Health Insurance Denials Contradict DEI, ESG and Fairness Initiatives

This video provides an in-depth exploration of how health insurance denial practices, particularly for high-cost medical treatments, fundamentally contradict the principles of Diversity, Equity, and Inclusion (DEI) and Environmental, Social, and Governance (ESG) initiatives. Dr. Eric Bricker begins by recounting a compelling case study published by ProPublica concerning a Penn State student. This student, suffering from severe ulcerative colitis, required a specialized, high-dose regimen of biologic medications, developed by a world expert at the Mayo Clinic, which successfully brought his condition under control after other treatments failed. The cost for less than a year of this critical treatment amounted to $807,000, which his UnitedHealthcare policy, provided through Penn State, subsequently denied.

The presentation then delves into the mechanisms behind such denials, specifically "medical policy" and the "peer review" process. Medical policy is described as the extensive, often opaque fine print within health insurance plans that outlines myriad exceptions to coverage, effectively detailing what healthcare services are not covered despite the perception of comprehensive insurance. The peer review process, intended as an exception mechanism, involves a patient's treating physician discussing the case with a doctor contracted by the insurance company. In the Penn State student's case, UnitedHealthcare utilized an outsourced company, MRI of America, for this review. Shockingly, internal documents revealed that UnitedHealthcare received conflicting peer reviews—one denying and one approving the treatment—but chose to bury the approval and misrepresent the denial, prioritizing cost savings over the patient's health.

Dr. Bricker then connects these insurance practices to the broader societal movements of DEI and ESG. He highlights that many organizations, including Penn State, have robust DEI policies aimed at promoting fairness and justice. The question is posed whether contracting with an insurer that engages in such denial practices aligns with these stated DEI goals, concluding that it does not meet the standard for "equity" or justice. Similarly, ESG investing, a rapidly growing sector with trillions of dollars under management globally, seeks to direct capital towards companies demonstrating social responsibility. The video argues that investing in health insurance companies that deny medically necessary care for financial reasons directly contradicts the "social good" component of ESG principles. The speaker emphasizes the significant growth in both DEI policy adoption and ESG investment, urging organizations to move beyond rhetoric and ensure their operational arrangements, especially with health insurance providers, are truly consistent with their stated values.

Key Takeaways:

• Significant Financial Burden of Denials: Health insurance denials for high-cost, specialty medications can leave patients with astronomical bills, as exemplified by the $807,000 charge for ulcerative colitis treatment, highlighting a critical access barrier for effective therapies.
• Opaque Medical Policies: Health insurance plans contain extensive "medical policies"—often over 80 pages long—that detail specific exclusions and limitations to coverage, which are rarely explained to policyholders and create a false sense of comprehensive insurance.
• Potential for Corruption in Peer Review: The peer review process, meant to provide an avenue for exceptions to medical policy, can be compromised by financial incentives, with insurers potentially burying favorable reviews and misrepresenting denials to avoid paying for expensive treatments.
• Outsourced Review Companies: Many insurers, including UnitedHealthcare, outsource their peer review processes to third-party companies like MRI of America, which can introduce additional layers of complexity and potential for bias in coverage decisions.
• Contradiction with DEI Principles: Health insurance practices that deny medically necessary care based on opaque policies and potentially manipulated reviews directly contradict the "Equity" component of Diversity, Equity, and Inclusion (DEI) initiatives, which strive for fairness and justice.
• Inconsistency with ESG Goals: Investing in health insurance companies that engage in practices of denying legitimate medical coverage for financial gain is inconsistent with the "Social" component of Environmental, Social, and Governance (ESG) investing, which aims to support companies contributing to social good.
• Organizational Responsibility: Organizations, such as universities or employers, that provide health insurance to their constituents must critically evaluate whether their chosen insurance providers' practices align with their own stated DEI and ESG commitments.
• High Cost of Biologic Medications: The video underscores the high cost of advanced biologic medications (monoclonal antibodies) used for conditions like ulcerative colitis, which often become targets for insurance denials due to their expense.
• Gap Between Rhetoric and Action: Despite the massive growth in DEI policy adoption (from 27% to 93% globally between 2018-2020) and ESG investing (trillions of dollars globally), there remains a significant gap between organizations' stated values and their actual operational practices, particularly concerning healthcare coverage.
• Call for Transparency and Alignment: The speaker advocates for greater transparency in health insurance policies and a fundamental alignment between the ethical principles of DEI and ESG and the practical operations of healthcare finance.

Key Concepts:

• Medical Policy: The detailed, often lengthy and obscure, contractual stipulations within a health insurance plan that specify what medical services, treatments, or conditions are excluded from coverage.
• Peer Review: An appeals process in health insurance where a patient's treating physician communicates with a doctor (a "peer") representing the insurance company to advocate for coverage of a treatment that might otherwise be denied based on standard medical policy.
• DEI (Diversity, Equity, Inclusion): A framework and set of organizational practices aimed at promoting fair treatment and full participation for all people, particularly those from underrepresented or marginalized groups. "Equity" specifically refers to justice and fairness in outcomes.
• ESG (Environmental, Social, Governance): A set of criteria used by socially conscious investors to screen potential investments. The "Social" component includes considerations like employee relations, human rights, customer satisfaction, and community engagement, often encompassing DEI principles.
• Biologic Medications/Monoclonal Antibodies: A class of advanced, often high-cost, pharmaceutical drugs derived from living organisms, used to treat complex diseases like autoimmune conditions (e.g., ulcerative colitis, rheumatoid arthritis) and certain cancers.

Examples/Case Studies:

• Penn State Student's Ulcerative Colitis Denial: A specific instance where a Penn State student's $807,000 treatment for severe ulcerative colitis, involving high-dose biologic medications prescribed by a Mayo Clinic specialist, was denied by UnitedHealthcare.
• UnitedHealthcare's Peer Review Manipulation: During a lawsuit, it was revealed that UnitedHealthcare received two conflicting peer reviews for the student's case—one approving and one denying—but chose to suppress the approval and misrepresent the denial to avoid payment, demonstrating a focus on cost savings over patient care.
• MRI of America: An outsourced company based in Salt Lake City, Utah, that contracts with health insurers (including UnitedHealthcare) to conduct peer reviews, covering an estimated 34% of Americans.