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American doctors are accusing US health insurance giants of causing deadly delays in life-saving medical procedures and care – and putting profits ahead of their patients’ health.
Firms including United Healthcare have denied the underlying scans, and taken months to review, according to doctors who spoke to The Guardian.
“There’s good evidence that these kinds of delays are literally killing people,” said Dr. Ed Weisbart, former chief medical officer for Scripts Express, one of the largest prescription benefit managers in the U.S. “For some people, this is not just a nuisance and an annoyance and an aggravation.
“It’s a death sentence and the only reason insurance companies do it is to maximize their profits. The fact that they can kill you is not in the equation of what they care about.”
AMERICAS Pass the most in health care in the industrialized world – one appreciated $4.9TN in 2023 – but have the worst health outcomes, according to analysis from the Commonwealth Fund.
UnitedHealthcare CEO Brian Thompson’s Fatal Factor last month prompted a spill BY public outrage towards the healthcare industry. While private insurers report billions in profits each year, many patients — and their doctors — struggle to navigate a complex financial system to get what they need.
Lobbyists for insurance firms insist they are “working to protect” people from higher costs and stress that everyone in the space, including doctors, is responsible for doing US Health The most affordable and easy to navigate system care.
But in a series of interviews, medical professionals described their frustration with a powerful industry that had prevented them from helping patients.
‘We’re stuck in this terrible, vicious circle’
Dr. Cheryl Kunis, a board member at Physicians for a National Health Program and a nephrologist in New York City, still thinks about what happened when one of her patients needed a PET scan. He had a tumor, and before deciding how to treat it, Kunis and her colleagues wanted to determine if it had spread.
“The surgeon was very honest that he only wanted to operate if the tumor was localized, and without the PET scan, he really wouldn’t have been able to make that decision,” Kunis said. “The surgeon and his office, as well as my office, spent hours on the phone. We were talking to someone sitting at UnitedHealthcare in front of a computer screen who really didn’t know the underlying medical problem or the test we’re asking the patient to have. “
After an initial denial, the patient’s appeal for the scan was finally approved six months later. By that time, the patient had died.
“We assume that if he had been diagnosed earlier, he might have been able to do better,” Kunis said. “There’s no way to prove it, but there was a reasonable chance he would have been in better shape if there hadn’t been a six-month delay in getting the scan.”
The health care system is “just stuck in this horrible, vicious circle,” she said, “of ever-increasing prices, a lack of regulation, and insurance companies unfortunately have leverage over patients who are trying to get care “.
‘It’s both demoralizing and insulting’
Health insurance companies often require “peer to join” reviews, where doctors are asked to speak with a medical representative from a health insurance company to justify treatment. But insurance representatives are often far less experienced, according to doctors who spoke to the Guardian, and may not even have training in the specific area they are weighing.
“When I’ve engaged in peer-to-peer review, the peer is never a physician who has my training,” said Dr. Philip Verhoef, an intensive care unit physician based in Honolulu, Hawaii, and the former president of Physicians for a National Health Program “It’s kind of a farce that we even call it ‘peer to join’. I’ve never had a ‘peer to join’ conversation that was actually with a real peer.”
Instead, representatives are “second-guessing our judgment as a clinic,” he claimed. “To be perfectly clear, I have no financial incentive to admit patients to the ICU. It is both demoralizing and insulting when a bureaucrat somewhere looks at a hospital claim and says, ‘The decision to admit to the ICU was wrong. .” “
Verhoef said he often sees patients come to the intensive care unit for preventable illnesses caused by health insurance company denials, such as refusing to cover required medications, such as insulin, or an asthma inhaler.
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“When people have to use their private health insurance, it really fails them,” he added. “Insurance is supposed to be there to cover you from financial disaster when unfortunate things happen, and the current system we have based on private health insurance has really failed everyone. I don’t think we’re going to mend our way to get out of this mess.”
The high volume of attrition patients encounter when seeking medical care or assistance is essential to insurance firms’ business models, according to Weisbart. “They don’t care about you, and they see you as an expense, not someone whose health needs to improve,” he said. “The healthier you are, the more they want you to have them as their insurance, and the sicker you are, the more comfortable they are with you being unhappy with them and looking for a different insurance company.
“Once they have that money, every time someone has to get health care, that’s just one expense they don’t want to give up.”
Insurance industry profits revolve around the delay and denial of medical care, Weisbart asserted. “When they delay your care by a day, by a week, by a month, or deny it altogether, it’s not a random event,” he said. “It’s a calculated business strategy to maximize their profits.”
‘The problem is getting much worse’
Many doctors have recently expressed similar issues with private insurers. Doctors “are forced to become insurance experts at the top of our medical expertise, spending countless hours on paperwork instead of caring for patients,” wrote Dr Bayo Curry-Winchell of Nevada ITEM for Katie Couric Media, while Dr. Claudia Fagan, chief medical officer of Cook County Health, wrote in a ITEM About common dreams she had “watched patients suffer and die in order to pad the bottom lines of corporate health insurers — and in recent years I’ve seen that problem get a lot worse.”
UnitedHealthcare did not respond to multiple requests for comment. AHIP, a lobby group for the industry, said in an emailed statement: “In the fragmented and highly regulated health care system, health plans, providers and drug manufacturers share a responsibility to make high-quality care possible affordable and easier to navigate for the people we collectively serve Health plans are working to protect patients from the full impact of rising costs while connecting them to care that is safe, evidence-based and coordinated “.
Doctors who spoke to The Guardian suggested fixing the problems with the US health care system will require more than tinkering around the edges.
Both Weisbart and Verhoef argued that the solution would require moving away from private health insurance toward a single-payer health care system similar to other wealthy countries that provide health care for all.
“The solution is effectively to fix the system completely and then start over with the national health insurance system,” said Verhoef. “Solutions that depend on trying to regulate the private insurance industry will simply fail.”
There is “no way to modestly reform a fundamental flaw in a business model,” Weisbart added. “Their business model is designed to delay, deny and redirect health care, we know a much better way: the much better way is to build a system into the traditional Medicare program. Fix the things that are wrong with Medicare … and then just insure them all.”
Moving to a single-payer, universal healthcare system would likely cost less than current national healthcare spending, according to a 2020 Academic analysis – and save tens of thousands of lives every year.
