Zehn Skin and Health

A continually updated list of injustices within the United State’s Health Care System.

2024-2025: Massachusetts AG Sues Insulin Manufacturers and PBMs for Price Inflation

The Attorney General of Massachusetts filed a lawsuit against major insulin manufacturers and PBMs, including CVS Caremark and Optum Rx, alleging collusion to artificially inflate insulin prices. The lawsuit accuses these corporations of working in concert to manipulate the insulin market, driving up the cost of a life-sustaining drug far beyond its production cost. This alleged manipulation forces diabetics to face unaffordable prices, ration their medication, and endure life-threatening health risks. AG Campbell Files Lawsuit Against Major Insulin Manufacturers And Pharmacy Benefit Managers For Unfair and Deceptive Insulin Pricing | Mass.gov

2024-2025: FTC Investigates PBM Price Gouging on Generic Drugs

The Federal Trade Commission (FTC) launched an investigation into Pharmacy Benefit Managers (PBMs), revealing evidence of systematic price gouging on generic medications. PBM giants like OptumRx, CVS Caremark, and Express Scripts were accused of inflating prices on generics, particularly for essential medications treating cancer, heart disease, and HIV. The FTC alleged that these PBMs profited by at least $7.3 billion through these practices, directly contributing to exorbitant drug costs faced by patients. FTC alleges generic price gouging netted major PBMs at least $7.3B – FirstWord Pharma

2024: Insurers Deny Mental Health Care Based on “Progress,” Leading to Relapse

ProPublica uncovered cases of insurers, such as Blue Cross Blue Shield of Texas, denying continued mental health treatment to patients because they were showing signs of improvement. Despite therapists documenting ongoing needs and risks, including suicidal ideation, insurance doctors overruled treatment plans based on brief reviews. The devastating consequence of these denials was patient relapse, with some individuals even attempting suicide after their mental health support was abruptly cut off for alleged cost savings. Her Mental Health Treatment Was Helping. That’s Why Insurance Cut Off Her Coverage. – ProPublica

2023-2024: UnitedHealth Group’s Algorithmic Denials and Barriers to Care

UnitedHealth Group (UHG) faced mounting accusations of creating systemic barriers to patient care. Stories emerged of UHG abruptly halting pre-approved surgeries, demanding further justification, and utilizing opaque algorithms to deny mental health treatment, including for children with autism. These practices suggest a pattern of prioritizing cost-cutting measures over patient well-being, leaving families in distress and doctors fighting against automated claim denials. UnitedHealth Group Abuse Tracker – American Economic Liberties Project

^this is an incredible living resource, chronicling UHC abuses/injustices.

2023: HealthCare.gov Insurers Deny Nearly 1 in 5 Claims

A KFF analysis revealed a concerningly high rate of claim denials by insurers on the HealthCare.gov marketplace. In 2023, nearly 20% of in-network claims were denied. The reasons for these denials were often vague, categorized as “other” or “not medically necessary,” leaving patients in the dark and struggling to understand why their claims were rejected for care they believed was covered and medically required. HealthCare.gov Insurers Denied Nearly 1 in 5 In-Network Claims in 2023, but Information About Reasons is Limited in Public Data | KFF

Spread Pricing: PBMs’ Hidden Markups Inflate Drug Costs (Ongoing, highlighted in 2018 Ohio Audit)

Hidden markups are bleeding our healthcare system dry. A 2018 Ohio Medicaid audit exposed how Pharmacy Benefit Managers (PBMs) are quietly pocketing millions through “spread pricing.” These middlemen charge the state more for essential drugs than they reimburse local pharmacies, skimming an average of 8.5% and adding millions to taxpayer-funded healthcare costs, all without providing any added benefit to those in need. Ohio Medicaid PBMs Rake in Millions Via Spread Pricing – State of Reform

2017: Anthem’s Retroactive ER Pre-authorization Policy Threatens Emergency Care

Anthem (now Elevance Health) implemented a policy requiring pre-authorization after patients sought emergency room care in Kentucky. This retroactive review allowed Anthem to deny coverage if they deemed an ER visit “unnecessary.” This policy created a dangerous chilling effect, potentially deterring individuals experiencing genuine emergencies from seeking timely medical attention for fear of claim denial, with potentially severe health consequences. Anthem to require ER pre-authorization in Kentucky – Louisville Business First

2016: “Ghost Networks” Deceive Patients Seeking In-Network Care

A report by the New York Attorney General exposed the widespread problem of “ghost networks” within health insurance plans. Major insurers, including Empire BlueCross BlueShield, Healthfirst, and MetroPlus, were found to have alarmingly inaccurate provider directories. Over half the time, listed doctors were either not in-network or not accepting new patients. This systemic inaccuracy deceives patients who carefully select plans based on network access, leaving them with unexpected out-of-network costs and struggles to find necessary medical care. Ghost Networks: Insurer Directories Often Inaccurate