The cost to the employees is paramount in our decision process. It’s not quite as comfy a relationship as you insinuate.

and the nuances of service will rarely be apparent in that process

By not approving claims. It's all a big vicious circle.

A large portion of most outpatient docs day is fighting these denials. That takes up time that could be used seeing other patients.

Then there's the fact that some percent of patients will switch insurance or die in the window you're denying them. As long as that outweighs the likelihood they end up in the hospital and cost you more than they otherwise would. You win.

Then you get large systems over billing in response because of their incentives, and a lot of money gets tied up in an arms race to fight the claims process better.

Every actor is doing things that are in themselves rational, but it creates a highly irrational system.

I am saying the individual does not have much or any say in choosing the insurer. Or has the ability to switch to another if they find the service provided unacceptable. It is a fundamental problem in our employer based system.

It is good that you strive to get the lowest cost for your employees. I suspect that for most of them that is the prime concern. For me it was secondary. However at no time in my career did I have any choice in insurance companies. That decision was always made for me.

The fact remains that the employer is the primary customer, not the individual insured.

Providers can go out of network. Employers can select a different plan. It’s not happening, but it’s at least possible in a way that isn’t with a single payer employing the same predatory strategy.

We’ve got one plan to choose from, only option is the level of deductible.

When I lived in Cali, we could opt for Kaiser HMO or HDHP, but even the Kaiser option was eventually scrapped by my company.

Do most companies give multiple options?

It is only employers and providers who have any leverage when the insurance companies behave badly. But optionality for those constituents theoretically keeps worse behavior in check. My point was to refute the claim that “single payer is the only answer”. I think the lack of optionality means that is not the case. In fact, one of the cases for single payer is that it will reduce cost specifically from the leverage the singular payer will have over providers.