Luigi Mangione and UnitedHealthcare CEO shooting details

Luigi Mangione’s manifesto

Major news organizations like Reuters observed how Mangione's act resonated with segments of the public…

NORC survey

A Vanity Fair piece reported that "Luigi Mangione isn't solely responsible" for the CEO's death based on a non-partisan survey…

Healthcare leaders denounced the violence and expressed their condolences to Thompson's family.

Nearly one in four physicians report that prior authorization delays or denials have led to serious adverse outcomes for their patients.

In a guest essay in the New York Times, the CEO of UnitedHealth Group, Andrew Witty, wrote, "... we need to improve how we explain what insurance covers and how decisions are made."

Senator Chris Murphy stated that while he will never condone violence, policymakers need to listen to the visceral anger Americans feel toward insurance denials.

17% of insured working-age adults reported having had an insurance claim denied for care their doctor deemed necessary.

In California, health plans are not required by the state to report on a regular basis how often they deny treatment, which means there's limited oversight on patterns.

Nataline Sarkisyan

Kathleen Valentini

Ryan Matlock

… a bloc of Democratic lawmakers wrote to regulators demanding a thorough review of UnitedHealth Group's practices…

The assassination of UnitedHealthcare CEO Brian Thompson in Manhattan last week has drawn more media scrutiny of America's healthcare system than we saw in the entire 2024 presidential election.

Senator Bernie Sanders referenced the case in advocating for Medicare for All

In one study, researchers estimated that as many as 66.5% of personal bankruptcies are tied to medical issues like high bills or lost income due to illness.

A Kaiser Family Foundation (KFF) analysis found that about 40% of insured adults who faced problems paying medical bills usually experienced a claim denial.

As of 2022, around 100 million people in America (roughly 41% of adults) carry some amount of medical debt…

In 2022, about 38% of adults reported delaying or avoiding medical care because of cost.

In 2023, national health expenditures were around $4.9 trillion (about 17.6% of GDP). Projections from the Centers for Medicare & Medicaid Services Office of the Actuary indicate that annual health spending is expected to grow by 5.6% per year over the next decade, outpacing the average GDP growth of 4.3%. As a result, health spending is projected to account for 19.7% of GDP by 2032.

One study suggested that by 2030, health spending could consume 32% of GDP if unchecked.

The average employer-sponsored family premium in 2023 was about $24,000 a year, and early reports for 2024 show it creeping towards $25,000.

There's a newly approved gene therapy for a rare disease with a one-time cost of $2.1 million.

Healthcare is consistently the top sector for federal lobbying spending, shelling out over $600 million in 2019 alone

America's Health Insurance Plans (AHIP), the main insurance industry trade group, spent over $13 million on lobbying in 2022.

In 2024 alone, AHIP spent $11.77 million on lobbying, while major insurers added much more: UnitedHealth Group spent $10.76 million in 2023, Cigna spent $8.25 million in 2024, and the Blue Cross Blue Shield system collectively spent a massive $27.1 million in 2024.

Campaign contributions from the insurance industry have grown exponentially over decades, from about $14.4 million in the 1990 election cycle to a record $128 million in the 2020 cycle…

In 2019, when Medicare for All was a hot topic, the industry coordinated through the Partnership for America's Health Care Future (a coalition of insurers, hospitals, and pharma) to run ads and lobby lawmakers to oppose it.

When President Bill Clinton proposed health reform in the 1990s, the Health Insurance Association of America (AHIP's predecessor) spent $14-15 million on the infamous "Harry and Louise" advertising campaign that helped sink Clinton's plan.

Several high-profile Democratic presidential candidates, including Pete Buttigieg and Kamala Harris, initially voiced support for Medicare for All but later reversed or softened their positions.

OpenSecrets reported that during the 2009–2010 Obamacare debates, the healthcare industry spent a record $270 million on lobbying in a single year and shaping the law to their liking.

AHIP secretly funneled $86.2 million to the U.S. Chamber of Commerce in 2009…

Over 2019–2024, UHG reportedly spent over $500,000 in Connecticut alone to block a state-level public option that threatened its business. UnitedHealth Group has been one of the top political spenders among insurers, contributing $4.47 million in campaign donations in the 2024 cycle alone.

In 2023, approximately 51 out of 62 UnitedHealth lobbyists were former government officials, exemplifying the "revolving door" between government and industry that strengthens its influence network.

When Congress created Medicare Part D (prescription drug coverage) and expanded Medicare Advantage in 2003, insurers and pharmaceutical companies deployed nearly 1,000 lobbyists (almost 10 per U.S. Senator) spending approximately $141 million on lobbying that year alone.

An analysis found that insurers and related groups filed 22.6% of all new federal lobbying registrations in early 2020, illustrating how heavily they were lobbying especially during pandemic policy-making.

In Colorado, a single-payer state constitutional amendment called ColoradoCare was defeated after insurers helped fund a well-resourced opposition campaign.

Similar scenarios have played out in California, where the insurance industry spent millions to defeat both a 1994 single-payer initiative (Proposition 186) and a 2014 proposition that would have required state approval for insurance rate hikes.

When President Harry Truman proposed universal public health insurance in 1945, the insurance industry supported the American Medical Association's record-breaking $1.5 million lobbying campaign to defeat it by branding it as "socialized medicine." The result? Truman's universal plan was blocked in Congress.

"There will be no health care for all Americans until our leaders are willing to take on an insurance industry that showers them with cash"

With palpable exasperation, one ICU physician described her son's denial letters as "mostly pages of gobbledygook" that made no sense.

A Los Angeles man received a denial for a heart procedure stating he had requested spinal injections that were "not medically needed." However, he had never requested spinal treatment.

A denial letter addressed to a newborn in the NICU claimed the infant was feeding and breathing on his own, making day four of intensive care unnecessary. The baby was on a ventilator and receiving nutrition intravenously.

A landmark legal case against United Behavioral Health (UBH) found the company used overly strict guidelines not aligned with accepted standards, resulting in the wrongful denial of mental health and substance abuse treatment for tens of thousands of patients.

One pediatric gastroenterologist noted that his patients’ MRE scans were routinely denied as “not necessary” in favor of older CT scans, even though MREs were the safer, recommended option for children.

For instance, in Cigna's MA plans, 80% of appealed "not necessary" denials were overturned.

Despite evidence of its efficacy for certain tumors, many insurers long refused coverage by classifying it as experimental.

One major insurer (Aetna) was sued in a class action for systematically denying proton therapy; it ultimately agreed to a multi-million dollar settlement over these practices.

In marketplace plans from 2021, about 8% of all denials were issued for no prior authorization or referral.

Dr. van Terheyden and Cigna's PXDX algorithm

UnitedHealth's Optum ALERT program

Robert "Skeeter" Salim, a prominent attorney, had his advanced throat cancer treatment (proton therapy) denied by Blue Cross as "investigational." Internal appeals were handled by external review companies that simply copied and pasted the insurer's guidelines to uphold the denial.

One insurer employed nurses with the literal title "denial nurse".

"They'll do anything to avoid paying, because if they wait long enough, they know the policyholders will die"

Dr. Debby Day described how nurses at Cigna would prepare denials for doctors to sign off. She characterized their work as "increasingly sloppy," with many cases that should have been approved getting denied upfront.

Studies by KFF found that about 69% of insured adults who experienced a denial did not even know their plan had an appeals process or that they had the right to challenge a denial.; Across all types of private health insurance, roughly 85% of denied claims go unappealed.

Veteran health journalist, Cheryl Clark, who attempted to map out the appeals pathways described it as a "mind-boggling labyrinth".

In ACA marketplace plans, of the over 48 million denied in-network claims in 2021, consumers filed only 90,599 appeals. That's an appeal rate of just 0.2% (approximately one in 500 denied claims).

According to ACA marketplace data, when consumers appealed, about 41% of internal appeals led to the insurer reversing the denial.

In MA plans, enrollees who appealed prior authorization denials won 80% of those appeals.

In 2021, marketplace insurers

In 2020, a plan even hit an astonishing 80% denial rate.

KFF's 2023 consumer survey

The KFF survey found those who use a lot of health services (i.e., visited their provider over 10 times per year) had higher rates of denial—about 27% of people in the top utilization group. In contrast, only 14% of those who visited their provider less than 3 times a year experienced a denial.

A joint report by federal and state regulators in 2022 found many insurers failing to comply with mental health parity, effectively denying mental health care at levels that would not occur for analogous medical care.

Insurance claim denials have risen 16% from 2018 to 2024.

From 2022 and 2023, commercial and MA claims denials increased an average of 20.2% and 55.7%.

Elisabeth Rosenthal's 2023 investigation notes that millions of Americans are now encountering denials for claims that "once might have been paid immediately".

The Commonwealth Fund reporting almost one-third of working-age adults struggling with medical or dental debt.

The Commonwealth Fund found that nearly 60% of people who experienced a coverage denial had their care delayed as a result.

Another former executive defended the practice from a business angle, illustrating the mindset: He said he understood the economics and that the system "has undoubtedly saved billions" for Cigna.

Health Net (a California insurer) was found to have paid bonuses to employees specifically for canceling coverage of sick policyholders to dodge big claims.

For every dollar Wendy pays, approximately 80-85 cents eventually goes to medical claims—hospital care, doctor visits, and prescriptions. The remaining 15-20 cents breaks down into administrative expenses (around 13-14 cents) and profit (roughly 1-4 cents).

UnitedHealth Group, America's largest health insurer, reported net earnings exceeding $20 billion in 2023.

UnitedHealth returned over $16 billion to shareholders through stock buybacks and dividends in 2023 alone.

A landmark study published in the Annals of Internal Medicine found that bureaucracy consumed approximately 34% of total U.S. healthcare spending.

For perspective, Canada's single-payer system spends about 17% on administration, or half the U.S. rate.

A typical American hospital employs more billing specialists than beds.

United Healthcare, for instance, employs over 350,000 people.

​​https://stockanalysis.com/stocks/unh/employees/

MA plans alone spend billions annually on television advertising, broker commissions, and direct marketing.

The insurance industry spent nearly $158 million on lobbying in 2023.

In 2023, UnitedHealth Group CEO Andrew Witty received $23.5 million in total compensation. CVS Health (which owns Aetna) CEO Karen Lynch earned $21.6 million. Cigna's CEO David Cordani earned $21 million.

Despite inflation and post-pandemic healthcare challenges affecting most Americans, the insurance giant reported a $5.6 billion profit, exceeding Wall Street expectations.

Federal regulators found some companies "gaming the system by misallocating expenses... while minimizing reported administrative expenses and profits".

An NBER study found that after the ACA's implementation, some insurers responded to the MLR rule by increasing claims spending by 7–11% rather than lowering premiums.

The MLR requirement has returned over $2 billion to consumers through rebates in 2020 alone.

Private equity's involvement in healthcare began in earnest in the early 2000s, but it accelerated dramatically following the 2008 financial crisis, when low interest rates and a search for stable returns pushed firms toward recession-resistant sectors.

​​https://pmc.ncbi.nlm.nih.gov/articles/PMC9125965

Initial acquisitions focused on niche specialties like dermatology, radiology, and urgent care. After the ACA expanded insurance coverage in 2010, private equity moved aggressively into core services, including hospitals, emergency medicine, and nursing homes.

As of 2024, PE firms own an estimated 30% of for-profit hospitals in the U.S.

Over the past decade, private equity has invested $1 trillion in U.S. healthcare.

Private equity firms typically aim for annual returns of 20-30%, far exceeding reasonable margins in patient-centered healthcare.

A landmark NBER study found that PE-owned nursing facilities were associated with a 10% increase in mortality compared to non-PE facilities.

Today, private insurers administer coverage for more than half of Medicare beneficiaries (through MA plans), most Medicaid enrollees (via Medicaid managed care organizations), and millions of Americans purchasing subsidized coverage on the ACA marketplaces.

Traditional Medicare operates with approximately 2% overhead, while MA plans take 12% or more for administration and profit.

Researchers calculated this administrative bloat costs about $1,155 more per MA enrollee annually compared to traditional Medicare.

A 2022 HHS Inspector General report found MA plans wrongly denied 13% of prior authorization requests and 18% of payment claims that met Medicare coverage rules.

The Congressional Budget Office estimates that MA plans cost approximately 4% more than traditional Medicare for comparable beneficiaries.

Recent analysis shows insurer gross margins per enrollee in MA (approximately $1,900) are about double those in employer plans.

After acquiring the health-tech firm Change Healthcare, Optum's data analytics revenues jumped 35% year-over-year.

The United States devotes 17.8% of its entire GDP to healthcare, nearly double the average for comparable developed nations.

On a per-person basis, we spend nearly twice as much as Germany (the next highest spender) and four times more than South Korea.

our life expectancy pegged at 78 years, falling four years below the average for developed nations.

We suffer higher rates of preventable death, meaning more Americans die from causes that timely care could have addressed.

The statistics are even more grim for vulnerable populations: our infant mortality rate stands 5.4 per 1,000 births compared to just 1.6 in Norway, while our maternal mortality rate is three times higher than peer countries.

Despite our astronomical spending, Americans see doctors less frequently than people in other wealthy nations.

One-third of Americans report skipping needed medical care due to cost, a phenomenon virtually unheard of in other developed countries.

We spend around $2,500 per person annually on healthcare administrative costs that provide zero clinical value.

That's nearly $496 billion per year with roughly 15% of all health spending going to billing clerks, claims processors, insurance middlemen, and administrative overhead.

American physician practices spend four times more on billing-related costs than their Canadian counterparts—about $83,000 per doctor annually in the U.S. versus $22,000 in Ontario.

There are now roughly ten administrators for every physician in the U.S., a dramatic shift since the 1970s.

Three-quarters of consumers report being confused by medical bills and insurance "explanations".

Cutting out middlemen would save an estimated $265 billion but also disrupt lucrative business models.

A 2022 investigation found U.S. hospitals and clinics spent $25.7 billion in one year just contesting insurers' claim denials amounting to nearly $57 in extra administrative costs per claim.

The practice dates back to World War II, when the federal government imposed wage freezes to control inflation. Companies couldn't attract workers by offering higher pay, so they began offering benefits, notably health insurance, as a workaround.

In 1943, the War Labor Board ruled that these fringe benefits didn't count as wages, and in 1954 the IRS cemented this by making employer health insurance contributions tax-deductible.

The number of Americans with job-based health insurance jumped from just 21 million in 1940 to 142 million by 1950.

Even today, job-based plans cover the largest share of Americans at approximately 60.4% of the non-elderly population.

Workers with employer insurance are significantly less likely to change jobs compared to those without, even when controlling for other factors.

A study by Families USA found that the average COBRA premium for a family plan equaled 84% of the average monthly unemployment check.

One analysis found that in nine states, the entire unemployment check wouldn't even cover the COBRA premium. In Alaska for example, family COBRA premiums were 132% of the state's average UI income.

Nationally, COBRA for a single person costs around $7,000 per year, and for a family about $20,000—untenable sums when you have no paycheck.

As part of the 2009 stimulus, the federal government temporarily subsidized 65% of COBRA premiums. With that subsidy, about 34% of eligible people opted for COBRA.

The vast majority who declined COBRA cited cost as the main factor, with 80% of non-enrollees complaining it was still too expensive, despite the subsidy.

When unemployment spiked, KFF estimated that nearly 27 million people risked becoming uninsured due to job loss during the initial wave.

One study concluded about 7.7 million workers lost jobs that provided health insurance, affecting an additional 6.9 million dependents who were on those plans.

By mid-2020, roughly 14 million of those who lost employer coverage became uninsured, despite ACA safety nets.

A comprehensive study by the KFF found that MA plan networks included less than half (46%) of all local physicians, on average.

Another KFF analysis of marketplace (ACA) plans found a similar pattern: enrollees had access to only about 40% of physicians in their area through their plan's network.

Nearly a quarter of enrollees were in plans that included 25% or fewer of local doctors. In Chicago, certain marketplace plans had only 14% of area doctors in-network.

South Dakota voters approved an "any willing provider" law in 2014, forcing insurers to accept any provider who meets their terms.

MA plans included only 23% of local psychiatrists on average.

In New York, the state attorney general conducted a secret shopper survey across 13 major health plans' directories for mental health providers. The result: 86% of the listed in-network mental health providers were effectively ghosts.

In an Arizona review, callers could not schedule appointments with two out of every five providers listed in popular plans.

New York passed a law in 2016 against ghost networks, but since then, regulators have issued only one fine of $7,500 to a plan, even after hundreds of consumer complaints.

Industry-wide, ProPublica noted that all fines combined across states amounted to a tiny fraction of 1% of insurers' profits—merely a "cost of doing business" that does not compel change.

Early reports found that less than half of hospitals fully complied with the price transparency rule.

One advocacy report in 2023 found only 34.5% of 2,000 hospitals surveyed were in full compliance.

A 2024 study by the Commonwealth Fund found that 45% of insured, working-age adults received a surprise medical bill or were charged for something they believed their plan would cover at no cost in the past year.

As of 2021, an estimated $88 billion in medical bills was in collections on Americans' credit reports.

Only 4% of MA TV ads referenced plan limitations like networks or need for referrals.

About one-third of MA enrollees are in plans with narrow physician networks (covering under 30% of doctors).

13% of prior authorization denials in MA were for services that met Medicare's coverage rules and should have been approved under traditional Medicare.

The OIG also found about 18% of payment denials were wrong, meaning providers were not paid for care that was indeed covered, likely deterring those providers from treating MA patients.

According to KFF, only about 11% of denied prior authorization requests in MA were appealed in 2021, but when appealed, 75% were decided in favor of the patient (the plan's denial was reversed).

Although patients can get 30% coinsurance in Japan, there is a monthly out-of-pocket maximum tied to income, beyond which the patient pays nothing.

The World Health Organization defines universal health coverage as enabling everyone to get the services they need without suffering financial hardship.

50-year-old Forrest VanPatten was denied coverage for CAR-T cell therapy…

A 2024 study at a major cancer center found that among patients initially denied radiation therapy, 10% had to accept lower radiation doses than prescribed due to insurer requirements, a dangerous change linked to decreased tumor control and survival.

This creates a perpetual obstacle course for the approximately 60% of American adults managing at least one chronic condition.

Christopher McNaughton, a college student with severe ulcerative colitis…

The AMA survey revealed 78% of physicians report that patients "abandon recommended treatments" because of authorization struggles and insurance red tape.

​​https://www.ama-assn.org/practice-management/prior-authorization/exhausted-prior-auth-many-patients-abandon-care-ama-survey

As of 2022, only 63% of American adults could afford a $400 emergency.

Medical problems such as sky-high bills, lost income from illness, or both are a leading cause of personal bankruptcy in the United States.

In the early 1980s, only about 8% of U.S. families filing bankruptcy cited healthcare expenses as a contributing factor. But by the mid-2010s, roughly two-thirds of personal bankruptcies involved medical issues, equivalent to about 530,000 American families filing for bankruptcy each year because of illness or medical bills.

A study in the American Journal of Public Health found that among those who declared medical bankruptcy, the majority had been middle-class earners and three-quarters had health insurance at the onset of illness.

In 2021, Andrea Coy's infant son contracted a severe pneumonia that necessitated an airlift by helicopter from a local hospital to a specialized children's hospital. The air ambulance was out-of-network, leading to a staggering $65,000 bill for the short flight. Their insurer (UnitedHealthcare) only covered about $28,000 of it.

GoFundMe's leaders have noted that while they never intended the platform to become a healthcare funding source, medical expenses have become the most common category of fundraiser on the site.

Internal estimates suggest roughly one-third of all GoFundMe fundraisers are for healthcare costs. As of the early 2020s, more than 250,000 health-related campaigns are started each year, collectively raising over $650 million annually.

A comprehensive study in the American Journal of Public Health found that only about 12% of medical campaigns met their goal, and 16% received no donations at all. In other words, nearly 88% of campaigns fail to reach their target, often collecting only a fraction of the cost of care.

One study noted that campaigns raised substantially less money in areas with higher medical debt, higher uninsurance rates, and lower incomes.

As one journalist noted, paying for care via GoFundMe is being "normalized as part of the health system, like getting blood work done or waiting on hold for an appointment".

As of March 2023, about 160 million Americans live in areas with mental health professional shortages, with over 8,000 additional providers needed to fill the gap.

In a National Alliance on Mental Illness survey

In 2021, only 47.2% of U.S. adults with any mental illness received treatment, and even among those with serious mental illness, only about 65% received care.

From 2010 through 2021, 136 rural hospitals closed across the United States, and by 2023 the total since 2010 had risen to over 150.

A recent report found that over 700 rural hospitals (about 31% of all rural hospitals nationwide) are at risk of shutting down due to financial losses.

Studies have found mixed evidence on health outcomes, but some research shows increased mortality for time-sensitive conditions after rural hospital closures.

One report noted 60% of Pennsylvania's rural hospitals have no labor and delivery services.

Data show that only about 1 in 500 denied claims is ever appealed.

One illustrative case is that of Liam Doxsee, an 8-year-old boy from Illinois born with severe combined immunodeficiency (SCID)

A revolutionary gene therapy for spinal muscular atrophy (SMA) can prevent a fatal or disabling outcome in babies, but it costs $2.1 million for a single dose.

According to the American Medical Association's 2024 survey, an overwhelming 94% of physicians report that prior authorization delays necessary patient care.

Nearly one in four doctors reported that prior authorization requirements led directly to a serious adverse event for a patient in their care…

Physicians complete an average of 43 prior authorization requests weekly, consuming nearly two full business days of staff time.

More than a third of doctors have had to hire staff dedicated exclusively to processing prior authorizations.

For every hour physicians spend with patients, they typically spend nearly two additional hours on electronic health records and desk work.

87% of physicians report that these requirements actually increase overall healthcare resource utilization.

By 2021, burnout rates among U.S. physicians reached a record high of 62.8%.

Physicians have among the highest suicide rates of any profession, with an estimated 300-400 doctors dying by suicide annually, more than double the rate of the general population.

In a 2022 physician survey, an overwhelming 98% identified onerous administrative tasks as significantly contributing to burnout.

Prior authorization requirements topped the list, with 95% reporting these insurance hurdles significantly increased their burnout levels.

During a typical day, physicians spend nearly half their time (49%) on electronic health records and desk work, while only 27% of their time is spent in direct patient care.

For every hour a doctor spends with patients, they spend almost two additional hours on paperwork.

Burnout has been linked to increased medical errors, lower patient satisfaction, and higher staff turnover.

A primary care doctor typically earns only about 1-2 RVUs (relative value units, the measure that determines payment) for a 20-minute office visit (roughly $50–$100) while a specialist performing an hour-long procedure can generate 10+ RVUs worth thousands of dollars.

A 2023 study found that shorter primary care visits were significantly associated with more inappropriate antibiotic prescribing for respiratory infections.

As of 2024, over 77% of physicians are employed by hospitals, health systems, or other corporate entities.

Between 2019 and 2023 alone, more than 44,000 physician practices were acquired by hospitals or corporations.

2023 marked the first time that corporate owners (including private equity firms and insurers) owned more physician practices (30.1%) than hospitals did (28.4%).

In total, nearly 60% of all physician practices are now owned by non-physicians.

The American College of Physicians found that most physicians view private equity's influence negatively, with only 10% regarding it in a positive light.

Doctors directly employed by private equity-owned practices were significantly less likely to report high job satisfaction or autonomy compared to those in independent settings.

Nearly 60% of doctors reporting that after their practice was acquired by a corporate entity, their ability to make the best care decisions for patients worsened.

Studies show that when physician practices are acquired by hospitals or health systems, prices for the same services typically increase by 14% or more.

For each additional minute a primary care visit lasts, the odds of an unnecessary antibiotic prescription drop by 0.11%.

A 2022 JAMA study estimated that to fully meet all preventive, chronic, and acute care guidelines for an average patient panel, a primary care physician would need to work 27 hours per day.

A recent survey found patient trust in doctors and hospitals fell significantly from 2020 to 2023

The American Medical Association published an article titled "It's time to stop treating doctors like assembly-line workers,"

Historically, very few doctors unionized (less than 2% of unionization petitions filed from 2000-2022 were for attending physicians).

Physician-led unions accounting for 23% of all new union petitions filed in recent years.

The Committee of Interns and Residents (CIR-SEIU) doubled its membership between 2021 and 2024, now representing over 37,000 trainee physicians.

In 2023, attending physicians at the Cambridge Health Alliance in Massachusetts voted to form a union, and similar efforts are underway nationwide.

Even the American Medical Association, which historically has never supported unions, now does so, endorsing physicians' right to collective bargaining and is working to expand those rights, especially as more doctors become employees.

While DPC is still relatively small (around 3% of family physicians as of 2018), interest is high.

Over 40% of family doctors not already in DPC said they were considering it as frustrations with insurance mounted.

Studies show promising results: one analysis found DPC patients had 65% fewer ER visits and about 35-50% fewer hospitalizations compared to similar patient populations…

In late 2023, all five physicians at a New York family practice (Linden Medical Group) resigned together to launch a new concierge clinic.

By 2020, they launched the East Texas Community Clinic, offering primary care on a free or pay-what-you-can basis.

Since 1999, the Accreditation Council for Graduate Medical Education has required "systems-based practice" as a core competency, pushing training programs to teach residents about the broader healthcare system.

The American Medical Association even published a textbook on health systems science for medical students.

One qualitative study of final-year medical students found they were shocked by the billing and coding demands they encountered during clinical rotations.

Dr. Linda Peeno, who worked as a medical reviewer for Humana in the 1980s, revealed in congressional testimony that during her job interview, she was specifically asked if she could "be tough" because she would be "expected to keep a 10 percent denial rate".

"In the spring of 1987, as a physician, I denied a man a necessary operation that would have saved his life and thus caused his death…”

In 2015, Dr. Jay Ken Iinuma, who served as an Aetna medical director, testified under oath that he "did not personally review patients' medical records" …

Natalie Collins, a former UnitedHealthcare service representative, explained that during her training, there was no instruction on how to actually pay the claim that a customer was disputing; "the entire training was about different ways to deny the claim".

He has stated that he once “described for senators how insurers make promises they have no intention of keeping.”

Researchers note that many clinicians feel demoralized by a health care system that puts profits ahead of patients…

Dr. Day

She pointed out that many listings for insurance claims reviewer positions explicitly warn that candidates "must be able to endure extreme stress"

She recounted getting a call with a gravelly voice saying, "You better stop doing this stuff," following one of her TV interviews.

Under various laws (like the False Claims Act, or OSHA regulations for health insurance under the ACA), an employee is theoretically protected from retaliation for reporting certain types of violations.

After 15 years at Cigna, he resigned abruptly in 2008 with no other job lined up.

Former Aetna CEO, Mark Bertolini, after leaving his post, expressed that we should debate single-payer and acknowledged the flaws in the current system.

California's Department of Managed Health Care reports that approximately 60% of "medical necessity" denials are reversed upon independent review.

These denials have even higher overturn rates, around 80% according to some state data.

Thanks to a 2023 rule change, families stuck in that predicament can now qualify for subsidized marketplace plans. This was projected to help nearly 1 million Americans obtain more affordable insurance.

In Pennsylvania, 50.1% of appealed denials were overturned by external review.

Nationwide, external reviews reverse insurance company decisions in approximately half of all cases.

The court ordered reprocessing of over 67,000 claims.

In January 2021, the federal Hospital Price Transparency Rule took effect, requiring hospitals to post their prices for services and negotiated insurance rates publicly.

A 2024 audit found that about 46% of hospitals still weren't fully complying with the requirements.

Platforms like Turquoise Health and Healthcare Bluebook compile the machine-readable price files from hospitals and provide searchable interfaces that let patients look up procedures and compare prices across facilities.

60% of Americans report paying for medications is a burden, and about 29% have foregone filling prescriptions due to cost

GoodRx claims to have helped consumers save around $30 billion on prescription costs since its launch.

Companies like MDSave and Sesame offer online marketplaces where patients can search for procedures and see set cash prices from local providers, often at significant discounts for paying upfront.

…is Apple Health Records on the iPhone. Launched in 2018, this feature allows patients to download and aggregate their medical records from participating hospitals and clinics. By 2022, it was connected to over 800 healthcare institutions covering 12,000+ locations in the U.S., U.K., and Canada.

More than 190 million patients actively use Epic's MyChart portal.

When patients have electronic access to health information and digital tools for self-management, many studies document positive outcomes like better disease control and higher satisfaction.

Since 2016, the country's national health system has used blockchain to ensure the integrity of electronic health records…

Startups like Patientory have launched blockchain-based personal health record services…

Before 2020, only about 8% of Americans had ever had a telemedicine visit. But during the pandemic's height, telehealth accounted for an estimated 13% of all outpatient visits nationwide.

In Medicare, the expansion was even more dramatic: 53% of beneficiaries used telemedicine at least once during the first year of the pandemic.

By late 2023, over 12.6% of Medicare beneficiaries were still receiving services via telehealth each quarter, and 86.9% of hospitals were providing telehealth services.

Teladoc Health alone reported facilitating over 50 million virtual visits as of late 2022, with about one in four Americans having access to their services through employers or health plans.

One study cited by the American Hospital Association found high satisfaction rates among both patients and clinicians with telehealth

According to the American Academy of Family Physicians, 9% of family physicians in 2023 reported operating a direct primary care practice…

Nationwide, as of 2024, there were more than 2,400 DPC practices operating in nearly every state, with membership increasing 241% from 2017 to 2021.

One Medical, recently acquired by Amazon for $3.9 billion, charges an annual membership fee (around $199 per year) for individuals.

By the end of 2022, One Medical had about 836,000 members across 200+ offices in 29 metro areas.

Forward Health takes a tech-forward approach: their clinics feature body scanners and genetic tests, with a flat fee (around $149 per month) covering all primary care services.

A typical DPC practice charges $50-$100 monthly for adults. The AAFP reports that 99% of DPC practices offer same-day appointments, and the average panel size for a DPC physician is around 413 patients

Websites like DPC Frontier maintain maps of DPC clinics nationwide.

ClearHealthCosts grew by partnering with media organizations in various cities, including CBS News, spreading the word and increasing data contributions from community members.

Companies like BurstIQ have worked with Colorado's Medicaid program on a pilot using blockchain for patient profiles to test if it improved data integrity and portability.

A report by Digital Health Insights notes that crypto payments can reduce transaction costs and delays in healthcare, particularly for global payments.

Smart contracts are another promising blockchain application for insurance: self-executing agreements that trigger payments based on predefined rules.

Companies like Etherisc have built decentralized insurance protocols that can adapt for health insurance applications.

In China, MediShares created a mutual aid health cost-sharing community on blockchain where members contribute cryptocurrency into a pool.

The Dentacoin foundation also proposed smart contracts for a "dental assurance" program, effectively a subscription between patient and dentist written to blockchain.

Highmark, a large Blue Cross Blue Shield insurer, deployed AI in its payment integrity department with remarkable results: in 2019 alone, their AI-driven fraud prevention saved approximately $260 million. Over five years, their AI implementations saved over $850 million.

A CDC report indicated tele-triage and symptom bots saw heavy usage during COVID surges, helping direct patients appropriately when systems were overwhelmed.

By 2022, 62% of healthcare executives had adopted AI-centric strategies, up from 33% in 2018, reflecting how mainstream AI has become in operational thinking.

Social media vs insurance stories

Mirana Yaver: https://www.theguardian.com/wellness/2025/feb/26/health-insurance-claims-social-media

In July 2024, over 100 patients, nurses, and advocates protested at UnitedHealth Group's headquarters, calling out an "epidemic" of claim denials amid record corporate profits.

Medical students and patients formed coalitions like #ProtectOurPatients in 2017

Research shows legislators are significantly influenced by constituent stories, especially when they highlight local impact.

The No Surprises Act, which protects patients from unexpected out-of-network bills, gained momentum after patients with enormous surprise bills were invited to the White House to share their stories.

Federal regulators have proposed rules to rein in prior authorization delays, responding to persistent patient testimony about harmful impacts.

The Fairness Project, a nonprofit that supports healthcare ballot measures, has helped win Medicaid expansion in six states through this process.

Before the No Surprises Act, 33 states had enacted some form of surprise billing protection, with 18 states implementing comprehensive laws covering both emergency and in-network hospital services.

New data shows 60% of "not medically necessary" denials and 80% of "experimental" treatment denials get reversed through IMR or insurer reconsideration.

In 2023, a class-action lawsuit was filed against Cigna

After a trial, a federal judge excoriated UBH's practices and ordered reprocessing of over 67,000 claims.

"Bill of the Month" Series: A joint KFF Health News-NPR monthly series examines outrageous medical bills. Since 2018, it has analyzed nearly $6.3 million in medical bills and spurred numerous improvements.

Two patients from this series were even invited to the White House to share their stories, experiences which helped drive Congress to pass the No Surprises Act.

The alliance Lower Drug Prices Now brings together patient advocates, seniors' organizations like AARP, nurses' and teachers' unions, and businesses struggling with employee drug costs.

Their sustained pressure contributed significantly to the drug pricing provisions in the 2022 Inflation Reduction Act.

The American Medical Association has worked alongside patient coalitions to streamline prior authorization, with both groups testifying to the harm caused by unnecessary delays.

Research shows that sustained engagement is more likely within supportive groups than through isolated action.

Several analyses suggest UCC could be implemented without increasing total healthcare spending and might even reduce it through administrative savings and better price negotiations.

Contribution limits are relatively low ($4,150 individual/$8,300 family in 2024), and you can't use HSA funds to pay for insurance premiums or many types of direct care.

By eliminating the insurance middleman, DPC practices operate with about 40% less overhead, allowing more resources to go toward patient care.

A Milliman analysis found DPC patients had 25-35% fewer hospital admissions and emergency room visits compared to traditionally insured patients.

Hospital prices in Northern California are approximately 70% higher than in Southern California.

Studies consistently show that hospital mergers lead to price increases of 20-40% in concentrated markets, with no reliable improvement in care quality.

As of 2021, hospitals must publish their prices, including negotiated rates with insurers.

… only 14% of hospitals fully compliant with transparency requirements.

Administrative costs consume between 15-30% of healthcare spending

Estonia has implemented blockchain to secure its national health records

After 20,000 of Google's contract and temporary employees participated in a walkout…

Community health centers served 30.5 million patients in 2022

Recently, public pressure helped achieve a federal $35 monthly insulin cap for Medicare beneficiaries.

… uninsured rate reaching a record low of 7.7% in 2023

Medicare runs with administrative costs around 2%, while private insurers often exceed 15-20%.

… $4.9 trillion healthcare industry