reasons, and that hasn't been implemented. We have a law in the books that authorizes the establishment of consumer assistance programs, ombudsman programs. New York state has an amazing one, congress appropriated some startup money for these programs back in 2010, and hasn't appropriated any money for them ever since. New York has kept your program going with state funds, and it's a model for the nation.

There's a program that New Yorkers can call if they've got a problem with their insurance, the people who answer the line are smart lawyers, they know the rules, and they will call and help you fix it. If you need to file multiple appeals, they'll file those appeals for you. Our survey tells us people overwhelmingly want to have an ombudsman program like that, so that when a problem does arise, they can just call somebody for help to fix it, and they don't have to deal with it.

Again, it's on the books. No money has been appropriated for those programs in 13 years. I think we have a lot of the tools to hold insurance accountable. The question is, how are we using them, or are we using them?

Brian Lehrer: All these little patches we're talking about, though, in our last minute, does KFF as a policy organization take a position on Medicare for all or some kind of other government single-payer program, which would probably wipe out all or most of what we've been talking about in this segment?

Karen Pollitz: We don't take positions on anything, including Medicare for all, but our report does compare the experiences of people who are covered by Medicare versus other kinds of coverage. Medicare is not perfect either, but by and large, people did better or reported better experiences, less confusion, more ability to understand their coverage, more ability to fix their problems when they arose, when they were covered by Medicare, compared to private insurance.

Brian Lehrer: Karen Pollitz, senior fellow and co-director of The Program on Patient and Consumer Protections and Health Insurance at KFF, formerly the Kaiser Family Foundation, thank you so much for coming on with us.

Karen Pollitz: Thank you.

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