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Notes -
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.
Profit as in profit margins is not egregiously high, but 4-6 percent of hundred of billions of dollars is a lot of money that could be spent elsewhere.
Moreover financial success can be spent on the company - inflating salaries for executives, finding no need to trim administrative fat, more general reinvestment.
I'm usually pro-CEO pay. Let people like Elon make a fuckton of money if they are bringing value, but the insurance companies are only bringing value by fucking over American citizens are further destabilizing an already fragile healthcare system.
So they are profitable in the sense that they help some people get rich at the expense of Americans, not profitable in the sense that they have excess profit margins.
Sure, I could always explain how I would better spend somebody else's money. My point here was however that these profits have been characterized as "absurd". I don't see how it is appropriate.
I don't think you could seriously defend the premise that this is the only thing they are doing.
I though it was properly fixed in 2010? Or at least a lot of people told us it would be. I wonder why nobody asks those people any questions about why our system has become so fragile after they fixed it so well? Why nobody even mentions that happened at all? Health insurance industry is one of the most thoroughly regulated industries of all, yet literally nobody discusses why no responsibility belongs on that side.
That's pretty much describes any American company, doesn't it? Now I think it's up to you to point our why existence of profitable businesses in America is a bad thing. I have lived in a country where there were no profitable businesses (at least not legal ones) and I tell you, I wouldn't advise anybody to get sick there. Not an experience I'd ever want to repeat.
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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.
Interesting point. You know I haven't seen anything that breaks out UHC separately from other private insurance, it is possible that the barriers involved actually move it away from the rest of them.
My suspicion is no because a lot of what they do is more an externality creation than explicit costs. Most doctors will be willing to stay late to try and get things approved for the patient. Doctors are almost always on salary for the purposes of this, and can't usually bill insurance for admin time the insurance generates (well we can but they never reimburse it). Nobody pays for said admin time directly, and the doctor would choose not take United but we are almost all employed now and have no choice.
Instead that doctor quits, goes part time, burns out and retires early or whatever. Doesn't show up in the balance sheet but is a bad outcome.
Certainly if your goal is to maximize shareholder value and so on whatever United is doing seems to work best, but we've already decided elsewhere that we aren't okay with people doing that in healthcare and it seems sketchy to let one of the more profitable actors do it.
It shows up on the balance sheet somewhere, no?
Somewhere up the chain of command is the person paying the cost of doctors (and the risks of burning them out) and who is also making the decision on whether or not to accept UHC. And that person often says "yes UHC but no Medicaid"
Unless we take as a given that the entire system is dysfunctional, and making exclusively bad choices, and implosion is imminent, I think this means UHC is actually good. Or, well, UHC is bad, but less bad than Medicaid.
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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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