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Doctors Say Dealing With Health Insurers Is Only Getting Worse

Doctors Say Dealing With Health Insurers Is Only Getting Worse

By Joshua Chaffin and Julie Wernau
The Wall Street Journal, Dec. 12, 2024

The killing of a top health insurance executive outside a Midtown Manhattan hotel last week triggered an outpouring of public anger at an industry many Americans blame for the ills of the nation’s healthcare system.

Count doctors among the aggrieved.

They deal day in and day out with insurers including UnitedHealthcare, whose chief executive, Brian Thompson, was shot to death last week by an assassin who targeted him outside the company’s annual investor conference. Doctors say their frustration is born of intimate experience and has been building for years.

Their chief complaint is the aggravation and expense of convincing insurance companies to pay them for their patients’ treatment. Even when they are ultimately approved, MRI scans and other vital but costly procedures often require days of campaigning and paperwork, say doctors.

“It’s getting worse,” said Dr. Zulfiqar Ahmed, an internist in Augusta, Ga., who has practiced in the U.S. for 35 years. “This is not only UnitedHealthcare—this is universal in this country.”

Like other clinicians, Ahmed made clear he was appalled by Thompson’s killing and those who have justified—or even celebrated—it on social media. “My heart is saddened for this Mr. Thompson,” he said. “He’s just part of the system, part of this big enormous system.”

Still, doctors say that sympathy doesn’t change their feelings about having to haggle with doctors employed by UnitedHealthcare and other insurers to evaluate proposed procedures—and oftentimes, reject them. “They hire certain doctors, and they sit at a desk, and their whole purpose is to deny or delay,” Ahmed said, echoing a common complaint among doctors.

Health insurers say they play a valuable role financing the medical care that saves the lives of many patients. Denials keep a lid on unnecessary care and high costs, companies say, thereby keeping treatment affordable for everyone. Insurers also note that doctors, hospitals and drugmakers play a big role in soaring healthcare spending that they are trying to restrain, while ensuring patients get the medical care they need.

In a message to employees Wednesday, UnitedHealth Group CEO Andrew Witty memorialized Thompson’s “profoundly positive impact” on people’s lives.

Doctors won a rare victory over an insurer last week. In November, Elevance Health’s Anthem unit had said it wouldn’t cover anesthesiology claims for surgeries in Connecticut, New York and Missouri that went beyond a certain time limit, prompting outrage from specialists and even New York Gov. Kathy Hochul. It reversed course last Thursday, a day after Thompson was killed.

An Anthem Blue Cross Blue Shield spokesman said its policy change had been widely misinterpreted. “It never was and never will be the policy of Anthem Blue Cross Blue Shield to not pay for medically necessary anesthesia services,” he added.

America’s Health Insurance Plans, a national industry trade association, said state laws dictate how long an insurer has to pay a provider and ensure that they are paid in a timely manner. Delays can be caused when providers go out of network or are using manual processes to submit claims and receive payments, it said.

The industry’s overall rate of prior authorization denials isn’t public. Medicare Advantage plans, a popular form of health insurance, denied 7.4% of 46.2 million requests submitted on behalf of enrollees in 2022, up from 5.7% in 2019, according to an analysis of federal data by KFF, a health-policy nonprofit. A recent Inspector General audit found that 13% of prior authorization denials from Medicare Advantage plans were for benefits that should otherwise have been covered under Medicare.

Even when insurers pay, doctors may still find themselves on the hook. Consider the plight of Dr. Anthony Ekong, an ophthalmologist specializing in retinal care who has built a solo practice in Bangor, Maine.

Last month, Ekong received a stack of letters from a company called Cotiviti, which is an auditor for the insurer WellCare, a unit of Centene. In an effort to provide excellent customer service, Cotiviti wrote, it had reviewed payments Ekong had received for treating elderly patients with macular degeneration and macular edema. It determined WellCare had overpaid. The bill: more than $300,000.

“We would have to shut down or file for bankruptcy,” said Ekong.

WellCare, in turn, suggested he make up the difference by billing his patients. But many are elderly and struggling to get by. Among them are Eugene Strout, 71, and his wife, Donna-Marie Strout, 72, who subsist on Social Security and Eugene’s occasional shifts driving a school bus. At one point, Ekong offered to pay the couple to clean his office every week to help fund the $600 a month they’d have to pay if they switched to another insurer. The Strouts ended up reluctantly moving their care to their local hospital, which still accepts their insurance. The Strouts worry that the hospital could also end up dropping the insurance.

“It’s egregious, invalid and a breach of trust,” Ekong said.

A representative for Centene said the company is looking into the issue further and hopes to amicably resolve it.

Andrew MacLean, chief executive of Maine Medical Association, said he receives phone calls every day from physicians struggling with health insurers demanding so-called clawbacks for bills that had already been paid.

“It almost feels like they do it because they can,” MacLean said of the insurers. “By no means do we applaud this or would we condone violence, but it’s a scary indication of just how frustrated people are about the current system and the imbalance of power—and physicians certainly feel that.”

In a recent post on X, Dr. Alan Nguyen, a spine specialist in Fort Myers, Fla., noted that when insurance-company doctors reject an MRI request, he now asks for their name and health provider identification number. “I tell them if a cancer is missed, then the patient will know who to sue,” wrote Nguyen. In an interview, he said he believes the situation had worsened significantly over the last five years. When insurers denied treatment, Nguyen observed, doctors were still left to deal with the patients and their pain.

A familiar lament among doctors is how sweeping changes over the last 20 years—some instigated by insurers, others not—have degraded their profession. Once autonomous and highly esteemed, doctors are increasingly employees of large hospital chains and find themselves trapped between insurers and their own cost-conscious management.

“Healthcare is run by the business types,” said Dr. Mark Davidian, a radiologist in Sacramento, Calif., who despaired at the loss of agency when caring for patients. He took particular umbrage when he discovered from news reports that UnitedHealthcare’s Thompson earned some $10 million last year and then imagined how that might be received by a cancer patient who had been denied treatment.

When Davidian finished his training 25 years ago, things were different. “Doctors had their own practices. They called the shots,” he said. If, for example, he was dissatisfied with the staff or the equipment at a particular hospital, he would send his patients elsewhere, he said.

Nowadays, he works for a hospital chain in northern California, and feels bound by the prerogatives of managers determined to contain costs. “Nobody speaks for the patient anymore that has any sort of power,” he said. “The problem is, with healthcare we’re supposed to care.”

While larger chains may have the wherewithal to grapple with insurers, the costs weigh heavily on smaller practitioners.

Dr. Richard Lechner, a family dentist in New Britain, Conn., for years paid for three administrative staff members whose days, he said, were mostly spent fighting with insurers. This for an office that consisted of one dentist and two hygienists.

“They’re always throwing up roadblocks for practitioners like me to get paid,” Lechner said. Requests for additional documentation, or claims of paperwork lapses, were, he said, “specifically designed to prolong, prolong, prolong and then hope the dentist gives up.”

Last year, Lechner did give up: He sold his private practice to Dental Associates of Connecticut, a company that operates a network of more than 40 dental offices across the state. Like Davidian, he is now an employee. Much of the work of chasing insurance claims is now handled by a specialist team at Dental Associates’ central office.

“The primary reason I sold my dental practice is because I couldn’t keep up with the insurance companies’ shenanigans,” he said. “I thought I was going to have a stroke.”

Joseph Walker contributed to this article.

https://msn.com…

If you reflexively blamed this insurer for its proposed anesthesia policy, you were right

The news of Anthem’s policy proposal helped provoke another round of a longstanding debate: Who is to blame for America’s health care woes?

By Adam Gaffney, M.D., M.P.H.
MSNBC, Dec. 11, 2024

Last Wednesday, amidst a national wave of animus toward health insurers, Americans turned their ire on a policy that Anthem Blue Cross Blue Shield announced last month concerning a new policy planned for three states that would deny claims for anesthesia for surgeries that went longer than a time limit set by Anthem. In addition to the groundswell of furor on social media platforms, New York Gov. Kathy Hochul, who leads one of the states where the policy was to be launched, slammed Anthem’s policy as “outrageous.” Connecticut was one of the other states, and Sen. Chris Murphy, D-Conn., called the planned policy change “appalling.”

Describing it as a miscommunication, Anthem soon announced it was abandoning its controversial new rule. Janey Kiryluik, staff vice president for corporate communications at Anthem’s parent company, Elevance Health, told The New York Times, “We realized, based on all the feedback we’ve been receiving the last 24 hours, that our communication about the policy was unclear, which is why we’re pulling back.”

The news of Anthem’s policy proposal helped provoke another round of a longstanding debate: Who is to blame for America’s health care woes? By and large the public — sick of sky-high deductibles, haggling over the phone to fight denials and of unexpected medical bills arriving by mail while still convalescing — has directed its outrage at insurers. Vox’s Eric Levitz, though, pointed a finger at doctors and argued that Anthem’s mistake was its retreat from what he called a prudent policy to reduce payments to well-paid specialists. Health care costs are primarily driven by “providers,” not insurers, Levitz argued. Thus, those providers are the reason, he said, “vital medical services are often unaffordable and inaccessible in the United States.”

But Levitz and writers such as Dylan Matthews and Matt Yglesias, who made similar points, are wrong. The details of this particular episode are beside the point. (Brookings Institution’s Loren Adler calls it a contract dispute between anesthesiologists and Anthem that might have had limited impacts on patients.) The public’s fear of getting stuck in the middle between what doctors charge and what insurers pay was justified. Our private health insurance-based system inflates costs and denies care, and in a well-designed universal system, this episode would not even be possible.

It is often noted that most health care spending ultimately goes to health care providers — to hospitals, nurses, doctors (like me), nursing homes and so forth — and not to health insurers. This is true, but it’s also all but a tautology. Obviously, most health care spending goes to health care provision, just as most education spending goes to schools and most defense spending to the military. The relevant question is how to realize savings while upgrading care for everyone, and the best answer is by eliminating the gargantuan waste that is our private insurance system.

The traditional, public Medicare program spends about 2% of its total revenue on administration. Private insurers, by contrast, take 10% (or more) of your premium for administration and profit. This fivefold difference accounts for the more than $400 billion in savings that the Congressional Budget Office projects could be saved annually from eliminating private insurance and moving to “Medicare for All.” Instead, we’re basically setting that money on fire.

But what about the “unit prices” for care in the U.S. that are much higher than other nations? Those “prices” are also inflated by our complex private insurance system. They include providers’ costs of dealing with innumerable insurance plans, each with its own complex payment systems and rules. Hospitals in the United States hire armies of billers and coders to bill and haggle with insurers and spend twice the share of their budgets on administration than Canadian hospitals do. Similarly, we spend more than $80,000 per physician in the U.S. just to cover the costs of their interactions with insurers, four times more than what’s spent in Canada. This is yet another price we pay for the profits of insurance companies — even though it appears on the “provider” side of the ledger.

No doubt there are also bad behaviors from some providers, particularly with the accelerating corporate takeover of care, including vampiric private-equity firms that strip-mine their acquisitions for profit before dumping them (whatever the consequences for patients). Private-equity-owned emergency physician staffing companies were, notably, responsible for an outbreak of devastating “surprise medical” bills. One study found that Wisconsin hospitals commonly and increasingly sue patients for unpaid medical bills, half the time garnishing their wages.

News reports from other parts of the country have described harrowing stories of patients aggressively targeted by hospital debt collection, which has included putting liens on homes and putting some patients in poverty. None of these behaviors should be countenanced. But they are, again, only possible because of a private health insurance system that leaves some uncovered, others with copays and deductibles, and others “out of network.”

In contrast, under a Medicare for All system, patients would be entirely protected from the process of care payment, eliminating the very possibility of medical debt or falling between the cracks — or of waking up from surgery with an unexpected anesthesia bill.

Still, on an even more basic level, when it comes to health care reform, there’s a fundamental difference between “providers” — our nurses, doctors, hospitals, social workers, respiratory therapists, clinics and so on — and insurance companies. We need providers, including the anesthesiologists who ensure that we survive sometimes dauntingly complex operations. But we don’t need insurers.

The public recognizes this and tends to apportion blame accordingly.

Dr. Adam Gaffney is a pulmonary and critical care physician, public health researcher, and an assistant professor at Harvard Medical School.  He is a former president of Physicians for a National Health Program and the author of “To Heal Humankind: The Right to Health in History.”

https://msnbc.com…

Deaths due to Willful Systemic Failings are Violent, Too

The shooting a few days ago of a UnitedHealthcare insurance CEO generated, predictably, horror at interpersonal violence. It also unleashed widespread rage at the pain and harm inflicted by private health insurer practices. More than just prior authorization denials, our corporate insurance approach constitutes systemic violence, annually killing tens of thousands.

A Man Was Murdered in Cold Blood and You’re Laughing?, What the death of a health-insurance C.E.O. means to America, The New Yorker, Dec. 7, 2024, by Jia Tolentino

The C.E.O. of UnitedHealthcare, fifty-year-old Brian Thompson, was murdered on the street in midtown Manhattan …

The public reaction has been wild, lawless. The jokes came streaming in on every social-media platform, in the comments underneath every news article. “I’m sorry, prior authorization is required for thoughts and prayers,” someone commented on TikTok, a response that got more than fifteen thousand likes. “Does he have a history of shootings? Denied coverage,” another person wrote, under an Instagram post from CNN. On X, someone posted, with the caption “My official response to the UHC CEO’s murder,” an infographic comparing wealth distribution in late eighteenth-century France to wealth distribution in present-day America. The whiff of populist anarchy in the air is salty, unprecedented, and notably across the aisle. New York Post comment sections are full of critiques of capitalism as well as self-enriching executives and politicians (like “Biden and his crime family”). On LinkedIn, where users post with their real names and employment histories, UnitedHealth Group had to turn off comments on its post about Thompson’s death—thousands of people were liking and hearting it, with a few even giving it the “clapping” reaction. The company also turned off comments on Facebook, where, as of midday Thursday, a post about Thompson had received more than thirty-six thousand “laugh” reactions.  …

The Norwegian sociologist Johan Galtung coined the term “structural violence” in 1969, in a paper that offers a taxonomy of violence—ways to distinguish between the forms that violence can take. … It can be manifest, or latent. Traditionally, our society fixates on only one version of this: direct physical violence committed by a person intending harm. …

On this point, though, everyone’s really in agreement. It’s just a matter of where you locate the decay—in the killing, or in the response to it, or in what led us here. The only way to end up in a situation where a C.E.O. of a health-insurance company is reflexively viewed as a dictatorial purveyor of suffering is through a history of socially sanctioned death. … Nurses, residents, aides, specialists—they are asked to absorb the rage and panic induced by the American health-care system, whose private insurers generate billions of dollars in profit and pay executives eight figures not despite but because of the fact that they routinely deny care to desperate people in need.

Of course, the solution, in the end, can’t be indifference—not indifference to the death of the C.E.O., and not the celebration of it, either. But who’s going to drop their indifference first? At this point, it’s not going to be the people, who have a lifetime of evidence that health-insurance C.E.O.s do not care about their well-being. Can the C.E.O. class drop its indifference to the suffering and death of ordinary people? Is it possible to do so while achieving record quarterly profits for your stakeholders, in perpetuity?

I Am Torn: Grappling With the Killing of UnitedHealthcare’s CEO, MedPageToday, Dec. 10, 2024, by James Young, M.D.

On the one hand, I shed no tears for Thompson. The man made millions off the suffering of others. More than $10 million last year, in fact. Likewise, every penny of the $22 billion in profit made by parent company UnitedHealth Group in 2023 was at the expense of the suffering of others.

I have no small amount of schadenfreude for what has happened to him. Sometimes, I even find myself wanting to crack jokes at his expense. Is Hell going to require a 2-night qualifying stay prior to admission? Does he have a skilled demonic need that would merit admission to Hell? Others have had similar reactions, posting online comments like, “Unfortunately my condolences are out-of-network,” and “Prior authorization is needed for thoughts and prayers.” …

I hate everything that Thompson stood for. I hate everything that his company stands for and will likely continue to stand for. I expect that the UnitedHealth Group PR and legal teams will use his death as an excuse to stifle any substantive debate or legitimate criticism about UnitedHealthcare with the mantra of, “We need to cool the temperature of the conversation,” or some similar, hollow PR statement.

And yet, I find myself troubled by jumping on the bandwagon of hate.

We need to take this opportunity to mourn the loss of another human being, taken by violence on our streets. We need to show compassion to his family.

We need to say with a single voice that we condemn the actions of Thompson and UnitedHealthcare as vehemently as we condemn the actions of his assassin. We need to warn that too many people — both patients and executives — will continue to suffer until insurance giants put the needs of the patient above those of the shareholder. While I don’t condone more killing or violence against health insurance executives, it’s not unlikely. In fact, it’s already happening. But it needs to be made clear that it’s not rhetoric or debate about insurance company malfeasance driving this action, but the companies’ own actions.

We as physicians need to be vocal, engaged, and seize this moment where the public is now engaged and the media watching, to make the case for why insurance in America is broken.

Ben Shapiro Fans TURN ON HIM Over United Health CEO Take, The Kyle Kulinski Show (on YouTube), Dec. 9, 2024

“It’s not left or right. It’s not black or white. It’s rich vs. poor.”

“Remember folks, Ben … knows exactly what he’s doing. He has more in common with the CEO than 99% of us. Radical change is not about the ‘left’ or ‘right.’”

Comment:

By Jim Kahn, M.D., M.P.H.

In my line of work – quantifying the health effects of health policies and programs – every death counts similarly. Death by illness, medical neglect, accident, or murder is … a death. So I bristle when people tell me that a specific death is particularly egregious. True – untimely, unexpected, avoidable deaths carry a particular emotional weight. And age at death can matter in our calculations. But, ultimately, our standard metrics mean that 100 deaths are, roughly, 100 times as bad as one death.

Thus, I resonated with the widespread response to an insurance CEO’s death. Yes it was a tragedy. It seems like he was a nice man, not deserving of this fate.

However, the job he did – CEO of the largest private insurance group in the United States – made him a symbol of what is wrong with our health insurance.

Indeed, our entire broken insurance approach, built on a foundation of private insurance, generates massive clinical harm. Annual deaths due to lack of insurance are estimated at 40,000 – 80,000. COVID deaths linked to uninsurance topped 300,000. Annual deaths attributable to under-insurance are substantial but much harder to estimate: about half of all adults skip or delay care. My own calculation in HJM based on international data estimates >190,000 excess deaths attributable to our fragmented insurance.

We know this, yet we don’t fix it. Why not? Opposition from corporations and the elected officials they support and lobby. That’s systemic violence.

One caveat: As suggested in the various comments and commentaries, what UHC does wrong is care denials. Certainly, those denials are painful, and symbolic of a lack of caring. Yet they are often clinically inconsequential. Much of what we do in medicine (perhaps 20%) is not effective or even harmful, according to the National Academy of Medicine. We are desperate to try every possible intervention to stave off death. Thus, most care denials probably generate little clinical harm. As reviewed above, the real problem is massive gaps in coverage and access.

How can we fix this? Abandon our for-profit corporate approach to health insurance. In favor of a single, not-for-profit public payer, covering everyone with excellent benefits. As many other wealthy nations demonstrate, this saves resources and prolongs life. Let’s protect individuals (CEOs and others), but most of all let’s protect our population.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

America’s unjust health system finally gets a hard look after insurance CEO’s killing

By Robert Vinetz, M.D.
Los Angeles Times, Letters, Dec. 10, 2024

Columnist Robin Abcarian notes that the single mother of a child with leukemia had to pay $900 a month for her child’s feeding device because her insurance company, UnitedHealthcare, denied payment for it. The mother asked, “Why did this happen? Could it be a systemic issue?” (“UnitedHealthcare’s chief executive was shot dead. Why did thousands react with glee?” Opinion, Dec. 6)

As both a patient (covered by Medicare) and a physician, I say yes, this is definitely a systemic issue.

It is an example of our failing, costly health insurance system, one that leaves some 85 million of us uninsured or inadequately insured. We worry that we and our families will not be able to afford or get care when we need it.

I am alarmed that insurance corporations, pharmaceutical manufacturers and Wall Street types will lobby Congress and the president to take away my traditional Medicare coverage, replace it with a system that puts profits before patient care (think so-called Medicare Advantage) and thereby take away my freedom to choose my own doctors and hospitals.

Too many Americans are already hurting from our current system. And it will only get worse unless we insist on a better system that is universal, publicly financed and not-for-profit.

https://latimes.com…

Wendell Potter on MSNBC

Former Cigna executive and health insurance industry whistleblower Wendell Potter was interviewed by MSNBC for a segment on December 9, 2024. Mr. Potter discussed the jarring outpouring of anger from Americans in the wake of the murder of UnitedHealthcare CEO Brian Thompson.

“Delays and denials are what people encounter these days,” he said. “Whether we’re talking about employers, patients, doctors—just about everybody despises health insurance companies in ways that I’ve never seen before.”

Use nonviolent means

By Henry L. Abrons, M.D., M.P.H.
San Francisco Chronicle, Letters, Dec. 9, 2024

The assassin who killed United Healthcare CEO Brian Thompson last week aimed at the wrong target, used the wrong weapon and wasn’t the right person to do the job.

The target should be United Healthcare’s profit-seeking business model.

The weapon must be legislation to replace private health insurance with universal health insurance through a fair publicly financed program.

The right folks to do the job are the voters and our elected legislators. We must remove health insurance CEOs by nonviolent political action.

Let’s go on the offense to establish single-payer health insurance (improved Medicare for all).

We know how to do this. We’ve done the research, developed the policies, written the legislation and shown the cost savings.

It’s up to us to help abolish private for-profit health insurance, may it RIP. Then we can enjoy the health care we deserve.

https://sfchronicle.com…

U.S. Seniors Experience Worst Cost Barriers to Care

The Commonwealth Fund just published a ten-nation survey of health care affordability for seniors. Guess who had the highest financial barriers to care? Yup, the U.S. Medicare helps (beats being young & uninsured or having massive deductibles), but needs lower cost-sharing.

Health Care Affordability for Older Adults: How the U.S. Compares to Other Countries, Commonwealth Fund, Dec. 4, 2024, by Munira Z. Gunja et al.

Like several other countries, nearly all adults age 65 and older in the U.S. have health coverage. But high out-of-pocket costs in the Medicare program may still make it more difficult for older Americans to receive affordable care compared to older adults in other countries.

Comment:

By Jim Kahn, M.D., M.P.H.

I just spent 3 days in Amsterdam, the Netherlands. Everyone seemed quite content. No wonder, given the extremely low prevalence of medical care cost barriers observed in this survey. Similar for most other nations included. The U.S. performs worst overall, by far, and worst or 2nd worst on each measure. I’m beginning to think that uncertainty in the U.S. on medical care affordability is a major underlying cause of stress, anxiety, and the drive for political upheaval (more on that in a future post).

Now I’m in Nairobi, Kenya, at a meeting about addressing dementia in low-income countries. These nations face huge challenges not only for treatment and care, but also for prevention programming. Because … they have very little money. We in the high-income nations need to do a lot more to help them, and they should more emphatically prioritize heath in their budgets.

The U.S. doesn’t have the excuse of being poor. We have plenty of money – the most in the world. Our problem is that we build our massive health care system (fully 40% of global health spending) to benefit for-profit intermediaries and providers. This drives up costs. And insurance coverage is designed on the flawed premise of “skin-in-the-game” (empirically, it does not control costs). Lots of pain, no real gain.

Best practices, learning from successful approaches, following the leaders … whatever phrase you prefer, it’s long past due for the U.S. to adopt proven practices from peer nations – to assure access while controlling costs.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Choice Among Private Insurance Options Isn’t Real Choice

The new Commonwealth survey of health insurance reveals persistent failings in coverage and access. The myth of “choice” in health insurance should be ended, in favor of real choice – of providers, enabled by excellent universal public insurance.

The State of Health Insurance Coverage in the U.S., Findings from the Commonwealth Fund 2024 Biennial Health Insurance Survey, Nov. 21, 2024, by Sara R. Collins and Avni Gupta

Survey Highlights:

More than half (56%) of U.S. working age adults were insured all year with coverage adequate to ensure affordable access to care. But there are soft spots requiring policy attention: 9 percent of adults were uninsured, 12 percent had a gap in coverage over the past year, and 23 percent were underinsured, meaning they had coverage for a full year that didn’t provide them with affordable access to health care.

Among adults who were insured all year but underinsured, 66 percent had coverage through an employer, 16 percent were enrolled in Medicaid or Medicare, and 14 percent had a plan purchased in the marketplaces or the individual market.

Nearly three of five (57%) underinsured adults said they avoided getting needed health care because of its cost. 44 percent said they had medical or dental debt they were paying off over time.

Delaying health care has health consequences: two of five (41%) working-age adults who reported a cost-related delay in their care said a health problem had worsened because of it.

Nearly half of adults (48%) with medical debt are paying off $2000 or more; half of those with debt said it stemmed from a hospital stay.

Comment:

By Don McCanne, M.D.

When we discuss the problems with financing our health care system, many in the policy or political communities brag about the advances we’ve made through insurance coverage. But these increases have largely been through private insurer models that hamper access: There has been a sharp increase in the numbers of individuals in Medicare Advantage plans, which typically offer narrow provide networks while vastly overcharging the government through diagnostic upcoding and risk selection. States rely widely on private Medicaid intermediaries, which have significant provider network issues. Employer-sponsored private plans increasingly shift direct costs to employees through higher premiums, greater deductibles and copayments, and more aggressive prior authorization. Similarly in ACA marketplace plans. Thus, increased reliance on private plans is really an expansion of the problems that are peculiar to the private insurance industry, as revealed in the newest Commonwealth Fund Health Insurance Survey.

Promoters of these plans say that they are giving us freedom of choice by placing health insurance coverage in the marketplace, which touts competition as being an important mechanism for controlling costs. But look more carefully at the choices we supposedly have. Insurance category is dictated: Medicare by age or disability, Medicaid by poverty, employer sponsored plans by your job, or ACA plans or individual private market plans merely because no other choice is available. Many retirement plans mandate Medicare Advantage, and dropping physician payments in traditional Medicare undermine that option. Most of all, we have no choice about the higher non-clinical spending required by superfluous private insurance intermediaries, via profits, cumbersome administration, and administrative tasks forced on providers.

Besides, what choice do we really want? Don’t we really want free choice of physicians, hospitals, and other medical services – that would be available through an equitably funded, universal, public, single payer program, a program that belongs to all of us rather than just to the millionaires and billionaires, a program where all of our health care dollars are spent just on health care? I don’t think we really want a choice of private plans that are designed specifically to use what should be our health care dollars to create greater wealth for the intermediaries that find innovative ways of diverting our funds away from health care?

Look at the choice we made through the recent election. We elected a president who is choosing administrative personnel who intend to eliminate our traditional government Medicare program that is free of private carriers, and replace it with a universal private Medicare Advantage program which has already been demonstrated to divert hundreds of billions in health care dollars to their private industry. Furthermore, our president-elect has brought in the richest man in the nation who intends to manipulate our government in a manner that will make him the world’s first trillionaire. Is that the choice that we want? giving our health care dollars and other funds to the wealthiest individuals in our nation, while leaving out many of those with genuine health care needs that are inaccessible to them under our current system so reliant on private insurers?

Let’s give everyone the freedom of choice in selecting the health care that they need and want instead of having false choice of which intermediary is going to take much of our health care dollars away and leave too many of us without the health care that we need.

What is our choice to be? Profits over patients? Billionaires over health care budgets? Or patients over our own health care system that is designed to take care of everyone? It doesn’t seem like that is a very difficult choice.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

New Government: Time to Revisit Single Payer?

Our fragmented, predominantly private health insurance serves corporations and shareholders, at the expense of financial affordability for patients. This is nothing new, but it’s worsening. What’s new is the shake-up of politics. Let’s insist on shaking up our failed insurance.

Complexity in the US Health Care System Is the Enemy of Access and Affordability, JAMA Forum, Oct. 26, 2023, by Larry Levitt and Drew Altman

Lack of insurance coverage, high costs, and poor outcomes are well-documented problems in the US health care system, and policies to address them have been hotly debated for decades. However, complexity is another under-appreciated problem that hinders access and affordability.

Almost 6 in 10 people with insurance reported a problem with using their health insurance during the past year (2022). The share increases to two-thirds of people in fair or poor health, three-fourths for those who need mental health services, and almost 8 in 10 for people who use the health system the most. The result is that many delay or skip care or accumulate bills they cannot afford.

The reality is that many people are hopelessly confused by how their insurance works. In Medicare, beneficiaries can now choose from an average of 43 private Medicare Advantage plans, and during open enrollment season, the airwaves are flooded with ads that may do more to confuse rather than illuminate. And people getting ACA coverage through healthcare.gov have a choice of more than 200 plan options on average. The complexity of too many choices can also lead to paralysis on the part of consumers.

Yet, any push for health care simplification inevitably clashes with commercial interests. The system is structured to simultaneously maximize profits, control costs, and serve customers, which are competing goals that add to the challenge of simplifying it.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

Although Health Justice Monitor commented on this article a year ago, political developments have not only failed to provide significant improvement in our expensive but underperforming health care system, it appears that the malfunctioning of our system will only become worse.

We have been increasingly reliant on private insurers as demonstrated by the increase in conversion of traditional Medicare to private Medicare Advantage plans and the greater reliance on commercial plans through the Affordable Care Act. So we are spending ever more of our health care dollars on an industry with a mission that places a higher priority on diverting health care dollars to private investors instead of directing all of those dollars to achieving comprehensive health care for everyone.

We have an abundance of health policy research that demonstrates that the defective private insurance model increases costs and decreases access to care. It should be eliminated and replaced by a public single payer program that would, by design, not only provide health care for absolutely everyone, but also control costs while improving the allocation of health care dollars. That model would be similar to traditional Medicare except that it would offer more comprehensive benefits, eliminate cost sharing that currently causes financial hardship, assure free choice of providers and facilities, and equitably finance via progressive taxes which would be affordable for everyone without materially diminishing the lifestyles of the wealthy despite their paying more (they can afford to!).

In our recent presidential election, one of the major parties emphasized neoliberal policies which eliminated any consideration of the superior single payer model, instead supporting small incremental changes which would have negligible impact in healing our sick health care system. The other major party vaguely promised system improvement but hinted major cuts in public spending. They also selected individuals as likely heads of HHS and CMS who would shred the program that we have at a cost of lives, health, and worse financial hardship for patients.

Wouldn’t it be better set aside politics, and instead adopt policies that provide definitive solutions to the problems of high personal health care costs and financially squeezed providers? We have ample examples from countries of varied political leanings of how to use funds well.

Shouldn’t we encourage our legislators, all of them, to join together to approve a system that would work so well for everyone? Now that we have an incoming president who would like to take personal credit for radically redirecting government to serve the public, maybe we have a chance.

https://healthjusticemonitor.org…

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Health care policy hurts Hawaii patients

By Stephen Kemble, M.D.
Honolulu Star-Advertiser, Nov. 19, 2024

The current health policy fad is “value-based payment” — blaming high health care cost on fee-for-service and overutilization of care and instead, offering upfront payment per member, or capitation, as an incentive to reduce utilization and control costs.

This analysis is contradicted by Hawaii’s experience. Hawaii’s Prepaid Health Care Act has included an employer mandate since 1974, with the broadest coverage of the population, richest commercial insurance benefits, lowest patient cost-sharing, and among the lowest insurance premiums in the country. And we had the lowest per-capita Medicare spending in 2009, when everyone was paid with fee-for-service.

But since widespread imposition of “value-based payment,” encouraged by the Affordable Care Act and aggressively implemented by HMSA and MedQUEST, health insurance premiums have more than doubled. By 2019 our per-capita Medicare spending had climbed from lowest up to 9th-lowest and rising. And many Hawaii doctors are quitting practice or exiting the state, leaving a severe and worsening doctor shortage and worsening access to care.

Capitation requires defined “members” to enable payment per-member, whether the payee is a health plan, such as a Medicare Advantage (MA) or Medicaid managed care plan, or an organized group of doctors or doctors and hospitals paid as an Accountable Care Organization (ACO). In any case, the performance of a capitated plan depends heavily on which “members” it captures.

Many studies claim to show that MA plans and ACOs can reduce Medicare spending and demonstrate improved quality measures. BUT, the savings for Medicare are quite small, and if the administrative costs for the MA plan or ACO are included, capitation always costs more than fee-for-service.

And very few studies account for the ability of capitated plans to capture healthier “members” and avoid or eject sicker, more expensive ones. If the pool of “members” in a plan or ACO is healthier than average, then of course cost will be lower and quality measures will be higher because the members were healthier to begin with, without any improvement in care.

Upfront payment with capitation introduces perverse incentives to capture the healthy and avoid the sick; to up-code to game the risk adjustment formula; and to skimp on care, necessary and unnecessary alike. And capitation of health plans creates major opportunities for profiteering, fraud and abuse in health care.

The poster child for these problems with “value-based payment” is Medicare Advantage. The Medicare Payment Advisory Commission has concluded that MA plans are overpaid by 22% compared to if the same beneficiaries were in traditional fee-for-service Medicare. Studies show MA plans do capture healthier-than-average members and up-code, often to the point of fraud, and they skimp on care, including denial of necessary care.

MA is the most profitable line of business for health insurance companies, far outstripping commercial insurance. It is rapidly draining the Medicare trust fund, threatening insolvency in less than a decade.

MA plans often restrict beneficiary choice with narrow and “ghost” networks of doctors not actually available to plan members. Doctors complain of excessive time wasted on prior authorizations. And worse, when for-profit insurance companies and private equity firms buy up physician practices and secure “value-based” government contracts with Medicare and Medicaid, they then seek return on investment by pressuring doctors to compromise patient care to serve their corporate owner’s financial goals, driving an epidemic of “moral injury” and burnout.

“Value-based payment” carries much higher administrative costs than fee-for-service, so capitated plans can be profitable only by gaming the payment formula to be overpaid and/or by denying care. This is no way to achieve real value in health care.

Dr. Stephen Kemble is a retired psychiatrist; in 2011, he was appointed to the now-inactive Hawaii Health Authority, charged with designing a universal health care system for Hawaii residents.

https://staradvertiser.com…

Medicare Advantage can’t deliver the moon

By Carol Paris, M.D.
Chattanooga Times Free Press, Letters, Nov. 16, 2024

During Medicare open enrollment, seniors are asked to choose from a dizzying array of plans. As a retired physician, and now a senior on Medicare, I know how confusing these choices can be, and what an impact they can have on our health and our pocketbooks.

Medicare Advantage plans, run by corporate health insurers, tend to promise the moon and the stars, but deliver aggravating restrictions. Not so with traditional Medicare.

Advantage plans also put a strain on the patient-doctor relationship. Many physicians are distressed when they feel corporate interests prevent them from delivering the care they know their patients need.

I saw this firsthand when I visited an orthopedic surgeon for knee pain. He balked when I asked which he would recommend.

“It doesn’t matter what I recommend,” he said, “only what your insurance will authorize.” But when I explained that I had traditional Medicare instead of a corporate plan, his face brightened. “In that case,” he said, “I can give you my best advice and administer the injection today.”

We would all be better off with an improved version of traditional Medicare, and both patients and physicians are fighting to realize that vision. Until that day comes, seniors should be aware of the impact privatized plans can have on their quality of care and choose wisely.

https://timesfreepress.com…