Health insurance ought to epitomize a conduit to medical attention rather than a deterrent. Yet, an appreciable number of commercial health insurance company schemes frequently orchestrate deferment, discontinuity, and declination of medically indispensable interventions for patients.
Myriad instances of such maneuvers, culled from diverse corners of the nation, have gained prominence in recent media narratives.
A 67-year-old woman who smoked a lot had trouble with her insurance company. They kept saying no to getting an MRI to check for lung cancer. They thought the MRI was unnecessary. Later, she had to go to the emergency room because a big tumor was pressing on her windpipe. The delay caused by waiting for permission from her insurance company limited her choices, as explained by her son. Sadly, she died less than six weeks later.
A university student in Pennsylvania, who was struggling with ulcerative colitis, faced an unsettling situation. His health insurance company labeled him as a “high-value liability” and declined his treatment request for the severe stomach issue.
This decision was made despite their own doctor’s warning that leaving it untreated could be dangerous. Subsequent legal proceedings brought to light audio recordings where insurance personnel mocked the patient. ProPublica’s investigation uncovered these recordings and discussed the company’s efforts to justify their denial of treatment.
Further afield, a neonate was denied coverage for neonatal intensive care. The insurer, in elucidating the rejection, directly corresponded with the infant, asserting, “You are nourished by a vessel.”
These instances, albeit merely the visible apex, merely hint at a broader iceberg. The majority of patients who encounter repudiation remain obscured from the limelight, their predicaments failing to secure headlines.
The records of the American Hospital Association hold numerous similar stories originating from medical institutions and healthcare providers entangled in battles to support their clients, highlighting a growing problem.
Commercial insurers are increasingly obstructing patient access to essential healthcare and adding more requirements, creating a concerning situation. Apart from delays in obtaining prior authorization, some insurers are enforcing “fail first” strategies. This forces patients to first follow the insurer’s preferred treatment plan, regardless of the doctor’s recommendations.
Inequities exist in designated covered facilities. For example, some people are only allowed to receive their cancer treatment from certain providers, even if there are better options available. This can force people to switch to new providers with whom they may not be familiar.
Freshly conducted research by Morning Consult on behalf of the AHA serves to underscore the gravity of the situation. Over the last biennium, a staggering 62% of the surveyed cohort, numbering 1,500+, lamented treatment postponement due to their insurance providers, a trajectory linked with deteriorating health conditions.
While 54% of patients grapple with the economic viability of their health insurance, commercial insurers luxuriate in record-breaking profits. Conceivably, the encumbrances they institute encumber, indeed retard, care provisioning for their patrons.
These measures transgress not only upon patient access but also vitiate the ability of physicians, nurses, and allied clinical practitioners to discharge their duties. Prior authorization mandates siphoning valuable time away from the pursuit of life-rescuing healthcare interventions, potentially consuming hours each day. A 2022 poll conducted by the American Medical Association reveals that physicians and their retinue expend an average of 14 business hours—nearly 48 hours weekly—tackling prior authorization requisites.
In the same vein, roughly 95% of hospitals attest to the burgeoning temporal investment in responding to prior authorization submissions and registering appeals against denials. Much of this endeavor is devoted to contesting flawed insurer assessments, as the majority of appeals ultimately subvert denials. All these factors conjoin to impede clinical engagement with patients, amplifying the challenges faced by healthcare institutions in enlisting and retaining a commensurate workforce.
Over 80% of medical practitioners have identified this as a salient factor impacting their medical practice, a pivotal factor in the calculus. Concurrently, over half of nurses report a profound plunge in occupational contentment, attributed to the administrative burdens hoisted by insurers. Poignantly, the overwhelming consensus among patients reinforces the primacy of clinician determination in shaping their healthcare trajectory, relegating the role of health insurance.
