Mammon, god of greed,worshiped by those who value only money and material wealth.
Medicine, Politics and Money
Every wonder why money came to dominate all things medical in America? This page aims to untangle the mystery.
Marketplace Insurers Denied Nearly 1 in 5 In-Network Claims in 2020
Denial Rates Vary Widely Across Insurers from a Low of 1% to a High of 80%
Healthcare.gov marketplace insurers denied nearly one out of every five claims (18%) submitted for in-network services in 2020, though why the denial rates are so high and the ultimate consequences for consumers are difficult to access from the publicly available data, a new KFF analysis finds.
The Affordable Care Act requires insurers to report data about claims denials and appeals to encourage transparency about how insurance coverage works for enrollees. The analysis examines data released by the Centers for Medicare and Medicaid Services on more than 230 million claims submitted to 144 insurers selling marketplace coverage in 2020, the most recent year available.
The analysis finds a huge variation across insurers, which have average denial rates as low as 1% and as high as 80%. Denial rates also vary by state, though insurers within the same state often show wide variations as well. In Florida, for example, the average denial rate was 15%, but the three insurers with the largest market share of enrollees reported denial rates of 10.5% (Florida BCBS), 11.1% (Health Options), and 27.9% (Celtic Insurance).
The CMS data include some information about why in-network claims are denied, though the vast majority (72%) fall into a broad category of “all other reasons,” likely including administrative or paperwork errors and other issues.
Relatively few claims cite a specific reason such as lack of prior authorization or referral (10%), an excluded service (16%) or lack of medical necessity (2%). Among the claims denied for reasons of medical necessity, about 1 in 5 involved behavioral health services.
Consumers appealed few of the denied in-network claims in 2020, with fewer than 61,000 appeals in 2020, reflecting just over one-tenth of 1% of those denials. Following those appeals, insurers usually upheld their initial denials (63%), and consumers rarely took the next step to file an external appeal.
Healthcare.gov marketplace insurers denied nearly one out of every five claims (18%) submitted for in-network services in 2020, though why the denial rates are so high and the ultimate consequences for consumers are difficult to access from the publicly available data, a new KFF analysis finds.
The Affordable Care Act requires insurers to report data about claims denials and appeals to encourage transparency about how insurance coverage works for enrollees. The analysis examines data released by the Centers for Medicare and Medicaid Services on more than 230 million claims submitted to 144 insurers selling marketplace coverage in 2020, the most recent year available.
The analysis finds a huge variation across insurers, which have average denial rates as low as 1% and as high as 80%. Denial rates also vary by state, though insurers within the same state often show wide variations as well. In Florida, for example, the average denial rate was 15%, but the three insurers with the largest market share of enrollees reported denial rates of 10.5% (Florida BCBS), 11.1% (Health Options), and 27.9% (Celtic Insurance).
The CMS data include some information about why in-network claims are denied, though the vast majority (72%) fall into a broad category of “all other reasons,” likely including administrative or paperwork errors and other issues.
Relatively few claims cite a specific reason such as lack of prior authorization or referral (10%), an excluded service (16%) or lack of medical necessity (2%). Among the claims denied for reasons of medical necessity, about 1 in 5 involved behavioral health services.
Consumers appealed few of the denied in-network claims in 2020, with fewer than 61,000 appeals in 2020, reflecting just over one-tenth of 1% of those denials. Following those appeals, insurers usually upheld their initial denials (63%), and consumers rarely took the next step to file an external appeal.
How much will Medicare-for-all save Americans? A lot.
National Health Insurance- The Time Has Come
Can Small Independent Medical Practices Survive?
Unfortunately Medical Costs Are Out of Control- Why?
What’s the Point of a Primary Care Doctor?
How Medical Care Is Being Corrupted
When we are patients, we want our doctors to make recommendations that are in our best interests as individuals. As physicians, we strive to do the same for our patients.
But financial forces largely hidden from the public are beginning to corrupt care and undermine the bond of trust between doctors and patients. Insurers, hospital networks and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctor’s decisions.
Contracts for medical care that incorporate “pay for performance” direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice.
For example, doctors are rewarded for keeping their patients’ cholesterol and blood pressure below certain target levels. For some patients, this is good medicine, but for others the benefits may not outweigh the risks. Treatment with drugs such as statins can cause significant side effects, including muscle pain and increased risk of diabetes. Blood-pressure therapy to meet an imposed target may lead to increased falls and fractures in older patients.
Physicians who meet their designated targets are not only rewarded with a bonus from the insurer but are also given high ratings on insurer websites. Physicians who deviate from such metrics are financially penalized through lower payments and are publicly shamed, listed on insurer websites in a lower tier. Further, their patients may be required to pay higher co-payments.
These measures are clearly designed to coerce physicians to comply with the metrics. Thus doctors may feel pressured to withhold treatment that they feel is required or feel forced to recommend treatment whose risks may outweigh benefits.
It is not just treatment targets but also the particular medications to be used that are now often dictated by insurers. Commonly this is done by assigning a larger co-payment to certain drugs, a negative incentive for patients to choose higher-cost medications. But now some insurers are offering a positive financial incentive directly to physicians to use specific medications. For example, WellPoint, one of the largest private payers for health care, recently outlined designated treatment pathways for cancer and announced that it would pay physicians an incentive of $350 per month per patient treated on the designated pathway.
This has raised concern in the oncology community because there is considerable debate among experts about what is optimal. Dr. Margaret A. Tempero of the National Comprehensive Cancer Network observed that every day oncologists saw patients for whom deviation from treatment guidelines made sense: “Will oncologists be reluctant to make these decisions because of an adverse effects on payments?” Further, some health care networks limit the ability of a patient to get a second opinion by going outside the network. The patient is financially penalized with large co-payments or no coverage at all. Additionally, the physician who refers the patient out of network risks censure from the network administration.
When a patient asks “Is this treatment right for me?” the doctor faces a potential moral dilemma. How should he answer if the response is to his personal detriment? Some health policy experts suggest that there is no moral dilemma. They argue that it is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole.
We fear this approach can dangerously lead to “moral licensing” — the physician is able to rationalize forcing or withholding treatment, regardless of clinical judgment or patient preference, as acceptable for the good of the population.
Medicine has been appropriately criticized for its past paternalism, where doctors imposed their views on the patient. In recent years, however, the balance of power has shifted away from the physician to the patient, in large part because of access to clinical information on the web.
In truth, the power belongs to the insurers and regulators that control payment. There is now a new paternalism, largely invisible to the public, diminishing the autonomy of both doctor and patient.
In 2010, Congress passed the Physician Payments Sunshine Act to address potential conflicts of interest by making physician financial ties to pharmaceutical and device companies public on a federal website. We propose a similar public website to reveal the hidden coercive forces that may specify treatments and limit choices through pressures on the doctor.
Medical care is not just another marketplace commodity. Physicians should never have an incentive to override the best interests of their patients.
But financial forces largely hidden from the public are beginning to corrupt care and undermine the bond of trust between doctors and patients. Insurers, hospital networks and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctor’s decisions.
Contracts for medical care that incorporate “pay for performance” direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice.
For example, doctors are rewarded for keeping their patients’ cholesterol and blood pressure below certain target levels. For some patients, this is good medicine, but for others the benefits may not outweigh the risks. Treatment with drugs such as statins can cause significant side effects, including muscle pain and increased risk of diabetes. Blood-pressure therapy to meet an imposed target may lead to increased falls and fractures in older patients.
Physicians who meet their designated targets are not only rewarded with a bonus from the insurer but are also given high ratings on insurer websites. Physicians who deviate from such metrics are financially penalized through lower payments and are publicly shamed, listed on insurer websites in a lower tier. Further, their patients may be required to pay higher co-payments.
These measures are clearly designed to coerce physicians to comply with the metrics. Thus doctors may feel pressured to withhold treatment that they feel is required or feel forced to recommend treatment whose risks may outweigh benefits.
It is not just treatment targets but also the particular medications to be used that are now often dictated by insurers. Commonly this is done by assigning a larger co-payment to certain drugs, a negative incentive for patients to choose higher-cost medications. But now some insurers are offering a positive financial incentive directly to physicians to use specific medications. For example, WellPoint, one of the largest private payers for health care, recently outlined designated treatment pathways for cancer and announced that it would pay physicians an incentive of $350 per month per patient treated on the designated pathway.
This has raised concern in the oncology community because there is considerable debate among experts about what is optimal. Dr. Margaret A. Tempero of the National Comprehensive Cancer Network observed that every day oncologists saw patients for whom deviation from treatment guidelines made sense: “Will oncologists be reluctant to make these decisions because of an adverse effects on payments?” Further, some health care networks limit the ability of a patient to get a second opinion by going outside the network. The patient is financially penalized with large co-payments or no coverage at all. Additionally, the physician who refers the patient out of network risks censure from the network administration.
When a patient asks “Is this treatment right for me?” the doctor faces a potential moral dilemma. How should he answer if the response is to his personal detriment? Some health policy experts suggest that there is no moral dilemma. They argue that it is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole.
We fear this approach can dangerously lead to “moral licensing” — the physician is able to rationalize forcing or withholding treatment, regardless of clinical judgment or patient preference, as acceptable for the good of the population.
Medicine has been appropriately criticized for its past paternalism, where doctors imposed their views on the patient. In recent years, however, the balance of power has shifted away from the physician to the patient, in large part because of access to clinical information on the web.
In truth, the power belongs to the insurers and regulators that control payment. There is now a new paternalism, largely invisible to the public, diminishing the autonomy of both doctor and patient.
In 2010, Congress passed the Physician Payments Sunshine Act to address potential conflicts of interest by making physician financial ties to pharmaceutical and device companies public on a federal website. We propose a similar public website to reveal the hidden coercive forces that may specify treatments and limit choices through pressures on the doctor.
Medical care is not just another marketplace commodity. Physicians should never have an incentive to override the best interests of their patients.
America's Epidemic of Unnecessary Care
Medical Advertising. Patient Beware!
The lawyers advertising on TV are obviously looking to get rich. What of medical ads? Advertising by health care professionals was considered unethical until fairly recently. All hospitals are engaged in branding- advertising to proclaim institutional excellence. But what of other medical providers who advertise? Most prominent among physicians who advertise are doctors who offer services not covered by insurance- hair replacement, plastic surgery or laser treatment for spider veins. These doctors perform cosmetic procedures which patients are eager to pay premium prices to obtain. Physicians promoting procedures paid for by insurance such as surgery to promote weight loss and elective orthopedic procedures should also be looked at with caution. Some of the retail clinics within pharmacies raise even more alarming concerns. Clinicians are encouraged to stroll through the aisles wearing lab coats and ask shoppers about their health-care needs. They approach customers in the aisles and offer to explain different products and schedule appointments for them in the clinic. What does this advertising really tell you as a health care consumer? Money drives much of American medical care. Like any marketplace, caveat emptor. Patients beware!