Do you have a dumb question that you're kind of embarrassed to ask in the main thread? Is there something you're just not sure about?
This is your opportunity to ask questions. No question too simple or too silly.
Culture war topics are accepted, and proposals for a better intro post are appreciated.
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Notes -
It is a very important job. Somebody has to tell doctors and patients no. That said, I sure wouldn’t want to do it.
I think it is hypothetically possible for a health insurance CEO to be so cartoonishly evil that murdering him on the street becomes ethically justified. I haven’t seen the evidence yet. I assume if it existed it would be plastered all over the internet.
And, empirically, making that a for profit middleman who gets to keep the money when he says no works badly. There is a reason why self-insured employer plans are the majority of the private market, and the insurers with the best reputation are provider co-ops (like Kaiser) or non-profits (like most of the BCBS affiliates).
The situation in the UK is different because private insurance is a top-up to the NHS, but once you exclude self-insured employer plans the biggest non-profit insurer is sufficiently dominant that "BUPA" is used as a generic term for private healthcare in the same way as "Hoover" or "Xerox".
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Have you been looking at the same internet I have? I haven't done the rigorous fact-checking yet, but nurses and other health workers were ostensibly celebrating what happened. The stories I've seen were that his health company denied twice as many complaints as the industry average, had a kick-back arrangement of some kind with an epilepsy drug manufacturer which meant they forced doctors to hand out medicine that they knew wouldn't work before approving anything that would and that this ceo approved an AI/algorithm with a 91% error rate to deny claims.
I hadn't seen any of those stories yet. The last is particularly interesting. I will Google it but a link from you may be nice too.
The problem with complaints about claim denial rates are that all insurers in America make more money the more claims they approve. They are only allowed to make a specified margin between premiums and claims.
There are only two "evil" reasons to deny claims:
If they've already reached their statutory minimum of 85% of premiums collected paid out in claims, doesn't paying additional claims reduce profits? I can see how there's a global incentive for all insurers to pay more claims in general, so that they stimulate cost growth in health care and premiums have to go up overall, but at some point they have to try to stop paying claims to cover admin and shareholder returns.
For a given year? Yes. Then, the next year, they will destroy and recreate the plans with higher premiums.
This is true, and I'd be interested to see how claim denial rates line up with a given FY cycle. They could be just vastly incompetent, making all of their customers hate them for no reason by being unable to predict claim demand, even with the vast swaths of data they have.
More likely though, it has to do with being lower price in any competitive market. After all - consumers generally don't see the premiums, but do see the denials. They may be making another $3k a year because their employer saved money on health insurance, but that's rarely transparent to an employee.
I am very curious about this as well.
Though comparing claims denial rates between insurance companies isn't useful without more context? It's true Kaiser has a denial rate of 7%, but aren't they famously (though not exclusively) an HMO? 7% seems low, if you ignore the fact that (pulling this out of my ass) 99% of medical providers are not allowed.
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Do you have a cite for the epilepsy thing? I'm not able to find anything.
This sounds bad but the details are too short for me to judge with.
FWIW the case is still pending but UHC argues that it was not used for coverage decisions. The Stat News article which describes it in detail is paywalled, but here's Ars for a teaser
https://arstechnica.com/health/2023/11/ai-with-90-error-rate-forces-elderly-out-of-rehab-nursing-homes-suit-claims/
Also, sorry for the look but I was wrong - it isn't epilepsy drugs but seizure drugs.
https://old.reddit.com/r/nursing/comments/1h6hm17/unitedhealth_ceo_attacked/m0epbzz/
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Reading this article makes it sound even worse than I thought when I first heard about it, and by the time I got to the end of it I supported the assassin more than I did at first.
I used to work on Wall Street and every time an article was written about something nefarious we were supposedly doing, it was so incredibly wrong and ill informed that it burned me out on investigative reporting. Doubly so if it's about an unpopular industry.
My knee jerk reaction in the situation, as someone who really doesn't understand the health care business, is to remain skeptical.
I'll probably have to wait six years for the court case to work itself out before I draw conclusions.
I'm willing to infuriate my colleagues by supporting insurance companies at times. For instance insurance companies increase documentation burden on us to make sure we don't over bill. It's annoying trying to keep track of the constant web of changing requirements here...but they do it because there are unethical doctors who would take advantage and up code everything. Every year medicare finds someone who does this and comes down on them.
However a lot of what happens is comically unethical, with united being one of the worst.
Dr. Glaucomflecken, (the one good medfluencer) has a story of how he died at home (cardiac arrest), and had to spend nearly a year after his resuscitation trying to get United to pay for the hospital stay because he didn't take the right ambulance. While he was dead with his wife manually pumping his heart.
Another common thing that happens is that insurance companies will randomly deny things. If I bother to schedule an appeal they will usaully decide to cover, but they know we are busy so if they randomly deny a good number of things will be dropped. Especially cheap drugs - sometimes it's easier to send the patient to Walmart and cash pay than fight the insurance company. I have a limited amount of time. They abuse this. When they do decide to fight your "peer to peer" review is generally with someone in another specialty who retired 40 years ago and has no idea what the actual standard of care is.
They effectively practice medicine by controlling the purse strings but are able to avoid the scrutiny that should come with that by claiming they are not in charge.
If you go on meddit you'll see weekly threads complaining with horrifying examples. Not all of it seems to make sense, for instance they'll refuse to cover rehab stay for a patient and suggest they stay in the hospital instead, hoping that the person will improve enough to be sent home instead. This is a risky gamble that I'm sure works actuarially, but the human cost is somebody's grandma getting a hospital acquired infection and dying and because the rehab stay wasn't covered in time and she wasn't safe to go home with a broken hip.
You'll see asinine stuff like "get an x-ray" "we already have a CT that shows the finding, and is more reliable" "my algorithm says you need an X-ray" "so you want to expose the patient to more radiation for now reason" "it says I have to."
"You said the patient is sick, according to my documentation you need to edit the note to say the patient is ill" (in this example replace sick/ill with specific interchangeable technical terms).
Another classic is that their exists a number of inhaler products for disease like asthma. They are all mostly equivalent and very expensive. Each year, or quarter, the insurance changes what they cover (some have speculated kickbacks are involved). They don't make this obvious. So suddenly the patient goes for a refill and has a massive bill and then we have to spend a bunch of time switching agents and hopefully getting good clinical effect...
Now everybody does this stuff but somehow United is appreciably worse.
Thanks for the reply!
In general, reading about this is fascinating to me. It sounds like an arms race and like providers can get an edge if they have research and analytics firms (or departments) staying on top of this stuff and helping them route through each company's bureaucracy.
This sounds like a class action lawsuit waiting to happen so I'm surprised they do it, but maybe I'm naive about the wheels of justice.
Are they better or worse than Medicaid?
Few providers in my area take Medicaid, and the ones that do have very long waits to see. I understand it's because they have pitifully low reimbursements but also have high claims denial rates.
Oooh! Wait! One more, one more!
The insurance landscape in Hawaii is famously bad, they'd rather fly patients to another island and put them in a hotel room for multiple days than pay a fair wage to specialists on whichever island the patient was coming from. Now I'm sure the negotiating math makes sense such that this is ultimately the better decision. It is also insane.
The insurance industry lobby is extremely profitable and has excellent PR, they are very good at turning people against doctors for instance. See this discussion on Meddit for example: https://old.reddit.com/r/medicine/comments/1h9lli9/the_vast_majority_of_us_excess_healthcare/
They have a large number of loop holes they can use "we aren't practicing medicine, you are practicing medicine, you recommend what you feel the patient needs, we just won't pay for it" is the most famous example. Another common one is using the reviewers as liability sponges. I haven't worked in this environment so I don't know how it works exactly (and nobody is willing to admit to it haha) but I suspect they make it understood somehow that you need to deny a certain number of claims, and then fire you if you don't, then if regulators look they fire the reviewers and claim they were bad actors. Proving systemic malfeasance is challenging.
Pharma and insurance are absurdly profitable and influential, and again they both are very adroit at blaming other aspects of the system. See me banging my drum every time someone complains about physician salaries or the "AMA cartel" those are distracters from the real villains and not really part of the problem.
Medicare and Medicaid are both also awful but generally for different reasons. They are government entities so you can imagine how pleasant they are to work with. They still have deals with manufacturers that are almost always to the manufacturers benefit and very confusing but are more above board more or less because it's directly from the government. You also get weird stuff like instead of prior-authorization you may get an audit afterwards that decides if what you actually did was justified and then you get paid or not paid accordingly. Miss a new rule that requires you to document X required thing? Guess your practice or department is in the red. With private insurance you can at least try and adjust in advance.
The bigger problem is that they are often below cost. You'll have to forgive me on the numbers because it's been a few years since I looked this up, but it's something like Medicaid pays .8, Medicare pays .85, and private pays 1.1-1.2 times cost.
If you have a payor mix of mostly public insurance, you go out of business or require bailouts. Hahnemann University Hospital went under a few years ago mostly because of this and that caused huge problems (it had the most residents of any health system).
This also results in some services flat out not being offered anymore in a non-emergency setting, or things like public insurance not being taken.
If you see a doctor who is willingly taking Medicaid/Medicare (usually they are taking it because they are employees of a health system and the system takes it, often because of government funding or legal requirements) that means they are deliberately taking a pay cut to help people (which happens a lot because of martyr complexes) or have some way they are abusing the system (which can actually be legal and fairly harmless but isn't always).
I find numbers from 4% to 6% profitability for insurance companies. Why are those numbers "absurd"? It looks to me as comparatively modest profit margin. Wikipedia shows 371b revenue, 23b net income on 273b assets for United in 2023 - I would want to hear an explanation why those numbers should be considered "absurdly profitable"? How much would be reasonably profitable, given that some zero-risk savings accounts paid out around 5% at the same time?
Pharma does seem to be much more profitable, with 25-30% profit margins being common for companies like Pfizer and Merck.
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[...]
I can see how in a certain system of ethics it's bad that UHC denies claims so aggressively. But in another system of ethics the fact that you can run a health care provider business taking UHC but not if you take Medicaid says something important, as well.
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My redpill was all the stories about how white the tech industry is.
If your only tool is a hammer, everything is a nail...
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I'm still not sure what makes socialized or single-payer systems inherently less cruel. They are rationing care too? Not only do they have longer waits, but from what I can tell the providers often follow the government's story: you have abdominal cancer? So sorry. It's fatal. Consider assisted suicide.
At no point is the patient informed that you can actually do a long shot treatment for this, and it's very expensive. And it's only available in the US.
Canada performs 14,000 assisted suicides a year. Are we really sure all of those persons have terminal illnesses? Or is the same cold hearted private health care denial of payment still there, but translated into denial of all hope as well?
I'm not even sure it's wrong! If a patient has a cancer with a very bad prognosis and the treatments are expensive and kind of grim, it might actually be better to lie to them and say they're fucked instead of telling them to try to raise $200,000 in a few months and maybe you have a small chance at surviving.
But I hardly ever see socialism enjoyers acknowledging that this is the system they plan to build. They just smugly declare that in our system all receive treatment regardless of means.
Yep.
Healthcare in the U.S. is comically complicated, expensive, and frustrating - with an intense human cost in what we do to the people who work in it.
In return we get best in the world access to care, immense human capital investment, the highest quality of care in the world (both for the poor and even more so for the rich - outcome problems are driven by our poor health in the country aka obesity). In addition because of the amount of profit available we do a huge portion of the world's research.
When people talk reforming the system they almost always propose things that are sure to break one of those pillars (like introducing rationing) with much more questionable ability to actually decrease costs.
Funny, I was pretty gung-ho about M4A until I read that Elizabeth Warren's own research she linked which showed how meager the efficiency wins would be. Surely the system is super expensive because it's very weakly coordinated! but apparently single-payer's biggest crusader doesn't think so?
I think cost disease in general teaches me we aren't going to improve the cost side of the system with M4A. Too many bad actors and hands reaching into the till. If I was god, or failing that a dictator, I could probably do it (with appropriate subject matter experts obviously). But nobody is, so zero chance of that happening.
A good example is physician salaries. Obviously I care about this because I'm a doctor and want to get paid, but a lot of people want to crash MD salaries as much as possible, it will be one of the first things that happens when M4A inevitably happens. It also doesn't do much to help costs because MD salaries aren't a major driving factor. However you'll get a dramatic reduction in quality and shortages as people flee the field. A lot of nurses retired from bedside nursing because of a lawsuit result that was totally justified and wouldn't negatively impact nurses at all, they just didn't like the vibes. The jobs are so miserable that people are champing at the bit to leave and cutting salaries drastically is only going to hasten that.
And that's just one specific line item in the many catastrophes that would inevitably happen.
There are plenty of things we can do to improve things without crashing the system however. Tort reform is the obvious example. You don't even need to remove the ability to sue, just put in expert juries (and that doesn't need to be all doctors) instead. As it is now you can follow the standard of care and still be sued for all that you are worth. The protection isn't to never make a mistake, because you can still get sued for not making a mistake, instead its to provide the "safest" care possible which is super expensive and can actually be a negative for patients (unnecessary imaging leads to increase in lifetime cancer risk but is hard to sue over thirty years later).
Fix the things that are actually fixable first and see how stuff looks.
Make all insurance functionally non-profits, cap administrative salaries, etc as another example
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