I’m going to take a stand on something that really gets my blood boiling… health insurance companies. People want to blame physicians for bad outcomes (I’m looking at you NRA supporters that are claiming we, as physicians, need to fix our own lane first). They want to blame hospitals for long wait times, they want to blame administrators for burnout, they want to blame nurses for their pain, they want to blame anyone and everyone. I, personally, think that health insurers deserve 90% of the blame for the problems with healthcare in the US–the rising overall costs, skyrocketing premiums, the poor outcomes (especially when prescribed treatments aren’t approved), etc, etc. No where else in the world do insurers get to have such a big say in the care that is provided (or not). No where else in the world does the CEO of a single health insurance company make more than anyone on an entire hospital staff of physicians.
Let’s just start with my own personal frustrations before we get to the news stories and history. First, insurance companies are requiring “pre-authorization” for more and more procedures/studies all the time. Pre-authorizations do nothing but delay diagnoses and needed procedures. They don’t save money because they are simply additional steps for physicians to take to provide the care they are trained to provide. That means physicians pay more overhead to fill out forms and spend time on hold on the phone, all the while insurers are “saving” money. But that money doesn’t make it back to the people paying the premiums, it makes it back to the executives pockets. Second, denials. Denials to pay for care provided, denials to approve a patient for an appropriate level of post-acute care services (for instance, not approving a patient for inpatient rehab after a hip fracture). Third, delays. We often have patients staying in the hospital for anywhere from 2-7 days waiting on decisions from insurance companies regarding approval for the “next” step/appropriate disposition. Fourth, peer to peer reviews that are anything but “peer to peer”. These are often internists telling surgeons what’s appropriate, and guess what? Internists don’t know anything about surgery. They weren’t trained to know when or when not to operate, what that operation requires, and what the immediate recovery process really is. That’s just not their forte. I recently had an inpatient stay denied for a patient with a small bowel obstruction because they didn’t require surgery. Mind you, they need to observed until all bowel function returns and they are tolerating a diet. They usually require a nasogastric tube (I.e. a hospital based intervention) and ongoing monitoring and even other studies before they can be cleared for discharge home.
How do I know that it’s not just me dealing with these things? Let’s look at some news stories from the last couple of years.
In January of 2018, Centene was sued for not providing an adequate network of providers. In other words, people are paying for coverage but there are so few physicians on their plans that they don’t actually have access to care. This has always been my argument about “mandatory” health insurance–coverage DOES NOT equate to access. And this lawsuit proves it. They are one of the largest for-profit insurance companies to provide coverage for Affordable Care Act plans making this an even bigger problem.
In February, California began investing Aetna after a former medical director admitted that he never looked at actual patient records when deciding to approve or deny care. All that time we spend arguing with insurance companies basically amounts to nothing and will no better serve a patient than talking to your own mother for an hour.
The latest trend among insurers is not paying for ER visits when it turns out that the problem was emergent. The major issue with this is that leaves patients to diagnose themselves. For instance, when Brittany Cloyd thought she might have appendicitis, she very well should have gone to an ER in case she needed surgery. Instead, she had ovarian cysts (which I know from experience can be excruciatingly painful) and was given the entire bill when her insurance company, Anthem, denied the payment. I understand trying to keep minor aches, pains, chronic issues, colds/sore throats from bogging down ERs, but this policy goes entirely too far. Thus, multiple physicians/physician groups have proceeded to sue Anthem/BCBS for this detrimental policy.
Humana took it upon themselves to terminate contracts mid-contract with multiple groups of anesthesiologists in Texas resulting in lack of access to in-network providers for patients. Therefore, the hospital they went to would be in-network but the ONLY anesthesiologists available at those facilities were out-of-network. Patients were then balance billed for the differences. Again, more money out of patients pocket, into the insurers pockets, and certainly not being paid to the people providing the care.
Cigna has been accused multiple times of overcharging patients. They have been sued for artificially inflating pharmaceutical costs and diverting administrative fees to patients and calling them “medical expenses”. Lawsuit after lawsuit, but their pockets are deep.
UnitedHealth Care has been accused by the State of California of denying life saving treatments for seriously ill members and claim denials for providers and hospitals. Again, this was all to maximize profits rather than maximize benefits.
As if the opioid epidemic isn’t bad enough, California has accused HealthNet (owned by Centene who was mentioned above) more than once for refusing to pay providers that care for substance use patients attempting to recover from their addictions. This results in denials that are incongruent with their coverage policies and delays in processing/paying claims. Often these patients can’t afford the “balance billing” in these situations, leading providers to bankruptcy and even less access to care for substance abuse disorders.
HealthNet is also under fire for having an incentive program that rewarded employees with bonuses when they revoked policies.
More than 10 years ago, the CEO of UnitedHealth brought home $13.2 million. The company has multiple times been accused of funneling profits to the CEO rather than to its policyholders. Money that should be spent on medical treatments is actually directly pocketed by the CEO. In fact, by back dating his stock options, the former CEO was able to obtain $1.6 BILLION (with a B) in options as UnitedHealth’s stock rose. He eventually settled in court and still had more than $800 million in options and another $530 million in compensation. I, as a physician, will likely not amass these kind of numbers in 35 years of practice AND investing…not even with a second physician income in the house.
So who is really winning out these days? Are you spending 8-10% of your income on your healthcare premiums and another 1-2% on copays and coinsurance or even more? Is health insurance bankrupting its own policyholders while delaying the treatments that can save them their lives?
I wish I had the answers to these problems. I, myself, have signed up for as many health insurance companies as possible in order to prevent my patients from being handed the bill for out-of-network services. But that choice isn’t always up to the physicians themselves. Would a single payer system solve these issues? Would giving an additional 10% in taxes to the government for guaranteed services be worth it? Or would the government do what private insurers have done and continue to line their own pockets while patients continue to suffer? Would a free-market system be affordable for patients? There’s a lot to be said for physician owned hospitals where they set up front prices and don’t use insurance (The Surgery Center of Oklahoma for instance) or the multitude of direct primary care practices sprouting up across the country (which I also use myself).
What do you think? Can we fix the health insurance system? Can we get patients the care they deserve, return deserved autonomy to physicians, and perhaps share millions (or even billions) of profits with the general public?
REFERENCES:
https://edition.cnn.com/2018/02/11/health/aetna-california-investigation/index.html
https://www.fiercehealthcare.com/payer/cigna-american-specialty-health-lawsuit-cost-shifting
What a telling perspective you have as a provider. My brother and brother-in-law, who got their masters in healthcare admin, both share similar concerns towards the health insurance issues. My wife is in med school right now at UNT and cringes when she hears about the terrible dysfunction within the system.
This may be obvious, but as with most highly complex systems within any society, I don’t think a one-size-fits-all approach would solve the problems you mentioned. A multi-faceted approach will be needed, and leadership to communicate it simply and clearly or else the socialized healthcare “solution” is going to gain momentum. I think any blanket policies/changes would create worse problems, (especially patient outcomes).
Do you think one facet of the solution could be a government mandate requiring all insurance companies to be structured as non-profits? And I’m talking 501(c)(3) organizations, not the others structured like the NFL used to be, 501(c)(6)
I don’t think a one-size-fits-all-approach is the answer either. I also don’t think the government is best at running most programs so I’m not trusting of their take over in a single payer system. I do think some massive overhauling, not piece-meal, is what it will take to truly change healthcare in the US, and I think insurance companies need to take the brunt of the fall. Unfortunately, that also means lots of people could be out of jobs since the insurance sector provides so many. Sadly those jobs are created on something that is fraud in my opinion. I do think a non-profit structure would help; however, CEOs of many “non-profit” organizations (including hospitals) make far more than I think they are qualified for as well. So with their current amount of corruption, I don’t even think 501(c)(3) will change how the money is dispersed.
My face hurts after reading this. The problem seems so immense and unwieldy that I’m left completely flummoxed. What can one lowly physician do in the face of some of the most pernicious and well funded corporations? What if anything are our professional societies really doing for these problems?
I agree somewhat. I work in Radiology and I know exactly what kind of testing I need to see the issues I have yet insurance requires I go through other testing first before I get to the one I know will show exactly what I need. Ridiculous.