We don't have enough livers for every transplant case; someone needs to say no to some of them. If you think that's necessarily an evil act, you need to think harder.
The issue I see with all this is the anger isn't because this CEO denied claims that should have been accepted (that would be reasonable anger), it's that they denied claims at all. How do people expect insurance to work? An insurance company that never denies claims doesn't stay in business.
(And obviously, yes, I think the US healthcare system is lousy. But in the system you have now, you have insurance companies, and they need to operate in the real world.)
> More than 100 doctors at three of the nation’s top medical centers have weighed in on her case, which is complex and exceedingly rare. Their conclusion: The only way to save Erika’s life is to give her a new liver.
> After weeks of evaluation at the Cleveland Clinic in December and January, Erika finally got her big break.
> On February 2, doctors there approved putting her on the wait list for a liver transplant.
> But Erika hit an immediate wall. Her insurer, UnitedHealthcare, denied coverage for the transplant, saying it would not be a “promising treatment.” She appealed and was rejected again.
1. It's explicitly stated, including by the doctor involved, that this is a "groundbreaking" (read: experimental) procedure, having been performed exactly twice in the US this century.
2. The doctor even says "he can somewhat understand the insurance company’s initial reluctance at coverage".
3. The insurance company denied it because "unproven health services is not a covered benefit" - this is expected, the insurance company can't just take a single doctor's word that "it'll totally work, I'm super good at this surgery".
4. The insurance company ended up approving her claim.
Yah, that's a mistake (or lie) by the article; from your CNN article, she was initially put on the transplant list on Feb 2, and ended up approved by mid-May (it's after May 2, but before Mother's Day, on May 13).
She was delayed by "insurance issues" by at most 3 months.
She waited more than a year for a liver because she wasn't a good candidate for a liver transplant.
> Earlier this year, a Senate committee investigated Medicare Advantage plans denying nursing care to patients who were recovering from falls and strokes. It concluded that three major companies — UnitedHealthcare, Humana and CVS, which owns Aetna — were intentionally denying claims for this expensive care to increase profits. UnitedHealthcare, the report noted, denied requests for such nursing stays three times more often than it did for other services. (Humana had an even higher figure, denying at a rate 16 times higher.)
> As United reviewed McNaughton’s treatment, he and his family were often in the dark about what was happening or their rights. Meanwhile, United employees misrepresented critical findings and ignored warnings from doctors about the risks of altering McNaughton’s drug plan.
> At one point, court records show, United inaccurately reported to Penn State and the family that McNaughton’s doctor had agreed to lower the doses of his medication. Another time, a doctor paid by United concluded that denying payments for McNaughton’s treatment could put his health at risk, but the company buried his report and did not consider its findings. The insurer did, however, consider a report submitted by a company doctor who rubber-stamped the recommendation of a United nurse to reject paying for the treatment.
There are right answers though. Certainly far more "right" than what they currently do.
They can, in fact, have their billions of profits while not putting their customers in the grave. It's just slightly less profit than they currently get.
Squeezing the blood from the stone here is entirely a choice.
That shows the gross margin of insurance companies (based on premiums vs paid claims). Note that it's negative in some states, and also that's gross margin - so all the insurance companies' costs need to be paid out of that.
They are not making as much profit as you think they are.
I think reducing healthcare costs in the US is an important problem with no right answers, and this sometimes involves denying care that people think they need.
That’s not the problem being solved. If it were, the answer would be to pay out the same amount taken in. As evidenced by the fact that the company in question has investor meetings, the problem being solved is to pay out as little relative the amount taken in.
