The United States, despite being the highest spender on healthcare globally, faces a paradoxical reality with some of the worst health outcomes among industrialized nations. In 2023, the country is projected to spend an estimated $4.9 trillion on healthcare. Yet, physicians across the nation are raising alarms about the deadly delays caused by health insurance giants, which impede access to essential medical procedures and care. This inefficacy stems from a business model entrenched in delaying, denying, and redirecting healthcare services. While lobbyists for insurance companies argue they are protecting consumers from higher costs, doctors stress that mere superficial changes will not resolve the systemic problems within the US healthcare system.
Physicians assert that transitioning to a single-payer, universal healthcare system could potentially reduce national healthcare expenditure. A 2020 academic analysis supports this claim, revealing that a single-payer system could save tens of thousands of lives annually. Yet, private insurers continue to report billions in profits each year, while patients and their doctors struggle with navigating a convoluted financial system. This complexity is intrinsic to the insurance firms' business models, where insurance representatives often lack the specific medical expertise needed to make informed decisions.
“In the fragmented and heavily regulated healthcare system, health plans, providers and drugmakers share a responsibility to make high-quality care as affordable as possible and easier to navigate for the people we collectively serve.” – AHIP
Dr. Philip Verhoef, a vocal critic of the current system, highlights the inefficacy of "peer to peer" reviews in medical decision-making processes.
“When I have engaged in ‘peer to peer’ review, the peer is never a physician that has my training,” – Dr. Philip Verhoef
“It’s kind of a farce to even call it ‘peer to peer’. I’ve never had a ‘peer to peer’ conversation that was actually with a real peer.” – Dr. Philip Verhoef
This disconnect leads to significant delays in care, as evidenced by instances where patients are denied basic scans, and appeals take months to resolve. One such case involved a patient's request for a PET scan, which was approved six months after initial denial.
“To be totally clear, I don’t have a financial incentive to admit patients to the ICU. It’s both demoralizing and insulting when a bureaucrat somewhere looks at a submitted claim from the hospital and says, ‘The decision to admit to the ICU was wrong.’” – Dr. Philip Verhoef
The criticism extends beyond procedural inefficiencies. Dr. Ed Weisbart emphasizes that private health insurance fundamentally fails patients when they need it most.
“When people need to use their private health insurance, it actually fails them,” – Dr. Philip Verhoef
The insurance industry's focus on profit maximization often conflicts with patient care needs.
“They don’t care about you, and they see you as an expense, not someone whose health needs to be improved,” – Dr. Ed Weisbart
“The healthier you are, the more they want you to have them as their insurance, and the sicker you are, the more comfortable they are with you being dissatisfied with them and searching for a different insurance company.” – Dr. Ed Weisbart
The business model incentivizes companies to delay or deny care to reduce costs, impacting patient health outcomes.
“Once they have that money, every time somebody has to get health care, that’s just an expense that they don’t want to let go of.” – Dr. Ed Weisbart
“When they delay your care by a day, by a week, by a month or totally deny it, it’s not a random event,” – Dr. Ed Weisbart
“It’s a calculated business strategy to maximize their profits.” – Dr. Ed Weisbart
The complexity of the US healthcare system poses challenges for patients who must navigate through bureaucratic hurdles for necessary medical assistance. Insurance representatives often lack adequate medical training compared to physicians, complicating care decisions further.
“Insurance is supposed to be there to cover you from financial calamity, when unfortunate things happen, and the current system that we have based on private health insurance has really failed everyone. I don’t think that we’re going to regulate our way out of this mess.” – Dr. Philip Verhoef
Many physicians argue that superficial reforms will not address the fundamental flaws in the current business model. Instead, they advocate for a complete overhaul of the system.
“The solution is effectively to overhaul the system entirely and then start from scratch with the national health insurance system,” – Dr. Philip Verhoef