Malign processes, not malign people

No, back when I had cancer there wasn’t some insurance company bureaucrat personally stalling the approvals for my diagnostic work in hopes that I’d give up and pay the extra co-payments under “Tier II.” There was simply a slow and clumsy process that created an incentive for people in my position to buy their way out of waiting.

My post on insurance-company-driven health-care-rationing-by-waiting drew a comment from Paul Krugman, which in turn drew a link from Matt Yglesias.

I’m happy to have the attention, but on one key point my writing proved unclear.

Krugman quotes me as saying:

It was only later that I discovered why the insurance company was stalling; I had an option, which I didn’t know I had, to avoid all the approvals by going to “Tier II,” which would have meant higher co-payments.

and adds, reasonably,

To be fair, Mr. Kleiman is only surmising that his insurance company risked his life in an attempt to get him to pay more of his treatment costs.

To be clear: I didn’t, and don’t, imagine that there was some insurance company bureaucrat deliberately stalling my approvals in particular in hopes that I would (in the industry jargon) “go Tier II.” I did and do believe that the approval process was deliberately made slow and clumsy, with no “out” for time-sensitive tests, in order to create an incentive for patients to opt for Tier II coverage to jump the approval queue.

In my case, it would have worked, except that no one told me about the option until it was too late. Of course I should have found out on my own. After all, it was my life that was at stake.

But it’s worth remembering that I was deathly ill at the time, and probably not at the top of my decision-making form. That’s a fact about health care finance I haven’t seen much reference to in the literature: what seems like at least a marginally reasonable process if you imagine a healthy well-educated person dealing with it becomes less reasonable if the person is poorly educated or elderly and frail or, like many patients, very sick.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: