So any plan-approved doctor can try anything at any expense? Biologics are the accelerant for this problem, given their 6-figure annual costs.
No. A review process of some kind is reasonable. One utilizing hand-picked doctors who haven't practiced in 30 years (see the section with Dr. Nady Cates), and not ever in the relevant speciality, is less reasonable.
For a case this complex, the denials shouldn't take minutes. They shouldn't be able to hand-pick a doc from the supposedly independent review organization. And they shouldn't be able to suppress reports from their own experts that say it's medically appropriate.
> Dr. Nitin Kumar, a gastroenterologist in Illinois, concluded that McNaughton’s established treatment plan was not only medically necessary and appropriate but that lowering his doses “can result in a lack of effective therapy of Ulcerative Colitis, with complications of uncontrolled disease (including dysplasia leading to colorectal cancer), flare, hospitalization, need for surgery, and toxic megacolon.”
> Unlike other doctors who produced reports for United, Kumar discussed the harm that McNaughton might suffer if United required him to change his treatment. “His disease is significantly severe, with diagnosis at a young age,” Kumar wrote. “He has failed every biologic medication class recommended by guidelines. Therefore, guidelines can no longer be applied in this case.” He cited six studies of patients using two biologic drugs together and wrote that they revealed no significant safety issues and found the therapy to be “broadly successful.”
> Gesk discovered it by accident when he was listening to a recorded telephone call produced by United in which Kavanaugh mentioned a report number Gesk had not heard before. He then called MRIoA, which confirmed the report existed and eventually provided it to him.
I don't care how much a drug costs and nobody should. The reason we pay for insurance is to use it when we need it. Same goes for disability insurance. All these insurance companies will do anything possible to weasel out of paying.
I don't know a single person happy with health insurance companies that has used them extensively.
If there is a case study that shows a certain drug resolved symptoms that a physician's patient is suffering from, he should be allowed to prescribe them off-label.
US spends 18/% of GDP on healthcare, and we still have to pay into the insurance scam. I would at least expect to get the best care in the world and access to any medication my physicians desires without any bullshit.
High healthcare cost is the entire reason we pay for health insurance. If treatments were cheaper, UNH would not be worth half a trillion dollars.
Put another way, this is exactly what UNH signed up for. They actively lobby against efforts to reduce healthcare costs at the expense of their profits, which largely derive from amortizing the risk that some of their customers will have treatments too expensive for them to afford.
As an analogy, a home insurer doesn't get sympathy when they try to dodge rebuilding costs after a fire or other disaster reduces their profits. The insurer explicitly signed up for the job of paying for the rebuilds, and that was not contingent on the cost of the hypothetical future rebuilds.
They have the scale to influence healthcare costs through means other than denying claims. And they have the financial heft to (for example) buy makers of expensive niche treatments if they dislike other market participants capturing healthcare dollars.
TL;DR; this is a problem entirely of UNH's own making, for which they are well compensated by the markets. Regulators should not allow them to operate in our regulated markets in this manner.