Episode 90 Recap – Pulse check: Insurance Coverage of GLP-1s, Cyberstalking, and UnitedHealthcare’s use of AI

The Print Version of Episode 90 of the FLATLINING Podcast

On this week’s podcast, Matthew and Ron hit some of the headlines in healthcare news looking at recent legislation in Minnesota that will remove for-profit Health Maintenance Organizations (HMO) from handling the state’s Medicaid program. Then our team discusses recent comments on the GLP-1 medications. These are the weight loss drugs that are changing lives for those with chronic obesity. Ron and Matthew dissect some recent comments from Senator Bernie Sanders. They wrap up with a story on a patient cyberstalking his insurance company.

Before diving into what is going on in Minnesota and its Medicaid program, Matthew asks Ron what’s the purpose of operating a for-profit HMO versus a non-profit. Ron discusses the positive impacts of a free market in general terms, but points out that in the delivery of healthcare, it can lead to a conflict of what is good for the insurance company is not good for patients or the doctors he said.  Ron said he heard somebody recently say, “Are we talking about budget care or patient care because those can be two different things.” This is the underlying question, he said. Should there be a profit motivation in health insurance when we are using public funds for poor people and those with critical needs using Medicaid?

Matthew asked Ron if all states contract out the running of their Medicaid programs or if some take care of it themselves. Ron said he thought there might be a few that handle it themselves, but most states contract out some or all of their Medicaid population. It is similar to the federal Medicare Advantage programs, he said.  Matthew thought as a consumer it seems to make sense that a private company would save the state money by not having to hire all the personnel to run the program. But he acknowledged, that you then start getting into the profit motivation that Ron talked about.

Matthew summarized the StarTribune article stating that Minnesota has used HMOs for years to run their managed Medicaid programs and had blocked for-profit HMOs for decades from participating until a new law was passed in 2017. That law allowed for-profit HMOs to run the Medicaid program. That law is now being reversed and will take effect next year.  

Matthew asked Ron if it matters if the private company running the Medicaid program is non-profit or for-profit. Ron said he sees two issues, the first is a matter of appearance. He explained that when you have a very profitable publicly traded company making billions of dollars off public money, it doesn’t look good. Ron said “What we got here is, a United Healthcare making more money per enrollee on Medicaid than they do on employer care. It’s more profitable.” The second issue, he said, is we should ask if the non-profit is better at managing Medicaid than the for-profit. Ron said he had not seen any data on this point. This recent action from the Minnesota legislature may only address the appearance issue, he said.

The conversation shifted to the GLP-1 drugs that have been providing drastic improvements for those struggling with chronic obesity and are not generally covered by private insurance, Medicaid or Medicare. Matthew shared recent comments from Senator Bernie Sanders who said these drugs will “have the potential to bankrupt Medicare and our entire healthcare system.” In an article in Becker's Healthcare, the senator said “The unjustifiably high prices of these weight loss drugs could also cause a massive spike in prescription drug spending that could lead to an historic increase in premiums for Medicare and everyone who has health insurance.” Matthew also mentioned a recent study from Blue Cross Blue Shield (BCBS) that said six in ten patients don’t receive a meaningful health benefit while on these drugs.

Matthew asked Ron if Sen. Sanders is thinking that these drugs may soon get coverage and their high cost would be too much for the system to handle. Ron said yes and thinks it will be more difficult not to cover these drugs as the clinical data continues to roll in showing positive results. Once you start to cover these drugs he said, “It breaks the bank.” Ron said he does agree with Sanders’ math on this point. Matthew said he is aware of a few states were starting to cover the GLP-1s, but had not seen anything on what it is costing or the outcomes.

Ron proposed one method that could affect the price is market forces. He explained that with two drugs currently on the market, a large employer that wanted a healthier workforce could go to the drug manufacturers and offer to buy exclusively from one company to whoever could give the best price. If this happens it could drive the price down, he said.  

Ron shared his story of taking GLP-1s and how it has had a positive effect, and not just on his weight, but across several health indicators. He is paying out of pocket but noted that it is worth it. He then questioned where BCBS got their data that six in ten people saw no effect from taking GLP-1s. Matthew asked Ron if this could be a case of finding the right data to prove your point. Ron shared that as an economist and someone with an advanced degree in statistics, you can make data fit what you want it and noted that this may be a case of making your sample fit your desired outcome. Ron said he understood why insurance companies are hesitant to provide coverage of a drug that could impact this many people and cost this much money. He doesn’t think the right solution is not to cover something like this when it is given to the right patient it has a massive clinical benefit.   Matthew closed by pointing out that when you dig into the study, it showed six in ten people stopped taking the drug before it took effect.

The team wrapped up the GLP-1 discussion by talking about how costs could come down, Ron shared how he was able to get a 50% discount working directly with the drug manufacturer, but he is still paying $500 per month for the drug. Ron said that the manufacturers are having a tough time producing enough of the drug and reiterated his belief that if some large employers put pressure on the market for these drugs, costs could come down.

The next conversation shifted to AI being used by UnitedHealth Group. In an article from Becker's Healthcare, CEO Andrew Witty recently said at a conference that they were experimenting with AI to improve efficiencies in their administrative processes. Matthew said he has used Chat-GTP for some non-work related projects and found it helpful and reminded listeners that FLATLINING did an in-depth interview with Dr. Matthew Stephens on the use of AI in radiology.   

Matthew questioned if United’s use of AI would benefit patients, given Cigna’s use of PXDX, a program used to review medical records and generate auto-denials.  United HealthCare used a similar program. Ron said he is also not confident that it will be a benefit given their track record. He said, “All of our experience says, that they don’t use these things for the betterment of patients.” He said that insurance companies do what is good for insurance companies and not necessarily for patients. He did agree that AI has a lot of potential, and could increase efficiencies in administrative processes at United. But, he said, we all need to have a healthy dose of skepticism about how these systems will be used initially.

Ron pointed out that there is generally less concern for the use of AI on the medical side by physicians because they are liable for their decisions. In a sense, he said, that liability and the desire to keep their license, affects their behavior.  On the insurance side, there is nothing to hold them accountable. The payers often hide behind the statement that they are making a payment decision, not a medical decision. Ron said there are two options, either open the insurance companies to be sued for their bad actions against patients or involve the federal government to regulate them. Ron said he would prefer opening the opportunity for patients to take direct action.  

The final topic in the podcast this week, touched on a bit of payer rage, with a former Astra Zeneca executive being charged with cyberstalking for allegedly sending violent threats to CVS Health and Aetna after he had complaints about “personal claims reimbursement” Matthew said.  Ron said first of all it’s never ok to threaten anyone virtually or otherwise, but he said, he could understand the frustration. When someone is dealing with a difficult medical situation and getting coverage denials or challenges from the insurance company over courses of treatment, it can be maddening, Ron said.

He went on to share a story about a friend and his challenge getting the insurance company to cover treatment options after a recent suicide attempt. He pointed out how the payer continued to deny what any commonsense person would see were symptoms directly related to his friend’s condition. He reiterated that what the person in the story did was not right, but that we have an insurance industry that creates an atmosphere where people think this behavior is their only option, he said.  You can read the article here, note that there is graphic language in the article.

Matthew mentioned that FLATLINING will feature more guests in the next few weeks, they will talk with Dr. Gus Geraci about electronic medical systems and other health topics and welcome former Cigna executive Mr. Wendel Potter, to talk about Medicare for All.