Denying Your Health Care Is Big Business in America | NYT Opinion
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- Опубликовано: 13 мар 2024
- Should your insurance company be allowed to stop you from getting a treatment - even if your doctor says it’s necessary?
Doctors are often required to get insurance permission before providing medical care. This process is called prior authorization and it can be used by profit-seeking insurance companies to create intentional barriers between patients and the health care they need.
At best, it’s just a minor bureaucratic headache. At worst, people have died.
Prior authorization has been around for decades, but doctors say its use has increased in recent years and now rank it as one of the top issues in health care.
To produce the Opinion Video above, we spoke to more than 50 doctors and patients. They shared horror stories about a seemingly trivial process that inflicts enormous pain, on a daily basis. The video also explains how a process that is supposed to save money actually inflates U.S. health care costs while enriching insurance companies.
Prior authorization has come under intense scrutiny in Congress in the past few years, but bipartisan proposals have repeatedly stalled. Under public pressure, some insurance companies - like United Healthcare and Cigna - have said they would reduce the use of prior authorization. And in January, the Biden administration finalized a plan to put limited guardrails around this practice. But doctors say that these efforts only scratch the surface and should go further.
This issue is ultimately about the role of insurance companies in American health care: Should they have more power than your doctor to decide what’s medically best for you?
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Hi! My name is Alex Stockton. I'm a video journalist with New York Times Opinion and I produced this video. For our reporting, we spoke with more than 50 doctors and patients. They told us horrific stories of being blockaded by insurance companies. Has this happened to you? Let me know about your experiences navigating this system. And I'd be happy to answer any questions. Thanks for watching
It happened to me with migraine medication. My nurse practitioner said that since January, she's noticed insurance companies denying prior-auths a lot more often. Makes you wonder if it's a deliberate budget-cutting measure they all approved this quarter.
@@natashalavender7758 migraine meds? ia it Fioricet? if so you are one lucky person! firoricet contains barbiturates and theres even a version with codeine in it!
Thank you for this reporting, Alex.
I live in France and what was shown, very professionally on this video, would be impossible here. I’m. grateful of the health care system here and wish for US nationals to have access to a better healthcare, but it’s up to them to demand it, the current system is inhumane, to say the least.
@@natashalavender7758 I'm sorry to hear that! I've heard about delays and denials for so many types of medications
If insurance companies are making medical care decisions and patients are being harmed they should be legally liable for malpractice.
Insurance companies donate lavishly to Congress. They are unlikely to pass any legislation against them.
So many people let big daddy government manipulate and intimidate them into "healthcare" decisions during convid and the govenrnment has yet to be held liable for all the people harmed emotionally, mentally, physically by that.
They would say that they never tell a physician how to practice only what they will pay for.
thankyou - yes - if i were one of those pts id prob take this to the court system itll happen just watch i tell you
@@wholeNwonyes, they will say that they aren’t denying care, just not paying for it, but when they send the doctor and the patient letters saying that they have determined the medical care is unnecessary, THAT is a medical decision allowed only to licensed doctors.
This is what happens in a country that measures its success on GDP, the stock market, and profit rather than happiness, life expectancy, and human flourishing.
Correct. Society treasures coin, connections, clout, crews, computer code, control, corrupt communities, and lucrative opportunities. If you lack those, you're utterly w0r+hl3$$. That's just how it be in 202x.
RFK Jr. 2024
@@carolyng.6405 He got sick from Covid
@@carolyng.6405LOL
He's a kook who doesn't believe in medical science.
Profits over people: The American Way.
Fighting the insurance companies was harder than fighting the cancer I had.
Geez
Every day above ground is a beautiful day. Cheers to being on the right side of the grass, Sir!
😢
They insurance companies are a cancer to society clearly
My dad was diagnosis with stage 4 lung cancer, he lost his battle after 9 terrible weeks. I wish I tracked the amount of time I spent on the phone with his insurance fighting for treatment, medicine and medical equipment. Hours upon hours trying to get things approved, messaging his doctors for them to resubmit the same request allover agian. Having someone you love who is sick and dying is so hard, having to deal with these insurance companies is just cruel. Those hours I spent on the phone I could have spent with my dad, holding his hand, hearing his stories, telling him I loved him. Our system is beyond broken.
I am very sorry to hear this. It makes me angry that we cannot seem do anything against this crap.
Healthcare should NOT be for-profit, period.
What a stupid thing to say.
@@MicheleBartonThomas
Since a free-market in health care is functionally impossible, it’s not stupid at all.
@@timdowney6721 we are not operating in a true free market so your statement is flawed.
@@MicheleBartonThomasand that's a good thing, because if it were, then providing the minimum care possible to increase profits would be incentivized.
@@georget.5048 Also profits are already incentivized by big daddy government. The medical industrial complex got paid money by the gov't for denying people life saving treatment during convid and putting them on vents unnecessarily which led to their deaths. They also got money for the injections. It's a whole corrupt system all the way around. The people have been sold out on all sides. So if you think all these healthcare workers are just trying to save you and only insurance companies are bad, you are very naive.
Aren't insurance companies the primary reason healthcare is expensive to begin with?
No, that would be the actual healthcare providers themselves (hospitals, clinics, doctors, etc) and the pharmaceutical companies creating and manufacturing treatments, who are all private entities/businesses who are themselves operating for profit.
Capitalism is the cause. Insurance companies play a major role by adding expense without adding any value.
Healthcare is an inelastic product that doesn’t adhere the supply and demand model. Unbridled capitalism doesn’t work because demand is constant.
Death avoidance is currently extorted and capitalized by shareholders because your life is priceless and they know it.
@@RHLWfalse, insurance companies specifically require hospitals to inflate their prices that charge to all patients during their negotiations. Then the insurance company gets a deal where they only pay a fraction. Negotiating the official price up (not the discounted price) is designed to make it harder for smaller insurance companies or businesses that want to self insure to be able to do that. Insurance companies absolutely increase the cost of healthcare
@@RHLWnot all physicians are in a corporate owned practice or hospital. However, that is the “hard place” for doctors and patients in the “rock and a hard place” of getting squeezed by corporate suits in healthcare. Private firms buying up practices to “streamline” operations (I.e. fire nursing staff, reduce pay where possible, and attempt to strong-arm physicians into seeing more patients for less time and prescribe systematically rather than taking the individual patient into consideration).
And the funny thing is, a lot of larger insurance companies are inserting themselves into healthcare in this way too, so they get to manipulate prices by wearing two hats. Healthcare issues in the US boil down to corporate greed from people who don’t even know the first things about medicine.
Not necessarily. The whole payment system is messed up. I think hospitals and pharmaceutical companies are really what's increasing the cost of healthcare, because they charge ridiculous prices to the insurance. Medications in Europe only cost a fraction of the cost in the US.
2 months ago I went to my doctor for recurring pain in my neck, shoulder, and arm. I hadn't injured myself in any way that I could remember. My doctor said, ok, let's get you an xray, and mri, and a nerve test to check for damaged nerves, pinches, broken bones, etc.
My insurance allowed xrays and nerve test.. They denied my mri, telling me I needed to do 6 weeks of 'conservative' treatment which was basically physical therapy. I did the 6 weeks of physical therapy, which has made the pain in my neck WORSE. My doctor says it's definitely a nerve issue, that the mri would have given us a clear indication of. But now I have pain that MIGHT be permanent because my insurance decided that their profits are more important than my health and happiness.
This video is my story, and the story of hundreds of thousands of other Americans. We need to burn this whole system to the ground.
Share the name of insurance company, so that we can avoid it.
I once was in a similar bind, and my mother recommended I pay out of pocket to get the care I needed. I did, and it was worth the piece of mind to have the health issue resolved.
@@marymccluer1630 I pay over $400 a month for insurance (and that's just my contribution, employer contributes more in addition). The MRI I need has an out-of-pocket price range of $500 to $11,800, depending on provider, location, contrast. I am entitled to coverage from my insurance. I am not paying even more than I already am, and putting myself into debt for the privilege. I am glad you were able to afford such a cost, but surely you can agree that insurance shouldn't be making the decision on what is covered and what isn't.
should have saved your money and paid out of pocket LOL wake up slave insurance has always been a scam just like lawyers.
I’m assuming the nerve test was a conduction study or an EMG. Was that abnormal? If it was, then an MRI should have happened sooner as there may be a lesion amenable to neurosurgical options. However, if the nerve studies were normal MRI would likely not change course of conservative management. You would definitely be waiting much longer for an MRI in Canada, UK, etc. Insurance companies should be able to deny some requests as doctors will often just order tests at the whim of patient’s desires. However, if a doctor calls or writes and explains their reasoning, insurance companies should be absolutely held liable if their delays harm the patient.
People in the US need to rise up and throw off these insurance companies. They are standing between you and universal health care.
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As a physician, this is the bane of my existence everyday. I didn’t go all these years of medical school and training to do this BS paperwork
I hear you! My excellent primary, aged 57, just up and quit one day this year. Shocked the whole system because he was GOOD. But he had a quota to meet and an allotted time with each patient, his office was always busy. I'd had him for 25 years and I could tell something was up because it showed in his face. I asked him, are you planning to retire soon? He said no, still had kids in college so he wasn't going anywhere. But that all changed fast. And the paperwork was killing him. So? Good bye to all......I hope you don't have to leave because of paperwork, that would be a real loss......
Today I literally screamed when insurance requested "peer reviewed scholarly articles" and at least one written testimonial from a provider supporting why the patient needed that particular drug. Oh, and power of attorney. I hate it.
Some years ago I saw a news video about some physicians who had set up a practice where they didn't take insurance. It was a kind of subscription that people paid which seemed very affordable and there was a list of the usual things that people seek out medical care for that was covered. It worked economically because they didn't have to hire a large staff whose job was to do nothing but deal with insurance. I always wondered how it is working out.
You should look into hiring a PA clerk. I’m a pharmacy tech for a specialty pharmacy and my day is spent on just submitting PAs and appeals for medications.
Clearly, the hassle is by design. The insurance companies hope they have annoyed you enough that you won't bother to call them.
absolutely ridiculous system of healthcare here in America
more like deathcare...
Its better than paying for someone elses mistakes!!!
@@RicardoMontaniabetter to go bankrupt and then die because you got sick than pay towards someone else getting sick and having free healthcare when you need it. I get you, that's a much better system /s
The US doesn't have a healthcare system. It has an insurance system.
@@WhichDoctor1 they'll be begging for that care when they need it and don't have it. Can't wait to see it.
On several occasions my insurance has denied diagnostic treatments that my doctor said I needed. Each time I told my doctor to go ahead and do the treatment and if my insurance does not pay, I will. Each time, the treatments proved to be successful and the insurance paid the bill in full. I refuse to put my health in the hands of insurance companies even if I can't pay the bill. I also informed my congressman and senators about these situations. This is how I am fighting back.
Except the majority of our reps are not interested in fighting for us to have quality, affordable care and to preserve Medicare. Keep writing them though, and let's let them know they won't get our vote if they don't make healthcare a priority.
I live in Canada. Several years ago I had black spots and flashes in my eyes and I went to the hospital emergency. Yes I had to wait three hours to see the doctor. After my initial exam, he said your retina is threatening to detach, you’re not going anywhere we are calling in a specialist to do laser surgery on your eyes.I waited another two hours the specialist arrived and did the surgery. I paid nothing out out of pocket except for the parking fees.
Unfortunately that’s the best case scenario for Canadian healthcare. Where I live you expect to wait 12+ hours in the Er if you even get seen, and specialist care involves years waiting time. I haven’t seen a doctor in 10 years because of how much of a shortage there is in care providers. And I still pay for insurance every month to cover prescription drugs, dental and eye care. But sure, Canadian healthcare is so much better…
It’s ok, we wait 3-5 hours to be told nothing can be done here in the US. Don’t see how my fellow Americans can use your system as a negative comparison now “oh, but they take hours to see a doc in the ER!” Or “it takes months to see a specialist!”. Yeah… that is the reality now here too except worse 🤦
@@melissamargolese8782 In the US you can also spend 12+hours, see a doctor who will say there's nothing they can do, then charge you $50,000.
@@melissamargolese8782 I don't think that's an accurate picture overall. If urgent care is required it is generally done expedititiously. It is indeed possible to wait months to see a specialist if the issue is not urgent. But 'years waiting time' is clearly an inflated statement. There is a definitely a shortage of family doctors, but in my city at least there are also walk-in clinics and a number of Urgent Care Centres that act as a relief valve for busy ER's.
After years of regular annual monitoring, I had an MRI last summer to investigate a possible early stage cancer (i.e. 10 -15 years survival expected without any treatment). The result indicated a biopsy, which was done in November. I had my first appointment with the oncologist in February and the treatment was done in March. If it had been an aggressive form of cancer it would have been dealt with more quickly. Again, the only cost to me was for a handul of over-the-counter medications.
The Canadian healthcare system is far from perfect but every single individual in the country is covered regardless of financial or social status, and - bottom line - survival rates for all conditions are comparable to other developed countries including the US, despite spending only half as much as the US per capita. There are definitely frustrations, and perhaps we should be spending more. But after my experience this year I'm incredibly grateful that health care is seen as a basic service provided to all citizens, and that money considerations for individual patients don't come into it.
My mother lived in Canada, she waited 1 year to see a specialist, then 6 months for the surgery than got bumped foe a more urgent case, got the surgery another six month later then got to see her doctor for after surgery care 8 months later,!,
I don’t know where or when you went but for most Canadians this is now the norm.
Why are the US nationals not revolting against this?
Because they believe the idea disseminated by the rich that free enterprise is the best of all possible economic systems, that supply and demand will provide the best benefit for all, and that profits of any amount are to be protected above all else, even life. They are terrified of socialism, because most have never read a book since high school.
Haha they are brainwashed beyond repair
Too busy working extra hours to be able to afford groceries.
Too busy fighting each other over issues they deem more important because they aren't immediately in poor health. Look into how much the insurance industry gives to politicians, democrat, republican, independent, libertarian etc. This is an issue by design.
I would love to revolt, but unfortunately the US system mostly links health insurance to employment. I can’t really choose my insurer because it’s one of two options my employer provides, and I’m not the one deciding which insurance companies to contract with.
Faces you will never see, people you will never know, get to decide your quality of life, or death, in the name of making rich people even richer. We are fodder.
Fodder and product.
I’m a RN case manager and I was fired from my position when I fought for my elderly patients denial of service
Sorry to hear you went through that. You're a real fighter and a true winner. Good job on speaking out ❤
I am not happy about you being fired but i am truly happy that you were able to follow what your mind and eyes deemed right! That is really inspiring. Praying for you to get greater professional oppirtunities.
Just great.
The big argument about Universal Healthcare was nobody wanted a panel of bureaucrats deciding wether someone lives or dies or imposing long waits. We now have a private system that does exactly that.
Not a free market system
This is a CRIME AGAINST HUMANITY.
Yes it's organized crime
At $22 billion profit by just one insurance company it’s pretty obvious that insurance owns the government.
Something like that. The wealthiest and most powerful have the most sway. The poorest and least known... have none. That's just the reality of existence. People need to remain in their own lanes, or else... they gotta get RICH. If they can't, then that's the way it be. Acceptance is key.
@@Novastar.SaberCombatwe will never accept a corrupt system!
Capitalism owns the government. This health denial system is allowed to exist because it makes a few already wealthy people even richer.
Only because Congress sold us all down the river. And who voted for them?
This is preposterous, even if that is true! Insurance companies and other big corporations are not and should not be the boss of the government, no matter how much money they have to cheat us normal taxpayers out of education and health that our taxes SHOULD be covering, instead of military bases in other countries.
When I had a major medical problem years ago and saw what had happened to 2 people in my life who died trying to get care, I knew I was going to have to really fight. I didn’t feel good enough to fight for care but I did it. I was not under threat of death. Can you imagine you find out for example that you have cancer, you are very sick and you are having to spend every day of your life fighting and fighting and fighting for care? It’s evil.
Our healthcare system is the #1 reason why I want to leave this country someday.
You'll likely live longer if you do.
To have insurance but can't use it.
Vote and campaign to get others to vote for Medicare for all. It is already inevitable, but of more people get serious during election seasons, we will speed it up.
My husband & I are planning for this as well.
So much corruption. People deserve proper care.
If you're rich, you're fine. If you're not, you ain't. Simple.
Prior authorisation is a euphemism for death farming.
Corporate death panels.
.....that's good one.....wow!
I guess the insurance company doesn't factor in that if a patient dies - they lose a premium paying customer
@@ssquints8056 people who are sick and dying are only costing them money. At a certain point once you’ve paid enough premiums the best case for insurance company is for the patient to die quickly, thus reducing their expenses and then they get to net the profits from that persons 20-40 years of premium payments.
look up Georgia Guideposts for the end game.....bring the worlds population down to 500,000,000 according to the powers that be, one world government, remember this all you globalists.
Prior auths are one of the main reasons I work inpatient, instead of as a primary care physician. It broke my heart when I couldn’t get my patients their medications for absurd reasons.
As someone with both Crohns and Ulcerative Colitis - insurance is an extreme nightmare and nobody wants to approve any treatments for either of these issues
I was a healthcare worker for 40 years. Everyone deserves proper medical and dental coverage. We need universal healthcare. It should not be a for profit industry. Unfortunately there are many politicians who would even end the AFA. The insurance companies only care about the bottom line.
I don't want to pay for someone elses mistakes. I earn my own money and they should too.
@@RicardoMontania People aren't always to blame if they need medical care. You can be in an accident or you can be born with complications like I was. Luckily I live in Brazil so I got two surgeries and don't owe anyone a dime.
@@RicardoMontania You already are. That's how insurance works - public or private. You don't pay into a fund called "Ricardo's premiums" which then pay out when you get sick. You, and a thousand other people, pay into a pool - and then when one of you gets sick, everyone's money is used to treat that one person.
And what happens when someone gets sick through no fault of their own?
Universal healthcare would be great OR politicians should have to buy their health insurance just like the rest of us. That way they'll have full knowledge of how the system works and doesn't work. Every aspect of healthcare in America is a dreaded nightmare. This is not an overstatement--it literally dictates how I live my life in the most ludicrous way just so I can manage to stay covered. It forces doctors to have to work the system in ways they never imagined just to process their patients' treatments. To say that decades ago, prior authorization wasn't as prevalent is nothing compared to the fact that decades ago, your employer paid for your health insurance and you were just responsible for the co-pay. Over time, it shifted to where you had to make small contributions from your paychecks. Now, your tier is based on your gross salary--not net. So if you make a meager $60k you have to pay a premium of $500-$700/month and then there's the $7k deductible. Not feasible (after taxes) with high NYC rent, expenses and bills. Forget about saving for retirement! The American healthcare system is a broken, unnecessarily complicated, exhausting, traumatizing and demoralizing experience. Just this week, my treatment was denied and my doctor will have to work his magic to make things right. What a waste of precious time! Thank you NYT for highlighting this issue. My heart goes out to all the people featured in the piece.
The problem also is if you do have reform, you have to layoff so many workers in healthcare because almost a 5th of the economy is spent on healthcare
Remember when politicians were talking about the “death panels” that would spring into existence if we had universal healthcare? The insurance companies apparently thought that was a really good idea.
Exactly.
The insurance companies are the death panels
Omg I say this ALL THE TIME!! But I guess being in a death panel is ok as long as it's run by a private corporation!!???
@@rrubens3026And let’s hope it’s isn’t initiated by a (gasp) black man.
We already have death panels, just not anything obvious. The insurance companies do it quietly, by denying care.
Primary Care Nurse here ✋️THANK YOU for bringing attention to the insane hoops that insurance requires providers to go through JUST to provide patient care! Nurses and Providers alike waste HOURS daily on prior authorizations and stay super late after the clinic closes to try to complete them just so our patients are able to get what they need!
@lyssavaught4958 I'm sure this is driving up the cost of healthcare exponentially when they do finally authorize something. Until it gets to the point where they aren't paying for anything at all. We need a different system. With health care costing between $800-1000 per person per month with $6k - 10k out of pocket costs before the insurance pays a penny, even if they allow something they are likely paying out nothing.
The sickest system in the world is American healthcare.
So Bernie Sanders was right after all; and the same ppl who said Medicare for All wouldn't provide good care, are waking up, wishing we had quality universal healthcare the way many countries of the world have had for a long, long time. The needs of the American ppl are not a priority to our lawmakers, but the wants of their donors -- the big health ins companies, & big Pharma -- are.
Enough already.
So insurance companies (who aren’t doctors) are the ones making judgements on what a patient needs? Makes total sense
Doc here... the insurance always hides behind "well we aren't saying you can't get the care, just that we won't pay for it, your doctor is still in charge and we aren't practicing medicine without a license" and this has given them near-total immunity over these absolutely criminal actions.
@@paintballplayer700 They are corporate death panels.
Good grief, you are naive. They have licensed healthcare professionals employed at the insurance companies evaluating the cases. Having said that, I knew someone who did this job for a very short time and then quit because they felt pressured by the insurance company to look more at the bottom line than what the patient needed. It was for an HMO. HMO's are crap. No one should have them but non critical thinking people get enticed by the sales pitch and sign right up.
@@MicheleBartonThomas Wendell Potter former executive tells us different. Quit lying,
No, they decide what they will pay for.
One thing that isn't touched upon is just how enraging the phone trees are. When you call the insurance company for a prior authorization you typically don't get somebody right away. The phone tree is designed in a way to completely infuriate you and to try to make the doctor give up before they ever even reach a human being.
No doubt the more they manage to frustrate providers and pharmacies, the more likely some of those people give up, and the insurance company "wins" and saves money. It's bad customer service by design.
@@marymccluer1630we are not the costumers that need satisfying, the rich and powerful stake holders are. They’ll make more money if they provide a poor service or run an understaffed industry. Capitalism breaks down when the costumer’s opinion on what business deserves their money doesn’t matter.
I injured my right knee. It was obvious that I needed an MRI to diagnose the injury, but 9 months later those requests were still being denied and the insurance company wanted me to go to physical therapy without a diagnosis. I chose to pay for an MRI myself; result, torn lateral meniscus. My injury was nothing compared to other stories told here , but it was clear that my quality of life was of no importance. My insurer is Providence and I have the best plan available.
This is my life- it is so emotionally exhausting. Getting PAs for albuterol for asthma patients, epipen for patients with food allergies, even prior authorizations for prednisone!!! for temporal arteritis patients. Constant denials. After hours of fighting it gets approved only to have to do the prior authorization again in 3 months. 5 full time staff to deal with prior authorizations just for one physician.
I’m a pharmacy technician for a specialty pharmacy. My job for 8 hours a day is literally getting prior authorizations approved for patient’s medications. I’m just one of a very large team.
This US hellscape in healthcare, education, judicial systems and work life looks so scary from Europe. Who tf would want to live like this? This used to be an attractive country to live in.
There's nothing anyone can do. The generations who care own the least wealth to change anything. The boomers created this system when they thought self interest would be a good, sole regulator for a economic system. Now it's entrenched
Poor people from third-world countries where the situations are much worse, the ones who want extremely high income with limitless opportunities and the ones who love firearms
yes its corporations and investors who have taken over our country - the richest are the greediest
We are late stage capitalism and unfortunately it’s hard to undo. Learn from us and ALWAYS vote to restrict lobbying, improve democracy and never treat a corporation as being more important than the workers. Trickle down economics doesn’t work. Too much to cover in a RUclips comment but it’s complicated and the interest of the federal government no longer aligns with that of the people.
I should also say, as long as you have money in the USA it’s not bad here. The problem is the inequality.
Should be able to sue your insurance company.
And here in Florida Ron DESATAN HAS REFUSED TO EXPAND MEDICAID BUT HAS SIGNED SO MANY HEALTHCARE "BILLS" called the BE HEALTHY INITIATIVE!! I CALL BS!!
in America, we have sick care not health care.
You don’t even have care.
No, we have a medical industry and an insurance industry. They use a skim coat of care to keep the money coming in.
America is a continent. South America is different. Brazil and Chile are different.
*Don't care
@@vickyvey1657People often say America as shorthand for the USA, kinda like how people sometimes say EU to mean the continent Europe as a whole (albeit mistakenly they say this), which is different than the European Union. Or how people sometimes will say Britain or Great Britain (just England, Scotland, and Wales) and the UK interchangeably, even though they’re different. It’s just one of those things, you can look up America in the dictionary and see USA.
Time to outlaw “prior authorization“. What a disgrace!!!
time to regulate healthcare products
The lady at the end broke my heart because of the negligence & denials she could not see, as well as the doctor who told the insurance person on the phone you are going to be the one denying the treatment and killing this patient... so I'm going to tell the parents that you killed them. Truly a horrible system that needs reform so people don't lose their health or lives.
"maybe i'd have a different life." that last line broke my heart. i'm so sorry.
This happens when a society is persuaded to believe that the right to seek profits is more than human lives.
Right
My husband was diagnosed with degenerative osteoarthritis in the neck. He could not move his head. The Dr. thought that some of his vertebrae were fusing. The Dr. ordered an MRI, but the insurance company ordered it stopped mid-procedure and required physical therapy first. That almost paralyzed him permanently.
oh, I forgot to add that the hospital in question was self-insured, so it was their bean-counter's decision against advice of the Dr.
That’s terrible to hear, I hope you’re doing OK.
as a malaysian with living some medical conditions, I am grateful I can get basically free consultation with experts and free medications. public healthcare is highly subsidise here. I was always shocked when i heard this kind of news about healthcare in US which is super rich country.
For-profit health care is the real problem
There are some countries in Europe whose healthcare is covered by private insurance companies, and they don't have this problem. We are probably in this pickle because America very anti-regulation. We mostly let companies operate as they please.
@@marymccluer1630you are right. Oversight is for OUR benefit. And yet as a nation we vote against oversight way more than we should.
Every member of Congress should have to report the name of every lobbyist who offers them MONEY
They do, the information is available.
@@user-wt5bf4rw7e
Interesting.
It is available but I doubt it is easily accessible.
Can easy connection be made between who gives money for what and how the legislator votes?
Well they do if it's actual liquid assets like US dollars. But they certainly don't track foreign exchanges of money, gifts that got written off as something or other. The rich and corrupt trade directly in promises paved by "small" gifts as a forward payment.
They do. Which shows you just how little they care and how cheaply they are bought. But of course they have the absolute best healthcare plan our taxes can buy them.
The Supreme Court has ruled, again and again, that donors who give big money to political super packs can remain anonymous. For that reason, we seldom know who is campaigning for or against important issues. There'll be some group no one has heard of, created for that one campaign, and the donors never get disclosed.
We are truly a Corporatocracy. It took decades, but it has happened.
From a journalistic-integrity standpoint, I appreciate you CALLING this an opinion in the headline, but it's a fact.
Thank you for this!!! I have chronic health issues, and prior authorizations are a NIGHTMARE. it's SO SAD how Healthcare in America is now.
Hear me out- they're basically making the job of the Doctor unnecessary. Yes, the Dr's diagnose, BUT THE INSURANCE COMPANIES ARE THE ONES DICTATING HOW TO TREAT
glad im canadian
we should use the insurance companies doctors then: ask the rep for the phone number!
I’ve watched this video several times today. I just can’t believe this
I'm glad I'm Australian.
I dated a nurse that worked writing denial letters. She told me there were 20 people writing the denials for every 1 employee writing approvals.
😮 wow. Just. Wow.
Absolutely sickening
My 96 year old mother’s experience in the U.K - it isn’t perfect but here is our journey
1. Felt unwell, ambulance sent. Emergency hospital- X-rays, possible pneumonia, sent home at her insistence with antibiotics.
2. Next day still unwell, rapid response paramedic sent, home oxygen machine ordered, GP ( family Dr visits) home oxygen machine delivered.
3. Starting to feel better.
4. Has a stroke, rapid response arrives, ambulance arrives, ER hospital, CT scans.
5. Next morning transferred to stroke assessment ward.
6. Hospital assessment, multiple visits - occupational health, social services. Stays in hospital until condition improves.
7.sent home with 3 visits per day from home carers - paid for by the hospital.
8. Hospital sends specialist to her home to approve and install any aids she needs.
Anytime a third party administrator gets hired to “administer” benefits, more of your benefits are spent on third party wages and compensation while they deny the subscriber benefits. PERIOD!
These third party people get paid rather than provide benefits. The more layers of bureaucracy that make money doing this the less value your getting out of your benefits due to practicing medicine without a license. 🤷🏼♀️
👏🏻👏🏻👏🏻 and then they make it as hard as possible for you to dispute
@@Aros4 I am a retired RN who used to do those hurdles the HP throws at us, documenting the rationale for prescribing or ordering diagnostics like MRI, CT scanning.
Yes!! THIS!!! I keep saying the self funded plans are becoming so problematic due to this!!
@@rrubens3026 ALL health plans are doing it, even and especially Medicare and Medicaid
Many denials are by computer.
Bonjour. My son and I noticed that our server was hearing impaired. We usually didn’t order beverages in order to leave a larger tip. We were chatting with the server and she told us that she was working at the restaurant as a second job because her hearing aids were not covered by her insurance in SC. I was so mad that I cried. The US healthcare dysfunction is just one reason that I now live outside the US. My current doctor has no nurse or receptionist. I can usually get an appointment within three days and he has televisits every night. I almost cried when my two specialists talked to each other during my visit. I never had that kind of care in the US despite having a well paid white collar job. I am happy to pay cash for my healthcare because it is amazingly affordable. Sometimes doctors do not even charge me. Visits are not limited to 15 minutes. I saved my life by leaving the US. With a broken Congress and the power of lobbyists, I can’t see things changing. I sincerely wish y’all good luck.
Where do you live? I’m assuming France?
I’m also assuming France? France has its own down side, but I only see more upsides to France compared to the US. This country is a death machine filled with successfully brainwashed hordes. I don’t want to be here anymore and am working on leaving.
Make the corporations liable again. They won’t deny care then.
It's about Time the NYT started covering this inhumane practice of prior authorization here in the US; but why hasnt the Times not even been covering the plight of 250,000 nyc public service retirees to not be thrown off of Medicare and their supplemental ins and put on inferior Medicare Advantage, which is notorious for putting sick patients through denials and prior authorizations. To not be regularly covering such an important issue (happening nationwide, as well) is a dereliction of duty.
The above video was well-made and important for all to see. We need much more of this uncovering.
We are a fallen country. Profit before lives, always. Despicable and abhorrent.
Profit before everything. As economist, Milton Friedman said, the only thing CEOs have to worry about is profits.
is either like this or its communism. this is their stupid justification.
@@ableite
Take a logic course…you’ll spot the flaw in your false choice.
@@timdowney6721 sicko - michael moore. go watch it.
This country is finished - George Carlin in 2006.
They saw a less than 2cm uterine cyst. They denied treatment and removal for over a year. It had reached over 4.5 cm, caused heavy monthly bleeding, triggered anemia, neutropenia, and subsequent infections all over my body before it was removed. I had to get extremely rude with the clinic before they took me seriously. My heath took a 180 after a less than fifteen minute procedure.
I’ve been having so much pain during the first few days of my period for a few months now. I went about two months after it keep happening and they told me I have a cyst the size of a grape in my ovary. Should I get it removed? I think they told me if it’s that small they can’t remove it :(
@@keilearreola3344 they kept telling me that too, that it was small and they don’t remove them when they’re small. That’s why I had to be rude and insist that it be removed. I knew my period was different and not in a tolerable way. The clinic insisted it was normal changes. My symptoms got so bad I developed anemia and neutropenia, I was getting bacterial infections that I’d treat then I’d get a yeast infection because of the antibiotics, the anemia was affecting other organs and systems. I alternated between the two every month for a long time. For some reason my digestive system basically stopped. I don’t know if it was the anemia or the size of the cyst. Having it removed really did make a big difference. My period shortened, the bleeding lightened, the pain went back to my normal my first period after the procedure. My bowels started working again and my anemia improved. I’m definitely not a Dr but I don’t see how getting it removed when they cause any symptoms, no matter the size, is a bad thing. It was so fast and minimally invasive. I opted to be knock out for the procedure. It wasn’t even a requirement. If getting the cyst removed is a viable option for you and you have symptoms/changes in your cycle or health I would consider getting it removed even if you have to get a little pushy. No matter how small it is a cyst has no place in a healthy uterus or ovaries.
During Covid, I was working for doordash. I slipped on ice in front of a customer's house. I mean, legs over my head and all of my body weight on my shoulder. It hurt immediately and I barely was able to drive home. I went to the Dr. the next day and she prescribed an MRI, denied. The insurance company wanted a more specific referral. My Dr. did that and denied again. I appealed. They said it wasn't warranted. My shoulder eventually did get better, aprox 2 years later. Never the same but better.
I stopped going to the Dr for anything serious. A waste of time.
This happened to me. Insurance was denied after open heart surgery even with prior authorization. They changed their minds. After the operation. My lawyer kicked their butts. It cost them twice as much in the end.
As a physician, I abhor what Prior-Authorizations stand for. When I prescribe a test or a treatment, it’s in the best interest of the patient. Stop telling me how, and when, and if I should do my job.
It's important to note that these decisions are made by recommendations from the AMA (American Medical Association) which is a lobbyist group that pays doctors to agree with insurance companies so they can make up rules for care that benefit big business. Lobbyists are doing this to enrich themselves and politicians are working with them, to enrich themselves.
It's a circle of extraction at the expense of your life.
Ahem, I think it's pure capitalist profit motive at work here. Let's call it like it is.
Denying drugs to patients must hurt the pharmaceutical companies - why aren't they in a froth about it?
I'm certainly not a defender of the AMA. In attempting to continue lobbying against the influence of the insurance racket in health care, they got into bed with Congress and that was their undoing. They can't out-bribe the industry, esp. since Congress granted insurance cos. special protection from regulation in 1945.
@@ssquints8056 They simply raise prices and they bought "part D" from Congress in a very late night session.
This is categorically FALSE. One of AMA's KEY issues is fighting against Prior Authorization, and has been for several years. Are you perhaps a health insurer? The physicians in this video are AMA members. #FixPriorAuth
Was referred to get an MRI. Insurance refused to pay and said if they had approved, my share would have been $630. Called the clinic and asked the cash price for the MRI...it was $500. I paid for the MRI, Stuff the insurance company. Moved out of the US; it's become a waste of space. Tax private equity and heath insurance companies at 100%, i.e. out of existence.
Bureaucratic bs at its finest... my heart breaks for people who needed to have prior authorization from their insurance company only to be denied. Prior authorization should be reformed. Period.
And yet, it's also our insurance companies that make the cost of many procedures and medications so prohibitive. 🤔
The fact this occurs and people are not in the streets protesting is beyond me.
The only problem is we won't know until it happens. And at that point people are too sick to protest.
Distracted by war in other countries or problems that don't matter.
It's because most people don't understand how insurance works. It's deliberately complicated, and goes beyond prior authorization, a term most people have never heard of and/or don't understand until it's happening to them. Then, it's so laden with medical jargon and unnecessary hoops to jump through that, like the narrator states, they just give up. The health care system is horribly broken, and medical insurance companies are a huge reason why that is. Keeping costs high while avoiding paying for anything.
I'm European and have lived in countries with free healthcare which I contribute towards with taxes.
What's going on in America is a crime against the American people. It's the wealthiest nation on earth, there's no way they shouldn't be able to afford similar healthcare covered by taxes. It's mad.
my perscription gets denied for "prior authorization"
finally glad to see it come to light of how scammy it is
We require a national healthcare system.
It'll never happen. And even if it does, the corruption and profiteering will simply max out, LOL.
Imagine just swapping insurance companies making healthcare decisions for you to the government making "healthcare" decisions for you. Do you socialized medicine freaks even have one working brain cell?!!!!
[🇺🇲🤝🇮🇱] ⌚️
That's communism
@@imeakdo7no it is not. It is a good idea.
Abolish insurance companies.
They are specifically sheltered by law and have been since 1945. The people are too apathetic to do anything about it.
Here in the UK the NHS actively tries to treat conditions as early as possible, since it is better for the patient and cheaper for the gov.
@@wholeNwon right
@@meahdahlgren6537Yes it is right.
Agreed!
I've been doing prior auths for doctors group for 20 years now. The insurance companies rule the roost and dictate care. Dr's are handcuffed by insurance companies. Total disgrace.
I'm a healthcare provider myself and tore my rotator cuff last summer. Aetna denied prior auth for my doctor's orders for an MRI to confirm the tear and create a treatment plan of whether surgery was needed or not. They deemed it's not medically necessary for an MRI because I just was reporting shoulder pain, but I had no range of motion and couldn't lift my arm up, making it impossible to perform my job duties for 8 weeks! This for profit insurance model needs to end in this country, its just out of hand.
My excellent primary doctor just up and left his practice because he had to see so many patients each day, and the paperwork was horrendous. He just walked out one day, never told anybody. Shocked all the patients he had too. And he is not practicing anywhere else. He quit. He's 57. Just THIS year. I could tell something was up; I'd had him for the past 22 years. Very fortunately my health is not at a critical state BUT my meds for diabetes and operations I have every 6 months to remove kidney stones is all covered. I'm 72. This is my definition of the health care system here: it's like legalized vampirism. They sink their fangs into you to bleed you of as much money as they can until you're dead. You are just a "premium" to them. Being sick is a very big business. I was talking with a insurance rep about why a certain medicine was not approved. They said the doctors there don't feel it's necessary. I said, all right, give me the number of your doctors, because they are obviously smarter than the one I have now, I should go to them. Silence on the other end. I've told my husband, maybe we should buy a number of shares in these insurance companies: at least we'd make enough dividend back to cover the co-pays we pay out. And I still miss my old primary........ You are watching this system implode. What a mess.........
One of my former coworker's wife had diabetes and needed dialysis. They had three insurance plans. I thought that was great, extra coverage. He said, no, it's terrible, because they all refuse to pay, saying the other two companies have to pick up the tab. This was more than two decades ago. She needed dialysis 3 times a week, for $10K each time.
I’ve had two primary care doctors just up and quit in the last ten years. One returned to his native Italy. The other is doing well operating a small chain of spas and salons. At least we don’t need prior authorization to get a haircut…..yet.
@@mariekatherine5238 ......hahaha!.....
One of the reasons I am moving back to Europe by the end of this year.
......got room in your luggage for one more? Me! Let's go! Vrrrrrrroooooom!
Go get outta here, no one likes you here anyway
what european country? Depending on the country, prior authorization still exists, it's not just a thing in the us
@@persoro4015 I’m from Switzerland.
@@persoro4015 The difference is that prior authorization is only needed in rare cases (or for inpatient admission to hospitals as the video said used to be the main purpose of prior auth in the US) in those countries. If there's some insanely overpriced drug that does not have good evidence for efficacy (lots of those in the US market), it's pretty likely that you would not be able to obtain them in those countries though.
The only large group that escapes this is people on original Medicare with a Medicare Supliment plan, On original Medicare your doctor is the one who decides your care, if Medicare covers what you need you get it. This does not happen on a Medicare Advantage plan, they have the dreaded Prior Authoration requirement.
Yes. However, medications are still outrageous on supplement plans. One med my husband takes is $1000 a month. He can get a generic through a Canadian pharmacy for $36/month but there isn't one available in the US. ACA is a total ripoff for many middle class households who make just slightly over 70k. You could end up paying 25-35% of your gross income when you factor in premiums and out of pocket maximums FOR ONE PERSON!!! Not including the co-pays and pharmaceuticals that aren't included in that number. If you insure a family it can cost you $40k or more per year before the insurance pays a penny.
I'm in the middle of a prior authorization fight right now. I'm extremely grateful this documentary was made. thank you for raising awareness of this incredibly awful experience.
So grateful I live in Australia! I just had a full open hysterectomy, with my choice of surgeon! I had to wait 6 weeks for the procedure but guess how much it cost me? NOTHING! That is peace of mind when you are sick for sure!
It didn't cost you NOTHING! You've been paying for it your entire life thru your taxes.
@@obsidianjane4413 that’s how taxes are supposed to work!
@@obsidianjane4413Are there no taxes in the USA?
What do you get for the taxes you pay even if you don't live in America?
@@garryparton553 innovation isn’t particularly relevant if people can’t afford the care they need. Australians live longer, healthier lives than people in the US - as do many people in other similarly-development nations. For all of the technology and innovation that the US has, you’re more likely to live longer and stay healthier by living in a developed nation somewhere else in the world than you are here in the US.
@@garryparton553 if you can’t pay for it, what’s the point?
The doctor decides what treatment you should get, not the health insurance...we can not let the health insurance control our lives...
Health insurance admins are practicing medicine without any medical license, which is illegal, but somehow ($$$) this is allowed?? Disgusting.
@@CestLaVieAZ They have licensed healthcare professionals employed at the insurance companies evaluating the cases. Having said that, I knew someone who did this job for a very short time and then quit because they felt pressured by the insurance company to look more at the bottom line than what the patient needed. It was for an HMO. HMO's are crap. No one should have them but non critical thinking people get enticed by the sales pitch and sign right up.
That's how it should be, not how it is.
Then organize and vote.
No free health care for congress or federal worker for government office.
I am 53 years old woman and I am 5'2". I work walking up and down aisles and ladders for 8 hour days. I swim at the gym. I eat healthy and I am FAT. My BMI is 44.1. My doctor prescribed Ozempic and my insurance denied me. I pay over $1000 every 28 days. I have genetic high cholesterol at 312. I also have sleep apnea. My insurance in Tricare.
Prior authorization is the health insurance industry’s biggest cash cow.
This is investigative journalism, not "opinion".
It’s both. The investigative journalism supports the opinions they expressed at 7:24.
@@freden9234 I think it was a possible solution to the issue rather than an opinion about the issue.
Evidence shows there IS an issue.
Abolish Prior Authorization
Yes. I'm a primary care doctor and can confirm we see this literally every day. It's to the point where I've encouraged people to go to GoodRX and other coupon services if insurances deny drugs, many of which are extremely basic. I too have had delays of care getting imaging authorized for certain conditions, one particular case that comes to mind was an MRI to characterize a liver mass that was denied by an OBGYN, mass turned out to be malignant. How dare they. The insurance companies aren't fulfilling their end of the deal in the least.
The same applies to HMOs - I broke my hand when I was 17 years old and was covered under my dad's insurance. I had to go through the HMO process - instead of getting it fixed, I spent 12 weeks seeing follow-up appointments with my primary care doctor and a hand surgeon. Did weekly tests only for them to say "your injury is healed and if you want to fix it, we will need to break your bone again so that it can heal properly." My parents were angry and I got my first true experience with insurance companies. When I was old enjoy to have my own insurance, I vowed never to deal with HMO insurance policies.
I have an HMO through Obamacare because my job's health insurance options are expensive. It sucks.
As a type 1 diabetic, It's almost imposible trying to get an affordable insulin pump
Biden's attempt to lower insulin and device prices is being fought in court by you know who and their allies such as The Chamber of Commerce and other righties.
Yes I know. I do the auths for the insulin and it is a circle of paperwork and madnesses. And after 37 tried I get it approved and then the pharmacies are out of stock of the insulin. So Doc has to prescribe another and the circle starts again.
Sorry to hear that. 😢
I'm glad this is a conversation. I've worked in health care for years and have worked on prior authorizations for patients and set up peer to peers for providers I've worked for.
Thank you, Dr. Jessica Korman at Capital Digestive Care for being apart of this conversation.
I have had a stroke and was on repatha for a year (this after multiple denied prior auths) when lo and behold, January 1st rolls around they started asking for a prior authorization AGAIN. Today I was denied for the 3RD time so this is nearly 3 months where I can get my medication. Thanks Aetna!
Health should not be privatized. PERIOD. All institutions of health care should be Non-profits
We are the only modern country that allows this to happen.
This will happen in the UK if the Tories get their way with the NHS. They are already sabotaging it.
I am calling my pharmacy, my doctor, and the medical insurance, repeatedly for the Prior Authorization for the medicine I have been on for a decade on other insurances. Once I was without it 6 months. It has been 3 months now. I decided to use a version of it I saved that causes me skin allergic reactions. I have no choice but to itch after using it. Then I go without a few weeks, and then do it again. I called them all today. I wait.
EDIT: Yes, they said they have to call tomorrow, because it was a lie that they didn’t send in a PA.
My insurance company is making me jump through hoops to get reimbursed for my albuterol inhaler. Absolutely ridiculous. They told me "All insurance companies have this process for non-formulary prescriptions. It's not denying your prescription, we have processes to help you get your prescription." My doctor has already sent them a prior authorization, letter of medical necessity, I've completed a form, and sent in both pharmacy receipts. Now they want another form to appeal the denial. For a $43 asthma inhaler that was removed from the formulary this year. When I complained the process was excessive, I was told that I'm young and don't know how the insurance industry works. I might be young but I'm old enough to know that "having processes to help patients get their prescriptions" is straight up BS when they're the ones creating the red-tape and enforcing a process that requires several forms requesting the same information 10 times over and preventing internal departments from sharing information with each other, thus putting the burden for navigating the process on patients and providers.
Imagine the societal cost here. Massive administrative delays and individual cost as outlined in the video are one thing, but people who are sick, blind or even dead are also not the same workers and consumers anymore. So even from a capitalist standpoint, these insurances demanding prior authorisation act in no one's interest but their own. Until they realise that dead and sick people are a poor source of income for them, too...
in California you have a very fast method of legally requiring them to do what you are asking.. get the DMHC (department of managed health care) in involved.. this is STATE level and their decisions are BINDING over the insurance companies, and they can and DO fast track serious cases
👏 CA is one of most advanced states when it comes to Healthcare. Unfortunately there's still 49 others and territories that aren't so lucky....
I got Hep C at a homeless shelter back in the early 00. I had UltraHell (United Healthcare) as my carrier. My Dr prescribed Harvoni. The cost for a 6 month treatment was $137,680.
It took 2 Dr recommendations then 2 "senior case managers" from UltraHell and 7 months of back and forth to get coverage, but in the end I did get it. 5 6 years later and still virus free
I’ve experienced this at a primary care level. Where I am required to pay up front for the visit and the insurance will consider and reimburse a percentage of the bill. The insurance also denies any visits with specialty doctors. Btw, I was paying $175 a month for this healthcare plan.
What healthcare do you have?
@@reaganhiggins8963 Don’t remember name, but it was offered by my employer.
Providers requiring payment up front is becoming more frequent. Reimbursement is no longer reliable so providers stick it to the patient. The system has turned providers into part of the problem. The losers are always the patients.
Thankyou for doing this NYT - Im a nurse practitioner student and a nurse and our textbook explains PAs as a necessary benefit to cost control…Im seeing just the opposite in almost all cases its necessary and the pt waits forreverrr and never gets the drug or whatever. And ppl just give up and die. Not to mention the people hospitals hire just to work on PAs. We need legislation NOW bc ppl are dying…
I was just hospitalized with discitis (bone infection in the lower lumbar spine). I was hospitalized for 5 days. The last day I could have gone home but my doctor had to fight with the insurance company to approve doing my infusions at home and once a week home healthcare to change the dressing on my picc line. It took them 2 days where I was racking up charges so if they claim they are saving money I call bs on that.
They are saving money in this situation. Because you no longer meet hospitalization requirements the insurance company will refuse to pay for those two days. This is despite the fact that it’s their fault you were unable to be discharged. I’m a doctor and my family works in hospital administration. This is a consistent pattern of insurance companies denying doctors discharge plans because they know if they can force the hospital to take you two more days without meeting their criteria that they will be able to justify not paying for those days… getting you two days of “free” medical care (essentially they are betting that we won’t be soulless psychopaths by kicking you out to the street). It causes a lot of harm to patients all the time and definitely increases the cost of medicine overall but it saves the insurance companies money.
@@skicreatureNope. They have already paid the bill including those days. I hit my out of pocket in February, so I am at 100% payment at this point. I have very expensive drugs I take and receive copay assistance. Luckily the insurance company sees this as out of pocket even though it is a 3rd party paying it.
Question: What do you have to pay?
@@dengamleidiotI am still receiving bills, but since I had already hit my out of pocket maximum it should be covered at 100% meaning I should not have to pay anything
End pre-authorization. Doctor's and patients need to be in charge of treatment.
I am the director of nursing at a SNF, and I have to fill out so many prior authorizations and they’re always denied.