After public outrage and political pressure, insurers like Cigna are rolling out “reforms” and glossy reports but the same opaque systems of denial, delay and self-policing remain.
People sometimes need comprehensive, compassionate, curative and comfort care. Medicare for ALL promises that care. Surveys are not helpful in this care.
(One plan yes ONE single insurance plan publicly funded)
Immediately prior to the Thompson murder, the ERISA Advisory Council of the Employee Benefits Security Administration, U.S. Department of Labor, decided to review aspects of the claims and appeals process, including prior authorization. They decided to continue their investigation and analysis despite the social media firestorm and public anger, and made a number of recommendations. See: https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/about-us/erisa-advisory-council/2024-claims-and-appeals-procedures.pdf
For plans subject to ERISA (probably covering 150+MM Americans), there are specific timelines and processes already in place. The regulations also identify different types of health care claims and the time limits for deciding claims as to each type. Urgent care claims, which are defined as situations where, in the opinion of a physician who has knowledge of the patient’s condition, the patient’s life or health is in jeopardy, or where the patient is in severe pain that cannot be managed without the care that is being sought16 must be decided within 72 hours of receipt. Pre-service claims must be decided within 30 days of receipt of the claim, while post-service claims must be decided within 60 days.
Importantly, 100+ MM of the 150+MM Americans with employer-sponsored coverage are in self-insured plans. In a self-insured plan, the claims administrator's fees are typically a function of the number and amount of claims paid. So, less prior auth, more paid claims, more fees to the claims administrator. However, almost all economists agree that workers pay the full cost of their health coverage, either directly (through contributions and point of purchase cost sharing such as deductibles, copayments, coinsurance, etc.) or indirectly (employer contributions preclude a payment of higher wages). That conclusion was a significant component of Health Reform, the Patient Protection and Affordable Care Act of 2010 ("Cadillac Tax" or "High Cost Health Plan" 40% excise tax - which was delayed and then repealed prior to implementation).
Your article suggests that providers perceive prior authorization (a dispute over the necessity or appropriateness of a particular service - ultimately deciding whether the recommended service is covered under the plan, and in turn, who will pay and how much) is almost always an "evil" of the private insurance/coverage system.
Your article asks for greater transparency. But, for the vast majority of employer-sponsored coverage, insured or self-insured, we already have the specific claims and appeals processes. Seems to me that each individual participant in an employer-sponsored plan actually gets notice of the prior auth decision, and has the ability to appeal - 100% transparency guaranteed to the patient/participant.
Instead, you seem to argue in favor of eliminating or severely curtailing the use of prior authorization. OK. My 46+ years of corporate benefits experience confirms that insurer /claims administrator profits are very much a function of the premium or funding received, and that, with prior authorization eliminated or severely curtailed, the insurance premium or funding would be significantly higher.
So, if Congress passed a law eliminating prior auth (say amending the Patient Protection and Affordable Care Act of 2010, which would change ERISA, the Internal Revenue Code and the Public Health Services Act), insurers / plan sponsors would have to appropriately price the coverage (with a greater margin), and, over time, insurers / claims administrators would consistently achieve higher profits (and expend less resources in processing prior authorizations, claims and appeals) - even after adjusting for the 15% Medical Loss Ratio limit.
Exactly my plan. A new health system, not insurance for all. We have the basics set up, the Public Health Service. We have an example, the VA medical system. Get rid of insurance, as they would say "it's not medically necessary" (to have insurance). I put out a plan in my book, "Fed Med". We don't need insurance.
You should approach your state representatives and have them pass legislation that would seek the appropriate waivers under the Patient Protection and Affordable Care Act of 2010 (Health Reform, signed into law 3/23/2010) so that you could pilot a single payer initiative and demonstrate for the other 49 states how single payer can succeed in America.
How would your proposal vary from what Vermont proposed and ultimately rejected prior to implementation - due to widespread concerns about the economic impact of increased taxation and the lack of clarity on cost sharing (both point of enrollment and point of purchase)?
Why would the premium have to be raised? That's EXACTLY what they want you to think. UHC made 44.4 BILLION in the first QUARTER of this year. I think they will survive without raising premiums.
While health insurer profits are substantial, they pale in comparison to the cost of coverage for the remaining uninsured individuals. And, in most Medicare For All proposals, there is a desire to reduce the point of purchase cost sharing, many prefer $0 spend out of pocket. So, unless you limit utilization and/or provider reimbursements, you will have to substantially increase revenue (whether you call it premium or taxes) in order to avoid adding to our annual federal deficit.
Keep in mind that precisely because the Medicare Modernization Act of 2003 and the Patient Protection and Affordable Care Act of 2010 failed to raise revenue, we started to add more and more to our federal budget deficits, where we have added $29+ Trillion to our national debt since 3/23/10 (the day President Obama signed Health Reform into law).
Again, Health Spending today is already 18+% of GDP, about 25% of personal income. Universal access and coverage would open the gates to increased utilization.
Either Americans would have to pay more, providers would have to accept less, or some of both.
Is that why the plans are dumping thousands of pagtients?? One CEO said if Medicaid wasn't "profitable", that the company would just have to "exit" those states. Profit over patients every time Jack.
You should approach your state representatives and have them pass legislation that would seek the appropriate waivers under the Patient Protection and Affordable Care Act of 2010 (Health Reform, signed into law 3/23/2010) so that you could pilot a single payer initiative and demonstrate for the other 49 states how single payer can succeed in America.
How would your proposal vary from what Vermont proposed and ultimately rejected prior to implementation - due to widespread concerns about the economic impact of increased taxation and the lack of clarity on cost sharing (both point of enrollment and point of purchase)?
Keep in mind, however, that it is insurance companies who serve as TPAs to process claims under traditional Medicare and Medicaid.
Further, given all of the fraud in Medicare and Medicaid, wildly underestimated by GAO during the Biden Administration as over $100 Billion a year (because no one challenges appropriateness before treatment, only post service), you should also expect the increased taxes, premiums, FICA-Med (whatever you want to call the funding) of a Medicare For All solution to go to an ever increasing number of ever more sophisticated fraudsters.
I would happil;y embrace a single payer program that works.
However, to date, the single payer most people want, a Senator Sanders "Medicare For All" solution, would be one with no deductibles or copayments or coinsurance that covers everyone and is funded by additional progressive taxation. Dependency on other people's money (e.g., tax the rich) will quickly devolve into "don't tax you and don't tax me, tax that guy behind the tree".
As we saw in Vermont, there isn't a willingness to pay. Lots of folks have been convinced that health care is a right, same as "free speech". So, any change that proceeds on a federal basis, where we are already have a crazy ~$2 Trillion a year in annual deficits, a $39+ Trillion national debt, and where we already expect massive increases in the existing federal commitments for medical spending makes no sense. At current deficit spending, the CBO predicts our national debt will approach $167 Trillion by 2055.
Federal health programs will cost over $26 trillion through 2036, under the Congressional Budget Office (CBO) baseline, making health care the largest category of federal spending. In this piece, we show:
Keep in mind that health care is already the largest area of federal spending, and projected to grow in size from less than $2 trillion today to over $3 trillion by 2036. It already adds substantial amounts to our federal deficits.
Without change, Medicare spending will double over the next ten years. Medicaid/CHIP will increase by over a third, as will Health Reform exchange subsidies.
Federal medial spending already exceeds all other areas of the federal budget. Total federal spending (Medicare, Medicaid/CHIP, Exchange subsidies) > spending on Social Security, defense, and interest on the debt, and the disparity will significant increase over the next decade.
I believe the federal government would be receptive to any state program of single payer that covers everyone yet saves money or arrests the inflationary trend.
Plopping down, of possible interest by some readers, an interview airing last night on Amanpour of health-policy writer, and former ER doc, Elizabeth Rosenthal.
Her focus is the problem of people waiting for hours or days in or in the halls just outside of ERs, waiting for a bed to be admitted.
I have the video pointed, though, to a spot where she counters the impression that hospitals structured as "not for profit" are that much less problematic than for-profit hospitals. (As I find a claim that our problem is the for-profit model an over-simple error made by numerous commenters here and all over Substack and everywhere else.)
A little later on in the video, I also find interesting the information that hospitals generally have a "VIP office", which is our society's social way of handling requests of those with more social power to jump over the rest of us.
Health insurance is not HEALTHCARE! We really don't need health insurance, it is one symptom of our current healthcare crisis. We need to start with a better model, funded appropriately and designed to provide care to all Americans. I describe it in detail in my book, "Fed Med". We need to get profitability out of healthcare. A federal system like the VA with improvements would establish care not profit as the overriding mission. It wouldn't be mandatory but the improvements would make private care obsolete. Remember the words they like to use "it's not medically necessary!" and apply it to the need for insurance. It is not medically necessary.
Headlines aren't going to solve the problem of trust. People don't trust the headlines, and they will see that things don't change. Oz and those in power (government and industry) continue to use the old methods, when people are noticing how they don't benefit people but are great for corporations. In the back of my mind, I wonder if our nightmare of a system will inevitably lead to universal health care, when things are so broken that's the fix. There are only more people going without that care, and the costs are eating GDP at scary rates (despite ACA intending to mitigate that...it wasn't enough, and the efforts to undermine it have been too successful). I also worry about how people are reaching a breaking point, and how much uglier that could get, when the powerful are not trying to solve the problems for the people.
I would love to be a guest on the show. I have YEARS of stories of what insurance companies and PBMs have put me through re: prior authorization. I also have recordings of conversations with PBMs. And I promise, this administration doesn't do anything unless they're getting benefit from it. We need single payer in the U.S., not Medicare for all, not universal coverage, SINGLE PAYER.
Also, right after Brian Thompson was murdered, the head of UHC's parent company literally said on an all hands (internal) call, that what we consider denial of care, they think is doing what's in the best interest of the patient and saving us money and senseless testing, etc. So he literally doubled down on "maximizing shareholder value." He was "replaced" shortly thereafter with someone who I'm sure will continue to "put the patient at the center of everything we do."
$79 trillion has been transferred from the working class to the wealthy over the last 50 years. This current Republican administration is transferring a whole lot more to the wealthy and family fortunes.
Even the wiser of Oz is attempting to deny care in our beloved traditional, original Medicare to ensure more grift.
Health insurance is not healthcare! We need to redo the structure of healthcare not just who pays for our healthcare. A system similar to the VA but with meaningful improvements. I lay it out in my book "Fed Med". There is so much more than just who is paying inflated costs for a shoddy product, we need to address them all. Medicare for all sounds good but would just inflate prices even more. Get rid of the profit motive, switch to providing care, period. A phrase that is used by the insurance industry should be applied to them. Health insurance "isn't medically necessary!"
They are money hoarders who deny care, but can afford PR, so maybe we don't notice.
Yes, private for profit commercial health insurance industry is constantly causing enormous confusion and gaining enormous corporate welfare & profits
People sometimes need comprehensive, compassionate, curative and comfort care. Medicare for ALL promises that care. Surveys are not helpful in this care.
(One plan yes ONE single insurance plan publicly funded)
Appreciate the article.
Immediately prior to the Thompson murder, the ERISA Advisory Council of the Employee Benefits Security Administration, U.S. Department of Labor, decided to review aspects of the claims and appeals process, including prior authorization. They decided to continue their investigation and analysis despite the social media firestorm and public anger, and made a number of recommendations. See: https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/about-us/erisa-advisory-council/2024-claims-and-appeals-procedures.pdf
For plans subject to ERISA (probably covering 150+MM Americans), there are specific timelines and processes already in place. The regulations also identify different types of health care claims and the time limits for deciding claims as to each type. Urgent care claims, which are defined as situations where, in the opinion of a physician who has knowledge of the patient’s condition, the patient’s life or health is in jeopardy, or where the patient is in severe pain that cannot be managed without the care that is being sought16 must be decided within 72 hours of receipt. Pre-service claims must be decided within 30 days of receipt of the claim, while post-service claims must be decided within 60 days.
Importantly, 100+ MM of the 150+MM Americans with employer-sponsored coverage are in self-insured plans. In a self-insured plan, the claims administrator's fees are typically a function of the number and amount of claims paid. So, less prior auth, more paid claims, more fees to the claims administrator. However, almost all economists agree that workers pay the full cost of their health coverage, either directly (through contributions and point of purchase cost sharing such as deductibles, copayments, coinsurance, etc.) or indirectly (employer contributions preclude a payment of higher wages). That conclusion was a significant component of Health Reform, the Patient Protection and Affordable Care Act of 2010 ("Cadillac Tax" or "High Cost Health Plan" 40% excise tax - which was delayed and then repealed prior to implementation).
Your article suggests that providers perceive prior authorization (a dispute over the necessity or appropriateness of a particular service - ultimately deciding whether the recommended service is covered under the plan, and in turn, who will pay and how much) is almost always an "evil" of the private insurance/coverage system.
Your article asks for greater transparency. But, for the vast majority of employer-sponsored coverage, insured or self-insured, we already have the specific claims and appeals processes. Seems to me that each individual participant in an employer-sponsored plan actually gets notice of the prior auth decision, and has the ability to appeal - 100% transparency guaranteed to the patient/participant.
Instead, you seem to argue in favor of eliminating or severely curtailing the use of prior authorization. OK. My 46+ years of corporate benefits experience confirms that insurer /claims administrator profits are very much a function of the premium or funding received, and that, with prior authorization eliminated or severely curtailed, the insurance premium or funding would be significantly higher.
So, if Congress passed a law eliminating prior auth (say amending the Patient Protection and Affordable Care Act of 2010, which would change ERISA, the Internal Revenue Code and the Public Health Services Act), insurers / plan sponsors would have to appropriately price the coverage (with a greater margin), and, over time, insurers / claims administrators would consistently achieve higher profits (and expend less resources in processing prior authorizations, claims and appeals) - even after adjusting for the 15% Medical Loss Ratio limit.
What do you recommend?
They keep us fighting the weeds when the answer is simple: single-payer universal healthcare.
Exactly my plan. A new health system, not insurance for all. We have the basics set up, the Public Health Service. We have an example, the VA medical system. Get rid of insurance, as they would say "it's not medically necessary" (to have insurance). I put out a plan in my book, "Fed Med". We don't need insurance.
Works for me.
You should approach your state representatives and have them pass legislation that would seek the appropriate waivers under the Patient Protection and Affordable Care Act of 2010 (Health Reform, signed into law 3/23/2010) so that you could pilot a single payer initiative and demonstrate for the other 49 states how single payer can succeed in America.
How would your proposal vary from what Vermont proposed and ultimately rejected prior to implementation - due to widespread concerns about the economic impact of increased taxation and the lack of clarity on cost sharing (both point of enrollment and point of purchase)?
https://en.wikipedia.org/wiki/Vermont_health_care_reform
https://www.npr.org/2017/09/13/550757713/why-bernie-sanders-single-payer-health-care-plan-failed-in-vermont
Why would the premium have to be raised? That's EXACTLY what they want you to think. UHC made 44.4 BILLION in the first QUARTER of this year. I think they will survive without raising premiums.
With 70% of profit off taxpayer’s dolly
Yes!
While health insurer profits are substantial, they pale in comparison to the cost of coverage for the remaining uninsured individuals. And, in most Medicare For All proposals, there is a desire to reduce the point of purchase cost sharing, many prefer $0 spend out of pocket. So, unless you limit utilization and/or provider reimbursements, you will have to substantially increase revenue (whether you call it premium or taxes) in order to avoid adding to our annual federal deficit.
Keep in mind that precisely because the Medicare Modernization Act of 2003 and the Patient Protection and Affordable Care Act of 2010 failed to raise revenue, we started to add more and more to our federal budget deficits, where we have added $29+ Trillion to our national debt since 3/23/10 (the day President Obama signed Health Reform into law).
Again, Health Spending today is already 18+% of GDP, about 25% of personal income. Universal access and coverage would open the gates to increased utilization.
Either Americans would have to pay more, providers would have to accept less, or some of both.
Is that why the plans are dumping thousands of pagtients?? One CEO said if Medicaid wasn't "profitable", that the company would just have to "exit" those states. Profit over patients every time Jack.
Again, works for me, ...
You should approach your state representatives and have them pass legislation that would seek the appropriate waivers under the Patient Protection and Affordable Care Act of 2010 (Health Reform, signed into law 3/23/2010) so that you could pilot a single payer initiative and demonstrate for the other 49 states how single payer can succeed in America.
How would your proposal vary from what Vermont proposed and ultimately rejected prior to implementation - due to widespread concerns about the economic impact of increased taxation and the lack of clarity on cost sharing (both point of enrollment and point of purchase)?
https://en.wikipedia.org/wiki/Vermont_health_care_reform
https://www.npr.org/2017/09/13/550757713/why-bernie-sanders-single-payer-health-care-plan-failed-in-vermont
Keep in mind, however, that it is insurance companies who serve as TPAs to process claims under traditional Medicare and Medicaid.
Further, given all of the fraud in Medicare and Medicaid, wildly underestimated by GAO during the Biden Administration as over $100 Billion a year (because no one challenges appropriateness before treatment, only post service), you should also expect the increased taxes, premiums, FICA-Med (whatever you want to call the funding) of a Medicare For All solution to go to an ever increasing number of ever more sophisticated fraudsters.
Show us how it should be and can be done.
I'm glad it "works for you" ...
I would happil;y embrace a single payer program that works.
However, to date, the single payer most people want, a Senator Sanders "Medicare For All" solution, would be one with no deductibles or copayments or coinsurance that covers everyone and is funded by additional progressive taxation. Dependency on other people's money (e.g., tax the rich) will quickly devolve into "don't tax you and don't tax me, tax that guy behind the tree".
As we saw in Vermont, there isn't a willingness to pay. Lots of folks have been convinced that health care is a right, same as "free speech". So, any change that proceeds on a federal basis, where we are already have a crazy ~$2 Trillion a year in annual deficits, a $39+ Trillion national debt, and where we already expect massive increases in the existing federal commitments for medical spending makes no sense. At current deficit spending, the CBO predicts our national debt will approach $167 Trillion by 2055.
Federal health programs will cost over $26 trillion through 2036, under the Congressional Budget Office (CBO) baseline, making health care the largest category of federal spending. In this piece, we show:
Keep in mind that health care is already the largest area of federal spending, and projected to grow in size from less than $2 trillion today to over $3 trillion by 2036. It already adds substantial amounts to our federal deficits.
Without change, Medicare spending will double over the next ten years. Medicaid/CHIP will increase by over a third, as will Health Reform exchange subsidies.
Federal medial spending already exceeds all other areas of the federal budget. Total federal spending (Medicare, Medicaid/CHIP, Exchange subsidies) > spending on Social Security, defense, and interest on the debt, and the disparity will significant increase over the next decade.
I believe the federal government would be receptive to any state program of single payer that covers everyone yet saves money or arrests the inflationary trend.
Plopping down, of possible interest by some readers, an interview airing last night on Amanpour of health-policy writer, and former ER doc, Elizabeth Rosenthal.
https://www.youtube.com/watch?v=7mdIwgwBBgY&t=680s
Her focus is the problem of people waiting for hours or days in or in the halls just outside of ERs, waiting for a bed to be admitted.
I have the video pointed, though, to a spot where she counters the impression that hospitals structured as "not for profit" are that much less problematic than for-profit hospitals. (As I find a claim that our problem is the for-profit model an over-simple error made by numerous commenters here and all over Substack and everywhere else.)
A little later on in the video, I also find interesting the information that hospitals generally have a "VIP office", which is our society's social way of handling requests of those with more social power to jump over the rest of us.
Health insurance is not HEALTHCARE! We really don't need health insurance, it is one symptom of our current healthcare crisis. We need to start with a better model, funded appropriately and designed to provide care to all Americans. I describe it in detail in my book, "Fed Med". We need to get profitability out of healthcare. A federal system like the VA with improvements would establish care not profit as the overriding mission. It wouldn't be mandatory but the improvements would make private care obsolete. Remember the words they like to use "it's not medically necessary!" and apply it to the need for insurance. It is not medically necessary.
Headlines aren't going to solve the problem of trust. People don't trust the headlines, and they will see that things don't change. Oz and those in power (government and industry) continue to use the old methods, when people are noticing how they don't benefit people but are great for corporations. In the back of my mind, I wonder if our nightmare of a system will inevitably lead to universal health care, when things are so broken that's the fix. There are only more people going without that care, and the costs are eating GDP at scary rates (despite ACA intending to mitigate that...it wasn't enough, and the efforts to undermine it have been too successful). I also worry about how people are reaching a breaking point, and how much uglier that could get, when the powerful are not trying to solve the problems for the people.
just subscribed as a paid member - want to say thank you for your reporting and candor
I would love to be a guest on the show. I have YEARS of stories of what insurance companies and PBMs have put me through re: prior authorization. I also have recordings of conversations with PBMs. And I promise, this administration doesn't do anything unless they're getting benefit from it. We need single payer in the U.S., not Medicare for all, not universal coverage, SINGLE PAYER.
Also, right after Brian Thompson was murdered, the head of UHC's parent company literally said on an all hands (internal) call, that what we consider denial of care, they think is doing what's in the best interest of the patient and saving us money and senseless testing, etc. So he literally doubled down on "maximizing shareholder value." He was "replaced" shortly thereafter with someone who I'm sure will continue to "put the patient at the center of everything we do."
$79 trillion has been transferred from the working class to the wealthy over the last 50 years. This current Republican administration is transferring a whole lot more to the wealthy and family fortunes.
Even the wiser of Oz is attempting to deny care in our beloved traditional, original Medicare to ensure more grift.
Y por eso los grandes amores….
M4A
Health insurance is not healthcare! We need to redo the structure of healthcare not just who pays for our healthcare. A system similar to the VA but with meaningful improvements. I lay it out in my book "Fed Med". There is so much more than just who is paying inflated costs for a shoddy product, we need to address them all. Medicare for all sounds good but would just inflate prices even more. Get rid of the profit motive, switch to providing care, period. A phrase that is used by the insurance industry should be applied to them. Health insurance "isn't medically necessary!"
Wiser of Oz do not should on yourself
Thank you for your persistent efforts. Ironically, nothing seems to change. Only their stocks keep going up. Here are today's prices.
Symbol Last Price Change (%)
UNH
370.74
+1.08%
ELV
376.63
+3.83%
CI
292.32
+2.60%
CVS
83.90
+3.61%
HUM
243.12
+5.83%
OSCR
17.93
-0.61%