Health plans need to take accountability for a broken system

Health plans need to take accountability for a broken system

The U.S. healthcare system is at a critical juncture marked by soaring costs, administrative complexities, and patient dissatisfaction. Central to these challenges is the role of health insurance companies, which have reported substantial profits while patients grapple with affordability and access issues. This article examines the current state of the healthcare system, the responsibilities of health plans, and potential pathways toward a more equitable and efficient system

The Current Landscape of Health Insurance

In 2023, major health insurance companies reported record-breaking profits:

• UnitedHealth Group: $32.4 billion

• CVS Health (Aetna): $8.4 billion

• Cigna: $5.4 billion

• Elevance Health (formerly Anthem): $6 billion

These figures highlight a stark contrast between corporate financial success and the financial strain experienced by many insured individuals. Patients often forgo necessary care or struggle to afford treatments, leading to widespread frustration and a sense of exploitation.

Administrative Complexities and Patient Burdens

The U.S. healthcare system is characterized by a complex mix of employer-based plans, Medicare, Medicaid, and a significant uninsured population. This fragmented structure results in high administrative costs and inefficiencies. An entire industry has evolved to assist individuals in navigating the convoluted process of selecting a health insurance plan, underscoring the system's complexity.

Patient Safety and Systemic Risks

Beyond financial concerns, patient safety remains a critical issue. In the United Kingdom, for example, systemic issues within the National Health Service (NHS) have led to approximately 13,500 avoidable deaths annually. While the U.S. system differs structurally, the emphasis on patient safety is universally relevant. Addressing these concerns requires comprehensive strategies that prioritize patient well-being over bureaucratic processes.

The Call for Accountability

Industry experts argue that health plan leaders must acknowledge and address the systemic issues contributing to patient dissatisfaction. Michael Waterbury emphasizes that patients feel "unheard, undervalued, and exploited," indicating a pressing need for health plans to realign their priorities toward patient-centric care.

Steps Toward Reform

To foster a more equitable healthcare system, several measures are proposed:

1. Enhancing Transparency: Health plans should provide clear, accessible information regarding coverage policies, pricing structures, and the rationale behind claim denials. This transparency can empower patients to make informed decisions and reduce feelings of exploitation.

2. Prioritizing Patient-Centered Care: Shifting the focus from profit maximization to patient well-being involves designing policies that prioritize access to necessary treatments and preventive care. This approach can lead to better health outcomes and increased patient satisfaction.

3. Streamlining Administrative Processes: Reducing bureaucratic hurdles can alleviate the burden on both healthcare providers and patients. Simplifying processes such as prior authorizations and claims adjudication can enhance efficiency and reduce delays in care delivery.

4. Implementing Value-Based Models: Transitioning from fee-for-service to value-based care models can incentivize quality over quantity. This shift encourages providers to focus on delivering effective treatments that improve patient health outcomes.

5. Addressing Social Determinants of Health: Recognizing and addressing factors such as socioeconomic status, education, and environment can lead to more comprehensive care strategies that go beyond clinical interventions.

Conclusion

The juxtaposition of substantial insurer profits against the backdrop of patient hardship underscores the urgent need for systemic reform in the U.S. healthcare system. Health plans must take accountability by embracing transparency, prioritizing patient-centered care, and addressing the administrative complexities that hinder access and affordability. Through collaborative efforts among insurers, providers, policymakers, and patients, it is possible to create a more equitable, efficient, and compassionate healthcare system that serves the needs of all stakeholders.

For decades, I was a cog in the machine, part of a health care system that has drifted far from its original mission — to care for people. I worked tirelessly at the top healthcare organizations, including UnitedHealthcare and Magellan.

Ultimately, I was driven by the demands of the system, rationalizing success through stock options and promotions, even as I was forced further away from the patients whose well-being was supposed to be at the center of it all.

Eventually, I couldn’t ignore the reality of how the system operated. The numbers made it impossible to look the other way. Recently, I calculated my own family’s health care expenses over the past 25 years. My family and my employer have paid more than $429,000 in premiums — $771,232 when adjusted for compounding investment value inflation — yet our actual medical costs, for a family of five, totaled only $200,000. The rest? That money didn’t go to care; it did not go to risk pooling for others’ health care cost — it went to health plan profit. And while I can accept that premiums cover more than my own family’s needs, the frustration comes when claims are denied or out-of-pocket costs soar despite paying more than enough into the system. This is the core problem with today’s health plans: Families and employers pour thousands of dollars into a system designed to prioritize margins over patients.

Recent headlines and social media feeds are filled with stories of rising premiums and out-of-pocket costs, denied claims, and families being crushed by medical bills. The entire healthcare community was shocked and saddened by the tragic incident involving United Healthcare’s CEO. While the reasons behind this tragedy remain unclear, the public reaction laid bare a deeper truth: People feel abandoned by the very institutions meant to protect them. The incident became a flashpoint, amplifying the cries of a system that is failing its members and crippling employers.

I worked with the leaders of these organizations. They are good people — kind, compassionate, and driven by a desire to succeed. It’s not them — it’s the system. A system so deeply entrenched in prioritizing profits over people that even the best intentions are swallowed by its machinery. Violence is never the answer, but the anger and desperation behind it cannot be ignored. Health plan leaders need to take accountability for what’s broken. If they want to stem the tide of resentment, they must act — now.