Since the Affordable Care Act went into effect in 2014, the United States has made great strides in getting more people insured. Percentage of Americans aged 18 to 64 who are uninsured down from 18% before the ACA In 2022, it will increase to 9.5%. And pre-existing conditions will no longer preclude coverage or lead to higher premiums.
But even for those who have health insurance, insurance does not guarantee access to health care, much less access to quality, affordable health care. According to research, 1 in 3 Americans Reports of delaying or discontinuing treatment due to “seeking treatment”administrative burden” Problems navigating health insurance and the medical system create additional barriers beyond cost.
Some of these tasks are basic, such as scheduling an appointment. But others concern the strategies health insurance companies use to shape the care patients receive, tactics that are often unpopular with both doctors and patients.
Additionally, more than 40% of Americans under age 65 are enrolled in high-deductible plans, meaning patients face significant upfront costs to receive treatment. As a result, almost a quarter Even though you have insurance, you are unable to pay your medical bills.
as a scholar quality of medical care and policywe study how health insurance affordability and design impact people’s health and out-of-pocket costs.
We would like to identify the five most common strategies used by health insurance companies to ensure the delivery of care. Medically necessary, cost-effective, or both.
At best, these practices help ensure appropriate care is provided at the lowest possible cost. At worst, these practices become burdensome; counterproductivedepriving the insured of the care they need.
Denial of claim
Claims denial strategies gained a lot of attention following the murder of UnitedHealthcare CEO Brian Thompson. Higher rejection rate than peers. whole, nearly 20% Percentage of Americans insured through the ACA-created health insurance marketplaces whose claims were denied in 2021.
Although a denial may be justified in some cases, such as when a particular service is not covered by the plan, this represents 14% of in-network bill denials. more than three quarters Of the 2021 denials, no specific reasons were listed. This occurs after the service has already been done. This means that if a claim is denied, the patient will receive an invoice for the full amount.
ACA is required, but standardized process In case of appeal, Patients often do not understand Or feel free to file a dispute. Even if you understand the process, going through all the paperwork and procedures for an appeal can be time-consuming. Income and racial disparities Pursuing and winning an appeal will only deepen mistrust among people already struggling to get proper care and make ends meet.
pre-approval
pre-approval In addition to improving the efficiency and quality of care, healthcare providers are required to obtain prior approval from insurance companies before providing procedures or drugs under the guise of “medical necessity.”
While it makes intuitive sense to be cautious about expensive procedures and drugs, in practice these policies can lead to: delay in care or Even death.
moreover, increased use In recent years, the use of artificial intelligence to streamline pre-approvals has come under scrutiny. This includes 2023 class action lawsuit Following a lawsuit against United Healthcare for algorithmic denial of rehabilitation care, the federal government issued the following order: new guidelines.
The American Medical Association found that: 95% of doctors They reported that addressing prior authorization “somewhat” or “significantly” increased physician burnout, with more than 90% believing the requirement would have a negative impact on patients. Physicians surveyed by the association also reported that more than 75% of patients were unable to perform recommended treatments “often” or “sometimes” because of problems with prior authorization.
On average, physicians and their staff may respond to dozens of prior authorization requests per week, taking time and attention away from patient care. For example, I had something like this: Almost 2 pre-approval requests That adds up to more than 46 million people per Medicare Advantage enrollee in 2022.
small network
Health insurance plans form networks by contracting with doctors and hospitals. ACA required This is to “ensure sufficient choice of providers.”
If it’s in your plan network too smallPatients may have trouble finding a doctor who accepts their insurance or have to wait a long time for an appointment.
Breadth of planning despite state oversight and regulation The network has become significantly smaller over time. Almost 15% of plans on HealthCare.gov include No doctor in network in at least one of the nine major specialties; and More than 15% of doctors There were no Medicaid patients listed on the Medicaid managed care provider directory. Inaccurate provider directories compound the problemThat’s because patients may choose a plan based on bad information and then have a hard time finding treatment.
surprise bill
of Surprise Prohibition Law It went into effect in 2022 to protect consumers from unexpected charges for care received out of network. These bills typically have higher deductibles and out-of-pocket limits. double height We offer in-network care as well as higher coinsurance rates.
Before this law, 18% of emergency department visits and 16% of in-network hospitalizations At least one surprise bill.
While the Surprise Prohibition Act has helped solve some problems, a notable gap is that the Act does not apply to ambulance services. Approximately 30% of emergency transports and 26% of non-emergency transports may have caused an accident. surprise bill Between 2014 and 2017.
Pharmacy Benefits Manager
All of the largest health insurance companies have their own pharmacy benefits managers.
Three of them were processed: Aetna’s CVS Caremark, Cigna’s Express Scripts, and UnitedHealthcare’s Optum Rx Approximately 80% of all prescriptions It will be dispensed in U.S. pharmacies in 2023.
beyond the way market concentration Insurance company-owned pharmacy benefit managers influence competition and prices. exploit a loophole How much money insurance companies have to spend on patient care.
The ACA requires insurance companies to maintain: Medical loss rate 80%-85%That means you’ll have to spend 80 cents to 85 cents on medical care for every dollar you pay. Pharmaceuticals are Expanding share Plans can keep their funds within the parent company through their own pharmacy benefits manager.
moreover, Pharmacy benefit managers inflate drug costs They tend to overpay for their vertically integrated pharmacies, which means higher out-of-pocket costs based on higher prices. Most Pharmacy Benefits Managers Also Sabotage Pharmaceutical Companies Co-payment assistance program They no longer count toward patient cost-sharing, such as deductibles, and patients have to pay out-of-pocket costs longer.
Policy goals and reality
Despite the United States’ continued efforts to ensure that most citizens have access to affordable health insurance, insurance is increasingly not enough to provide access to the care and medicines that people need. is not sufficient to guarantee that
Industry reports indicate that profit margins are slim. 3%～6%nevertheless, billions of dollars in profits For many people, what they earn each year is daily struggle This is to ensure that patients receive the care they need.
These insurer tactics can have a negative impact on patients’ health and trust in the healthcare system, leaving patients in an incredibly difficult situation. It also undermines the government’s goal of providing affordable health care for all.
This article is republished from conversationis a nonprofit, independent news organization providing facts and trusted analysis that help you understand our complex world. It was written by: Monica S. Aswani, University of Alabama at Birmingham and paul schafer, boston university
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Monica S. Aswani has received funding for the past three years from the National Institute of Allergy and Infectious Diseases and the Pediatric Arthritis and Rheumatology Research Alliance. The views expressed in this article are those of the authors and do not necessarily reflect the views of the funding agencies.
Paul Schaefer has received research funding from the National Institutes of Health, Agency for Healthcare Research and Quality, Department of Veterans Affairs, and Office of Personnel Management. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of these institutions or the U.S. government.
