A look at the state of insurance system
By Eva Briggs, MD
I’m writing this shortly after United Healthcare CEO Brian Thompson was murdered.
While of course I don’t condone murder, I understand the frustration of patients and medical providers alike with the current state of our country’s healthcare insurance system.
For example, on a recent podcast, physician Will Flanary (known on social media by the handle Dr. Glaucomflecken) described his experience with getting prior authorization for injectable testosterone.
He had both testicles surgically removed to treat cancer and therefore his body cannot make testosterone at all. And yet every year his insurance company delays refilling his prescription until he essentially proves that his testicles did not grow back.
Flanary has been outspoken, using humor and satire to expose the crazy world of insurance prior authorizations. In fact, he annoyed Aetna enough that they thought they could ask him to remove his videos from the internet.
Although I am now retired from the urgent care, I understand his frustration.
Insurance companies often issued denials of radiologic procedures (generally CT scans). On my very last day of work, I spent close to half an hour arguing with an insurance company peer reviewer about their denial of a CT scan. It was the patient’s third visit to an urgent care within a week for abdominal pain. She clearly had something wrong even though she didn’t meet the official criteria for ordering an abdominal CT — no fever, no known elevated white blood count (which we can’t obtain stat in the urgent care), no involuntary muscle spasms when her abdomen was examined. The CT was abnormal. It revealed the reason for the patient’s pain. That enabled me to offer the correct treatment and kept the patient out of the emergency room. Even so, the reviewer refused to budge and stated they would not pay for the CT scan.
We’ve also become victims of pharmacy benefit managers (PBMs).
They essentially act to interfere with the doctor-patient relationship, often denying what the physician feels is the best medicine and recommending a substitute that is in their formulary. That formulary medicine is often something that the company manufactures or has another financial relationship with the drug maker. In other words, their choice is based on profit not medical need. This enables these companies to wiggle around the 15% cap on profits limit required by the Affordable Care Act.
In July 2024, the Federal Trade Commission issued a report about PBMs. It can be found at www.ftc.gov/system/files/ftc_gov/pdf/pharmacy-benefit-managers-staff-report.pdf
The report describes “how amidst increasing vertical integration and concentration, these powerful middlemen may be profiting by inflating drug costs and squeezing Main Street pharmacies.” I’m sure the power of the big three PBM companies (Express Scripts by Cigna, Optum by United Healthcare and CVS Caremark) helped lead to the closure of our Main Street Pharmacy here in Marcellus.
Cigna responded by suing the federal government asking them to retract the report. Flanary points out that what Cigna may be forgetting is that the legal discovery phase of their lawsuit will likely require Cigna to reveal their business practices for public scrutiny.
United Healthcare’s profits were in the neighborhood of $6 billion in 2024. They deny 17% of claims — 850 million claims. And currently only 1% of those are appealed.
Warris Bokhari, a former practicing physician who worked for a while as an insurance company executive, estimates that this affects 80 million individuals every year.
Bokhari decided to start a company that help patients file appeals for denied claims. It’s called Claimable www.getclaimable.com. I’ve never used this service so I can’t comment on its effectiveness. They charge a flat fee. I’m guessing around $75 as on the podcast I listened to, they stated “less than $80.” There are also many informative articles on their website.
I don’t have an answer to the mess our healthcare and insurance system is in currently. As tragic as Mr. Thompson’s murder was, perhaps it will spark some changes, improvements and transparency in the system.
Eva Briggs is a retired medical doctor who practiced in Central New York for several decades. She lives in Marcellus.