The killing of a top health insurance executive outside a Midtown Manhattan hotel this month triggered an outpouring of public anger at private health insurance companies. WSJ’s Julie Wernau reports that many doctors are among the aggrieved. And two doctors explain how dealing with health insurers is getting worse. Further Listening: - The Suspect in the UnitedHealth Killing Further Reading: - Doctors Say Dealing With Health Insurers Is Only Getting Worse - Clues Left by a Killer Echo Widespread Anger at Health Insurers Learn more about your ad choices. Visit megaphone.fm/adchoices
Chapter 1: What sparked the public's anger at health insurers?
Our colleague Julie Wernow covers health and medicine. And for the last few weeks, she's been writing about the UnitedHealthcare CEO who was shot and killed in midtown Manhattan earlier this month.
This is something that really seems to have struck a chord with almost everyone. It is this singular moment where literally everyone is talking about the same thing.
The killing sparked a broader conversation about the role of insurance companies in the healthcare industry. And that conversation has found its way into Julie's inbox. She's been getting a ton of emails, many of them from people who are frustrated with their insurance companies. And one thing Julie's been surprised by was how many emails she's received from doctors.
Chapter 2: How are doctors feeling about insurance companies?
Can you just walk us through some of them and like maybe quote a couple?
Let me pull up my very crowded inbox. Just give me one second. Okay, here's one that says medical insurers are out of control. Regulators are worthless.
She read me several of them.
leaves countless patients and doctors outraged. The brazen techniques of UnitedHealthcare, which deny and delay approval and payment, that this is insurer misbehavior at its worst. And it's good to know people are becoming aware of the dangers of over-prioritizing profit over people.
Doctors the journal spoke with made it clear they disavow the shooting of the UnitedHealthcare CEO. Still, broadly speaking, doctors had two main complaints. One, patients are being denied treatment. And two, doctors are having to fight with insurance companies to get paid. It's something doctors have to deal with every day. And they say both issues are getting worse.
Welcome to The Journal, our show about money, business, and power. I'm Ryan Knudson. It's Thursday, December 19th. Coming up on the show, why doctors are fed up with insurance. How complicated would you say the insurance industry is?
Incredibly complicated. As anybody who has tried to understand it knows, this is a Byzantine world that only a select few number of people really understand. And it is even, you know, confounding to doctors.
How did insurers come to play this role in our healthcare system?
I mean, ultimately, I think that, you know, the system was set up for a society that truly believes in, you know, that the cheapest, best way to run things is through a marketplace. Right. And checks and balances. I mean, this is the way this was set up originally. I mean, the insurer in some ways is it is the check and balance of the system itself.
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Chapter 3: What challenges do doctors face with insurance approvals?
In Alan's case, he often has to lobby insurance companies to approve treatment before he can implement it, a process called pre-authorization. If it doesn't get approved, he can't do it unless the patient pays out of pocket. One procedure that he says gets denied a lot has to do with patients dealing with a spinal fracture.
There's a procedure I can do to fix that fracture. It's called kyphoplasty. I put some bone cement in there and for the right patient, they're up and walking with 95% pain relief right after the procedure. They come in a wheelchair and they come out, they walk out of there, you know, smiling and walking just fine. And sometimes insurance companies won't authorize that procedure.
What reason do insurance companies typically give for and denials it?
They say that the most common reasons would be that the patient doesn't need it, for instance, or it doesn't help, or it's experimental, or you didn't provide documentation to show that the patient has already tried X, Y, and Z before doing the injection.
Health insurers say denying certain treatments is an important way for the entire healthcare industry to keep costs down.
Sometimes there are a number of cheaper options available to a patient that they should be trying first before they skip right to, you know, a really expensive test, for instance, like an MRI, or even after the MRI that they continue in physical therapy before they get surgery. There's a stepwise process that, you know, health insurers use to try to keep costs down.
I asked Alan about this. What do you say to the insurance companies that say that, like, they're just trying to keep prices down and that physical therapy is a good and cheaper and less invasive option that ought to be tried first?
I completely agree with them. I'm not trigger happy. I don't like to inject patients with needles and medications. If they can get better naturally, that's what I would prefer. That's what I would want for myself. I've had injections before. If I had gotten better with just therapy, I would have preferred that. It's always an option I offer.
But sometimes they're in so much pain, they can't do physical therapy. I've tried to prescribe it, but I can't force a patient to do physical therapy.
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Chapter 4: What are the common reasons for insurance denials?
Alan has had mixed experiences with the peer-to-peer process.
Sometimes it works and sometimes it doesn't because sometimes it doesn't matter what you tell them. I can show them all the studies that they requested to back up the procedure. And they might still say, oh, our company's guidelines, my employer's guidelines say that it's experimental and we cannot authorize it.
But if you're a doctor speaking to another doctor trying to do what's best for the patient, you shouldn't let the company dictate what treatment the patient gets.
I mean, how do you feel about the fact that part of your job is doing that? You can't just make a decision that you also have to then go and justify it with an insurance company.
I think it's complete bullcrap because the middlemen, the insurance companies, undermine the physician-patient relationship. These are things we didn't learn about in medical school. We were taught that we should always do what's best for the patient, and we don't have a choice here because we get compensated by the insurance company.
When an insurer denies a treatment, there is an appeals process, though doctors say it can be cumbersome. AHIP, the health insurance trade organization, says the U.S. health system is, quote, fragmented and heavily regulated.
It added that health insurance companies are, quote, working to protect patients from the full impact of rising costs while connecting them to care that is safe, evidence-based, and coordinated. A lot of other doctors we've learned feel similarly to you. A lot of other doctors have written into the Wall Street Journal about this issue. Does that surprise you?
Not at all. Not at all. Because doctors complain about this stuff pretty often. We have Facebook groups where they post these kinds of stories all the time. But they're Facebook groups. They're private Facebook groups where you have to be a vetted physician to join. The public doesn't see it.
Mm-hmm.
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Chapter 5: How does the peer-to-peer review process work?
Chapter 6: Why are delays in treatment harmful to patients?
I think these complaints should be more public.
Coming up, how tussling with insurance companies can affect a doctor's business.
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Dr. Keith Berger is a gastroenterologist in Virginia. Keith runs a private practice, which means he's his own boss. Medicine runs in a family, and so Keith says private practice made a lot of sense for him.
I could practice it the way my dad, my grandfather, my son and my brother doctors. His son's a doctor. My daughter-in-law's a doctor. We understand medicine. We get terrific ratings from our patients, but we may not be making the big bucks, and we are not making the big bucks in our practice, but we are treating people really the way they want to be treated or better.
So how would you say that your relationship with insurance companies affects your practice financially?
Well, last year I lost money for the first time ever, ever, in 43 years of practice.
Keith says there's a variety of reasons he lost money last year, including higher expenses and fewer patients. But he says insurance delays and denials are part of it.
So imagine you've got maybe tens of thousands of dollars at stake and you don't know, are you ever going to get it paid? How are you going to get it paid? It's just aggravating to be working in that kind of environment where every day it seems like a breakdown of some kind, an issue, and you're going to have to handle it and you have to go through this very elaborate process. It's aggravating.
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