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Insurance & Benefits

Why Your Insurer Wants You to Go Back to the Doctor

Rising margins for insurance companies signal a dangerous fall-off in regular healthcare visits due to the pandemic.
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Fears about going to the doctor or hospital because of COVID-19 have been well documented throughout the pandemic. From 911 calls that were too late to missed cancer screenings, delaying or avoiding care is already having deadly consequences.

At the same time, insurance companies experienced significant increases in their gross margins through the first three quarters of 2020. According to data from the Kaiser Family Foundation, average gross margins for the individual and fully-insured market plans were 21 and 24 percent higher respectively compared to 2019. In the Medicare Advantage market, gross margins were 35 percent higher compared to the same period in 2019.

Insurers medical loss ratio, or the percent in premiums paid out by insurance companies for providing care, also went down in the individual, group, and Medicare Advantage markets between 2019 and 2020 after going up or staying level between 2018 and 2019.

Insurance plans are more profitable than ever, which could be due to patients simply avoiding the doctor. While missed care may provide short term gains, insurance companies would prefer that their members receive regular care to avoid the high cost procedures that could result from missed scans and check-ups.

UnitedHealthcare data show insurance claims for mammograms dropped by as much as 95% in April, and the company has seen one million fewer screenings this year for breast, colorectal and cervical cancer for Medicare Advantage members. “In six months, a lot can change with your health if you’re not tracking it and keeping on top of it,” says Dr. Ken Adams, the regional chief medical officer overseeing Texas with UnitedHealthcare Medicare & Retirement.

A study by Quest Diagnostics found that diagnoses for six types of cancer dropped 46 percent in 2020, and the National Cancer Institute predicted that missed or delayed screenings could lead to 10,000 additional deaths from cancer and colorectal cancer over the next decade. Cancer didn’t become less common during the pandemic. It just isn’t being detected as early, meaning worse outcomes down the line.

“If you are not getting your primary care needs met, that means that you are more likely to get those needs met in an ER or a hospital stay,” Adams says. The company’s priority is making sure its members stay as healthy as possible, and that means making sure they are receiving regular care. In the long run, what is best for patients is also best for the company’s bottom line. “Treating that heart attack is so much more expensive than giving you medications to lower your cholesterol.”

Hospitals are as full as they ever have been due to COVID-19, so if delayed care does end up causing a hospital visit, there may be resource issues, depending on the timing of the illness. “What’s happening is people who are coming in to the hospital because they’re sick with something else, like a burst appendix, are having trouble getting a hospital bed, because everything is full,” Adams says. “It’s pretty dire out there, especially in large urban areas.”

Adams has been working hard to work with local physicians to get members back to their doctor’s offices for regular check-ups, cancer screenings, and other routine care. There is ample data about the impact of a relationship with a primary care physician, which improves outcomes and helps patients avoid high cost emergency department visits. Telehealth has been a boon to consistent visits as well, as laws have changed to make them profitable for physicians.

UnitedHealthcare has also made a special effort to connect with vulnerable and elderly members in rural areas, where there is often a shortage of physicians. With regular calls to members who might not have access to a primary care physician, they have been able to help patients do everything from receiving their prescriptions to getting their lights back on. UHC serves 3.9 million people in Texas, and serves one in five Medicare beneficiaries nationwide.

“Ultimately, we want our patients to remain at home healthy, rather than be constantly admitted to a hospital,” Adams says. “That’s not good for our patients, and it’s not good for an insurance company.”

As the pandemic has dragged on, many clinics have experienced a return to normal business, though with added COVID-19 precautions that have required offices to become more efficient and avoid groups in waiting rooms while at times serving more patients than ever before. “Another silver lining to COVID is understanding how important it is to get your patients in quickly and not have them linger in the waiting room, and just move people through,” Adams says.

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