Anthem – JustCare

Americans are extremely angry about US health care

The murder of UnitedHealthcare CEO, Brian Thompson, has revealed extraordinary anger among Americans over our health care system. Will Congress finally act to guarantee people access to needed care and prevent insurers from inappropriate delays and denials of care? Likely not.

Tens of thousands of people on social media reacted unsympathetically to the killing. ““When you shoot one man in the street it’s murder,” one person posted on the social media site X. “When you kill thousands of people in hospitals by taking away their ability to get treatment you’re an entrepreneur.”

Wendell Potter, a former Cigna exec and whistleblower, explains on CNN how the CEO’s murder happened just ahead of a shareholder and investor meeting of UnitedHealthcare. UnitedHealthcare satisfies its investors through restricting access to care. That’s how UnitedHealthcare maximizes profits.

Potter explained that “There’s a lot of just pent-up outrage at this company and other companies that are middlemen that are standing between a patient and his or her doctor or hospital.” For their part, Minnesota physicians report excessively high denial rates by UnitedHealthcare.

As a result of insurance company practices, people are not getting the medically necessary care they need. The casings on the bullet of the gunman who killed Thompson echo the practices of the insurers: “delay” and “deny.”

According to the Minnesota Star Tribune, United Healthcare also has been accused of relying on a claims process, supported by artificial intelligence, that had a 90% error rate in determining whether a requested treatment was medically necessary.”

The Star Tribune further reports on UnitedHealthcare’s insanely high denial rates. In 2021, “UnitedHealth’s qualified health plans in Arizona denied almost 39% of in-network claims.” UnitedHealthcare is the largest health insurer in the US. Another 16 smaller insurers had denial rates that were above 30%.

Only a few days ago, Anthem decided not to go forward with a proposal to limit anesthesia coverage for certain surgeries and other procedures. It appeared to act in response to massive outrage at the policy. Had Anthem moved forward with the proposal, it would have driven up health care costs for Americans and maximized profits for the insurer.

Here’s more from Just Care:

December 9, 2024

Don’t let your supermarket choose your health plan

Nona Tepper reports for Modern Healthcare on a new health insurer strategy to enroll more Medicare Advantage members. Anthem is partnering with Kroger to offer Medicare Advantage plans in several cities. If you want to be able to see the doctors of your choice without a private health plan second-guessing your doctors, don’t let your supermarket choose your Medicare health plan.

Kroger and Anthem likely both benefit from a partnership. Kroger gets more traffic in its stores and at its pharmacies and additional health care income. Anthem gets to use Kroger supermarkets as a venue for the delivery of primary care services at low cost; it doesn’t have to invest in real estate. Right now the supermarket market is growing at a much slower rate than the Medicare Advantage market.

We don’t yet know the exact form this partnership between Kroger and Anthem will take. It is set to launch in 2022. But, Anthem has 2.7 million subscribers to its Medicare Advantage and Medicare Supplemental insurance products. Kroger has more than 2,300 pharmacies and 200 health clinics.

Will it improve Kroger’s profits, perhaps. With fewer people going to the grocery story given the pandemic, it arguably it has more room in its stores to devote to health care, where profit margins are higher.

Will it reduce Anthem’s marketing costs for new enrollees in its Medicare Advantage plans? Most likely, yes. The average marketing costs for each new member in 2019 was between $500 and $2,300. Even still, Medicare Advantage plans earned an average of $222 a month for each member.

Here’s more from Just Care:

September 7, 2021

Medicare Advantage gold mine puts traditional Medicare at grave risk

Beware of corporate health insurers with eyes on Medicare. To date, these insurers have been taking our money in exchange for offering people benefits through Medicare Advantage plans and then running back to their shareholders with a fat share of their revenue. Healthcare Dive reports that these corporate health insurers have eyes on every Medicare dollar they can get their hands on; they are lobbying heavily for taking over traditional Medicare’s book of business.

Medicare Advantage plans continue to reap huge profits, so they are expanding into more areas and offering lots of goodies to lure people to enroll. But, what matters most is the quality of the care they are delivering, the costs they are imposing on people with serious health conditions, and the legitimacy of what they are charging for their services. On those issues, we know precious little. What we do know is that government audits over and over again indicate big problems.

For sure, these corporate health plans are not competing to deliver high value care to older adults and people with disabilities. They are doing their best to enroll people who are healthy, who don’t use a lot of services, and then claim that some of these people are in need of care coordination in order to reap greater revenue from the Centers for Medicare and Medicaid Services.

Medicare Advantage plans must have one of the best business models going. They say they are offering people Medicare health care benefits but no one has a clue what that means. We don’t know the extent to which they are pocketing money that should be going towards the health and well-being of people with Medicare or how to hold them to account when they are violating their contracts. What we do know is that many of these plans have high denial rates, some have high mortality rates and others have been found to deliver poor quality care. They are contracting with poorer quality nursing homes and home care agencies to provide services to their members.

Why Congress would consider giving these corporate health insurers more business is hard to understand if our representatives are putting the interests of their constituents and the national treasury first. Yes, some Medicare Advantage plans are helping people who cannot afford supplemental coverage in traditional Medicare. But, the answer should be to strengthen and improve traditional Medicare, which is far more cost effective and allows people unfettered access to the care they want and need, not to hand more business to corporate health insurers who by at least one recent account are responsible for not meeting their members’ care needs, leading them to die.

Medicare Advantage plans have a huge bag of tricks to seduce more people to enroll with them in 2021. But, even the Trump administration’s Department of Justice recognizes that at least some of these health insurers are engaging in massive fraud. HealthCare Dive reports a recent DOJ suit against Cigna alleging $1.4 billion in overcharges. There was a suit against Anthem in March and Sutter Health settled a similar fraud suit for $30 million.

Some might think that these insurers only commit fraud against the government. Keep in mind that these insurers also can profit handsomely by delaying and denying care and creating other administrative and financial barriers to keep people from receiving needed services that Medicare covers. Whether the Medicare Advantage plan you are enrolled in or might be considering switching to does or does not do so is a gamble you should not take lightly.

Here’s more from Just Care:

October 7, 2020

Coronavirus: Second-quarter profits double for big health insurers

Reed Abelson reports for The New York Times that second-quarter profits doubled for big health insurers from the same period in 2019. The Affordable Care Act imposes a limit on the profit that health insurers can keep. But, people with health insurance are not likely to see money back any time soon.

Because few people sought medical care for anything other than COVID-19 between April and June, insurers paid few claims. But, they collected the same premiums they always collect. So, the pandemic has served them very well so far.

The Trump administration has suggested that the health insurers with outsize profits, such as UnitedHealth Group, Anthem and Humana, speed up rebates. But, it has no authority to require them to do so. It also suggested that they lower premiums. Again, it has no authority to require them to lower premiums.

Because insurers are not legally allowed to change their premiums during the year, the Centers for Medicare and Medicaid Services is giving them the right to do so. Big whoopee. Insurers are not going to lower premiums, even if they can, since that would work against the interest of their shareholders.

The Affordable Care Act (ACA) allows health insurers to keep 15-20 cents on the premium dollar, depending upon the type of insurance they are selling, individual, small group or large group. They must pay out the other 80-85 cents for medical care. Still, holding on to extra premium money for as long as possible benefits them financially. And, the ACA gives them three years to hold on to the money.

The ACA effectively protects insurers that charge excessive premiums from having to return the excess money quickly on the theory that health care costs fluctuate and premiums might be inadequate to meet insurer expenses later on. For example, if people start going to the hospital and doctor at twice the rate they have been, insurers would have a cushion to pay those claims. Of course, the laws on premium-setting also protect insurers. They can relatively easily raise their rates next year.

CVS Health, which owns Aetna, saw its net income increase in the second quarter by $1 billion. Last year, its second quarter net income was $2 billion. Anthem saw its net income increase $1.2 billion in the second quarter. UnitedHealth, the largest health insurer in the US, saw its net income rise by $3.3 billion.

Taxpayer money for Medicare and Medicaid private health plans–Medicare Advantage and Medicaid managed care–has likely been paid to private health insurers in exchange for providing far less care than projected. If Medicare Advantage plans are able to keep the payments that they received for the first half of the year, they would be making out like bandits. The same is true for Medicaid managed care plans.

The pandemic is hurting most hospitals and doctors. Many hospitals and doctors are struggling to generate the revenue to stay in business. And, private health insurers owe them nothing. Proponents of a single government health insurance system–one without private health insurers designing insurance policies–explain that in such a system hospitals and doctors would be on a global budget with guaranteed revenue in good times and bad.

One as of yet unanswered question is whether employees at companies that are self-insured are seeing reductions in their insurance premiums. And, if not, why not? Their employers should be paying out less in claims.

The marketplace is clearly not able to ensure that Americans are getting the health care they need at a fair price. “We’re looking at the fact that health care can’t be regulated by the marketplace,” said Representative Pramila Jayapal. It’s time for Medicare for all.

As of now, Vice-President Biden is opposed to Medicare for all. It would be great if these enormous insurer profits led him to rethink his position.

Here’s more from Just Care:

August 11, 2020

Justice Department sues Anthem for Medicare Advantage fraud

Bob Herman reports for Axios that the Department of Justice is suing Anthem for fraud. The lawsuit, filed by the US Attorney’s Office for the Southern District of New York, claims that Anthem intentionally charged the government more for its members in Medicare Advantage plans than it should have in violation of the False Claims Act. We’ve heard this story before.

Anthem is not the only health insurance company offering Medicare Advantage plans that the DOJ has sued for fraud. Many Medicare Advantage plans have been charged with wrongly overcharging the government to the tune of tens of billions of dollars. The government has not been able to recoup this money.

The overpayments happen when health insurers claim that their members are in worse health than they actually are. The health insurers are supposed to make sure that their members have the health conditions they claim they have before billing the government higher rates for them. They also are required to pay the government back for any overcharges, which they practically never do.

It costs the federal government a lot of time and a lot of money to try to recoup the overpayments. And, the health insurers fight back. Billions in government overpayments mean both higher costs to taxpayers and higher premiums for people with Medicare.

Like the other health insurance companies offering Medicare Advantage plans, Anthem says that its practices are defensible. It also claims that CMS is engaged in a double standard when it tries to recoup money from Medicare Advantage plans based on payment standards it “does not apply to original Medicare.”

Most people with Medicare–about 36 million– are enrolled in traditional Medicare. With traditional Medicare, they can see virtually any doctor and use any hospital in the US, without a referral or prior authorization. They are protected from unexpected costs so long as they have supplemental coverage–Medigap, retiree coverage or Medicaid. But, the upfront costs can be higher than traditional Medicare for people who need to buy supplemental coverage to pick up the deductibles and coinsurance costs.

The ranks of people in Medicare Advantage are growing. These plans tend to have few if any upfront costs. The problem is that when you get sick, there are many barriers to care, including narrow networks, limits on where your care is covered, prior authorization requirements and copays. Out-of-pocket costs for in-network care alone can be as high as $6,700 a year.

Here’s more from Just Care:

March 30, 2020

Anthem keeps people from getting ER care simply by claiming it may not pay for it

The New York Times has a follow-up story on Anthem, the insurer that unconscionably denied some of its enrollees coverage for emergency care if it did not believe their diagnosis warranted it. According to a new congressional report, Anthem has reversed its policy. Still, Anthem likely has deterred its enrollees from seeking ER care.

In 2017, Anthem denied coverage for more than 12,000 emergency room visits, stating that they were unnecessary and “avoidable.” However, the patients who appealed Anthem’s denials were successful in most cases. The benefit to Anthem is that most people do not know they can challenge an appeal and that it can be worth it to do so. So, they ended up stuck paying ER bills that they likely should not have had to pay.

Anthem says it has now changed its policy, limiting its denials for ER visits. And, there is some evidence that it is now approving ER care in most instances. But, there is also a fear that its enrollees are worried about being denied coverage for their ER visits and not seeking ER care when they need it.

Anthem has been sued by doctors’ groups, who allege that Anthem violated the law with its ER policy since it forced patients to determine whether they needed ER care when they did not know their diagnoses. Let’s get real. People generally do not know whether they are having a heart attack or heartburn.

Anthem says that it is simply trying to keep its costs down since ER care is so expensive. Of course, the less it spends on care, the more profits it makes. Rather than penalizing patients who think they need ER care because ER costs are so high, Anthem should be arguing for Medicare for all, which would include rational prices for care.

Congress, for its part, should step in and support Medicare for All. Senators and House members should recognize that commercial insurers are unable or unwilling to rein in excessive and unsustainable provider costs. Instead, they shift responsibility onto their enrollees

If you support Medicare for all, please sign this petition.

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July 24, 2018

Insurers donate to Democrats in attempt to undermine support for Medicare for all

Tarbell reports that commercial health insurers are supporting Democrats with larger campaign contributions as a way to undermine their support for a government-administered Medicare for all health care system that does away with commercial insurance.

An increasing number of people are supporting Medicare for all, which would do away with for-profit insurance in the US. The latest Kaiser/Washington Post poll shows that a little more than fifty percent of Americans (51 percent) support government-administered Medicare for all. Only 43 percent of Americans are against it. And, many members of Congress are following the public’s lead.

To cover their bases and protect their industry, the five largest for-profit health insurers—Aetna, Anthem, Humana, Cigna and UnitedHealth—are using their political action committees to support members of Congress on both sides of the political aisle. They have given more than $1.6 million to House campaigns alone. One member of Congress, Joseph Crowley, whom the insurers believed would be their ally, lost his primary race to Alexandria Ocasio-Cortez, who supports Medicare for all.

Other House Democrats who are recipients of the health insurers’ financial support are Cheri Bustos of Illinois, Jim Hines of Connecticut, Ron Kind of Wisconsin, Ann McLane Kuster of New Hampshire, John Larson of Connecticut and Richard Neal of Massachusetts.

The health insurers would likely be very happy with Medicare Advantage for all, doing away with government-administered traditional Medicare. Of course, what they and their allies do not explain and what the public needs to understand is that Medicare Advantage would look very different if it were not competing with traditional Medicare. Costs would skyrocket; today, traditional Medicare holds doctor and hospital costs down for the Medicare Advantage plans. And, Medicare Advantage networks would shrink; today, Medicare Advantage plans need rich networks in order to compete with traditional Medicare. Moreover, Congress would have the ability to cut payments to Medicare Advantage plans and shift more costs to older Americans and people with disabilities with Medicare.

The health insurers are giving considerable support to the New Democrat Coalition, a pro-business, more centrist body of 68 House members than the Congressional Progressive Caucus, with 76 members.

If you support Medicare for all, please let Congress know. Sign this petition.

Here’s more from Just Care:

July 10, 2018

Anthem penalizes patients who seek emergency room care

Your heart is racing, your head is spinning, you have excruciating stomach pain. Should you go to the emergency room? Even with health insurance, you may end up paying the entire cost of your ER treatment, if it is later determined that you did not need emergency room care. Leslie Small reports for FierceHealthCare that, in select states, Anthem Blue Cross Blue Shield, the largest health insurer in America, does not cover ER care in these circumstances, penalizing patients who are afraid for their health and seek emergency room care.

New Anthem policies now make some exceptions to Anthem’s general practice in Georgia, Missouri, Kentucky, New Hampshire, Indiana and Ohio of denying coverage to patients who seek emergency care when it turns out they did not need it. It will cover care for patients who are directed by their doctors to go to the ER, for patients under 15, for patients post-surgery or testing, and for patients traveling out of state.

On its face, Anthem’s failure to cover emergency care when it turns out not to be needed is unconscionable, even with the new policy exceptions. Adults may not be able to distinguish between a heart attack and heartburn or hundreds of other symptoms that may or may not turn out to require emergency attention. Forcing people to absorb the full cost of their ER care if Anthem deems it unnecessary based on their diagnosis is tantamount to deterring people from using the emergency room when it might be critical.

Most people visit the ER because they believe their condition is serious, but they usually cannot know for sure; they need trained professionals to make that determination. Even doctors in potentially emergency situations may not know whether ER care is needed. Moreover, the idea of needing to reach your doctor for permission to visit the ER, to ensure coverage, in the course of a perceived emergency, is preposterous.

It is completely reasonable to encourage people to get needed care at the doctor’s office or a clinic, where appropriate, and not the ER. But, it is beyond unreasonable to deny people ER coverage altogether based on their ultimate diagnosis as a way to discourage ER use. It may deter them from getting necessary care or may put them at serious financial risk. As it is, through large deductibles and copays, insurers ration care based on people’s ability to pay, putting people’s health in jeopardy and lives on the line.

As Michael Hiltzik writes for the Los Angeles Times, state regulators need to ban Anthem’s anti-consumer ER coverage policy swiftly.

Here’s more from Just Care:

February 21, 2018

Commercial health insurance unreliable, costly

With President Trump and the GOP working to end health care coverage available under the Affordable Care Act, the state health care marketplaces have been in turmoil. Given the uncertainty about the ACA’s future, insurers are pulling out of many counties or raising their cost-sharing requirements significantly. And, we are seeing, yet again, that commercial health insurance is unreliable and costly. This market instability coupled with high costs make a compelling case for improved Medicare for all, a reliable and cost-effective federal public health insurance option.

The New York Times reports that 35,000 Americans in 45 counties may have no health insurance options in their state health care marketplaces in 2018. Another three million people in 1,388 counties are likely to have the choice of one high-priced plan with restricted or no access to the doctors and hospitals they know and trust. People in rural areas are most affected. If everyone had the option of traditional Medicare, they would be guaranteed easy access to a wide range of doctors and hospitals anywhere in the country and be virtually assured continuity of care.

In February, Humana announced that it would no longer be offering insurance in the health care marketplaces. And, Anthem just announced that it plans to stop offering coverage in Ohio and, as of yet, has made no commitment to offer marketplace coverage in any county in the U.S. And, the situation could get far worse. The Seattle Times just reported that the 300,000 people buying coverage in the Washington State health care marketplace could see a 22 percent increase in premiums in 2018.

To guarantee people affordable reliable coverage, the California legislature is well on its way to passing legislation that would effectively do away with commercial insurance and give everyone in the state improved Medicare for all. If we consider health care as a right, we should not be relying on commercial insurers to deliver coverage. They are less cost-effective than Medicare and unpredictable.

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June 21, 2017

Tag: Anthem