Three years before being diagnosed with terminal lung cancer at the age of 47, Bradley Schnure saw a doctor he says could have saved his life.
If not for his insurance company, that is. Instead, he was twice denied a relatively cheap, roughly $250 test that might have caught this while it was still curable, he recalled.
The father of three young kids, who worked as a communications official for Republicans in Trenton, had no clue about the danger he faced until he was gasping for breath and his wife rushed him to the emergency room, where scans don’t require prior approval. By that time, he had stage 4 cancer and multiple blood clots reaching his lungs, each nearly killing him, requiring a more than $1 million hospital stay.
That alone is horrific. Now imagine what it felt like to tell his kids. “It was heartbreaking to see the tears in their eyes as they tried to understand that their dad might die,” he just wrote in a compelling op-ed. “I wouldn’t wish that experience on anyone.”
So last week, he joined Republican Sen. Jon Bramnick, who’s running for governor, at a news conference to discuss solutions. An infuriating pattern of profiteering has emerged among insurance companies that reject reasonable requests for care recommended by doctors. The insurers now often rely on outside consultants that ensure enough rejections to protect profitability, a practice documented by ProPublica and the New York Times.
What’s needed is a way to protect the consumer, a solution we should expect to come from government, not a gunman. The shooter of UnitedHealthcare’s CEO will be brought to justice, and rightly so. But what about all the pent-up fury spilling out over how insurers treat the sick?
Use of so-called “prior authorizations,” intended for big ticket items like expensive hospital stays, has exploded in recent years for every little thing: Your doctor recommends a test or treatment, but your insurer requires proof that it’s necessary – and then often still rejects it.
The outfit that twice denied Schnure’s scan for Horizon, called EviCore, said he didn’t get an x-ray first to “support further imaging,” according to a Horizon letter. Schnure and his doctor gave up trying and he ended up having surgery for what appeared to be a sinus issue. EviCore told the Record last week that Schnure’s account doesn’t match its files but refused to say what that means.
“I have no idea what EviCore is talking about,” Schnure told us.
Schnure with his wife, Nora, during the two-week hospital stay when he was first diagnosed with cancer.Brad Schnure
Most people don’t contest these denials, research shows, daunted by the bureaucratic hurdles. So insurance outfits can just twist the dial up on their reviews to meet their financial targets, ProPublica found – delaying and denying care at the expense of people like Schnure.
That’s wrong, and they should be held to account for it. We can begin with tighter oversight, and stiff penalties for bad actors. And slap a warning on the worst offenders with the highest rates of denial, so consumers at least know which companies are the most stingy.
The state has a lot of power here, at least over the parts of the market that it regulates; it could audit these insurers tomorrow, churn out reports, fine them millions of dollars for any of their business operations – including their denial rates for claims – and even ban them from selling coverage in New Jersey until they make reforms.
Yet under the Murphy administration, critics say, the watchdogs have largely been decimated at the Division of Banking and Insurance (DOBI), which is supposed to have eyes on this.
“Regulatory oversight and enforcement action has significantly dropped off since 2017 as critical, experienced staff at DOBI have not been replaced,” Linda Schwimmer, head of the New Jersey Health Care Quality Institute, told us last week.
A DOBI spokesperson did not say how many vacancies remain or if key positions have been filled after retirements, such as the director of insurance who left in 2017 and must be confirmed by the Senate, or the roles of other seasoned staffers who have left in the last few years.
“The lack of enough professional staff looking out for consumers and enforcing New Jersey’s insurance laws and fair trade laws is a problem that needs to be addressed,” Schwimmer said. “Action one should be hiring the right people at DOBI to better regulate our health insurance markets.”
The Legislature should hold hearings, too. New Jersey is taking a good step in the right direction with a new law, effective in January, that speeds up the process of insurance reviews and requires them to be done by specialists in the relevant field. But it will take much more than that to fix this problem.
Ending prior approvals entirely, as Bramnick proposes, is well-intentioned but overboard. It would explode costs for us all, and may be struck down in court as overreach. But with Schnure leading the way, Bramnick has again kickstarted a desperately needed discussion by pressing for this bill, co-sponsored by Senate President Nicholas Scutari, a Democrat.
Ask yourself: In what world does it make sense to deny a $250 scan that could catch a fatal illness that leads to a total of more than $2 million in bills for cancer treatment, as in Schnure’s case? If a specialist thinks it’s appropriate to test someone for cancer, an insurance bureaucrat shouldn’t be able to reject that without good reason.
And if you’ve finally found a drug that works for your debilitating migraines, why should an insurer force you to settle for a far less effective one, or go through prior authorization again and again? Another bill proposed by Bramnick raises this question.
“They’re making millions of dollars, and they’re doing it at the cost of the patients and my time,” said Dr. James Charles, a neurologist and associate professor at Rutgers New Jersey Medical School. Like his peers in other specialties, and the armies of office staff hired for this purpose alone, he’s constantly battling insurers over prior authorizations, he told us.
One possible remedy for this whole mess is a meeting of all the parties to get at the problem, led by the state. Doctors’ practices could agree to cut costs by using effective generic drugs when possible, or conducting procedures in lower cost settings, in return for insurers agreeing to exempt them from so many prior authorizations.
“New Jersey has been slower than other states to adopt these models,” Schwimmer of the Health Quality Institute told us. One successful example is Blue Cross Blue Shield of Massachusetts, which has long run a program in which it partners with providers like this.
In New Jersey, Bramnick noted the strength of industry lobbyists, who he says have blocked further reform on pre-approvals. “My friends on the insurance side of this issue have a lot of power,” he said. “They have a lot of influence over the Legislature.”
Meanwhile, major players like Aetna or Horizon, which now insures more than half of New Jerseyans with coverage, have built up much more control in the marketplace. When it doesn’t rein them in, the government must.
“How many of those horror stories could have been prevented if doctors didn’t have to beg insurance companies for permission to diagnose and treat their own patients?” Schnure wrote. “It’s a simple question that deserves an answer.”
Right. Now it’s up to the governor and the Legislature to find one.
Schnure with his wife, kids, and step-kids in 2022, a couple months before he says EviCore denied the CT scan that could have caught his cancer.Bradley Schnure
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