Navigating the U.S. health care system can often feel like being lost in a maze. What kind of doctor should I see? Who will cover my insurance? First of all, what is a copayment?
So investigative reporter Chris Hamby has devoted much of his five-year career at the New York Times to guiding readers through these dizzying questions. His latest article, published online this month, explored the complex subject of insurance claims.
Last year, Mr. Hamby began investigating MultiPlan, a data company that works with several major health insurance companies, including UnitedHealthcare, Cigna and Aetna. After a patient sees an out-of-network provider, insurance companies often use MultiPlan to recommend how much to reimburse the provider.
Mr. Hamby's research revealed that multiplans and insurance companies are being encouraged to reduce payments to providers. Doing so results in high fees paid by the patient's employer. Many patients are forced to cover the remaining costs. (MultiPlan said in a statement to the Times that it promotes “affordability, efficiency, and equity” by encouraging “fair reimbursements that providers are willing to accept in lieu of rate plans.”) Member for Balance (which said it was using “well-recognized and widely accepted solutions”). ”)
In the interview, Hamby described his experience poring over 50,000 pages of documents and interviewing more than 100 people. This conversation has been edited.
Where did your research begin?
We've been looking at health insurance issues extensively over the last year. In conversations with physician groups, physicians, and patients, MultiPlan kept coming up. Initially, it was unclear what exactly MultiPlan would do. Although there have been several lawsuits regarding its work with UnitedHealthcare, it has been difficult to understand the company's role in the industry. We ended up amassing more information about MultiPlan's relationships with major insurance companies.
What did doctors and other health care professionals say?
The main reason was that repayments had been drastically reduced in recent years, making it difficult to maintain operations. They said they had previously been able to successfully negotiate and obtain higher payments.
Perhaps the most surprising of your findings is that MultiPlan receives a portion of the money you save from your employer.
Yes, but I wouldn't call it a cut. It's very complicated. MultiPlan charges fees based on the savings it generates for the employer. However, in some cases, the savings may be passed on to the patient as a bill. In many cases, both the insurance company and his MultiPlan have a financial incentive to keep payouts low because they can receive more money.
But it wasn't always like that, right?
right. MultiPlan he was founded in 1980 and was a fairly traditional company that suppressed out-of-network costs. Doctors and hospitals agreed to modest discounts with MultiPlan and agreed not to try to collect more money from patients. It was a balancing act.
But that balancing act has changed over time. MultiPlan's founder sold the company to Carlyle Group, a major private equity firm, in 2006. The company moved away from negotiation and toward automated pricing. They bought one of his companies in 2010 and another major company in 2011, when he acquired the algorithm-driven tools that became the backbone of MultiPlan's business. did.
You read over 50,000 pages of documents for your research. How do you even begin to sift through so much information?
I love lots of papers. There were no major leaks. It focused on piecing together information from a variety of sources, including court documents, documents shared with me by providers and patients, and communications with MultiPlan and insurance companies. We asked a federal judge to reveal previously classified documents, including emails between Cigna executives, documents explaining how some of MultiPlan's tools work, and data on thousands of medical claims. He asked them to unseal some of the documents they had kept.
What was the biggest challenge in writing your report?
This is a very sensitive topic, so find patients and providers who are willing to go on record and talk about their experiences. Many insurance companies were concerned that if they spoke on the record, their insurance companies would retaliate. For many of the patients I spoke to, it also meant making their personal medical history available for the public to read.
As a reporter, what attracted you to the healthcare and pharmaceutical industry?
For many Americans, healthcare is almost universally a frustrating and confusing experience. It has a direct impact on people's health, their wallets, or both. I really like learning about things that affect people's health. I strive to make that information accessible to the millions of people who are affected but don't have much time to understand.
