This post is written by Dr. Manuel Momjian, MD – founder of Urgent 9.
It seems that health insurance companies have been making lots of money over the last four years, since the passage of the Affordable Care Act. Stock prices for major health insurance companies are outperforming the rest of the market across the board. At the same time, our health insurance premiums seem to be going up, and our out of pocket expenses are through the roof. But a new troubling trend is also emerging: major health companies seem to be denying care to patients without proper medical justification.
Earlier this month, Urgent 9 wrote a blog post regarding a decision by Anthem Blue Cross to pull coverage for IV anesthesia to patients that undergo cataract surgery. The California Medical Association first brought up the issue and urged an investigation. The new Anthem policy required those that needed IV anesthesia to pay for these services out-of-pocket. It’s hard to believe that this policy decision could have been made for any other reason than saving money. But why does Anthem even need to save more money? Anthem’s stock prices have more than doubled in the past four years.
In mid February, we also got ground-shaking news that the third largest health insurer, Aetna, is being investigated by both of California’s health insurance regulators for improper denial of care. The investigation started with an Aetna patient with a rare immune system disorder known as common variable immune deficiency. This patient needed regular expensive medications for this condition, which were denied by the insurance company. The patient went on to develop pneumonia and was hospitalized for a collapsed lung.
Aetna’s medical director recently admitted during a legal deposition that he had not looked at the patients records before denying coverage. The director also admitted that he had no experience treating this disease process. The California Insurance Commissioner, Dave Jones weighed in on these developments recently: “If a health insurer is making decisions to deny coverage without a physician ever reviewing medical records, that is a significant concern and could be a violation of the law,” Jones said.
Insurance companies regularly deny medical testing and treatments, in order to save money. The way this process works makes most doctors’ blood boil, because it can take hours to complete — and is usually not compensated work. The insurance company will refuse to pay for services that require an authorization until the patient or patient’s doctor makes a case to the insurance company that the services or treatments are necessary.
If this investigation into Aetna becomes fruitful, it might require significant changes to insurance company practices. Imagine if insurance companies are forced to send a specialist physician with adequate experience in treatment of a patient’s medical condition out to examine a patient, and review charts before a denial of coverage could be made. Now that sounds much more reasonable, especially when your health is on the line.
It is becoming evidently clear that the conflicts of interest between insurance giants and ordinary American patients may be untenable. Large publicly traded insurance companies are beholden to their stock holders to operate profitably. They will continue to raise their prices without explanation and they will not hesitate to put pressure on well paid medical directors to continue to cut costs and deny services.
Health insurance companies earned the trust of the American people over the past half century providing services to patients at their most fragile moments. But what we have been seeing over the last four years is something quite different. We are witnessing trusted insurance company reputations go down in flames. They have started to self destruct and are trying to make as much money as possible in the process.
In the aftermath of this current insurance meltdown, a grass roots effort needs to start to bring healthcare back to reality. Doctors need to take control back of our healthcare system by innovating new models of care. Doctors, not insurance companies should make decisions about when and how to treat patients. At Urgent 9, Urgent Care Center, we understand the problems with our current healthcare system — and we are actively working to make common sense solutions outside the constraints of the dysfunctional health insurance industry.