After Brian Thompson, the CEO of UnitedHealthcare, was killed in New York City, we saw a huge outpouring of anger

directed toward health insurance companies. The vitriol and the scale of the response was shocking to many. We

wanted to hear from doctors who deal with patients and insurers on a day-to-day basis. Have you been surprised

I think I have and I haven't. I mean, I certainly feel the undertones from my patients, the anger at

my staff that they can't do something right away. But I'm surprised at the amount of support there is, uh, for obviously

something that's inappropriate and shouldn't have ever happened.

I'm not surprised, to be honest. I'm not always

able to give my patients the care they need.

What is the worst thing you have to deal with from an insurance perspective?

The worst thing that we have to deal with from the standpoint of the patients is pre-authorizations. Prior authorization

means that the insurer has to approve whatever medical procedure that your doctor thinks you need.

Nearly all doctors surveyed by the American Medical

Association said that prior authorization requirements have delayed access to necessary care; something that pretty much didn't even exist when I

Instead of us being able to spend time in the office with our patients, we're wasting

Now we have entire teams dedicated just to the non-clinical, administrative side of

our practice that wasn't there when I started 10 years ago. And another pain point can come after the care is

rendered. Sometimes the care is given, and then the insurer decides in retrospect, perhaps, that it wasn't justified or it

doesn't fit the plan and shouldn't be paid for.

So what we see in healthcare workers is people get demoralized; people

Leave the business; it's a huge financial and emotional burden, and it can impact a patient's care. One in four

doctors said that prior authorization led to a serious or life-threatening medical issue. I had a patient; she had a history of

breast cancer. She had a double mastectomy. Several years later, she started getting pain in her chest, and

the appropriate test for her, unquestionably, was a CT scan. I ordered the test; it was denied by her health

insurance company. It was delayed until she actually got the test she needed. It showed a recurrence of cancer, and the

patient later died. This is a stark example, but not an uncommon example of what happens. It's not always a

discussion just between me and the patient as it should be; it's an insurance company getting involved and deciding that the care that I think is

necessary, the care that the patient thinks is necessary, is not necessary.

back to when things started getting worse? Certainly, the expansion of Medicare Advantage has made a massive

difference for us. Medicare Advantage, when private companies administer publicly funded insurance, has expanded widely. More than half of all eligible

people now have one of these private plans. With traditional Medicare, there's essentially no prior authorization. When Medicare Advantage takes over, now we

introduce significant prior authorizations. These private, for-profit insurers that run Medicare Advantage, they are absolutely in a league by

themselves, and the denials are, to my mind, completely capricious. Data shows that Medicare Advantage insurers denied

about 7% of prior authorization requests, according to a 2024 Senate report. Denial rates were much higher when it came to

Last year and this year, the journal has actually spent a lot of time looking at things that really aren't part of the

front door; they're kind of behind the scenes. One of our stories looked at the prevalence of diagnoses in Medicare

Advantage that did not actually come from a doctor treating the patient. They actually were added to the patient

records through activities associated with the insurer. So to understand Medicare Advantage, one thing you have to

understand is that the insurers that work in Medicare Advantage are paid more if the person that they're covering

has more health conditions. So there's a strong incentive for Medicare Advantage insurers to document more diagnoses, things like diabetic cataracts or morbid

obesity. It doesn't mean those diagnoses aren't true, but there is a greater payment for the insurer if they document

more diagnoses. Insurer-driven diagnoses in 2021 generated $8.7 billion in payments for UnitedHealthcare, and that

was the most in that year of any insurer. In response to the journal's previous reporting, UnitedHealth has said that

Medicare Advantage provides better health outcomes and more affordable health care for millions of seniors. When reached again for comment, they pointed

us to recent changes the company has made to streamline the prior authorization process. America's Health Insurance Plans, an industry trade group,

said in a statement to the journal that providers and drug makers also share in the responsibility to patients, and that

health plans work to protect patients from rising costs. So I think insurers do see themselves, and it is true, as

one of the few players in the system whose job is to try to tamp down those costs. However, the costs continue to rise.

I think it's important that there are checks and balances. The real problem is that what was intended to be a nice

Checks and balances have turned into a way of penalizing physicians and patients in order to increase profits for

shareholders. The universal feeling is that insurance companies are working against us, against what we want for our patients, what our patients need.

The Issues with Health Insurance Companies, Explained by Doctors | WSJ

The Wall Street Journal takes you inside carefully selected stories and events in a visually captivating way so you can dig deeper into the news and insights that matter to you. 

The Issues with Health Insurance Companies, Explained by Doctors | WSJ

Scripts