Even Doctors Are Frustrated With Health Insurance

0:04Our colleague Julie Wernow covers health and medicine. And for the last few weeks, she's been writing about the United Healthcare CEO, who was shot and killed in midtown Manhattan earlier this month. This is something that really seems to have struck a chord with almost everyone. It is this singular moment where literally everyone is talking about the same thing. The killing sparked a broader conversation about the role of insurance companies in the healthcare industry. and that conversation has found its way into Julie's inbox.

0:44She's been getting a ton of emails, many of them from people who are frustrated with their insurance companies. And one thing Julie's been surprised by was how many emails she's received from doctors. Can you just walk us through some of them and like maybe quote a couple? Let me pull up my very crowded inbox. Just give me one second. OK, here's one that says medical insurers are out of control. Regulators are worthless. She read me several of them. ...leaves countless patients and doctors outraged. Tell you the brazen techniques of UnitedHealthcare, which deny and delay approval and payment, that this is insurer misbehavior at its worst.

1:31And it's good to know people are becoming aware of the dangers of over-prioritizing profit over people.

1:41Doctors the journal spoke with made it clear they disavowed the shooting of the UnitedHealthcare CEO. Still, broadly speaking, doctors had two main complaints. One, patients are being denied treatment. And two, doctors are having to fight with insurance companies to get paid. It's something doctors have to deal with every day. and they say both issues are getting worse. Welcome to The Journal, our show about money, business, and power. I'm Ryan Knudsen. It's Thursday, December 19th.

2:21Coming up on the show, why doctors are fed up with insurance.

2:41How complicated would you say the insurance industry is? Incredibly complicated. As anybody who has tried to understand it knows, this is a Byzantine world that only a select few number of people really understand. And it is even, you know, confounding to doctors. How did insurers come to play this role in our health care system? I mean, ultimately, I think that, you know, the system was set up for a society that truly believes in, you know, that the cheapest, best way to run things is through a marketplace, right? And checks and balances. I mean, this is the way this was set up originally. I mean, the insurer in some ways is the check and balance of the system so that doctors can't sort of run amok and rack up a lot of medical expenses that are unnecessary, tests that are unnecessary just to get themselves paid.

3:50Still, many doctors say the system isn't working. They're seeing more and more insurance companies denying the care they prescribe. From a non-clinical standpoint, that's the worst part of my job. That's Dr. Alan Nguyen, a spine specialist in Fort Myers, Florida. It makes my blood boil. It makes me livid that someone else is dictating care for my patients when they have never laid hands on my patients. They've never seen my patient or interviewed them or questioned them to see the severity of their situation. How much time do you spend dealing with insurers? I have to put out maybe 30 minutes to an hour or so, three times a week.

4:32I work in a very large office, so we have a prior authorization department that sends in most of the information when the insurance requests it. But I have previously worked in offices where the doctor does not have a lot of resources and can't hire all the staff to do that. So they end up doing the majority of it, and the paperwork becomes very time-consuming. So how often does care that you're recommending get denied by an insurance company? A couple times a week, and it's becoming more frequent. — In Alan's case, he often has to lobby insurance companies to approve treatment before he can implement it, a process called pre-authorization.

5:17If it doesn't get approved, he can't do it unless the patient pays out of pocket. One procedure that he says gets denied a lot has to do with patients dealing with a spinal fracture. — There's a procedure I can do to fix that fracture. It's called a kyphoplasty. I put some bone cement in there. And for the right patient, they're up and walking with 95 % pain relief right after the procedure. They come in a wheelchair and they come out, they walk out of there, you know, smiling and walking just fine. And sometimes insurance companies won't authorize that procedure. What reason do insurance companies typically give for the denials?

6:00They say that the most common reasons would be that the patient doesn't need it, for instance, or it doesn't help or it's experimental. Or you didn't provide documentation to show that the patient has already tried X, Y, and Z before doing the injection. Health insurers say denying certain treatments is an important way for the entire healthcare industry to keep costs down. Sometimes there are a number of cheaper options available to a patient that they should be trying first before they skip right to, you know, a really expensive test, for instance, like an MRI. Or even after the MRI that they continue in physical therapy before they get surgery.

6:48There's a stepwise process that, you know, health insurers use to try to keep costs down.

6:57I asked Alan about this. What do you say to the insurance companies that say that, like, they're just trying to keep prices down and that physical therapy is a good and cheaper and less invasive option that ought to be tried first? I completely agree with them. I'm not trigger happy. I don't like to inject patients with needles and medications. If they can get better naturally, that's what I would prefer. That's what I would want for myself. I've had injections before. if I had gotten better with just therapy, I would have preferred that. It's always an option I offer. But sometimes they're in so much pain, they can't do physical therapy.

7:38I've tried to prescribe it, but I can't force a patient to do physical therapy. Julia says this is an experience she's heard from a range of doctors. They say these denials can discourage many patients from getting the treatments they need. They say that what happens is that patients who might really need treatment sort of now end up either waiting for treatment, or sometimes the delay to get that treatment means that the patient's condition worsens, or that they actually lose that patient. So one doctor I talked to had someone who was, they really needed an MRI that day, but because they were waiting for the pre-approval process, They had to send that patient home, wait 10 days, then, you know, her son had to try to get time off to bring her back for the MRI treatment.

8:27Often it's in that gap that patients just disappear. Sometimes before an insurance company will approve a claim, they require something called a peer-to-peer review. And what that's supposed to mean is that your doctor is matched up with a doctor inside the health insurance company to review your case and, you know, determine whether or not that care is needed. The idea is that it's an actual doctor at the insurance company who helps make the decision. The process usually requires the doctor submitting the claim to build a case for why an insurance company should approve and pay for the treatment.

9:03Now, some of these doctors are frustrated because the peer that they might be, you know, matched up with might not be someone who is in their specialty at all. So you might have, you know, an oncologist who's trying to have a peer-to-peer review with someone who's, you know, a family doctor or general practitioner, for instance. Alan has had mixed experiences with the peer-to-peer process. Sometimes it works and sometimes it doesn't because sometimes it doesn't matter what you tell them. I can show them all the studies that they requested to back up the procedure. And they might still say, oh, our company's guidelines, my employer's guidelines say that it's experimental and we cannot authorize it.

9:47But if you're a doctor speaking to another doctor trying to do what's best for the patient, you shouldn't let the company dictate what treatment the patient gets. I mean, how do you feel about the fact that part of your job is doing that? You can't just make a decision that you also have to then go and justify it with an insurance company. I think it's complete bullcrap because the middlemen, the insurance companies, undermine the physician-patient relationship. These are things we didn't learn about in medical school. We were taught that we should always do what's best for the patient and we don't have a choice here because we get compensated by the insurance company.

10:32When an insurer denies a treatment, there is an appeals process, though doctors say it can be cumbersome. AHIP, the health insurance trade organization, says the U.S. health system is, quote, fragmented and heavily regulated. It added that health insurance companies are, quote, working to protect patients from the full impact of rising costs while connecting them to care that is safe evidence-based and coordinated.

11:01A lot of other doctors we've learned feel similarly to you. A lot of other doctors have written into the Wall Street Journal about this issue. Does that surprise you? Not at all. Not at all. Because doctors complain about this stuff pretty often. We have Facebook groups where they post these kinds of stories all the time. But they're Facebook groups. They're private Facebook groups where you have to be a vetted physician to join. The public doesn't see it. I think these complaints should be more public.

11:40Coming up, how tussling with insurance companies can affect a doctor's business.

12:02Dr. Keith Berger is a gastroenterologist in Virginia. Keith runs a private practice, which means he's his own boss. Medicine runs in a family, and so Keith says private practice made a lot of sense for him. I could practice it the way my dad, my grandfather, my son and my brother doctors. His son's a doctor. My daughter's a doctor. We understand medicine. We get terrific ratings from our patients. But, you know, we may not be making the big bucks, and we are not making the big bucks in our practice. But we are treating people really the way they want to be treated or better. So how would you say that your relationship with insurance companies affects your practice financially?

12:45Well, last year I lost money for the first time ever. Ever. In 43 years of practice. Keith says there's a variety of reasons he lost money last year, including higher expenses and fewer patients. But he says insurance delays and denials are part of it. So imagine you've got maybe tens of thousands of dollars at stake and you don't know, are you ever going to get it paid? How are you going to get it paid? You know, it's just aggravating to be working in that kind of environment where every day it seems like a breakdown of some kind, an issue, and you're going to have to handle it and you have to go through this very elaborate process.

13:26It's aggravating. It's like a thorn in your side. For Keith's staff, that thorn is also very time-consuming. So when my staff are tied up doing, you know, fixing mistakes that insurance companies made or arguing with insurance companies about why they should pay for a colonoscopy or a CAT scan, you know, that sucks. First of all, it's really very discouraging because we work hard at being good at what we do and we hate to tell the patient, well, sorry, your insurance company isn't going to cover this when they should. uh so it's demoralizing from that standpoint and it's time you know like i said my office manager i only have one i pay her very well but how many jobs can she do and she's got to go through 100 charts that were underpaid by one of those insurance companies so i just imagine i don't know it's like sitting at a table of a poker game knowing that it's rigged how long do you want to play.

14:23How long do you want to play? Have you thought about selling your practice? I have. I got so dejected about this, my wife said to me, she said, honey, you got to make up your mind or you go understand. You can't, you got to stop complaining about this. I have some very good friends I've known for years in different GI practices. I looked at what they were doing. They were all bought out by private equity. For now though, Keith is staying independent. I used to tell people all the time coming out of medical school and residency, oh, you should go into private practice, be independent, it's great.

14:56You know, create the practice that fits you instead of kind of get in the corporate stress environment. Now I wouldn't advise anybody to do it. Insurance companies, of course, aren't solely to blame for the problems doctors are facing. Pharmaceutical companies, government regulators, and large hospital conglomerates also contribute to some of the same issues patients and doctors are frustrated with. Health insurance companies have said that, you know, they play a really important role in the healthcare system, that, you know, they're all trying to do the right thing here, that some of these complaints that come from patients and doctors are unjustified.

15:35You know, there's a lot of really important reasons that claims get denied. Often it's because, you know, there's not enough work being done to back up the claims that are being sent, you know, their lack information that would help them make a determination that would allow them to, you know, support a claim.

15:57Are you surprised by what you heard from doctors? What do you make of the fact that so many are angry? I think I actually, you know, I cover health care. I don't think I had, I don't think I realized how angry doctors were at health insurers. You know, I thought that they sort of understood that system more than I do as a patient or even as a reporter. And to get these letters, one after the other, saying, you know, we're just as angry as everyone else you're seeing on the internet, and we don't understand it either, and this entire industry is a total black box, and it's taking away our will to continue to be doctors, that was really troubling to me as someone who knows that this industry desperately needs more doctors.

16:48So after talking to so many doctors about the state of the insurance industry in the U.S., what's your takeaway? My takeaway is that if the health insurance, industry is working, it is unclear to Americans what it's supposed to be doing, why it makes the decisions it does. It's just become so complicated that people don't understand why they're getting charged what they're being charged, why they're being denied what they're being denied. And I think any attempt by the health insurance companies to pull back that curtain a little bit and let the public understand why these decisions are being made and how would really change the future of this industry.

17:54That's all for today. Thursday, December 19th. The Journal is a co-production of Spotify and The Wall Street Journal. Additional reporting in this episode by Josh Chaffin and Anna Wildey-Matthews.

18:09Thanks for listening. See you tomorrow.