의사들이 건강 보험사의 사전 승인 관행과 환자 치료에 미치는 영향을 비난하다

### 사전 승인이 의료 서비스에 미치는 영향
* 😠 필요한 치료를 받는 데 어려움을 겪으면서 의료 보험 회사에 대한 환자들의 분노가 사상 최고조에 달하고 있습니다.
* 👨 ↪CF_200D↩⚕️ 의사들은 사전 승인에 상당한 시간을 낭비하여 환자 치료에 집중할 수 없다고 보고합니다.  이제 팀 전체가 보험 관련 행정 업무에 전념하고 있습니다.
* ⏳ 사전 승인으로 인해 필요한 의료 절차가 지연되거나 거부되어 환자가 사망한 사례에서 볼 수 있듯이 심각한, 때로는 생명을 위협하는 결과를 초래하는 경우가 종종 있습니다.
* 📈 메디케어 어드밴티지의 확대로 인해 사전 승인 건수가 증가하고 거부율(약 7%, 재활 및 수술 후 치료의 경우 더 높음)이 증가하면서 문제가 더욱 악화되었습니다.
* 💰 메디케어 어드밴티지 보험사는 더 많은 진단을 문서화하도록 인센티브를 제공하므로, 2021년 보험사 주도 진단으로 인한 UnitedHealthcare의 87억 달러 지급액에서 알 수 있듯이 잠재적으로 청구가 부풀려지고 수익이 증가할 수 있습니다.
* ⚖ 보험사는 비용을 통제한다고 주장하지만, 의사들은 이러한 조치가 의사와 환자에게 불이익을 주고 환자 건강보다 이윤을 우선시한다고 생각합니다.
* 💔 현재 시스템의 상태는 의사의 소진과 사기를 떨어뜨려 의료 전문가들이 현장을 떠나는 결과를 초래합니다.
* 🤔 의사들 사이에서 전반적인 분위기는 보험회사가 의사와 환자 모두의 이익에 반하는 일을 적극적으로 하고 있다는 것입니다.

의료 보험사의 사전 승인으로 인해 필요한 치료가 지연되어 환자 피해와 의사의 소진을 초래합니다.

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 Wall Street Journal

의료 보험 회사와 의사의 경험에 대한 대중의 분노

CEO가 사망한 후 건강보험 회사에 대한 대중의 분노는 상당했습니다.

의사들은 보험 제한으로 인해 환자들의 분노를 경험하고 있습니다.

의사들도 부적절한 사건에 대한 지원 수준에 놀랐습니다.

한 의사는 보험 문제로 인해 필요한 치료를 제공할 수 없다고 말합니다.

사전 승인은 필요한 의료 절차를 지연시킵니다.

의사들은 환자 대신 보험회사를 상대하는 데 시간을 보내고 있습니다.

보험 문제를 처리하기 위해 관리 팀이 만들어져 비용이 추가됩니다.

보험사는 치료가 제공된 후 치료를 거부할 수 있습니다.

이로 인해 사기가 저하되고 직원 손실과 재정적 부담이 발생합니다.

거부로 인한 치료 지연이 어떻게 환자의 사망으로 이어졌는지 사례 연구를 통해 확인할 수 있습니다.

메디케어 어드밴티지 및 보험사 관행의 역할

메디케어 어드밴티지의 확대로 상황이 크게 악화되었습니다.

메디케어 어드밴티지 플랜은 기존 메디케어보다 더 많은 사전 승인을 도입합니다.

메디케어 어드밴티지 보험사의 거부는 변덕스러운 것으로 묘사됩니다.

상원 보고서에 따르면 특히 재활 및 수술 후 치료에 대한 사전 승인 요청에 대한 거부율이 높은 것으로 나타났습니다.

보험사는 의사의 입력 없이도 환자 기록에 진단을 추가합니다.

보험사는 더 많은 건강 상태를 문서화할수록 더 많은 보험금을 지급합니다.

보험사 주도의 진단으로 수십억 달러의 지불금이 발생했습니다.

업계 단체는 의료 서비스 제공자도 환자 치료와 비용 상승에 대한 책임을 공유한다고 주장합니다.

보험사는 스스로를 비용 관리자로 생각하지만 비용은 계속 상승하고 있습니다.

의도된 견제와 균형은 수익을 높이는 방법이 되었습니다.

전반적인 느낌은 보험회사가 의사와 환자에게 불리하게 작용하고 있다는 것입니다.