Many physicians have responded to the Luigi murder of United Healthcare CEO Brian Thompson, noting that while they understand the frustration of dealing with healthcare denials, killing a United Healthcare CEO isn't the answer to fixing the problem. Like other physicians, I don't approve of murder. The attention with the murder of Brian Thompson centers on insurance company denials. However, healthcare prior authorization denials come from many different payers. Physicians all have their particular experiences with various healthcare denials, from managed care organizations to Medicare and Medicaid. The problem is far bigger than just insurance companies.
I began practicing in 1977 and have dealt with all sorts of payers including Medicare, Medicaid, HMOs, and PPOs, I became just as disgusted with payer behavior as other physicians. I opened my first independent practice in 1989. By 1991, I wrote my first book, Modern Medicine, What You're Dying to Know. The book illustrates the problems created by corporate medicine, managed care, and insurances denying care to save money.
How much money? Well, the United Healthcare group is the largest insurance group. It makes almost 300 billion dollars per year and 28 billion dollars in profits. Reports of Thompson's compensation indicate about 10 million dollars.
Based on available in-network data for plans sold in the marketplace, Kaiser Permanente had the smallest claim denial rates by insurance company (7 percent). Kaiser once had the highest denial rate, but now that honor goes to United Healthcare at 32 percent.
Dr. Shakeel Ahmed in a KevinMD article says just the initial cost of the work of denying care costs about 25 percent of the health care budget, but nobody knows for sure because no one is tracking the cost to insurance companies of funding those employed to issue insurance denials. In Michael Moore's movie Sicko, he reports there are 1.4 million employees denying care for these companies.
Another topic no one is collecting data on is how much bigger and more expensive healthcare problems become when patient care is denied for problems in their early stages. How much does it cost to let little problems become big problems before treating the patients? No one knows because no one is tracking this data.
I have written here on Substack before about the cost of denying access to healthcare and how the U.S. has the most expensive health care in the world and a patient care record that ranks among the worst in the world.
Luigi reports that his mom started getting what sounds like peripheral neuropathy (PN) at about age 40. That is a young age to be developing PN. Now sometimes there are identifiable reasons for PN, such as diabetes, which can be treated and might offer some way to control PN pain. With PN, blood supply to the feet decreases for some reason. There are two problems with PN. One is that without feeling in your feet, it is easy to damage them, such as not noticing the cold or heat on your feet. The second problem is PN can cause a lot of pain, especially at night when trying to sleep.
People who have PN react in different ways. Often they become angry because there is no reliable treatment for the condition. Some want narcotics for the pain. At this time it is very difficult for physicians to prescribe opioids because of the campaign to prevent dispensing narcotics. The other problem with narcotics for pain is people tend to become used to one level of narcotics over time and keep needing higher and higher doses.
Another prescription option is gabapentin, but it doesn’t really work very well for PN. And besides, gabapentin is now on the disfavored medication list. According to Luigi’s story, his mom tried these meds, but as expected, they didn’t really do the job, partly because they never do. His mom had a lot of treatment and a lot of trouble, and of course mounting denials and delays. It appears to me that neither Luigi’s mom nor Luigi himself understood the diagnosis or the treatment of PN. In most cases, there really is no treatment besides learning to live with it.
The news coverage about Brian Thompson usually only includes information about insurance companies. As I mentioned earlier, I am just as frustrated as other physicians over the denial of needed care by insurance companies, but frankly, there are far greater problems with denials from state Medicaid programs than there are with insurance companies. Most articles on denial of care don't mention Medicaid. I have found the absolutely worst payer remains state Medicaid programs. With one of my patients, my office submitted one Medicaid claim 11 times. Everything was “wrong” including the size of the paper. So, when Luigi reports that United Healthcare said the notes had to be typed on paper, and after they were faxed, United Healthcare told the doctor that the notes couldn’t be faxed but had to be typed and sent by snail mail, it is no surprise. For patients as well as providers, this kind of circus doesn’t just occur once daily, but many times daily. Physicians are being forced to render bad care so payers can make more money. I believe you truly need to be without a conscience to participate in most insurance denials. In Michael Moore's movie Sicko, he shows a doctor testifying she felt guilty about denying care and was told by her employer to think about denying payment, not care.
In independent practice, I could provide what I considered to be necessary care even if I would not be paid for that care. Yes, I did the right thing many times when the payers did not. Since I was in independent practice, I had a lot of Medicaid patients who were high risk but I provided the care they needed whether Medicaid paid for my care or not. And I had no maternal mortalities in 6000 births.
Medicaid saved millions of dollars with my care. First, my free care provided good results for their Medicaid patients. This is something which is not understood by anyone looking at the cost of healthcare and there is no attempt to track these numbers. The best way to save money is to provide needed care. Preterm babies cost millions of dollars. Having healthy moms and healthy babies by providing needed healthcare is the basis of economical health care. The best care is the cheapest care.
Payers pretend to monitor and reimburse for good care, but the monitoring is not performed by a human being looking at the actual medical record. Increasingly requests for authorizations are done without human oversight. Questions and answers designed to fit the computer's ability to monitor data substitutes for determining good outcomes and the results often get the wrong answer because the computerized decisions are based upon incorrect endpoints. The endpoint in any research study is the outcome being monitored. Years ago, when Wyeth was doing studies of their Premarin, the study looked for improvement in cholesterol levels. Wyeth didn't monitor how long the subjects lived. When the Women's Health Initiative chose to look at life span as a desired outcome, it was found that Premarin lowered cholesterol levels, but also could decrease life span if started too late. The moral of the story—choose meaningful endpoints.
Decisions about whether to authorize medical care must include attention to the correct endpoint. Our legislators should be collecting data on the relationship between denial of health care and how long patients live after the denial of care. They should also be looking at the expense of treating a condition which was allowed to become worse by lack of early treatment. Wyeth and the public learned a hard lesson. Dr. N. Adam Brown writes about how sick of denials physicians are and suggests the time is right to correct this problem. Anything less is nothing more than denying care to make CEOs richer.
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