The Dark Side of the Healthcare System: Why it is Failing Our Community

Healthcare is failing our community. Despite being one of the wealthiest nations in the world, millions of Americans struggle to pay the high costs of healthcare, and while there is no single solution to this complex issue, there are steps that can be taken to address it.

The relationship between doctors, hospitals and insurance companies known as the BUCAs (Blue Cross, UnitedHealth Group, Cigna and Aetna) plays a significant role in this challenge. While these partnerships should be straightforward, they have led to prioritizing financial gain over patient care, where healthcare decisions are influenced, at least in part, by the restrictions and conditions set by the insurance companies. For example, doctors must consider which treatments are covered, which specialists a patient can see, or how much a patient might have to pay out-of-pocket when creating treatment plans. This can lead to adverse health outcomes or increased hospital admissions due to delayed care or denied treatments, especially for time-sensitive conditions like cancer or autoimmune diseases. Breaking away from traditional insurance companies can help take a system that prioritizes financial profitability and bring it back to one that focuses on what really matters–patient health. An approach that can provide greater flexibility, higher quality of care, and reduced costs.

How broker incentives and comfort levels can also negatively impact your plan options.

Doctors and hospitals are not the only ones choosing to work with the BUCAs. Too often, brokers are incentivized to push benefit programs that offer them the highest commissions. Sadly, rewards for volume and simplicity from traditional insurance companies and the ease of suggesting these cookie-cutter plans have become normal in the industry.

Brokers who continue to work with traditional insurance companies in this way contribute to a healthcare system that is less about supporting employees and more about benefiting the middlemen—whether they know it or not.

Many brokers are unaware or unwilling to offer alternative health insurance options that could meet the unique needs of their clients more appropriately than one-size-fits-all programs. And with rising healthcare costs and changing employee expectations, it is becoming essential for brokers to go beyond traditional plans and consider more comprehensive options.

Holding on to outdated benefits structures.

Because traditional insurance companies have long dominated the healthcare landscape, many employers can be hesitant to break away from traditional offerings, often sticking with what is comfortable and familiar. This mentality, while understandable, can result in outdated insurance options that don’t meet the needs of their people. The result? Employees who are left with high premiums, high deductibles and limited access to quality care. For employers, it can mean a benefits program that becomes underutilized and costly.

Offering a custom health benefits program provides an invaluable opportunity to focus on proactive, preventative care that can lead to earlier detection of health issues and a reduction in the need for expensive, emergency care. This approach can improve overall employee well- being and help reduce long-term healthcare costs, benefiting both employees and communities.

The problem is obvious: healthcare in America is a business, not a service.

It doesn’t stop there. In the 1960s, Pharmacy Benefit Managers (PBMs) were established to help insurers control drug costs. But over time, PBMs have leveraged their position to increase prices, limit patient choices, and take advantage of pharmacies—largely due to a lack of transparency and a growing interest in generating profit instead of accessing medication for patients at a more affordable price. But, in an industry that directly impacts patient health, there is no room for opacity.

Lack of transparency makes it difficult for employers, patients and consultants to know how drug prices are established and if the decisions support the best interest of patients. For example, PBMs negotiate discounts and rebates with drug makers, but these agreements don’t always translate into lower costs. In the current setting, it could be possible for PBMs to prioritize drugs with high rebates over ones that are better suited for the patient’s health needs. Hidden revenue sources like this also make it harder for stakeholders to control costs and advocate for lower prices. After all, how can employers or consultants challenge prices when the actual cost is hidden?

The fog must be cleared. Hidden revenue streams need to be eliminated and transparency about compensation needs to be enforced. It’s time to prioritize the needs of patients over profit.

While change takes time, it’s essential to begin making shifts now to create a more sustainable and compassionate healthcare system.

In the end, our communities are the ones who suffer the most. We are caught between the unyielding pressure of the BUCAs and the profit-driving motives of the medical system. The question is: when will we stop playing along?

If you are interested in creating change, contact us today. We are eager to help!