Health Policy

Private Health Insurance Organizations Shouldn’t Dictate Quality of Care

By LYNLY JEANLOUIS

Health insurance companies are standing in the way of many patients receiving affordable, quality healthcare. Insurance companies have been denying patient claims for medical care, all while increasing monthly premiums for most Americans. Many of the nation’s largest healthcare payers are private “for-profit” companies that are focused on generating profits through the healthcare system. Through a rigorous approval/denial system, health insurance companies can dictate the type care patients receive. In some cases, this has resulted in patients foregoing life-saving treatments or procedures.  

In 2014, Aetna, one of the nation’s leading healthcare companies, denied coverage to Oklahoma native Orrana Cunningham, who had stage 4 nasopharyngeal cancer near her brain stem.  Her doctors suggested she undergo proton beam therapy, which is a targeted form of radiation that can pinpoint tumor cells, resulting in a decrease risk of potential blindness and other radiation side effects. Aetna found the study too experimental and denied coverage, which resulted in Orrana’s death. Aetna was forced to pay the Cunningham family $25.5 million.  

In December of 2007, Cigna Healthcare, the largest healthcare payer in Philadelphia, denied coverage for Nataline Sarkisyan’s liver transplant. Natalie was diagnosed with leukemia and had recently received a bone marrow transplant from her brother, which caused complications to her liver. A specialist at UCLA requested she undergo a liver transplant, which is an expensive procedure that would result in a lengthy inpatient hospital stay for recovery. Cigna denied the procedure as they felt it was “too experimental and outside the scope of coverage”. They later reversed the decision, but Nataline passed away hours later at the University of California, Los Angeles Medical Center.

In another case, Brian Callister, Associate Professor of Internal Medicine at the University of Nevada, made a request to transfer two high-risk patients to local hospitals in California and Oregon for procedures not performed at his hospital. In both situations, the insurance companies denied the transfer requests as the procedures would have been too costly. Instead, they suggested physician-assisted suicide, which would have been covered through the insurance.

The American Journal of Public Health recently published results from a study that found that an average of 45,000 annual deaths are associated with lack of health insurance coverage. In March of 2009, Billy Koehler died from cardiac arrest after the batteries died in his heart defibrillator. After being laid off, Billy lost his healthcare coverage. He was then denied coverage from several private insurance companies because of his pre-existing condition. eTaking a step in the right direction, the Affordable Care Act made it so that health insurance companies couldn’t refuse coverage to patients based on pre-existing conditions (HHS.gov). Moving forward, under the new Presidential Administration, several states seek to remove pre-existing condition protection in the Affordable Care Act.

Taking a moment to look at look at both sides, we can’t place all the blame on health insurance companies, as there have been several fraudulent claims sent in by providers and healthcare organizations. In July of 2018, Health Quest and Putnam Health Center (two New York-based health systems) were forced to pay the federal government $14.7 million to settle a healthcare fraud case for submitting ineligible and inflated claims. Health insurance companies have always informed patients they are able to appeal denied claims or coverage requests through the proper channels within company. Unfortunately, it’s not a simple task, as many patients are often bounced back and forth between departments and administrative staff with no answers in sight.  

Some individuals may think it’s best to simply go without healthcare coverage and take their chances. However, a recent study conducted at Harvard Medical School and Cambridge Health Alliance, found that uninsured, working-age Americans have a 40% higher risk of death than their insured counterparts. Instead, I suggest we adapt a version of the universal healthcare model. Many individuals have expressed concerns about the pitfalls of this plan, which include significantly long wait times to see a healthcare provider. I propose we use this plan as an outline and work to make it fit our American healthcare system—because our current system just isn’t working.

It’s unfortunate that, as of 2017, our nation’s healthcare spending increased to about 3.5 trillion, yet patients are not able to receive lifesaving treatment. Access to affordable healthcare coverage to receive quality care shouldn’t be a pipe dream of public health professionals.

Lynly Jeanlouis is a Quality Improvement Healthcare Professional working in Manhattan.

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Well said, health insurance must facilitate access to medical care while ensuring the best quality since the patient pays for the best services.