Americans Demand Better Health Care: Holding Insurers Accountable a Good Start

Health care has always ranked highly on voters’ minds, but this past election cycle was different.

Voters consistently prioritized health care throughout the midterms, including in a Gallup poll that ranked health care above the economy and immigration as a voter concern. While there are countless factors that political scientists and pundits will attribute to this year’s record-breaking turnout, what is clear from exit polls is that worries surrounding health care costs and access were a driving factor.

While fixing health care may seem daunting, it’s clear from my work with cancer patients that one place to start is to address the power imbalance between patients and their insurers. For far too long, health insurance providers have played games with patient care. Headline after headline highlights the improper delays and denials that are all too common for patients seeking doctor-recommended treatment. It’s time for policymakers to hold insurers accountable.

Recently, federal investigators with the Office of Inspector General for the Department of Health and Human Services released a report revealing the scale of private insurers’ unfair and arbitrary rubber-stamped denials. Looking at Medicare Advantage plans, a popular private-insurance alternative to the traditional Medicare program, the report concluded that insurers “inappropriately deny access to services and payment in an attempt to increase their profits.”

Even more troubling, the OIG reported that when patients and their physicians appealed a denial, Medicare Advantage Organizations overturned 75 percent of their own denials. According to the report, the high number of overturned denials “raises concerns” that many patients should have received access to the care they needed from the beginning.

Why put patients and physicians through this process if only to turn around and approve care following an appeal? It’s a numbers game for the insurance companies, and the investigation found that only 1 percent of beneficiaries and providers ever appealed a denial, thereby increasing insurer profits when they deny care.

While this report wasn’t specific to cancer care, it highlights a pattern of bad behavior among insurers that has been repeated in the private insurance market for cancer patients whose physicians recommend proton therapy.

A broken review and appeal process recently landed one insurance provider in an Oklahoma court and resulted in a $25 million award for a cancer patient’s family after the jury determined that Aetna improperly denied proton radiation. In this case, lawyers cited bias on the part of Aetna’s medical review staff because doctors and nurses who denied the patient’s claims received profit-based bonuses. This information and other evidence led jurors to find Aetna guilty of “reckless” disregard.

In May, my organization released a report showing that private insurers deny proton radiation treatment six out of 10 times. Similar to the OIG report, these denials were reversed a third of the time, calling into question their rationale. Appeals took an average of five weeks, endangering the lives of cancer patients who don’t have time on their side.

Patients’ stories of successfully fighting insurance denials say as much about the problem as the data.

Randy Montgomery, a former country radio show host, had his treatment for HPV oropharyngeal cancer delayed by several weeks because of an improper denial. His physician recommended protons because the treatment is more precise than traditional radiation and, given the location of his tumor, would minimize damaging side effects, including potential loss of his ability to speak. Throughout his treatment, Randy received conflicting and confusing information from his insurer. He faced nearly $100,000 in medical bills after his insurer initially paid for the treatment and then asked for the money back. It wasn’t until he took his fight public that Blue Cross Blue Shield of Texas backed off.

For Kim Jones Penepacker, a young trial lawyer, a two-week course of radiation to treat Hodgkin’s Lymphoma turned into a two-month battle for the care she needed. Kim’s physician recommended proton therapy because it would minimize the risk of recurring or secondary cancers, which are a greater risk for young adult cancer patients. Kim enlisted the help of her state legislator, who asked the Texas Department of Insurance to review her case. The state overruled Blue Cross Blue Shield of Texas’ improper denial, but that didn’t lessen Kim’s unnecessary mental and emotional strain.

For every Randy or Kim who takes their fight public, there are countless other Americans who are so focused on fighting their cancer, they are unable to take on their insurer. Voters are demanding better health care, and putting a stop to improper delays and denials that ignore physicians’ expertise and patients’ best interests is an important step. Clear principles for holding insurers accountable, outlined in our Cancer Patients’ Timely Treatment Bill of Rights, are a good place for policymakers to start.


Daniel E. Smith is executive director of the Alliance for Proton Therapy Access.

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