Patients in the Dark About the Performance of their Health Insurance Plans

Most health insurance plans hide information about the quality and quantity of the treatments they approve in Puerto Rico.

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Many times the staff who evaluates and denies the approval by the insurer is not a doctor of the same specialty as the patient's doctor, according to several doctors.

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María Crespo has been hospitalized for almost two weeks. Since July, her cancer has progressed while waiting for her health insurance, Triple S Vital, to approve the treatment she needs. Vital is the government-financed health insurance.

Her daughter, Marisol Marrero Crespo, in tears, told the Center for Investigative Journalism (CPI, in Spanish) that the treatment with the drug “Enfortumab Vedotin”— which her doctor advised to treat her cancer —was not approved. She had found out through a letter from her mother’s health insurance.

Her mother was diagnosed with cancer in her bladder about a year ago. 

“The requested treatment is not supported by the National Comprehensive Cancer Network (NCCN) Compendium of Drugs and Biologics,” the letter stated.

Triple S Vital states there is no evidence to support that this drug is safe or effective for metastatic bladder cancer, according to the document.

However, this drug is recommended by the NCCN, contrary to Triple S Vital’s assertion. It is also approved by the US Food and Drug Administration (FDA), according to the NCCN guidelines obtained by the CPI.

Dr. José Novoa, Triple S’s chief medical officer, told the CPI that the health insurer has oncologists to handle requests from cancer patient doctors and that the health insurance industry relies on the guidelines before issuing a determination.

“We must be sure that the chemotherapy includes the appropriate studies for the tumor, where the condition is, or where the cancer is. That’s what the guidelines are for, which aren’t guidelines created by Triple S, or any plan. They are set by the oncological community who with evidence and scientific data created them, and what it establishes are guidelines for ‘such a tumor,’ ‘in such a state,’ these are the medications that should be used first and then others,” he said, without making specific reference to María’s case. 

He said the order in which medication is used is also important for the approval, even if a product is in the guidelines, and stressed it’s “not a matter of cost, but effectiveness.”

He said the FDA also establishes how the medication should be used.

“The doctor can call, and they have an oncologist [in Triple S] who they can speak to and discuss the case with. And sometimes, we make exceptions. If the therapy is justified for a reason, even if it’s not in the NCCN guidelines, we proceed. There’s an option,” he said.

“In oncology, we have many safeguards to benefit the patient,” he added.

He said the decision might be appealed, and if the patient is insured by Triple S Vital, there is a protocol through which his company evaluates and approves new treatments even if they are not included in their current contract with the government’s  Health Insurance Services Administration (ASES, in Spanish).

But those options have not been offered to María, who has been affected by a prior decision by the plan. She faced another denial once before for prescriptions from her doctor that she fought to the Office of the Patient Advocate. The problem was solved after that agency intervened, Marisol said.

“[Triple S Vital] didn’t want to give me the right products. They gave me whatever they felt like giving me, the brand they felt like giving me, the size they felt like giving me, and they weren’t even providing me with urostomy bags; they were providing colostomy bags. That’s why my mother always woke up wet and fell into a depression,” her daughter said about what they experienced after her mother underwent an operation due to her illness.

María is just one of the thousands of patients affected by arbitrary medical insurance decisions, sometimes against the doctor’s recommendations.

Furthermore, most health insurance companies keep secret the information about the quality and quantity of treatments that they approve for patients in Puerto Rico, at a time when a shortage of physicians and restrictions on coverage plans and medications worsen the quality of health services on the island, a CPI investigation found.

The few health plans that are open to evaluation and allow their data to be public received low grades for the services they offer, especially in the areas of illness prevention and treatment of mental health conditions.

This is established in the public files of the National Committee for Quality Assurance (NCQA), which is the chief independent entity that evaluates the private medical plans that do business in Puerto Rico, including those that receive Medicare funds. The CPI also reviewed the complaints filed with the Insurance Commissioner’s Office (OCS, in Spanish) and with the Office of the Patient Advocate (OPP, in Spanish), and interviewed health professionals for this investigation.

The NCQA review is required for all Medicare Advantage plans. However, the result of that evaluation may remain confidential if so requested by the insurance company. Medicare Advantage plans are those that many of the recognized health insurers in Puerto Rico such as Triple S, Humana, MCS and MMM offer to cover Medicare Parts A and B, instead of traditional Medicare, and must adhere to the standards established by the federal program, according to official Medicare information. The NCQA review is required for all Medicare Advantage plans. However, the evaluation result may remain confidential if requested by the insurance company.

In the case of the other types of health plans offered by the insurers to individuals, who pay them out-of-pocket, to employers and to the government health insurance, the evaluation is optional. Only Humana Health Plans underwent the NCQA review process and disclosed its results.

NCQA reviews are the main independent evaluation tool available to citizens and the government to know how well or poorly private health plans have been rated and how well they manage the health of their patients, both preventively and during treatment. That is, whether they are giving them access to the tests and treatments they need and consequently, the impact on their health.

According to NCQA data, Humana Health Plans of Puerto Rico scored 2.5 out of 5 stars on its commercial coverage plan. The other plans that reported to NCQA were Humana’s own Medicare Advantage products, MCS, and Sierra Health.

None of the plans reviewed by NCQA earned a maximum of five stars. Of the medical plans that offer services on the island, Sierra is the one that got the best rating, with 4 stars. However, Sierra, owned by UnitedHealthCare, only has 46 Medicare members in Puerto Rico, according to the same NCQA data.

Sierra was sued in 2019 by relatives of a Las Vegas, Nevada, a man who died after the plan denied him treatment for lung cancer. The family prevailed and Sierra had to pay them $200 million, according to press reports.

Other insurers offering Medicare plans that were evaluated were MCS with three stars and Humana with 3 and 3.5 in two plans of this type.

Although Triple S Advantage and MMM Healthcare insurers are listed on the NCQA website, their information is not publicly available.

Andy Reynolds, NCQA associate vice president for external relations, told the CPI in writing that when “No data reported” appears on its website after a health insurance name, it could mean one of two things: that the plan reported its data to NCQA but asked that it be kept confidential or that it did not report at all.

The NCQA’s ratings are based on data from a tool that measures the performance and quality of health insurance coverage and services, which is known in the health industry as HEDIS (Healthcare Effectiveness Data and Information Set). This is the main data used by CMS and other agencies such as ASES to make their quality assessments. NCQA also uses a study through which consumers rate plans.

Although more than a dozen companies operate on the island, known as health insurers or insurance organizations by the OCS, offering dozens of different types of medical plans, ranging from large commercial and Vital to those tied exclusively to a hospital and its network of doctors, 95% of the market is concentrated in the medical plans of five health insurers: Triple S, Humana, MCS, MMM, and First Medical, according to the OCS 2021 Annual Report.

Novoa, Triple S’s chief medical officer, told the CPI that they did not undergo the NCQA evaluation, but that their commercial plan is certified by URAC — an acronym for its original name Utilization Review Accreditation Commission — another organization that evaluates health plans and health service providers.

Meanwhile, Humana indicated in writing that “the measures reported to NCQA are related to the HEDIS program, which is required for a specific account. It doesn’t represent the total rating of the commercial portfolio.”

Irmarie Cervera, communications director of MMM, which became the only plan accredited by the NCQA in Puerto Rico in 2009, did not specifically answer if they participated in the evaluation in 2021 and why the information is not available.

In a statement sent to the CPI, Cervera said that MMM is getting another certification from NCQA to assist in coordinated health care plans, identify their patient’s health needs, and improve services.

MCS’s Chief Medical Officer, Dr. Inés Hernández Roses, said in written statements that the company did not submit its commercial plans to evaluation with the NCQA because “the regulatory entity does not require these processes.”

She also defended the low rating of its Medicare Advantage product, noting that “the HEDIS measures reported by NCQA are only a partial review in that they provide an overall score that is lowered because we did not choose to fully participate in NCQA’s full private program.”

MCS was the insurer that reported the most profits to the OCS in 2021, with $89 million among its three subsidiaries that offer health insurance plans.

As for its level of responsibility in Puerto Rico’s health services crisis and the complaints of denial of services to patients and payments to providers, the health insurance representatives had separate differing reactions.

Novoa acknowledged that health insurance plans need to improve some areas in order to contribute to the solution, such as the credentialing of health professionals and their contracts.

Meanwhile, despite the Insurance Commissioner’s orders to that effect, MCS and Humana denied that they failed to comply with the terms of providers’ payments.

“At MCS we do everything in our power to improve the service experience of our suppliers, with whom we fully comply with their payments and contractual agreements,” said Hernández Roses.

Cervera said MMM’s payment record “is the best in the industry.”

Claims for the publication of quality results

The NCQA’s associate vice president of External Relations believes it’s important that all medical plans submit their data so that citizens can know the details about the quality of their service.

“Anyone in the United States looking to be sure that their health insurance provides scientifically recommended tests, screenings or treatments should want their health insurance to report their quality results publicly,” Reynolds said. “HEDIS reports and NCQA health insurance ratings bring performance, transparency, and accountability to health care. That, in turn, provides peace of mind for residents of any state or territory,” he added.

Hiram Rodríguez, an internist who has become the voice of his colleagues and patients to denounce the practices of health insurers against those who need medical services and health professionals, agreed on the importance of the NCQA so that patients can know the caliber of health insurance plans beyond the ads they place in the media.

“It’s very important to have an objective and standardized system to measure the quality of the services offered by health insurers, especially during the [enrollment] period when patients choose the medical plan for the next year,” said Rodríguez.

The internist began his fight against insurers after they did not let him join the network of advantage plans, including Triple S Advantage, even though he belongs to the traditional Medicare network.

Physicians and patients suffer

Over the past decade, Puerto Rico has been losing doctors and health professionals at a brisk pace and the biggest complaint from professionals has been the low rates they are paid and the delays and denials of payment by health insurance plans, said the president of the College of Medical Surgeons, Carlos Díaz Vélez, and other doctors interviewed.

Patients or their relatives also frequently denounce denial of services and medications, in addition to waiting months for appointments due to the shortage of specialists, said Quetzy A. Soto Lugo, assistant attorney at the Office of the Patient Advocate (OPP) Auxiliary Office for Programmatic Affairs, and Insurance Commissioner Alexander Adams Vega.

To make matters worse, the Puerto Rico Community Pharmacies Association (AFCPR, in Spanish) has warned about the denial of medications to patients by companies contracted by health insurers to handle the pharmacy aspect.

In the last 18 months, the number of citizen complaints received by the Office of the Patient Advocate has doubled, increasing from 1,200 in 2020 to 2,414 in 2021, and the first six months of 2022 continued at this accelerated rate with 1,205.

While this is happening, health services insurers had reported multimillion-dollar profits in the last three years, the first year of the pandemic being when they earned the most money, according to their reports to the Insurance Commissioner.

They made a combined $162.2 million in 2019, $252 million in 2020, and $180 million in 2021.

In Puerto Rico, investigations against health insurers only occur when a patient files a complaint with the Insurance Commissioner’s Office (OCS, in Spanish) or the Patient’s Advocate.

However, filing a complaint with the OCS is practically a mystery and complicated, as the CPI confirmed when, as part of an exercise for this investigation, it tried to file a complaint electronically.

The Insurance Commissioner recognized that the complaint filing process is underutilized, so the number of complaints his office receives is low and not representative of the reality of citizen complaints over the service provided by their health insurance plans. However, he said that his goal is to solve this oversight problem.

“When we talk about how many complaints a year are filed in our office for denial of coverage, we’re talking around 70 to 90 complaints in the last three or four years,” said Adams Vega.

The “denial of coverage” is when the health insurer alleges that the requested service is not contemplated within the coverage that the patient has.

The Health Insurance Services Administration (ASES, in Spanish) oversees evaluating the services that some of these companies offer to the 1.5 million beneficiaries of Vital — the government’s health plan. However, the most recent evaluation it provided to the CPI is from 2019.

The CPI asked ASES for the data on the quality of services offered by the Vital insurers, but the agency did not deliver it, so the CPI turned to the Superior Court on July 13 with a special resource of access to public information. As of press time for this story, the government was still resisting in court to deliver the data.

The president of the College of Medical Surgeons,  Díaz Vélez, agreed that one of the factors that has affected doctors and patients for years is the practice of health insurance plans to request authorization for medications and studies.

“I deal with health insurance plans, that as a cardiologist I’m ordering a test, which is exclusively mine, and I’m going to perform it, which I’ll review and interpret myself, and I find myself [in the situation] in which I have to ask authorization [from the insurer],” Díaz Vélez complained.

“I see why they can ask me to get authorization for an MRI or a study of another part of the body, but if I’m a cardiologist, why do they have to require authorization if I’m the one who is going to interpret the study and I need to make decisions based on that test for the patient, and that delays the patient’s diagnosis and treatment,” he said.

Meanwhile, the Commissioner explained that his office also works with denials of services due to “lack of medical criteria.” This refers to when a health insurance plan refuses to pay for the service or medication because its staff, which evaluates requests for approval, believes that the service or medication ordered by the doctor or specialist treating a patient is not necessary or suitable, or is not covered. Often, the staff that evaluates and denies approval by the insurer are not doctors of the same specialty as the patient’s doctor, according to physicians consulted for this story.

These types of complaints can be filed by both patients and providers, the latter on behalf of a patient, however, the requests received are few and do not represent reality, he explained.

“In the past year, I think there were 12 requests,” he added.

“Providers often know that they have to file a complaint procedure against an insurer or health services organization, but they fear that this may ultimately lead to losing a contract,” the official said.

He said that providers prefer to present it as groups or associations.

He mentioned that this procedure is also sometimes tedious for providers given the time they must invest outside their office to, for example, appear at a hearing on the matter.

The Commissioner pointed out that, knowing that the number of complaints or lawsuits filed does not respond to reality, his goal is to make the agency more proactive in detecting these situations and expanding the investigations, including monthly monitoring of claims payments to health service providers.

Regarding payment to providers, in January, the OCS detected 98,000 claims from providers that insurers had not paid in the 30-day period, which represented $7.1 million owed. The insurers paid after the OCS issued orders requiring late payments plus interest.

Access to specialists and subspecialists is limited

Quetzy A. Soto Lugo, assistant attorney at the Office of the Patient Advocate (OPP) Auxiliary Office for Programmatic Affairs, told the CPI that the type of complaints they receive the most associated with health insurance plans is for the denial of medications and for access to services, such as, for example, the limitation of providers or specialists within the network.

In 2021 they received 2,414 complaints and 1,848 calls for advice, and from January to June 2022, they received 1,205 complaints and 3,737 calls for orientation. However, she could not specify how many of these complaints are due to issues with health insurance plans.

“The biggest limitation is the budget limitation, which doesn’t allow us to have the necessary resources to meet the demand for services that we have. I think that this is the main challenge that the office currently faces,” said Soto Lugo.

She predicted that before December, they would begin to publish adverse determinations against health insurance plans, including Medicare Advantage, on its website.

By law, every health insurance company, health service organization, or other authorized health plan provider in Puerto Rico must submit quarterly reports to the Patient Advocate with the total number of adverse determinations or denials of service, as well as their justifications.

No oversight for PBMs

Linda Ayala, executive director of the Community Pharmacy Association, told the CPI that pharmacies are concerned about prescriptions denied to patients by so-called Pharmacy Benefit Managers (PBMs), which are companies contracted by insurers to handle the pharmacy part.

“The norm, from what we know, is that they [the PBMs] are the ones that establish the drug list for the benefit of the insurer, which, in fact, is always [set] to seek savings for the insurer,” she said.

She explained that if the prescribed medicine is too expensive, they change it for a cheaper one, leading the person not to receive the therapy prescribed by their physician or specialist.

“There are patients for whom it’s important that the drug they receive is branded and they change it for a generic one,” added Ayala.

He estimated that daily, dozens of people face the process of denials of medications and must pay for them, but not all patients have the resources to do so.

The Insurance Commissioner pointed out that the PBMs are the only entities that are not regulated and that the Fiscal Control Board recently paralyzed Law 82 of 2019, which would have regulated them.

“Puerto Rico is one of the few jurisdictions in the United States that currently doesn’t even have a regulation to require registration of a PBM. This entity isn’t even registered with the Insurance Commissioner’s Office or any other regulatory entity,” she said.

“There’s no frame of reference in which neither the Office of the Patient Advocate nor the Insurance Commissioner’s Office can determine the responsibilities and duties that have been delegated to that entity,” she added.

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