(As a result of this report, Attorney General Brown has opened an investigation into insurance company practices.  Great, great work by the CalNurses. – promoted by David Dayen)

It’s time to stop talking about make believe death panels, and talk about the real ones.

Six of California’s biggest insurance companies have rejected more than one in five claims the past seven years — according to data the insurance giants, Blue Cross, PacifiCare, Kaiser Permanente, Health Net, Cigna, and Aetna report to the state Department of Managed Care.

Researchers from the California Nurses Association/National Nurses Organizing Committee analyzed data reported by the insurers to the California Department of Managed Care. From 2002 through June 30, 2009, the six insurers rejected 45.7 million claims — 22 percent of all claims.

For the first half of 2009, as the national debate over healthcare reform was escalating, the rejection rates are even more striking.

Claims denial rates by leading California insurers, first six months of 2009:

• PacifiCare — 39.6 percent

• Cigna — 32.7 percent

• HealthNet — 30 percent

• Kaiser Permanente — 28.3 percent

• Blue Cross — 27.9 percent

• Aetna — 6.4 percent

As the news got out to the media, the insurance bean counters fell all over themselves digging up explanations, denials, and justifications for their unjustifiable behavior.

From the Los Angeles Times, the Sacramento Bee, and other reports, you can see them scrambling to shift the blame to the doctors, to the hospitals, to the nurses for daring to criticize them.

Left hanging in the air is a bigger question. If the private insurers are not paying for care, why do we have private insurers?

While not every denial results in patient death or injury, far too many do. As CNA/NNOC co-president Deborah Burger put it, “Care denials have a human face, a real patient enduring unnecessary pain and suffering.”  

Cigna, for example, gained notoriety two years ago for denying a liver transplant to 17-year-old Nataline Sarkisyan of Northridge, Calif. and then reversing itself after protests organized by her family, her friends and community, CNA/NNOC, and netroots activists. Tragically the reversal came too late to save her life.

 

PacifiCare denied a special procedure for treatment of bone cancer for Nick Colombo, a 17-year-old teen from Placentia, Calif. Again, after protests organized by Nick’s family and friends, CNA/NNOC, and netroots activists, PacifiCare reversed its decision. But like Nataline Sarkisyan, the delay resulted in critical time lost, and Nick ultimately died. “This was his last effort and the procedure had worked before with people in Nick’s situation,” said his older brother Ricky.

In 2008, six days before RN Kim Kutcher of Dana Point, Calif., was scheduled to have special back surgery, Blue Cross denied authorization for the procedure as “investigational” even though the lumbar artificial disc she was to receive had FDA approval.

At the time of denial, which she calls “insurance hell,” Kutcher notes she had “already gone through pre-op testing, donated a unit of blood, had appointments with four physicians.” Kutcher paid $60,000 out of pocket for the operation and is still fighting Blue Cross.

Why do they companies deny claims? Because it pays.

Rejection of care is a very lucrative business for the insurance giants. The top 18 insurance giants racked up $15.9 billion in profits last year.

It’s also a reason why private insurers divert up to 30 cents of every healthcare dollar to overhead — much of it spent to support warehouses full of claims adjustors needed to deny care, to keep down their “medical loss ratio” or profits lost on approving claims.

So why aren’t these obscene, all too routine denials of claims — and ultimately care — more widely discussed in the national debate over proposed healthcare reform?  

The sad truth is there is little in the main proposals emanating from Congress and the White House to change these deadly practices.

Our nation remains the only one in among industrial nations to link access to healthcare to private profit.

That’s one reason for data like this:

Data released in late August by the Organization for Economic Co-operation and Development, which tracks developed nations, found that among 30 industrial nations, the U.S. ranks last in life expectancy at birth for men, and 24th for women.

One way to end this disgrace is to unhinge care delivery to profiteering by expanding Medicare to cover everyone. Isn’t that the best way to finally end this disgrace once and for all?