[100ideas]

You just answered my question:

Is it the case that UnitedHealth and Cigna each own (or control) one of the "big three" PBMs? If so, that is a just crazy - the control insurance premium pricing, benefit decisions, AND the pricing of covered medications?

yadaebo wrote below "Medical Loss Ratio (MLR) is capped at 85% in the US which means 85% of revenue must go to patients". Does controlling a big PBM allow an insurance company a loophole?

[bugglebeetle]

It gets even better (quoting from ceejayoz down-thread):

>UHC is the largest single employer of doctors in the US.

https://www.statnews.com/2024/07/25/united-health-group-medi...

> It’s no secret that UnitedHealth is a colossus: It’s the country’s largest health insurer and the fourth-largest company of any type by revenue, just behind Apple. And thanks to a series of stealthy deals, almost 1 in 10 U.S. doctors — some 90,000 clinicians — now either work for UnitedHealth or are under its influence, more than any major clinic chain or hospital system.

>They purchase physician groups... and then pay themselves higher rates.

https://www.statnews.com/2024/11/25/unitedhealth-higher-paym...

> UnitedHealth Group is paying many of its own physician practices significantly more than it pays other doctor groups in the same markets for similar services, undermining competition and driving up costs for consumers and businesses, a STAT investigation reveals.

https://news.ycombinator.com/item?id=42717812

[nradov]

For better or worse, the incentives created by federal legislation since the 1940s make this healthcare industry consolidation and vertical integration inevitable. Payers (insurers) have been merging to gain more negotiating power over provider rates and hold down medical costs. So provider organizations have reacted by consolidating themselves to maintain their negotiating power and keep rates high. Increased costs to comply with federal and state rules around security and interoperability also drive provider consolidation to achieve economy of scale. Many areas are now dominated by only one or two large health systems. So, the logical next step is for payers to vertically integrate and bring more care in house where they can better control cost and quality.

UnitedHealth Group is hardly unique in this regard. They're the largest but all the major commercial payers (including the non-profit ones) are pursuing similar strategies. Essentially they're copying the existing Kaiser-Permanente model of having a payer and provider organization under one roof.

I'm not defending this system, just explaining why the current structure exists. Any major improvements will require an Act of Congress to better align the incentives with the interests of patients / consumers / taxpayers.

[bugglebeetle]

>the logical next step is for payers to vertically integrate and bring more care in house where they can better control cost and quality.

…except you skipped over the part where UHC billed at higher rates for the clinics they own so they could screw customers with premium hikes, take a bigger percentage of of the inflated bills, as well as profit from whatever costs they didn’t cover and people were forced to pay.

[franktankbank]

Why does it need an act of congress?

Isn't this clearly in need of trust bust?

[nradov]

From a strict legal perspective it's not at all clear that UHG or any of the other large payers meets the definition of a trust. Any attempt to apply antitrust law would likely be tied up in the courts for many years, and even if UHG were eventually forced to divest some parts of their Optum business it wouldn't solve any of the systemic problems. If we want to bring down costs and improve access to care it will require a major realignment of incentives that impact all the participants.

[theGnuMe]

Seems like it does. This is where the FTC needs to act.