[[link removed]]

BETWEEN YOU AND YOUR DOCTOR: HOW MEDICARE ADVANTAGE CARE DENIALS
AFFECT PATIENTS  
[[link removed]]


 

Matthew Cunningham-Cook
March 6, 2024
The American Prospect
[[link removed]]


*
[[link removed]]
*
[[link removed]]
*
*
[[link removed]]

_ As UnitedHealth racks up unprecedented profits, the people it
insures battle for care. _

, PATRICK SISON/AP PHOTO

 

In 2023, insurance behemoth UnitedHealth spent $8 billion
[[link removed]] buying back its
stock to juice its stock price—and its executive compensation, which
is tied to the company’s stock price. It spent 39% more on stock
buybacks in 2023 than in 2022. In 2023, it also spent $6.7 billion
[[link removed]] on
dividend payments—a 10% jump from the prior year.

The company’s CEO, Sir Andrew Witty
[[link removed]],
pulled in nearly $21 million
[[link removed]] in
2022—a 13%
[[link removed]] hike
from 2021. (His compensation for 2023 hasn’t been disclosed yet.)
Also in 2023, UnitedHealth spent $10.76 million
[[link removed]] lobbying
Congress. That doesn’t count the trade groups it belongs to; it
pumped $9.9 million
[[link removed]] into
those memberships in 2022 and hasn’t released the latest numbers
yet.

All of those reasons and more explain why Jenn Coffey, a 52-year-old
former EMT in Manchester, New Hampshire, can’t get the medicine she
needs to be able to enjoy life.

“UnitedHealth doesn’t care about me,” Coffey said. “I’m a
liability, I cost them too much money. They make a profit by not
giving me the care I need. The company is in charge of deciding who
does and doesn’t get care. My doctor says, ‘You need this
infusion.’ UnitedHealth is standing in the doorway saying, ‘No you
don’t.’”

With 33 million enrollees, Medicare Advantage plans now cover more
than half of all total Medicare beneficiaries. And while there are
major concerns about the program’s cost—as much as $140 billion
annually to taxpayers over traditional Medicare—equally if not more
concerning is the way MA plans often block access to care through
“prior authorization.”

Prior authorization, which is rarely used in traditional Medicare, is
when an insurer inserts itself in the decision-making process between
a doctor and a patient. It’s a practice that is supposed to reduce
costs and ensure appropriate care but is often used excessively by
private insurers and frequently results in significant treatment
delays.

Coffey has complex regional pain syndrome, a rare illness that
typically emerges after surgery or a heart attack. One of the few
effective treatments for CRPS is intravenous ketamine infusions. After
numerous appeals, UnitedHealth agreed to expedite its prior
authorization process for Coffey. But after paying for just one of her
ketamine infusions, the company stopped paying and stopped expediting.

“I have to get a prior authorization before I go in for an
infusion,” Coffey said. “It’s a never-ending nightmare with
them. I didn’t ask to get complex regional pain syndrome. I paid
into the system thinking it would be there for me. Now it’s not
there for me. I get nauseated and horrible headaches from being on the
phone for hours with UnitedHealth trying to get the care I need. But
it’s my only option. My only other choice is to do nothing and let
myself decay and die.”

UnitedHealth didn’t respond to a request for comment from _HEALTH
CARE Un-covered_.

Representative Pramila Jayapal (D-Wash.), the chair of the
Congressional Progressive Caucus, said in November that prior
authorization “has turned into a process of basically just stopping
people from getting care.” Senator Ron Wyden (D-Ore.)
told _Politico
[[link removed]]_,
“It was stunning how many times senators on both sides of the aisle
[during a recent Congressional hearing] kept linking constituent
problems with denying authorizations for care.”

In February 2023, researchers from KFF, a health policy think
tank, estimated
[[link removed]] that
there were 35 million prior authorization requests in 2021, the most
recent year for which data was available, and two million of the
requests were denied. Only 11% of the denials were appealed, but of
82% of the denials that were appealed, the original denial was
overturned. A rough estimate would suggest that there are as many as
1.5 million improperly denied Medicare Advantage prior authorizations
in a given year.

Sen. Ron Wyden told Politico, “It was stunning how many times
senators on both sides of the aisle kept linking constituent problems
with denying authorizations for care.”

The number is likely to continue to grow. As I reported for _The
Lever _last year, the two million denials in 2021 represented a
massive escalation from the 640,000
[[link removed]] in
2019 as estimated by the Inspector General for the Department of
Health and Human Services.

The Centers for Medicare and Medicaid Services (CMS) doesn’t
currently track denials by Medicare Advantage plans in any sort of
systematic fashion or publish plan-specific data on denials. That’s
why in December a bipartisan group of senators led by Elizabeth Warren
(D-Mass.) pushed
[[link removed]] CMS
Administrator Chiquita Brooks-LaSure to begin collecting data on prior
authorizations. In January, CMS released a set of technical rule
changes to prior authorization that should improve practices somewhat.
The changes, however, do not include
[[link removed]] drugs in the
requirement to report data on prior authorization denials, thus
excluding a huge potential dataset that would allow consumers to make
more informed choices about their Medicare Advantage plan. They also
don’t include cases like Coffey’s in which UnitedHealth is
refusing to cover the cost of her ketamine infusions. CMS did not
respond to a request for comment from _HEALTH CARE Un-covered__._

Even with at least two million prior authorization denials annually,
UnitedHealth could be taking steps to further restrict care in its
Medicare Advantage plans. In a financial filing
[[link removed]] from
February 2023, UnitedHealth complained about the Biden
administration’s decision
[[link removed]] to
slow growth in Medicare Advantage payments, saying the moves by CMS
would fall “well short of what is an increasing industry forward
medical cost trend, creating continued pressure in the Medicare
Advantage program.” The company said that as a result of the
administration’s actions, it might “seek to intensify our medical
and operating cost management, make changes to the size and
composition of our care provider networks, adjust member benefits and
implement or increase the member premiums supplementing the monthly
payments we receive from the government.” In other words, instead of
suspending stock buybacks and dividends for shareholders, it will
consider reducing benefits and making enrollees pay more.

Bill Kadereit, the director of the National Retiree Legislative
Network, said insurers’ aggressive use of prior authorization can be
lethal. “The bigger issue is the request for approval for a
procedure,” he said. “The time factor is as much of an issue as
the fact that a service is denied. People can die in the interim.”
In October 2023, the Medical Society of the State of New
York released
[[link removed]] a
survey showing that 94% of surveyed physicians found that prior
authorization delayed care and 89% reported that excessive prior
authorization had negative clinical impacts on patient outcomes. This
followed a March 2023 survey by the American Medical Association
which found
[[link removed]] that
one in three doctors said prior authorization had led to a serious
medical event, ranging from hospitalization to death or permanent
disability.

Coffey has been working with People’s Action
[[link removed]], a national network of community
organizing groups, to resolve her care crisis. They’ve made
progress: UnitedHealth has paid for one ketamine infusion and has
agreed to continue paying for them.

A report from Kaiser Family Foundation found 35 million prior
authorization requests were submitted to Medicare Advantage plans in
2021.

People’s Action was also able to help 30-year-old Carly Morton of
Beaver, Pennsylvania, get the care she needed. Morton has MALS, or
median arcuate ligament syndrome, a disease that can cause severe
stomach pain. The only cure for it is open-stomach surgery. For
months, UnitedHealth refused to pay for the surgery her doctor
requested.

“The pain got worse and worse and worse,” she said. “I was on a
feeding tube because I couldn’t eat. There weren’t surgeons in the
state who had the qualifications to do the surgery. I have a high risk
of dying in the next five years. Getting off the feeding tube greatly
increases my chance of thriving. The only other option is to
disintegrate into weakness. UnitedHealth was denying the surgery
because it was out-of-state.”

Morton said UnitedHealth had crafted a byzantine set of regulations
that was impossible for her to maneuver through. “I’m not
unintelligent. The way they have the system set up makes it impossible
to navigate.”

Despite repeatedly contacting UnitedHealth as her condition was
deteriorating, “I had gotten nowhere. I was desperate and at a point
that I had no hope,” Morton said.

But at that nadir, Morton was made aware of People’s Action’s
campaign to hold Medicare Advantage insurers accountable.

“Once I started working with them, they had advocates and a lawyer
experienced in the insurance industry,” and things finally began
moving. Among other things, People’s Action launched a petition with
more than 2,800
[[link removed]] signatures.
But even then, her hurdles were not overcome.

“Even once I understood things more and People’s Action got
involved, it was so much work to get the paperwork saying that I was
approved,“ she said. “It was ridiculous, and I was in so much
pain.”

Now, eight months after her surgery, Morton said, “It’s a world of
difference. I’m off the walker and the feeding tube. I’m
weightlifting. I’m so much healthier. My life is completely
different.”

The logic behind People’s Action’s work is to use individual cases
like Coffey’s and Morton’s to spark broader change across the
entire U.S. health care system.

“We are shedding light on the way Medicare Advantage insurers are
denying care and the way that those care denials impact people’s
ability to live the healthy lives they deserve and in turn juxtapose
it with the profits these companies are taking home,” said Aija
Nemer-Aanerud, the director of People’s Action’s Health Care for
All campaign.

“We’re organizing folks around the country to fight back against
unfair claim denials. And that’s an opportunity to organize a lot of
folks who are not yet politicized around the need for a public health
care system.”

Meanwhile, despite Morton’s success, Coffey, the former EMT, is
still fighting to get the care she needs and deserves.

“I have the one doctor in the state of New Hampshire capable of
giving me life-saving treatment,” referring to the ketamine
infusions. “If UnitedHealth doesn’t pay him and he closes his
doors, where do I go?”

_This article is a co-publication with HEALTH CARE un-covered, a
website about the health insurance industry. It is available
at wendellpotter.substack.com [[link removed]]._

_Matthew Cunningham-Cook is a writer and researcher with expertise in
health care, retirement policy, and capital markets. He has written
for The Intercept, The Lever, The New York Times, The Nation, Al
Jazeera, and In These Times._

_Read the original article at Prospect.org.
[[link removed]]_

_Used with the permission. © The American Prospect, Prospect.org,
2024. All rights reserved. _

_Click here to support the Prospect's brand of independent impact
journalism. [[link removed]]_

* Medicare Advantage
[[link removed]]
* For Profit Health Care
[[link removed]]
* patient care
[[link removed]]

*
[[link removed]]
*
[[link removed]]
*
*
[[link removed]]

 

 

 

INTERPRET THE WORLD AND CHANGE IT

 

 

Submit via web
[[link removed]]

Submit via email
Frequently asked questions
[[link removed]]
Manage subscription
[[link removed]]
Visit xxxxxx.org
[[link removed]]

Twitter [[link removed]]

Facebook [[link removed]]

 




[link removed]

To unsubscribe, click the following link:
[link removed]