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One Patient’s Pain and UnitedHealth Group’s Payday

Two news stories – a patient's struggle in St. Louis and a payor's Q3 earnings – show just how damaging the U.S. insurance industry has become.

By Wendell Potter

It was another big quarter for UnitedHealth Group, the nation’s largest health insurer. On October 14, the company announced an eye-popping, Wall Street-pleasing $5.7 billion in profits between June 1 and September 30. The earnings were so unexpectedly positive that investors rushed to buy more shares, pushing the share price to an all-time high.

The next day, the St. Louis Post-Dispatch published a story about a little girl who is in constant excruciating pain. Her doctors say she should be admitted immediately to a children’s hospital that has expertise in treating her condition. However, the same UnitedHealth has repeatedly denied her parents’ and her doctors’ request to approve coverage for her care.

I frequently write about how the profit-driven business practices of insurance companies harm American families. But it can often be abstract and hard to understand. That’s why I need you to meet Lyla McCarty.

From the St. Louis Post-Dispatch:

Nine-year-old Lyla McCarty was baking a cake when she started screaming in pain and fell off the chair at the kitchen table.

Her parents, Heather and Derek, couldn’t figure out what was wrong. They didn’t see any injury on her left foot, where she said it hurt. It was a Sunday night in late February.

The next morning, Heather drove her daughter to the pediatrician. She carried her inside. When Lyla’s X-rays came back normal, they took her to St. Louis Children’s Hospital. The doctors ran more tests and sent her home with a walker.

Before this mysterious pain, Lyla, who lives in Arnold, loved to play soccer and volleyball and run around with her friends in fourth grade. Now, she hid behind chairs in her bedroom, cried inconsolably and refused to go to school. Additional tests and blood work came back clear. Nearly a month had passed without any answers. Then, Lyla’s foot started turning purplish red and was cold to the touch.

That’s when they got a diagnosis — Complex Regional Pain Syndrome, a rare type of chronic pain that often affects an arm or leg. Her parents had never heard of it. When Heather Googled it, she saw it referred to as the “suicide disease.”

One way to restrict access – prior authorizations

One of the ways UnitedHealth and other insurers have been able to make such record-breaking profits year over year, even during the pandemic, is to deny prior authorization requests, which is what is happening to Lyla.

Private insurers often require physicians and hospitals to seek permission before treating their patients or prescribing medications. Insurers maintain that prior authorization is necessary to reduce unnecessary care, but it often results in millions of Americans not getting the care they need.

A recent American Medical Association survey found that 94% of doctors reported delays in treating their patients because of insurers’ requirements, and 79% said patients abandoned treatment “due to authorization struggles with health insurers.”

The St. Louis Post-Dispatch story perfectly illustrates how prior authorization requirements put patients in jeopardy. Lyla’s parents share how their active, loving daughter has become withdrawn and inconsolable as UnitedHealthcare has repeatedly refused to cover the inpatient treatment her doctors say she needs.

Heather McCarty’s mother told me the UnitedHealth customer service representative assigned to her has been of little help and refused to even provide evidence that the doctor UnitedHealth used to review Lyla’s case is even a pediatrician.

I reached out to UnitedHealth for a comment and received this reply from Matt Stearns, the company’s senior vice president and head of external affairs: “While I can’t comment on the specifics of this situation due to privacy laws, we do regularly work with our members to find care options to meet their needs.”

Record-breaking profits

This statement just reiterates what we already know. These policies aren’t likely to change as long as they continue to spur record-breaking profits year after year.

UnitedHealth’s profits in particular have skyrocketed in recent months. It’s notable that UnitedHealth reported profits of $5.7 billion in just the third quarter of this year alone, the day before the Post-Dispatch’s story about Lyla appeared. And while Lyla’s family launched a GoFundMe campaign to cover the medical expenses that UnitedHealth won’t cover, the company was telling Wall Street that it had “returned $1.4 billion to shareholders in the third quarter via dividends…and repurchased 2.5 million shares for $1.1 billion in the quarter.”

Meanwhile, policymakers seem to be turning a blind eye to the many barriers that insurers have established in recent years that prevent patients from getting the care their doctors know they need. It is those barriers—excessive cost sharing requirements, shrinking provider networks and unnecessary prior authorization demands—that make those outsized profits possible.

This isn’t an accident. Insurers spend enormous sums of our premium dollars in campaign contributions and lobbying expenses. In 2020, UnitedHealth doled out more than $5.5 million to federal candidates and more than $4.1 million in lobbying expenses in Washington.

With all that money flying around, it gets more and more difficult to stomach stories like Lyla’s. It’s true that health insurance is a business, and businesses have an obligation to remain solvent. But the level to which insurance companies have been able to profit on the backs of families like the McCarty’s puts the entire industry in question. Increasingly, it seems that the sole purpose of an insurance company is not to provide a coverage product that protects Americans, but to fill the pockets of shareholders at their expense.

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