I hope Minnesotans read about the testimony of UnitedHealth Group CEO Andrew Witty at the U.S. Senate Committee on Finance Wednesday. It’s an eye-opener about the corporate practices of our Eden Prairie health insurance/big data/whatever behemoth. 

Witty was on the receiving end of scathing comments from a bipartisan group of senators — and justifiably so. 

The health insurer — which keeps growing like a voracious weed, encompassing physician groups, pharmacy benefits management and payments technology — has become too big to fail, evidenced recently by a major hack of it’s Change Healthcare systems. 

In health care, no one is bigger than UnitedHealth Group, the nation’s largest private health insurer and largest employer of physicians. The nearly $400 billion umbrella company also helps run hospitals, has rapidly acquired outpatient surgery centers, is expanding into home health services — and fell victim to a cyberattack this winter that brought the U.S. health-care system to its knees and has prompted congressional hearings this week.

Lawmakers in both parties said they’re unhappy about so much of America’s health system running through a single organization, making thousands of hospitals and doctors vulnerable to a single point of failure.

“It needs to be busted up,” Rep. Buddy Carter (R-Ga.) said at the congressional hearing on Change Healthcare this month, citing his frustrations as a practicing pharmacist who dealt with UnitedHealth and its subsidiaries.

UnitedHealth is “so damn big,” added Sen. Elizabeth Warren (D-Mass.), singling out the company’s $227 billion Optum division, which employs more than 90,000 physicians. “One in every 10 doctors in America has been sucked into the Optum system. Most patients probably don’t know that their doctors are working for a giant corporation bent on maximizing profit, instead of working for themselves,” Warren said.

Once her doctor recommended sinus surgery, and insurance confirmed prior authorization wasn’t needed, Christine Knirk focused on getting the procedure and getting better. The outpatient operation happened just over a year ago and has brought the medical relief Knirk sought.

But getting the procedure paid for by insurance has created months of aggravation for the 65-year-old Burnsville resident.

Knirk’s story is a window into the continuing — and perhaps growing — tension between health insurers and health care providers over coverage denials. Denials without a clear reason can be maddening for patients who are often left feeling helpless. It also highlights the lack of comprehensive public data on how often and why denials happen.

“We’ve always been frustrated with the lack of transparency … trying to figure out what are the types of services that are being denied and what are the reasons,” said Kaye Pestaina, a vice president at the California-based health policy group KFF.

UnitedHealth Group Inc. Chairman Stephen Hemsley and three senior executives netted a combined $101.5 million from stock sales made over four months leading up to when the public became aware of a federal antitrust investigation.

The sales occurred between Oct. 16, a week after the largest health insurer in the US reportedly received notice of the Justice Department probe, and Feb. 26, the day before Bloomberg News and others published stories about the investigation. The stock dropped after the investigation was widely reported.

UnitedHealth, CVS, and Cigna’s PBMs are using their market share and pull in Washington to drive one of the key levers to manage healthcare costs—independent pharmacies—out of business.

Pharmacy benefit managers (PBMs) are the shadowy middlemen who decide what drugs you can buy, where you can buy them, and at what cost—without disclosing how much they charge to your employer, to your doctor, or your pharmacist. And as HEALTH CARE un-covered has reported, the biggest PBMs are now owned by Big Insurance.

Should your insurance company be allowed to stop you from getting a treatment — even if your doctor says it’s necessary?

Doctors are often required to get insurance permission before providing medical care. This process is called prior authorization and it can be used by profit-seeking insurance companies to create intentional barriers between patients and the health care they need.

At best, it’s just a minor bureaucratic headache. At worst, people have died.

Cole was diagnosed with severe asthma at only a year old. He had just recently moved out on his own with opportunities to chase his dreams, until his life was cut short earlier this year.

“January 10, he went to the pharmacy to get his prescription and was told it was no longer covered by his insurance,” said Shanon.

He was told there was no alternative option and no generic drug would be covered. Cole didn’t know how to respond and couldn’t cover the extreme out-of-pocket cost of his Advair inhaler on a $19/hour income. An inhaler-dependent patient left the Walgreens Pharmacy with no medication. Five days later he suffered an extreme asthma attack and was taken to the hospital. He arrived at the Emergency Room lifeless and spent the next six days in the ICU on a ventilator.  

“We were told he’s never going to wake up again,” said Bil.   

UnitedHealth’s recent cyberattack underscores a critical truth: no entity, no matter how vast its resources, is immune to the ever-looming threat of cybercrime. This breach, resulting in the potential theft of sensitive patient data, is a stark reminder of the urgent need for comprehensive health care reform–and reining in the growing power for-profit corporations like UnitedHealth have over all of us.

For years, the health care industry has operated under a profit-driven model, prioritizing financial gain over patient well-being. This relentless pursuit of profit has left our health care infrastructure vulnerable and ill-equipped to defend against modern threats like cyberattacks.

The probe opens a new layer of scrutiny on the largest US health insurer that operates in pharmacy benefits, medical care, technology and other services. It emerged out of concerns about UnitedHealth’s acquisitions of health-care providers and data companies, according to one of the people, who asked not to be identified discussing information that isn’t public.

UnitedHealth has drawn criticism for years as it has expanded its reach across the health-care system. Best known for its UnitedHealthcare insurance unit that covers more than 47 million Americans, it gets a growing share of revenue and profits from health-services businesses under its Optum arm. Optum’s clinics, home-care services, drug plans and pharmacies frequently provide services to UnitedHealthcare members, allowing the company to turn expenses in its insurance business into revenue for Optum

The Justice Department has launched an antitrust investigation into UnitedHealth, owner of the biggest U.S. health insurer, a leading manager of drug benefits and a sprawling network of doctor groups. The investigators have in recent weeks been interviewing healthcare-industry representatives in sectors where UnitedHealth competes, including doctor groups, according to people with knowledge of the meetings.

After being sold to Optum, a subsidiary of the health care colossus UnitedHealth Group, naviHealth denied coverage for at least two elderly patients against their doctors’ advice, forcing them to accumulate tens of thousands of dollars in out-of-pocket expenses before they died, according to reporting from STAT News. Employees alleged that UnitedHealth executives pressured them to deny coverage or lose their jobs. The reports most recently led to a class-action lawsuit.

In short, naviHealth was transformed from a company meant to better manage post-acute care to a machine that maximizes profits. It was UnitedHealth-ified.

Over the last decade, however, Minnesota has lost more independent pharmacies than any other state.

The demise of independent pharmacies in Minnesota and many other places is being hastened by another group of businesses — the PBMs.

UnitedHealth Group limits the ability of its workers to deviate from the AI projections, according to the lawsuit. Citing the news article, the complaint says employees who don’t follow the model are disciplined and terminated, without regard to whether patients needed more care.

The nation’s largest health insurance company pressured its medical staff to cut off payments for seriously ill patients in lockstep with a computer algorithm’s calculations, denying rehabilitation care for older and disabled Americans as profits soared, a STAT investigation has found.

UnitedHealth Group has repeatedly said its algorithm, which predicts how long patients will need to stay in rehab, is merely a guidepost for their recoveries. But inside the company, managers delivered a much different message: that the algorithm was to be followed precisely so payment could be cut off by the date it predicted.

The document from Allina Health arrived in February, stating the 61-year-old Woodbury resident owed the hospital a staggering sum — $155,493. It made no sense, Christensen said. He had coverage through his employer from a reputable health insurer. And the need for the care was undeniable; Christensen was hospitalized for about a month for treatment of a rare and deadly blood cancer.

But his insurer, Empire BlueCross BlueShield, refused to pay because Allina hadn’t obtained authorization for Christensen’s transfer to a new hospital, which happened about halfway through his inpatient stay. The company has a policy stipulating that when interfacility transfers aren’t approved, all claims for care at the second hospital can be deemed not medically necessary.

In theory, pharmacy benefit managers like to recommend generic drugs and keep prices lower than brand-name pharmaceuticals. But it doesn’t always work out that way when the same company owns a PBM and the retail pharmacy — it can be in the company’s interest to keep prices higher.

Today, United is the fifth-largest public company in the U.S., bigger than JPMorgan Chase. Its insurance products serve 50 million members, more than the population of Spain, and its $186 billion health services division, Optum, has 103 million patients, more than Vietnam’s population. Earnings came to $28.4 billion last year, putting it in the top 30 of companies worldwide.

United even has a bank. Optum Bank is a way for consumers to manage health savings accounts, but the company’s latest financial service is a payday loan system called Optum Pay Advance for independent physician practices. While they wait for reimbursement from United for their claims but have to make payroll, doctors can get money from United to tide them over … with 35 percent interest.

“Large insurance companies continue to do all they can to deny, delay or reduce payments for emergency care,” Dr. Christopher Kang, president of the American College of Emergency Physicians, said in a statement. “Immediate action to strengthen enforcement of the prudent layperson standard and other existing laws can help hold insurers responsible for their rampant bad behavior and protect patient access to emergency care.”

Underpayment from Caremark has caused many non-CVS pharmacies to close, creating “pharmacy deserts” in many urban neighborhoods and rural areas.

CVS Health has been able to achieve and abuse its power through a series of mergers and acquisitions. Had our existing antitrust laws — such as the Clayton Act — been enforced correctly, this consolidation should never have been allowed.

Three major companies control 80% of the prescription-drug market: Optum, ExpressScripts, and CVS Caremark. These companies leverage their dominance to engage in practices like “patient steering,” which is requiring patients to fill prescriptions at their pharmacies, even when it’s less convenient. “Spread pricing” is another tactic, whereby PBMs reimburse pharmacies like Kemper Drug an inadequate rate for dispensing certain drugs, which can lead to the pharmacies closing their doors.

According to a recent survey , Minnesota lost 30% of its independent pharmacies between 2010 and 2019, which is the most of any state. In a recent two-week period, at least six independent pharmacies closed in the state. This loss of local pharmacies has been especially hard on rural areas, where alternate options are few and very far between.

Deborah Leedahl, owner of the pharmacy and gift shop in downtown Elk River, told the Star News there were a lot of factors that went into the decision to close, but the primary reason is pharmacy benefit managers who have been chipping away at her profits for years. The last straw came Jan. 1 when one of them kicked Kemper out of a network.

Insurers have wide discretion in crafting what is covered by their policies, beyond some basic services mandated by federal and state law. They often deny claims for services that they deem not “medically necessary.”

When United refused to pay for McNaughton’s treatment for that reason, his family did something unusual. They fought back with a lawsuit, which uncovered a trove of materials, including internal emails and tape-recorded exchanges among company employees. Those records offer an extraordinary behind-the-scenes look at how one of America’s leading health care insurers relentlessly fought to reduce spending on care, even as its profits rose to record levels.

As United reviewed McNaughton’s treatment, he and his family were often in the dark about what was happening or their rights. Meanwhile, United employees misrepresented critical findings and ignored warnings from doctors about the risks of altering McNaughton’s drug plan.”

Internal documents and former company executives reveal how Cigna doctors reject patients’ claims without opening their files. “We literally click and submit,” one former company doctor said.

They both had around $320 billion in 2022 revenue. Only four U.S. companies are larger: Walmart, Amazon, Apple and ExxonMobil. Companies tend to grow slowly when their annual revenue is in the multihundred-billion-dollar stratosphere. But by buying their way into so many segments of the health care system, UnitedHealth and CVS are still growing strongly.