Even Doctors Are Frustrated With Health Insurance

Summary

Podcast Summary: The Journal – "Even Doctors Are Frustrated With Health Insurance"

Introduction

In the December 19, 2024 episode of The Journal, hosted by Ryan Knutson and Julie Wernau from The Wall Street Journal and Gimlet, the discussion centers around the growing frustration among doctors with health insurance companies. Titled "Even Doctors Are Frustrated With Health Insurance," the episode delves into the systemic issues within the U.S. healthcare insurance landscape, highlighting personal anecdotes from medical professionals and analyzing the broader implications for patient care and medical practice sustainability.

Background: The Incident That Sparked the Conversation

The episode opens with a reference to a recent tragic event where the CEO of United Healthcare was shot and killed in Midtown Manhattan [00:05-00:33]. This incident served as a catalyst, igniting widespread discourse about the influence and role of insurance companies in the healthcare sector. Julie Wernau notes, “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” [00:16].

Surge in Doctor Complaints

Following the incident, Julie Wernau received an overwhelming number of emails expressing dissatisfaction with health insurers. Notably, a significant portion of these emails came from doctors, illustrating a heightened level of concern within the medical community. Julie shares examples from her crowded inbox, highlighting sentiments such as:

• “Medical insurers are out of control, regulators are worthless” [01:10].
• “Plans leave countless patients and doctors outraged. Tell you the brazen techniques of United Healthcare which deny and delay approval and payment. This is ensure misbehavior at its worst. And it's good to know people are becoming aware of the dangers of over prioritizing profit over people” [01:19].

Complexity of the Insurance Industry

Julie describes the insurance industry as “incredibly complicated” and “a byzantine world that only a select few really understand” [03:15]. This complexity not only frustrates patients but also baffles many healthcare providers who must navigate these convoluted systems daily [03:38].

Historical Context: Insurers' Role in Healthcare

Discussing the origins of insurers in the healthcare system, Julie explains that the system was designed under the belief that a marketplace approach with checks and balances was the most efficient way to manage healthcare costs and prevent unnecessary medical expenses. Insurers were intended to act as a regulatory mechanism to ensure that doctors wouldn’t overprescribe or perform unnecessary tests purely for financial gain [03:42-04:20].

Primary Complaints from Doctors

Despite the intended role of insurers, many doctors report that the system is failing both patients and practitioners. The two main issues are:

1. Denial of Patient Treatments: Doctors are increasingly witnessing insurance companies deny necessary treatments, forcing them to seek additional approvals or face patients paying out-of-pocket.
2. Fighting for Payments: Medical professionals are spending excessive time and resources battling insurance companies to receive proper compensation for their services.

Personal Testimonies: Dr. Allen Nguyen's Frustration

Dr. Allen Nguyen, a spine specialist in Fort Myers, Florida, shares his firsthand experiences:

• Denial of Care: “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” [04:28-04:31].
• Time Consumption: “I have to put out maybe 30 minutes to an hour or so three, three times a week” dealing with prior authorizations [05:27].
• Frequent Denials: “A couple times a week, and it's becoming more frequent” [05:39].
• Specific Example – Kyphoplasty: Dr. Nguyen discusses how insurance denials prevent him from performing kyphoplasty, a procedure that provides significant pain relief for spinal fractures, often deeming it unnecessary or experimental despite its proven benefits [06:00-06:26].

The Peer-to-Peer Review Process

A significant hurdle is the peer-to-peer review, where a doctor must justify the necessity of a treatment directly to another doctor within the insurance company:

• Ineffectiveness: Dr. Nguyen points out that even with extensive documentation and supporting studies, insurance reviewers may still deny procedures based on arbitrary guidelines [09:33-09:58].
• Mismatch in Specialties: Often, the reviewing physician may not be a specialist in the relevant field, leading to misunderstandings and further denials [09:20-09:55].

Impact on Patient Care

Julie highlights that these denials don’t just affect doctors but also have dire consequences for patients. Delays in necessary treatments can lead to worsening conditions or patients abandoning their care altogether:

• Patient Disengagement: “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” [08:21-08:52].

Financial Strain on Medical Practices

Dr. Keith Berger, a gastroenterologist in Virginia who runs his own private practice, illustrates the financial toll that insurance denials take:

• Financial Losses: “Last year I lost money for the first time ever, ever, in 43 years of practice” [14:12].
• Operational Challenges: Insurance-related issues consume significant staff time, leading to operational inefficiencies and increased overhead [14:57-15:01].
• Consideration of Selling Practice: Frustration has led Dr. Berger to contemplate selling his practice, as comparable practices have been acquired by private equity firms [15:50-16:13].

Insurers' Defense and Perspectives

Despite the overwhelming criticism from healthcare providers, insurance companies defend their practices by emphasizing the necessity of cost control to sustain the broader healthcare system. Julie acknowledges that insurers argue denying certain treatments is essential to maintain affordability and prevent unnecessary expenditures:

• Cost Management: “Sometimes there are a number of cheaper options available to a patient that they should be trying first before they skip right to a really expensive test” [06:58-07:27].
• Regulatory Stance: AHIP, the health insurance trade organization, describes the U.S. health system as “fragmented and heavily regulated,” with insurers aiming to protect patients from rising costs while ensuring access to safe and evidence-based care [11:02-11:42].

Broader Industry Challenges

Julie notes that health insurance companies are not the sole entities contributing to the frustrations in the healthcare system. Pharmaceutical companies, government regulators, and large hospital conglomerates also play roles in the complex dynamics that affect both patients and providers [16:32-16:48].

Conclusion: Call for Transparency and Reform

Julie Wernau reflects on the collected insights, emphasizing the opaque nature of the insurance decision-making process:

• Lack of Transparency: “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” [17:32-18:25].
• Need for Clarity: She suggests that insurance companies need to “pull back that curtain a little bit” to help the public comprehend their processes and decisions, which could fundamentally transform the industry [18:16-19:22].

Final Thoughts

The episode underscores a critical tension within the U.S. healthcare system: the delicate balance between cost management and quality patient care. As doctors like Allen Nguyen and Keith Berger navigate the labyrinthine insurance landscape, the overarching sentiment is one of disillusionment and urgent need for systemic reform to restore trust and efficacy in patient care.

Notable Quotes with Timestamps

• Julie Wernau: “Medical insurers are out of control, regulators are worthless” [01:10].
• Dr. Allen Nguyen: “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” [04:31].
• Dr. Allen Nguyen: “A couple times a week, and it's becoming more frequent” [05:39].
• Dr. Keith Berger: “So imagine you've got maybe tens of thousands of dollars at stake and you don't know, are you going to get it ever going to get it paid? How are you going to get it paid? It’s just aggravating” [14:30].
• Dr. Keith Berger: “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. You 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” [16:17].
• Julie Wernau: “This entire industry is a total black box, and it's taking away our will to continue to be doctors” [17:32].
• Julie Wernau: “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” [18:25].

Takeaway

The December 19 episode of The Journal provides a sobering examination of the extant challenges within the health insurance framework from the perspective of medical professionals. It highlights the urgent need for increased transparency, streamlined processes, and regulatory reforms to alleviate the burdens on both doctors and patients, ensuring that healthcare remains patient-centric rather than being overshadowed by bureaucratic impediments.

Transcript

[Ryan Knudsen]

Our colleague Julie Wernau 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.

[Julie Wernau]

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.

[Ryan Knudsen]

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. She'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?

[Julie Wernau]

Let me pull up my very crowded inbox. Just give me one second.

[Ryan Knudsen]

Okay.

[Julie Wernau]

Here's one that says medical insurers are out of control, regulators are worthless.

[Ryan Knudsen]

She read me several of them.

[Julie Wernau]

Plans leaves countless patients and doctors outraged. Tell you the brazen techniques of United Healthcare which deny and delay approval and payment. This is ensure misbehavior at its worst. And it's good to know people are becoming aware of the dangers of over prioritizing profit over people.

[Ryan Knudsen]

Doctors the Journal spoke with made it clear they disavow the shooting of the United Healthcare 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. Coming up on the show, why doctors are fed up with insurance.

[Julie Wernau]

This episode is brought to you by Workday. Get the whole band together with Workday and pair finance and HR on one platform for an epic performance. With Workday AI at the core, you'll make confident decisions faster than ever.

[Keith Berger]

And you'll drive flawless business and finance.

[Julie Wernau]

Operations with an agile platform that constantly evolves. To future proof your organization, be a Finance and HR Rockstar with Workday. Visit workday.com to learn more. More.

[Ryan Knudsen]

How complicated would you say the insurance industry is?

[Julie Wernau]

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.

[Ryan Knudsen]

How did insurers come to play this role in our healthcare system?

[Julie Wernau]

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, you know, rack up a lot of medical expenses that are unnecessary, tests that are unnecessary just to get themselves paid.

[Ryan Knudsen]

Still, many doctors say the system isn't working. They're seeing more and more insurance companies denying the care they prescribe.

[Allen Nguyen]

From a non clinical standpoint, that's the worst part of my job.

[Ryan Knudsen]

That's Dr. Allen Nguyen, a spine specialist in Fort Myers, Florida.

[Allen Nguyen]

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.

[Ryan Knudsen]

How much time do you spend dealing with insurers?

[Allen Nguyen]

I have to put out maybe 30 minutes to an hour or so three, three times a week. I 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.

[Ryan Knudsen]

So how often does care that you're recommending get denied by an insurance company?

[Allen Nguyen]

A couple times a week, and it's becoming more frequent.

[Ryan Knudsen]

In Alan's case, he often has to lobby insurance companies to approve treatment before he can implement it, a process called pre authorization. If 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.

[Allen Nguyen]

There's a procedure I can do to fix that fracture. It's called 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 their, you know, smiling and walking just fine. And sometimes insurance companies won't authorize that procedure.

[Ryan Knudsen]

What reason do insurance companies typically give for the denial?

[Allen Nguyen]

Is it, they 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.

[Ryan Knudsen]

Health insurers say denying certain treatments is an important way for the entire healthcare industry to keep costs down.

[Julie Wernau]

Sometimes there are a number of cheaper options available to a patient that they should be trying first before they skip right to a really expensive test, for instance, like an mri, or even after the MRI that they continue in physical therapy before they get surgery. There's a stepwise process that, you know, health insurers use to try to keep costs down.

[Ryan Knudsen]

I 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?

[Allen Nguyen]

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. I've tried to prescribe it, but I can't force a patient to do physical therapy.

[Ryan Knudsen]

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.

[Julie Wernau]

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. 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. Often it's in that gap that patients just disappear.

[Ryan Knudsen]

Sometimes before an insurance company will approve a claim, it requires something called a peer to peer review.

[Julie Wernau]

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.

[Ryan Knudsen]

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.

[Julie Wernau]

Now, some of these doctors are frustrated because the peer that they might be matched up with might not be someone who is in their specialty at all. So you might have an oncologist who's trying to have a peer to peer review with someone who's a family doctor or general practitioner, for instance.

[Ryan Knudsen]

Alan has had mixed experiences with the peer to peer process.

[Allen Nguyen]

Sometimes it works and sometimes it doesn't. Because sometimes 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. But 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.

[Ryan Knudsen]

I mean, how do you feel about the fact that, like, 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?

[Allen Nguyen]

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.

[Ryan Knudsen]

When 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 US Health system is, quote, fragmented and heavily regulated. It added that health insurance companies are working to protect patients from the full impact of rising costs while connecting them to care that is safe, evidence based and coordinated. A 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?

[Allen Nguyen]

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.

[Ryan Knudsen]

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

[Julie Wernau]

This episode is brought to you by Dutch Bros. Get stoked for all the holly jolly vibes this season at Dutch Bros. Stay cozy with returning winter faves. Hazelnut truffle mocha and candy cane mocha. Plus, the new winter Shimmer Rebel energy drink blends up sweet cream and blue razz flavor with soft top and shimmer sprinks to keep those spirits energized all winter long. Download the Dutch Bros app to find your nearest shop, order ahead and start earning rewards. This episode is brought to you by Amazon Prime. There's nothing sweeter than baking cookies during the holidays. With Prime, I get all my ingredients delivered right to my door, fast and free. No last minute store trips needed. And of course, I blast my favorite holiday playlist on Amazon Music. It's the ultimate soundtrack for creating unforgettable memories. From streaming to shopping, it's on Prime. Visit Amazon.comprime to get more out of whatever you're into.

[Ryan Knudsen]

Dr. Keith Berger is a gastroenterologist in Virginia. Keith runs a private practice, which means he's his own boss. Medicine runs in the family, and so Keith says private practice made a lot of sense for him.

[Keith Berger]

I could practice it the way my dad, my grandfather, my son and my brother doctors. His son's a doctor, my daughter in law is a doctor. We understand medicine. We get terrific ratings from our patients. But 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.

[Ryan Knudsen]

So how would you say that your relationship with insurance companies affects your practice financially?

[Keith Berger]

Well, last year I lost money for the first time ever, ever, in 43 years of practice.

[Ryan Knudsen]

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.

[Keith Berger]

So imagine you've got maybe tens of thousands of dollars at stake and you don't know, are you going to get it ever going to get it paid? How are you going to get it paid? 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. It's aggravating. It's like a thorn in your side.

[Ryan Knudsen]

For Keith's staff, that thorn is also very time consuming.

[Keith Berger]

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. It just, 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. 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 the insurance companies. So 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?

[Ryan Knudsen]

How long do you want to play? Have you thought about selling your practice?

[Keith Berger]

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're going to stay, and 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.

[Ryan Knudsen]

For now, though, Keith is staying independent.

[Keith Berger]

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. You, you 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.

[Ryan Knudsen]

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.

[Julie Wernau]

Health insurance companies have said that they play a really important role in the healthcare system, that they're all trying to do the right thing here. Some of these complaints that come from patients and doctors are unjustified. You 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, they lack information that would help them make a determination that would allow them to, you know, support a claim.

[Ryan Knudsen]

Are you surprised by what you heard from doctors? What do you make of the fact that so many are angry?

[Julie Wernau]

I think I actually, you know, I cover healthcare. 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.

[Ryan Knudsen]

So after talking to so many doctors about the state of the insurance industry in the U.S. what's your takeaway?

[Julie Wernau]

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, you know, 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.

[Ryan Knudsen]

That's all for today. Thursday, December 19 the Journal is a co production of Spotify and the Wall Street Journal. Additional reporting in this episode by Josh Chaffin and Ana Wilde Matthews. Thanks for listening. See you tomorrow.