JustCare

Tag: Delay

  • Will UnitedHealth stop denying care inappropriately or simply deny doing so?

    Will UnitedHealth stop denying care inappropriately or simply deny doing so?

    Shareholders at UnitedHealth are proposing that the company study and report publicly on the financial and public health consequences of its policies that lead to delays and denials of health care. These shareholders want people to vote on their request at UnitedHealth’s annual meeting, reports Rylee Wilson for Becker’s Payer.

    Specifically, the shareholders want UnitedHealth to report on the frequency of delays of care and foregone care, as well as harm to patients, resulting from UnitedHealth’s prior authorization requirements. Put differently, they want the company to disclose how its prior authorization requirements affect access to treatment.

    UnitedHealth claims it will respond to these shareholders once it schedules its annual meeting in June. The shareholders, represented by the Interfaith Center on Corporate Responsibility, represent more than 300 institutional investors. (UnitedHealth has more than 5,000 institutional investors.)

    The shareholders argue that these inappropriate delays and denials might boost short-term profits, but they risk hurting the UnitedHealth brand.

    Wendell Potter, head of the Center for Health and Democracy, explains that the inappropriate care denials harm more than patients. UnitedHealth defends its behavior saying that it pays 90 percent of claims, which might be true. The problem is that the 10 percent of claims it denies are often for coverage of expensive life-saving or otherwise critical care.

    Meanwhile, UnitedHealth is poised to announce big year-end profits. Some say UnitedHealth will have more than an eight percent year-over-year earnings growth. Fourth-quarter earnings are projected to be about $6.72 a share. If so, it would be a 9.1 percent increase from last year’s fourth quarter.

  • Americans are extremely angry about US health care

    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:

  • Doctors and hospitals face increasing claims denials

    Doctors and hospitals face increasing claims denials

    The big health insurers are destroying our health care system, while profiting wildly. They cannot rein in costs, so Americans with insurance often cannot afford their care. Moreover, the insurers don’t appropriately reimburse physicians and hospitals for the services they deliver. Jeff Lagasse reports for Healthcare Finance on a new report revealing the increasing rate of claims denials health care providers are facing.

    In his review of The State of Claims 2024 report by Experian, Lagasse points out that providers do not have the technology to contest insurers’ claim denials efficiently. The report also focuses heavily on provider concerns about insurer preauthorization rules and policy changes that prevent them from getting paid appropriately.

    Our government allows corporate health insurers to hold all the cards. They decide what health care services to pay for and when, second-guessing treating physicians on what services are medically necessary. And, they are rarely accountable for failing to cover services they are supposed to cover or for delaying payment. Rather, they are accountable to Wall Street to increase profits, which creates a powerful incentive for them to deny and delay care and provider reimbursements.

    Policy changes, claims denials and payment delays are three ways insurers are increasingly profiting at the expense of providers:

    • 77 of providers say that insurer policy changes are occurring more frequently.
    • 73 percent say that insurers are denying claims more frequently.
    • 67 percent say that insurers are delaying payment more often.

    Nearly four in ten providers (38 percent) say that insurers are denying claims ten percent of the time or more. More than a third of the time, insurers refuse to authorize care. The rest of the time, insurers claim that data is missing from provider claims.

    The rate of Medicare Advantage denials is increasing with each passing year. The Kaiser Family Foundation recently reported that in 2022, Medicare Advantage insurers denied 7.4 percent of prior authorization requests, up from 5.8 percent in 2021 and 5.6 percent in 2020. It’s no wonder that this year alone more than 24 health systems have cancelled their Medicare Advantage contracts.

    Lagasse cites a 2017 report revealing that health care organizations several years ago lost $262 billion on claim denials out of $3 trillion in claims submitted, in a single year. After appealing, at a cost of $8.3 billion, the providers recouped 63 percent of that money. Insanity.

    Maybe AI can deliver greater efficiencies for health care providers and increase their revenues, as some suggest. But, you have to imagine that the insurers will always be at least one step ahead.

    Here’s more from Just Care:

  • Hospitals delay care for older adults in ERs, causing them needless harm

    Hospitals delay care for older adults in ERs, causing them needless harm

    Judith Graham reports for KFF Health News on the plight of older adults in hospital emergency rooms. Hospitals often keep older adults in their ERs for extended periods before getting them admitted to the hospital. Hospitals could benefit financially from these delays, but patients can suffer.

    The evidence shows that older adults often can wait more than a day to be admitted to the hospital, although their doctors have recommended a hospital admission long before. In the ER, patients often are not getting their care needs met. They are prevented from moving much, and they are usually not well fed or hydrated.

    The problem is only getting worse, according to ER physicians. And, older adults appear to be kept in ERs longer than most other people. But, there’s little data to understand how common ER boarding is and which hospitals are the worse offenders. Hospitals do not need to report this data. It’s also not clear which hospitals do not have adequate space for patients.

    Why are some people spending so much time in ERs? In some cases, hospitals are short-staffed. In other cases, people needing care that is highly profitable get preferential treatment and are moved out more quickly than those who need less profitable care. In still other cases, hospitals don’t have enough beds because they are unable to discharge patients for home health care or to a nursing facility as quickly as they should be able to.

    In an ER, older adults can quickly see their conditions worsen. They lose muscle from sitting or lying all day. They may not be taking their medicines. They may become delirious.

    Unnecessary stays in the ER can mean longer hospital stays and more health issues for older adults. Patients generally don’t get proper care in the ER, except to address an immediate crisis. They can fall, get hospital-acquired infections, bedsores and worse. They are more likely to die in the hospital if they spend the night in the ER needlessly.

    What to do if you’re admitted to the ER? Don’t go alone. Make sure you have a family member or friend or caregiver with you to speak out on your behalf, ensure you are fed properly, and otherwise well cared for. Bring a list of your medicines and bring a bag with the medicines you take, if possible.

    Also, protect yourself against delirium. Bring your hearing aids and glasses to avoid being disoriented and some food and drink. If you can get up and move around, do so.

    Here’s more from Just Care:

  • Hospitals dropping Medicare Advantage because of concerns with patient care

    Hospitals dropping Medicare Advantage because of concerns with patient care

    St. Charles Health System, a large hospital system in central Oregon likely will not continue to participate in Medicare Advantage, reports KTVZ.com. The hospital system’s leaders are concerned about patient care in Medicare Advantage. People with Medicare who want to know they have access to the best hospitals, including access to cancer centers of excellence, should switch to traditional Medicare.

    St. Charles is not alone; many hospital systems are not taking Medicare Advantage enrollees. St. Charles’ CEO says that the hospital system has considered dropping Medicare Advantage plans for some time because of mounting concerns. He reports that his hospital system is not alone. Hospital systems throughout the country are concerned about patient care in Medicare Advantage. The Mayo Clinic stopped taking Medicare Advantage enrollees at some sites last year.

    In the CEO’s words: “The reality of Medicare Advantage in Central Oregon is that it just hasn’t lived up to the promise. A program intended to promote seamless and higher-quality care has instead become a fragmented patchwork of administrative delays, denials, and frustrations. The sicker you are, the more hurdles you and your care teams face. Our insurance partners need to do better, especially when nurses, physicians and other caregivers are reporting high levels of burnout and job dissatisfaction.”

    The American Hospital Association (AHA), the trade association for most hospitals reports that it “is increasingly concerned about certain (Medicare Advantage) plan policies that restrict or delay patient access to care, which also add cost and burden to the health care system.” To make matters worse, it appears that some Medicare Advantage plans are engaged in fraud as well as inappropriate delays and denials of care and coverage.

    St. Charles hospital executives see higher rates of denials of care in Medicare Advantage and long arduous processes for getting Medicare Advantage plans to approve medically necessary care. St. Charles health system is considering whether it will renew Medicare Advantage contracts with PacificSource, Humana, HealthNet and WellCare.

    The bottom line: With traditional Medicare, your treating physicians call the shots, deciding what care is medically reasonable and necessary, and Medicare covers that care, without second-guessing and coming between you and your doctors. With Medicare Advantage, many insurance companies second guess treating physicians and deny care or delay care, endangering patient health.

    The Office of the Inspector General has reported widespread and persistent inappropriate delays and denials of care and coverage in Medicare Advantage. But, the Centers for Medicare and Medicaid Services (CMS) has so far refused to identify the bad actors or sanction them appropriately, putting older adults and people with disabilities at serious risk.

    Healthy patients in Medicare Advantage should be fine. But, even if you are healthy today, you could need complex care tomorrow and your insurance should cover that care. That’s why we have health insurance. In some Medicare Advantage plans, you might not get needed care in a timely manner, if at all, regardless of whether you need it.

    Here’s more from Just Care:

  • Congress sits on its hands while Medicare Advantage insurers gouge taxpayers and enrollees

    Congress sits on its hands while Medicare Advantage insurers gouge taxpayers and enrollees

    The Medicare Advantage program, Medicare Part C, which allows corporate health insurers to contract with the government to offer Medicare benefits, was born with the assumption that it could save Medicare money. Instead, a new report out of the mainstream USC Schaeffer Center for Health Policy and Economics estimates that Medicare Advantage plans are costing taxpayers and people with Medicare an additional $75 billion in overpayments this year alone. The report only confirms findings by University of California at San Diego professor, Richard Kronick, of massive government overpayments to Medicare Advantage, but Congress sits on its hands.

    Republicans in Congress don’t seem to care about eliminating all the waste in Medicare Advantage. It’s the health insurers offering Medicare Advantage plans that will help fund their 2024 reelection campaigns. And, that’s not something they want to jeopardize. Many Democrats in Congress also appear to live in fear of losing support from the corporate health insurers and are doing little to address the massive overpayments, as they should.

    How do these Medicare Advantage overpayments happen? Medicare Advantage overpayments happen for a variety of reasons, but the largest reason is that people enrolled in Medicare Advantage are considerably healthier than people in traditional Medicare.  Because of a defective payment system, the government pays Medicare Advantage plans as if their enrollees are sicker than people in traditional Medicare. The high proportion of people who are healthy in Medicare Advantage cost these Medicare Advantage plans on average less than $1,000 a year as compared to the more than $12,000 a year the government typically pays Medicare Advantage plans to care for them.

    MedPac, the agency overseeing these government payments, has calculated the overpayments at $27 billion this year because the Medicare Advantage plans assign multiple diagnosis codes to their enrollees in order to boost their earning and often get quality bonus payments as well. But, MedPac has not factored into its calculations the $50 billion or so a year in Medicare Advantage overpayments resulting from the Medicare Advantage population being so much healthier than the traditional Medicare population.

    The researchers at USC appreciate that the Medicare payment system for Medicare Advantage plans is defective and needs an overhaul. Paying the insurers offering Medicare Advantage plans as the government currently does leads to massive overpayments. The researchers, however, do not speak to the fact that the defective payment system–upfront payments unrelated to the cost of services delivered– also leads to massive inappropriate delays and denials of care to people. People with cancer, heart disease, stroke and other costly and complex conditions are most at risk–and that’s most of us, if not now, down the road.

    The USC researchers like the idea of competitive bidding among MA plans as an alternative to the current payment system, which I hear is a nonstarter from the MA plans’ perspective. That shouldn’t matter, but it does. Regardless, competitive bidding doesn’t address the need to ensure that the payment system stops creating a disincentive for the Medicare Advantage plans to withhold care from the people who most need it–the 10 percent of people with Medicare with the costliest conditions.

    The government’s payment system will be right only if and when the Medicare Advantage plans are promoting their high value care for people with cancer, heart disease and stroke. Until then, consider enrolling in traditional Medicare if you can. If you enroll in Medicare Advantage, beware the Medicare Advantage plans engaged in widespread delays and denials of care. The administration is not naming them for the most part. And sometimes, it is giving them four and five-star ratings.

    Here’s more from Just Care:

  • Poll: Many more older adults delayed care because of cost in 2022

    Poll: Many more older adults delayed care because of cost in 2022

    Nearly four in ten Americans reported that they or a family member delayed health care last year because of the cost. That’s an all-time high and a huge increase from the year before. Even with Medicare, many more older adults also report delaying care.

    The Gallup poll shows a 12 percent increase in Americans skipping health care in 2022 from 2021. There was no change in people’s response to the question of whether they or a family skipped care between 2020 and 2021. But, 2022 was  a year of tremendous inflation, which has made life even more difficulty for most adults.

    Even more troubling is that Americans reported that they or their family members often delayed treatment for serious conditions in 2022. Of the 38 percent who reported delays in care, 27 percent said that the delays were for very serious or somewhat serious treatments.

    Not surprisingly, people with annual incomes under $40,000 were more likely to say that they or a family member had delayed care for a serious health condition (34 percent) than people with incomes above $100,000 (18 percent). And, 12 percent more people with lower incomes delayed care for serious conditions in 2022 than in 2021. People with incomes between $40,000 and $100,000 delayed care almost as much as people with incomes under $40,000 (29 percent).

    Women and younger adults also were more likely to report delays in getting medical treatments for serious conditions for themselves and family members. Almost one in three women (32 percent) reported delaying care in sharp contrast to one in five men. That’s an increase of 12 percentage points for women in just one year.

    About one in eight (13 percent) people with Medicare reported delaying care in 2022. That’s nearly double– a six percent increase–those reporting delays in care just a year earlier. Still, people with Medicare were less likely to report delaying care because of cost than working people and young adults.

    Here’s more from Just Care: