Five of America’s largest health insurers reported more than $11bn in profits in the second quarter – a decline from the same period last year when the Covid-19 pandemic helped drive sky-high profits yet they are having more of a say on patients’ treatments even when HCPs disagree.
A vibrant 83-year-old man hurt his back while gardening. His neurologist diagnosed the problem as a disk issue that could be fixed with surgery. After the surgery, the patient was fine but needs rehab to build back the muscles in his leg and back. Unfortunately his insurance company, he pays $1400 a month for additional insurance, said no and put him in a nursing home for three days.
More and more insurance companies are putting profit ahead of patients
Then there is prior authorization. Doctors have long asserted that prior authorization — the need to get approval from the patient’s insurer before proceeding with treatment — causes delays that can hurt patient care.
In an American Medical Association survey conducted in December 2021, one-third of physicians reported that such delays have caused at least one of their patients to experience a serious problem, such as hospitalization, the development of a birth defect, disability, and even death.
In that same survey, more than 80 percent of surveyed doctors said patients at least sometimes abandon their recommended treatment because of prior authorization hassles. Just over half of the physicians who treat adult patients in the workforce said prior authorization has interfered with patients’ ability to do their jobs.
Prior authorizations also exact a toll on doctors, who say the paperwork has gotten out of hand. The average physician must now seek approval for dozens of prescriptions and medical services each week, an administrative burden that contributes to burnout and costs physician practices an estimated $26.7 billion in time each year.
Even when patients want a new drug their insurance company often says “no”. Many insurance companies refuse to cover new weight loss drugs that their doctors deem medically necessary.
Novo-Nordisk, the maker of Saxenda, and patient advocacy groups have been aggressively lobbying insurers to pay for weight-loss drugs. They also have been lobbying Congress to pass a bill that has languished through three administrations that would require Medicare to pay for the drugs.
No one disputes the problem — more than 40 percent of Americans have obesity, and most have tried repeatedly to lose weight and keep it off, only to fail. Many suffer from medical conditions that are linked to obesity, including diabetes, joint and back pain, and heart disease, and those conditions often improve with weight loss but insurance companies see the drug as a vanity drug and not a medical necessity.
People who pay for health insurance have seen their premiums increase but even when a doctor prescribes a treatment or medication it may not be enough. The idea that insurance companies could influence how patients should be treated emerged in the 1980s when insurers began requiring pre-approval for some hospital admissions and high-cost procedures before they would agree to pay for them. In the ensuing decades, prior authorization was extended to new high-cost drugs.
Prior authorization isn’t just a quick phone call to the insurance company and an immediate answer; rather, it’s often a weeks-long tug-of-war in which only the insurer knows the rules of the game.
The Medical Group Management Association, a trade group for physician practices, polled its members in 2019, a year after the consensus statement. Ninety percent said prior authorization requirements had increased. In its latest survey, conducted this spring, 98 percent said the situation had gotten worse or stayed the same over the past year.
Insurance companies profit while some patients lose.