Insurance companies are growing by leaps and bounds controlling more of the healthcare dollars by engaging in a practice known as “vertical buying.”
What is vertical buying?
Vertical buying is the act of purchasing downstream healthcare services and companies that are outside of the role of being an insurance company to influence more of healthcare spending and make money. They are expanding way beyond the role of a simple insurance companies into mega corporations with United Health Care (UHC) and Humana in the lead.
UHC due to its “mega growth,” is now under investigation by the DOJ (Department of Justice) for alleged anti-trust violations that became painfully apparent during a recent cyber-attack.
Q: Can the insurance companies choose my doctor?
Yes, they can choose your doctor by having limited networks so you can only see the doctors in the network. They can also employ your doctor either directly or indirectly through “value based,” purchasing relationships-or paying “physicians for performance.” And, in fact, UHC or United Health Care is the largest employer of physicians in the U.S.
Q: What happened in the cyber-attack?
In February of 2024, the release and payment of healthcare goods and services came to a screeching “halt,” throughout the entire United States and delayed the distribution of medications and services to patients, pharmacies, hospitals, and physicians due to a ransomware attack.
This raised great safety concerns about the power and impact that one company can wield and anti-trust violations challenging the legitimacy of “vertical buying,” strategies which is now under investigation by the Department of Justice (DOJ).
Q: New laws to regulate insurance companies?
Yes, the other big news is in May 2024 Oregon doubled on attempts to ban or regulate the “Corporate Practice of Medicine,” along with similar bills in California, Florida, and Minnesota.
The bill, HB-4130 was put in place to preserve the ethical duty of a physician to you the patient vs. the Healthcare Corporation’s duty to its shareholders. This purpose is to allow physicians to practice medicine ethically without the looming threats of healthcare corporations.
Q: How does the “big,” insurance companies affect me?
If you have health insurance, “vertically buying,” will allow your insurance company to control more of your health care choosing which doctors or nurse practitioners you are allowed to see, how they provider their care, and where you can receive your care. It will also control which medications and treatments you are allowed to receive.
Simply put, we are no longer dealing with insurance companies but large “Healthcare Corporations,” where profits and losses may unfortunately dictate the care you receive ranging from pharmacy, medical supplies, physician services, and hospital care. This has also led to higher spending and in fact, the Medicare Advantage plans (Medicare ran by insurance companies) have costed the taxpayer 23 % more than traditional Medicare (ran by the government) without adding value to your care.
What kind of health insurance is right for me?
Medicare, a government payer mostly for people over the age of 65 or with qualifying conditions, is allowing the insurance corporations to manage your healthcare dollars through their “Advantage Plans.” In fact, there has been a shift where more that 50 % of eligible Americans are choosing these plans.
What patients may not realize when signing up for an Advantage Plan, if you get sick there may be limitations on the care you are allowed or “authorized,” to have that is not is place with a traditional Medicare plan. In other words, much of your care will require “pre-approval,” by large teams of nurses and automated systems whereas there is no “pre-approval,” with traditional Medicare.
If you are younger than 65 years of age and have a commercial plan (Atena, Cigna, United Health Care, etc.,) you may be “hit,” by big deductibles before the insurance every pays for your healthcare potentially leaving you wide open for enormous costs.
For example, going to urgent care with some plans may cost $100 co-pay, but going to the emergency room may cost you $500 co-pay plus out-of-pocket deductible (that can be quite steep $5,000 to $10,000 and even higher) before the insurance will pay. It is very important to always read the fine print before choosing your plan.
Q: Who can I reach out to if I have a quality concern with my insurance company?
If you feel your insurance company or corporation has not been fair, with unsatisfactory payment of claims, delays in payment, or quality in care then first step is to file a complaint with the insurance company, and if still not satisfied then can escalate further to a variety of local and state departments. If you are a Medicare member you can also file with Medicare.gov. on the federal level.
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