“We thought it might fall into a legal gray zone,” said the former Cigna official, who helped conceive the program. “We sent the idea to legal, and they sent it back saying it was OK.”
Reading this article is just maddening. I've been dealing with different insurers for the past 7 years or so, and it's my experience they must all do something similar. Anyone with any kind of serious health condition is regularly driven CRAZY dealing with insurance. It's just an insane and broken system.
Wife is a nurse. Required surgery for lifesaving/severe disability (inherited congenital, killed her father). Insurance was Aetna and Hospital Self Insured. Surgery recommended by world class surgeon she worked with.
Finally pre-approved on 3rd appeal after 8 months and 150pages of documentation of every piece of every single communication (who, when, response, expected next contact) only weeks before surgery scheduled >6 months before. First rejection was automatic, second was revealed to be a dermatologist, third was a gynecologist. (They really hated that we figured out who the person was, their specialty, the state they worked in, and pending disciplinary actions).
Standard answer is we can't tell you why you were rejected (code only) because the criteria are from a third party and their review document is proprietary. When you find an online leaked document with the same code it says "unnecessary cosmetic surgery". Wrong contact numbers are provided, people go on vacation and do not respond for weeks, "that person doesn't work here".
If you're not a professional in the field with time on your hands and a detail oriented A-hole, you will be denied anything expensive that isn't considered immediately lifesaving at a trauma ICU recommended by the attending.
After pre-approved surgery with excessive blood loss and an extra 12 hours in recovery... Overcharge/All-claims-denied. Multiple appeals until involving Hospital CFO who agrees to split the extra (self-insured) cost of the insurer and get the final insurance reimbursement check... it is $3k less than promised (hospital paid the correct amount). Surgeon was going to start charging late fees and interest or send it to collection after 4 months.
The sneaky thing to do is have your attorney send a letter to the insurance carrier's liability insurance provider, detailing everything you uncover and that they will be on the hook for the malpractice claim. That will get you an highly aggressive advocate with teeth.
This is excellent advice, and isn't restricted to the medical arena.
Corporate counsel for insurance companies comprise one of the very few spots on the brontosaurus with low-latency innervation from the brain. Poke it, you'll usually get a response that will arrive faster than the usual appeals processes.
Is "not perfect" strong enough criticism if people are being covered by services that do nothing? Today's article is saying that that large insurers might just be rejecting claims without reading them. Without the ACA, presumably money wouldn't be being spent on companies that literally just take the money for compliance reasons then don't provide a service.
This is one of the more annoying failure modes of socialised medicine; when things go wrong the consumer has no control over the waste because they aren't in control of the money being spent.
Absolutely pick a different phrase, but it'll still have applied before the ACA and it'll apply after except for people with preexisting conditions, eliminating lifetime caps, and maximum out of pocket limits.
Like Bernie Sanders? Who was then placed in a debate in an “insurance town” where every audience question was some insurance leech complaint that his plan would destroy their jobs? Yeah dude. That’s the point, your job is bullshit and you shouldn’t be doing it.
The media also loved to bring on people who “adored their current insurance plan and would hate to lose it”. I’ve never met someone like that in real life, but the MSM would have you believing you
were the only one in all of America who had any ill thoughts about their insurance company.
There’s nonviolent revolution, too. But it’s still likely to yield violence in response because these systems are inherently violent and ultimately enforced with violence.
The mainstream media also doesn't mention that Americans already spend, on a per capita basis, the most on socialized medicine on the planet. I wonder if it has anything to do with those drug commercials that they play constantly?
By my understanding, that's the most on health care. This includes private insurance premiums, which is why the "we like private because it's cheaper" argument doesn't hold water.
Interesting. In the summary, it's not clear what qualifies as "compulsory health insurance":
> Health care is financed through a mix of financing arrangements including government spending and compulsory health insurance (“Government/compulsory”)
Digging into the source report[0], we see the following footnote exclusive to the US:
> All spending by private health insurance companies reported under compulsory health insurance. Category “Other” refers to financing by NGOs, employers, non-resident schemes and unknown schemes.
The root is you. The root is people believing they can change things. The far right believed it and has (unforunately) achieved inconceivable successes based only on utter bullshit and madness.
That’s one way of looking at it certainly. However I’ve never in all my life voted in any election where my vote had any capacity to have any bearing whatsoever on the outcome of the election. This is by design: America is about clumping people together into voting blocks so large that first past the post dynamics prohibit any but the most conventional of viewpoints rising to the surface.
What have the “far right” changed? And was it through voting or other means? In a sibling I admit violent revolution as a plausible change causer, and claim it is unique in that regard.
So, no, definitely not perfect. Also, some people are alive today because of it, and many are healthier. I'll take that over a better reform that doesn't get passed, and keep working to elect the people necessary for better reforms in the future. This stuff just doesn't happen overnight, sadly.
I’m a U.S. voter, so yes I’m part of this collective failure to vote well/convince my countrymen to vote well. I’m not sure why you think I’m blaming somebody else?
You talk about a 'system'. The system is in the mirrors, yours and mine. We are it. American tradition is that one person makes a difference, which seems pushed aside now by the fetishization of despair and doom.
Also, it's about far more than voting. Voting is done every once in awhile. Citizenship is every day. Powers-that-be are watching and investing enormous energy in manipulating public opinion - for a reason. It's powerful. Today is the day to act.
I’m not sure that our comments are really all that connected, I used “single payer healthcare system,” as in the term-of-art for a way of distributing funds for healthcare. You seem to have gotten latched onto the word “system” and seem to be using it in a sort of broad “fight the system” way.
There definitely aren’t any healthcare systems inside of my mirror, not even the bathroom one with a cabinet behind it.
I mean, I don't want to say "start shooting them until they get the message that we won't put up with their bullshit", but I honestly can't think of a better plan given that people will find all sorts of excuses to keep voting for the kinds of assholes who prefer it this way.
I'd really like to hear one, cause the violence option isn't really very appealing.
This. So, so, so many flavors of the "abuse of the public to make a few bucks" that is codified in the business models and job duties and KPIs of all sorts of organizations is only viable because people bend over and take it. If there was real risk that came with abusing the public employees would either a) not do that part of their jobs b) demand compensation, likely making the abuse not economically worthwhile c) seek other jobs. Any of these cases would force entities who are abusing the public as part of regular business to change their business or bleed out and die.
To the extent there is anything that can be called "objective" morality, betraying social contract and causing other people to suffer for your own profit is going to be on the "wrong" side of that.
Going all philosophical here is, what, you making excuses for being a monster? Because what you're saying is that ruining other people's lives for your own profit is fine.
And yeah, violence is an extreme and distasteful solution, as I said. But if the only other option is to suck it up and let the exploiters win, then that's on them. You don't get to have a hypocritical morality system where it is ok for you to inflict harm on others for your own profit and not ok for them to inflict harm back in self defense.
Seriously consider a universal healthcare. Accept that it will be imperfect, but more balanced and will offer a chance to everyone. Another way to look at it: everyone pays for a healthcare insurance --> everyone gets covered.
Universal healthcare falls victim to the "I'm an above average driver" brainworm.
"I'm a healthy 22-year old male with no family history to worry about, go ahead and ravage the program to save me a nickel on taxes."
or, from the other side,
"I might need an ingrown toenail treated and how dare that go into a triage list and I have to come back in six months because there are more seriously ill people-- don't they know I'm rich and important?"
Every business has insurance, including insurance companies. This is because they specialize in their own business and outsource non-core business.
An insurance provider for a specific industry has teams of skilled attorneys that are expert in that specific domain. Cigna might self insure if they consider medical malpractice a core part of their business. In that case, your attorney sends the letter to their corporate counsel.
Often times, day to day business people just ignore liability risks because it's not in their core mandate. But the corporate counsel is in charge of managing legal risk, and they will see such a situation as unacceptable. Corporate counsels also hold a lot of sway within a businesses structure.
> Standard answer is we can't tell you why you were rejected (code only) because the criteria are from a third party and their review document is proprietary
So you paid for a service, and you don't get the service you paid for, and you will not be told why?
If I did this in my line of work, I would be in prison for fraud.
Here’s an example of something that happened to my sister that isn’t exactly the same, but is the same sort of philosophy in action.
My sister was the manager of a coffee franchise named after a certain character from classic literature. Her location was doing extremely well, she was a competent type-A who commanded a great deal of respect in her entire district, and was generally assumed to on the fast-track for promotion.
One day, $200 was missing from her daily cash. She was fired the next day. Not for the missing money; they came showed her a list of very minor issue (clerical errors, an unwashed countertop on a random inspection, a couple unhappy customer feedbacks) that had come up in her eight-year career, and said she was fired for general incompetence.
Two weeks later, one of her ex-employees called up, crying; she was doing her laundry, and found $200 in one of her pockets. She had gone to the safe to make change for the register and screwed up.
The point here is: corporations understand that you can't fire someone or deny coverage based on reasons that can be contested. It's not fraud if you fire them for some other reason. It's not fraud if you don't even know why you denied coverage. You're only in trouble if you play fair.
We’re Americans and we love this sht and it's no wonder the CEO of that coffee company thought he deserved to be President.
I don't think you understand. They only have to make case for "their end" to not apply to the specific case, and it's okay. Same as firing someone for incompetence because you suspect them of theft. Realize, an employer has this option always. Why bother "playing the game".
> [...]you can't fire someone or deny coverage based on reasons that can be contested. It's not fraud if you fire them for some other reason. It's not fraud if you don't even know why you denied coverage.
That is a good question. The first appeal was "free" so we didn't have to justify it with anything other than, "no really the surgery is necessary". They only gave us a rejection number on the second and third rejections and we had to request the written forms by mail, which took weeks. The written form didn't have much more, mostly boiler plate, but it did have the number (and maybe a chapter/paragraph number citation?) and on the second one it had a signature by the reviewing doctor along with his typed name, which was luckily relatively uncommon. We had to provide statements from our doctors and surgeon (who also didn't get a reason for the refusal) justifying the surgery's need and effectiveness.
From the doctor's name and the Midwest area code for review center we were able to filter down the doctor's name to a single individual and then do a search in the state medical board system (I'm not sure if this is readily available to non-medical personnel). That popped up his med school, residency, work history (ended more than a year before) and some pending issues with his performance. When we replied by registered mail we made an obvious CC to a local lawyer.
Speaking to the surgeon we were also able to makes some guesses as to the rough name/title of a justification document they would use and that along with the citation number in a google search popped up a downloadable pdf which was 5-6 years old, but seemed about right. And when we looked up the paragraph and rejection it was pretty clearly related to roughly the right kind of surgery. That let us make a more focused/documented appeal to the rejection. When they finally approved we got a bit more documentation about the prior rejections and who reviewed them. I assume ass covering.
In the end the thing that really pissed me off is that they didn't even pay what they promised to and we knew it would another 100hrs of work to get it.
Edit: we paid ~10% out of pocket on a $60k surgery + their shortchange. good news is 15y later totally successful and healthy!
P.s. this is by memory but somewhere we’ve still got that notebook and all the paperwork filed that I’d rather forget.
How on earth can some one read this and think that the American Health System isn’t fucked up?
Can someone explain to me why the model we choose to pay for the health for the populous of this country is through insurance and not straight up taxes??
Because it works well enough for them now, and they seem to have no capacity to either understand or care that others are suffering under the same system. For some, the demand for maintaining the status quo is far more cruel.
> Even on death’s doorstep, Trevor was not angry. In fact, he staunchly supported the stance promoted by his elected officials. “Ain’t no way I would ever support Obamacare or sign up for it,” he told me. “I would rather die.” When I asked him why he felt this way even as he faced severe illness, he explained: “We don’t need any more government in our lives. And in any case, no way I want my tax dollars paying for Mexicans or welfare queens.”
America's health care system is shaped and maintained by those who benefit economically from its configuration. Configuration maintenance tools include lobbying, gerrymandering, targeted tax favors, and wide dissemination of misinformation.
It's a very small fraction of "we" that maintains this status quo.
All it takes is a last name. You dont even need a first name or state I believe, although you may need a lot of patience and some luck to find the right "smith" without a state. Once you have at least a last name, you could look up the doctors specialty even practice address in the public NPES system.
Good for you though! Never though non surgeons would review surgery claims. Seems insane to me and grounds for a professional liability suit
You do need access to the state board if you want to check out complaints. i dont think You will find much though. Doctors rarely get "written up"
Good grief. I'm sorry you had to go through that, the bureaucratic trauma involved in health billing/insurance increasingly seems as bad as or worse than the medical issue itself.
It was definitely a learning experience. If you're in the hospital under a doctor's care it's a lot easier, but if you have major (expensive) preventative care, then the insurers want to discourage or delay that as long as possible.
Instead of paying monthly insurance premiums, the company directly funds the claim payments as they come in. They outsource the work of adjudicating claims, negotiating with providers/facilities, cutting checks, setting approval criteria and first level appeals to another company, called a Third Party Administrator.
Now, who happens to have all the skills and expertise to do the job of a TPA? The big health insurers. These are giant companies with many lines of business. One of those lines is selling insurance to individuals and small businesses, another is selling administrative services to larger ones.
Note that even with a self-insured plan, there’s often insurance involved too: the company will buy a separate “stop-loss” policy that kicks in and starts paying after the employer has paid out a certain amount in total over a year. This protects them from the risk of covering a plan member with a particularly expensive condition.
When someone in my family does not get pre-approved for care, I write a letter and and ask my physician to sign, and ask the other doctors at his practice to sign a letter that goes like this:
"I beleive this procedure _____________ is medically necessary for __________. Time is of the essence, and this procedure should be performed as close to immediately as possible."
In the signature block, I include the degree, specialty and medical school of the doctor. I then fax the letter in, and within 30-40 minutes, I have a phone call apologizing for rejecting and giving me pre-approval for the care. I learned about this when my (at the time) 15 year old was rejected for a cardiac procedure and the billing person pulled out a pre-printed deck of letters that was pre-signed by every department head at the hospital. The one thing the insurance people fear most is risk.
This must have been before insurers adopted the mantra "we aren't denying care, only paying for the care!" With that legal magic wand, there is no risk to the insurer.
I have Crohn's disease, and I'm fairly certain dealing with health insurance's ineptitude directly led to multiple hospitalizations and a major surgery last year.
Had it not been for their constant denials of a drug I had been on for over two years prior, I might still be taking that medication instead of having developed antibodies for the 6 months they denied.
My doctors office gave me free samples as long as they were able, but in 2022 they were wiped out as all patients that were on that drug were being denied coverage.
Worse still, insurance recommended "use drug X, which is similar"... but I couldn't because I was on drug X—until I had anaphylaxis from it!
I also have Crohn's and am going through this right now. Months of delays and denials for a new drug lead to two hospitalizations. I'm currently on TPN (IV nutrition) while I taper my Prednisone dose as low as possible prior to surgery.
The funny/sad thing is: between my hospitalizations, TPN and related home health care, and surgery, this is all going to cost my insurance far more than the drug they were denying would have. One would hope this provides them with motivation to better judge the necessity of treatments, but I'm not holding my breath.
It's simple. Some executive gets a bonus soon if he saves the company money right now. Nobody gets a bonus for saving the company money over a 5-year period, and nobody gets punished for costing the company money over a long period either. The incentives are all about the next quarter.
It still doesn't make sense. This whole ordeal has taken place over about 6 months. If anything, forcing me down the surgery route has pulled their costs forward in time, not pushed them back.
Situations like this are infuriating to me. Our healthcare system needs to have some kind of provision for "this patient needs to be on treatment X probably for life. They are authorized for this treatment and subsequent claims will be approved unless there is a qualifying event (e.g. a recall, condition changes, patient and their doctor switch treatment, etc)."
I have UC that's well-controlled with mesalamine, and I've had a few scares (my insurance rolls out a new prior auth every year, and I have to call my provider to have them sign it for some reason, or the new insurance only covers the name brand (not generics) because of PBM antics). The thought of having to come off of mesalamine for even a week is terrifying. I really feel for you because your condition seems much more severe/hard to control.
Why do I need a new prior auth every year? My medication hasn't changed, and neither has my condition. It's a bureaucratic hoop, and if I don't jump through it I get to spend my whole day on top of a toilet. That's a terrible way to treat a human being.
Even from a purely amoral capitalist perspective, I know the cost of my medication is a small fraction of the dollar value that doesn't get generated if I can't take it. I don't benefit and society doesn't benefit if I'm sick - the only group who benefits is the insurance company who gets to pocket my premiums and avoid paying out. It makes me furious.
Here's a simple solution. Insurance HAS to pay if a doctor recommends it. This is what premiums are for. If insurance cannot pay, they can go out of business.
I don't love insurance companies and I don't love the profit incentive they have.
If a patient breaks a leg and a doctor recommends not experiencing gravity for a while, do we fly them to space?
I am using hyperbole to demonstrate a point: there are meaningful economic limits that must be created by some entity and enforced.
What is the value of a human life? The GDP of a nation is a hard upper limit. The total money a particular person in question has access to is the lower limit.
If you run an insurance company (or you run government run healthcare) you can't avoid answering that question with an actual real dollar amount.
At some point spending money on a person with a particular condition does mean that someone else with a different condition can't have money spent on them.
That's why it's better to have everyone covered under insurance, so that the risk pool is larger, and the cost to the individual is lower.
That's why it's important to spend money on research; to develop new technologies and techniques, and improve existing technologies and techniques; that can make cost of care lower.
That's why it's important to have standards of care and treatment, for all medical providers to follow.
I get your example is hyperbole, but just for fun: the space flight would be recognized as an experimental treatment since it’s known not to be a routine/established procedure. Expenses would be covered if a legitimate clinical trial of space flights were being conducted. Otherwise, costs would be out of pocket unless a special approval were granted. If space flight were being seriously studied for an extremely rare disease, it would likely be paid for by the research institution.
You aren't wrong, per se, but until the incitive for the insurance company stops being "maximize profit", they shouldn't be allowed to make decisions about how health care dollars are allocated.
"For every complex problem there is an answer that is clear, simple, and wrong." - H. L. Mencken
Even a moment's thought about the power disparity between an insurer and an individual facing medical problems leads me to conclude your "simple solution" has little to recommend it.
I have an Aetna PPO and experienced a stroke last year. $100,000+ hospital stay and insurance just… covered it. I paid $1,100 out of pocket.
I had a $100,000+ surgery a few weeks ago to repair a heart issue that may have led to it. They just covered it. No fuss, no hassle. I paid $3,300, which was the remainder of my total annual out-of-pocket, and now I will pay $0 for healthcare for the rest of the year.
For the surgery, I called in advance to double check that it was covered and after five minutes on the phone with a concierge they confirmed that it would be covered.
Obviously I am only a single data point and I can’t speak towards other conditions or procedures. But Aetna has done right by me, at least from within the perspective of our insane for-profit healthcare system.
I'm glad you had such a good experience. Not a counterpoint, though.
Healthcare is like running water, bridges, or banking systems - a high-volume system with extremely high stakes. We need many nines of consistency as protection against preventable harm.
There are around ~35M hospital admissions in the US every year. Even if 9/10 patient experiences are like yours, that means more than 3.5 million people had a sub-par experience that year - that's the entire population of LA. We need to strive for a much higher bar of quality and consistency.
I was simply trying to say that, within the confines of the current system, this particular actor has not gone out of their way to fuck me over in the same way that I hear about so many other actors.
I have no idea if my experience with Aetna is common or an outlier. My hope was that by posting this, it would provide a data point for people forced to choose a private health insurance provider in the future. I also hoped to hear from others who had experiences either mirroring or opposite my own.
If I could, I would dismantle our current system in a heartbeat and replace it with some form of single-payer. I can’t, so I tried to provide information about one player within the incredibly fucked up system Americans are forced to operate within.
My father had a stroke here in Ontario at the beginning of COVID. Total out of pocket costs: $0. This includes 2 ambulance transfers between hospitals because our local hospital didn't have the correct facilities for diagnostic imaging. The only real downside of the system in Canada is that medications aren't covered, but most people get some amount of drug coverage in their employee benefits.
Depends on the demographic. Moving away from the rich (relatively) HN-er data point is the american in an average earning job much richer than the european after salary difference and tax?
I personally don't understand where these numbers come from. When I moved to Europe, my total tax outlay went down, not up. Aggregating costs across a large pool (everyone in the country) means that I paid less than I did in the US.
Right, and also the actual cost of the insurance which is about $20k per family of four per year. That cost will be born by the employer, partly by the employee, or by the taxpayer via aca subsidies.
Yes. I would gladly prefer to live in Europe and benefit from a sane healthcare model.
I don’t and neither do the hundreds of millions of others who remain in the US. So for those people, I wanted to provide a data point that might help them when they, like me, are forced to make decisions about their healthcare in this system.
Also this is anecdotal. I too have an Aetna PPO and can tell you of horrid stories and countless hours on repeated phone calls with them.
Not saying you just did this (you obv did not) but as a whole in this country we need to start dropping the “it didn’t happen to me so something must be wrong with you” mentality. It is pervasive in the healthcare topic and unfortunately in many other facets of American life.
Germans in WWII that enjoyed the fruits of the regime have sang its praises - that didn’t mean the war machine on the whole wasn’t decimating the people and their country. We shouldn’t lose focus of how our country is being decimated by our collective ineptitude.
> Also this is anecdotal. I too have an Aetna PPO and can tell you of horrid stories and countless hours on repeated phone calls with them
Please do!
My point was simply to say that this option is one that has done right by me so far. If there is significant evidence this is an outlier experience, I (and I’m sure others) would benefit from knowing so.
As long as insurance is subsidized by our tax dollars and is regulated to include (forcefully) everything, then theres no way out.
For the record, to comprehend what this means from the doctors side, this means that Doctors (and billers) must be aware of every possible permutation that is "allowed" for billing by every insurer, for every CPT (procedure code).
I did some quick math to measure:
A) There are ~12000 valid CPT codes. (I could not google the exact number but CPT codes go from 0xxxx to 99xxx, plus therr are also S codes (Sxxxx), J codes (Jxxxx) etc.)
B) There are 155,000 ICD-10 diagnosis codes [1].
There are roughly 900 payors in USA. [2]
This means there are 1.67 x 10^12 rules a doctor billing insurance must know.
Even if you consider the narrow view that a doctor of X specialty may bill only top 100 cpt codes, for maybe 50 payors, thats still a huge number (25M!!!) because diagnosis DX (I.e. ICD-10) is not narrow and requires knowledge of related conditions - billing z11 is different result vs billing z11.26 and you must know that.
Its insane to think anyone will memorize 25 million combinations to know what to bill or not bill. And this calc does not consider modifiers OR primary DX....
> His claim was just one of roughly 60,000 that Dopke denied in a single month last year
60,000 / 20 workdays in a month / 8 hours in a workday => this guy rejected about 375 claims per hour, on average. Over six claims a minute. He spent less than 10 seconds on each claim, for a full month of work time.
This alone should be grounds for a class action lawsuit. It’s ridiculous they do this in an obviously automated way. If they want to raise the bar on requirements of “submitting a claim “ that’s fine, our healthcare admins can figure it out. But patients should be allowed to be dragged through the mud like this.
It's funny when it comes to the law including civil disputes, us commoners are always told "oh no the judges look at the intent behind the deal, and consider what a reasonable person would expect" when it comes to explaining why bank errors and such don't work in our favor.
No reasonable person would ever enter into a contract for health insurance with a company that would reject their claim after a doctor looks at it for literally 10 seconds, but apparently when it comes to the big end of town, the exact letters of the law become much more important.
This rate is pretty ridiculous. I wouldn't be surprised if there is automated software or a farm of non-medical staff working behind the name of the doctor, similar to how shady contractors will "rent" the license of a legitimate but retired contractor.
... it literally says in the article they have a program that goes over claims, says deny if it "thinks" it's "not needed" and humans confirm it in batches of 50.
Her employer should be jailed as well, all the way to the top of the company. Such behaviour cannot exist without at least the tacit agreement of everyone higher in the chain of command.
They are already being autodenied, the human is in the loop only for superficial compliance with rules requiring a qualified medical professional “reviewing” before denying.
"A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments."
"Cigna said its review system was created to “accelerate payment of claims for certain routine screenings,”
This sounds like simple automation with an error rate that is acceptable by Cigna. Of course it's not acceptable to anyone wrongfully denied a claim.
Now that's an issue I don't see in the article. How many claims were wrongfully denied? I can't get worked up about the situation when critical information is missing.
Not only the automation is a problem. Cigna is the only one that knows the rule set.
This forces the patient or biller to try out multiple combination of codes until he strikes told. This is why healthcare is so expensive. Remove cpts and icds and the admin overhead syatem goes away
But that requires insurances to be there for catastrophic care only (I.e. reverse lottery) , and this is not palatable with the govt crowd
I work for Cigna, and recently went through cancer treatment. They rejected every scan and treatment until my doctor challenged. My first doctor couldn't figure out how to challenge and it set back my initial treatment.
Then last year the CEO did a town hall with a tear jerker clip show about how evicore is helping cancer patients. But evicore is the part of Cigna that kept rejecting my treatment. It was incredibly insulting, and I've been ashamed to work there since.
> They're very convinced that evicore delivers superior outcome at lower cost.
A superior outcome by what measure? Non-treatment with a cheaper life insurance payout than cost of treatment is "superior". Treatment with a worse long term outcome that is cheaper overall is "superior".
Insurance companies' primary master is always the payor. Always.
They talk about serving the patients, but payors are who pay the bill.
"Superior outcome" = Careful dance between aggregate average outcome vs total cost of care. It's a typical insurance industry doublespeak, and an very effective way to sell to payors.
Once you get the treatment and feel better, please share it with your local news stations. This is the kind of story that should take the company out of business.
The local news station probably receives a big part of it's budget and profits from medical ads. It won't run any material that can threaten it's main income.
This has been happening to me for the past several months.
1. Cigna will not tell you for any reason, why the claim is denied
2. Reps will not help at all other than "Oh I see the issue, will reprocess" which often just results in another denial
3. The issue that a helpful rep finally disclosed: Cigna's own claim form for providers has a box that is overloaded for procedure code and equipment code; apparently the CPT code for therapy is the same as the equipment code for injections.
So one claim processor decided that the claim was for injections and denied it. Then every subsequent claim has been denied under the same reason.
4. At this point the only option for me is for my provider to appeal every single claim (which takes months), as this is the only way to get someone to actually read the claim and make an intelligent decision.
> 1. Cigna will not tell you for any reason, why the claim is denied
Of course not. Fight fire with fire. Get care providers to sign a letter to Cigna saying the procedure is medically necessary Going through the process will not work and will go slow. But putting them on notice by having licensed, local care providers say something is medically necessary and urgent will work almost 100% of the time.
I always wonder if small claims court could be somewhat viable. In the instances where I’ve fought and gotten approval, I’ve spent my own time, my own money, and had my health deteriorate. Ideally, I’d like to be compensated for the time I’ve spent defending myself to this company, and I’d like some form of remuneration (somewhat for retribution, somewhat as a negative incentive to the company) for my now diminished health…
There needs to be something like the CFPB for health care. I couldn't get an actual human to acknowledge me when dealing with PNC when they ate up my bank, but one CFPB complaint got them to do exactly what I asked. That way you never get to the point of burning time, money, and health because they're afraid of action from the agency.
It would be the state’s insurance regulator, although do not know if they are as effective as CFPB. Financial issues tend to be much less complicated than health issues, and usually just a result of understaffing and underinvesting in customer service.
If you have health insurance from your employer, it's probably covered under ERISA. This is federal, so no help from your state insurance agency and no small claims, and I have found that there are few lawyers who will touch it even in a large city.
I genuinely think every health insurance denial should have to come from a named doctor at the health insurance company who is personally and professionally liable for the health outcomes from a denial.
Deny someone life-saving care without a sound medical reason? That’s a malpractice lawsuit and a potential loss of their medical license.
Yep, basically we should make it much easier to identify the specific doctor that is responsible for the denial (to make them easier to sue personally, and discipline professionally), and we should make the liability for such a denial extremely explicit.
the claim denier worked for insurance. he had a complaint on file for entering a hip replacement backwards
the tweeter thread shows devastating images . the point is that a provider like that, has no business denying coverage. plus apparently he was not board cert and other issues from lapses in licensing
In a way, a denial is accusing the ordering/prescribing of trying to commit some type of insurance fraud. I agree if you’re trying to override a doctor that knows me, has cared for me, likely already done some labs/scans/etc to make their order, well - the burden should be yours to prove it’s not necessary.
More and more often care is gated by prior authorizations by insurance. This is because insurance companies have more and more often required many procedures to have a prior authorization before hand and will refuse to pay bills if a prior auth wasn’t obtained.
My proposed policy would apply both to prior authorizations and post care claims.
Post care claim denials can be serious too. If you need repeated treatments a denial to a claim can have an impact on your ability to receive subsequent treatments.
I have a dear friend that was suddenly paralyzed, and now needs ongoing PT from specialists to work to regain use of their limbs. Their insurance has tried to get out of paying the bills several times (they’ve gotten it done so far, but each of the claims has been… a near thing). If one of those bills doesn’t go through, their ability to continue PT at this facility would almost certainly be impacted.
So, yes, a claim denial may impact ongoing care in similar manner to a prior authorization denial.
———
Finally, I’d actually want to add criminal liability for what was described in this particular article.
> “We literally click and submit,” one former Cigna doctor said. “It takes all of 10 seconds to do 50 at a time.”
A doctor working for an insurance company issuing medical denials in this kind of a scheme should be facing jail time, not just personal liability or professional discipline.
The article is about claims, which are a difficult thing than pre-auths.
There are some restrictions on pre-auths and when an insurer can require one. If you are in need of immediate care to save your life, they are not required and your provider will give you care before even telling your insurance company about it.
The grey area with pre-auths is with nonemergency care that could lengthen someone’s life. There are requirements by law for appealing these denials but yes, this is where those stories about “I can’t get my cancer treatment” come from.
This is not the situations in the article, though.
What’s shitty about the actions in the article is that many people don’t even realize that erroneous health insurance denials are common and they just accept the denial and pay out of pocket. It is very common to get a denial, send in a challenge like “no this should be covered” and then they pay.
Critically, many patients also require ongoing services, where a claim denial wouldn’t prevent you from receiving the first service, but it may absolutely impact the second, third, etc.
So, I don’t think I’d exempt claim denials from my proposed regulation. Named doctor, personally and professionally liable from the consequences of their denial.
I was on a jury on a civil case that involved medical claims.
The insurance company doctor seemed like a doctor who sort of plodded his way through jobs and eventually just found a place where he could be a doctor and just reject insurance claims.
Dude didn't seem to actually know all the medical claims involved in the case, seemed confused about what kind of care was done ... just not at all on the ball.
When we deliberated and reviewed the evidence absolutely nobody on the jury had any faith in the insurance company's doctor and we disregarded his testimony entirely.
I honestly felt like there should be some consequences for someone acting as a "doctor" testifying in a court case and having very little clue what was going on, but choosing to testify.
> there should be some consequences for someone acting as a "doctor" testifying in a court case and having very little clue what was going on, but choosing to testify.
It will make no difference. It is the people higher up and the investors in the company who are responsible. The doctors in question don't behave as they do just because they want to, they do it because that is what the company that employs them demands.
What kinds of complaints warrant a formal investigation?
In general, any complaint that would warrant disciplinary action if
substantiated (e.g., sexual misconduct, gross negligence and/or
incompetence, etc.) is referred for investigation. Other kinds of
complaints may also require a formal investigation. These include physician
impairment, unprofessional conduct and unlicensed practice issues.
I thought similarly when reading the part of the article where the legal team said that Cigna's policy wasn't illegal. Maybe it isn't against any laws for the company to do it, but isn't it unethical for doctors to do it? If the law requires that licensed doctors be the ones to review the claims, maybe the most effective way to change this practice is for medical boards to start sanctioning doctors who do this.
The fictional story “The Rainmaker” is about a fictional insurance company with a secret internal policy to deny all claims on first submission, and only fulfill some claims on appeal.
It was meant to be fiction, but I suppose it’s not. This whole company should go down for fraud.
Yeah that's basically a true story, also before the ACA there were plans that would deny your insurance claiming that you lied during the underwriting process if you used the insurance. It was big news at the time and lots of state action against those plans.
I think Cigna needs to be sued class action style for denials. I think it would probably work in the case where Cigna is operating as the claims administrator which is where your company self-insures (so they pay the claims) but Cigna just deals with the paperwork. I would not be surprised if Cigna advertises its services to large companies as "cost effective" etc...
I’m not familiar with class-actions, but I assume they would not work well for a class pool that has an extremely wide ranging list of claim value, and background evidence/ailments.
1. The doctors who signed of on those batches should be sued for medical malpractice and negligence. Where is the AMA on this issue?
2. Why are the tests so expensive? All it requires is to add some chemicals to the blood sample or whatever and see if it changes color or something? $1000 of dollars?
3. Isn't there a trust relationship between Cigna and the doctors who authorize the tests? Does Cigna believe that some of its doctors have a relationship with the testing companies where they receive kickbacks for authorizing the tests?
4. The patients whose tests were signed of in batches must file a class action lawsuits against each doctor separately and Sigma. The doctors and Cigna are colluding in medical fraud. Even if subsequent indepth evaluations indicate that declining a tests was justified they should still be sued as they signed off the tests without actually doing the tests for real.
5. I think American doctors, their healthcare institutions and their medical schools have a serious problem with the medical ethics if so many doctors are that criminally minded.
My insurance is denying mental health care for my teenager who has Autism. They also rejected prescriptions given by my doctor for reasons that the doctor would already have taken into account.
Both rejections came with a note to “not stop getting care”.
In my opinion, insurance companies should not be able to override a doctor.
I'm self employed, pay a crap ton of money for "good" insurance, and it's horrible. It's very difficult to find good doctors in network. Everything gets rejected from insurance and the Dr has to appeal it multiple times in order to sometimes get them to budge. It's absolutely broken, and even more so for those on individual and family plans (ie not through an employer).
Last year I was with United Healthcare, this year Blue Cross blue shield. Both are horrible. Both are massive companies.
In the US at least the underlying problem is that we pay more for basically every medical procedure, drug, and device, so you end up paying more to get less. Largely this is due to having engineered a shortage of doctors combined with no negotiation on drug and medical device prices.
Because doctors and patients won't fix it.
Doctors can charge whatever they want.
They could see more patients, charge less, and charge cash.
They could do their own diagnostics during the visit.
People from other countries will be shocked to know that US doctors never do their own diagnostics, and instead refer patients to other providers, which require their own payment and paperwork, another round of appointments.
Putting the patient through all that for an ultrasound is "standard practice", which also happens to be maximally profitable for multiple providers and their associated office staffs, and the enormous industries that exist to service this deeply problematic "standard practice".
Europe's healthcare isn't perfect like many Americans make it out to be. It has its own list of cons. Although it is very nice when you go to a Dr there and talking about money isn't even a thing.
My wife is German. There are Dr's that refuse to work with insurance altogether. There are procedures not covered at all. The employer pays for half the insurance, the state (aka taxes... so you) pay for the other half. Self employed people who failed to pay their "half" can still end up with life crushing bills (personal experience in the family). Not sure what happens if unemployed (I assume the State does step in there to cover it 100%?).
It can be. You make it a public service. Much like roads, public health a "loss making" industry, so the options are "a public service that treats everyone" or "a for profit industry that works to avoid treating people while charging as much as possible".
A true free market is when anyone should be allowed to practice medicine including your barber. That would give your regular doctor a run for their money and have them perform better that the barber.
Similar goes for pharmaceuticals, a true free market does not exist.
This already exists and we know what the outcome of it is. It's alternative medicine. Insurers will gladly and gleefully let you do holistic woo bullshit because it saves them money.
A 'free market' as you state just results in people falling for bullshit care.
>This already exists and we know what the outcome of it is.
No, you cannot prescribe mainstream drugs (some of it which are indeed useful) if you are not licensed. Cannot do surgery etc, either. All of it is 'illegal'.
>A 'free market' as you state just results in people falling for bullshit care.
Not trying to be a shill, and would happily discuss my entire healthcare experience with Kaiser, but I highly recommend them if you have the option. Obviously, don’t change unless you do research etc. and again happy to discuss my experience with them for anyone interested.
What do you mean by fixed? Affordable? That means we would have to lower medical professional income and we have a shortage of them. Insurance have tried to push down their rates but they just stop taking insurance so we have to pay more to see a decent doctor. We could be more punitive to insurance companies for denying claims but the cost of insurance would become even higher.
I doubt you'll find many other industries that have as many unnecessary employees as you would in healthcare.
Given that they're for-profit, they have every incentive to hire as many people as possible to answer phones and create a bureaucratic nest of people who go to work to literally make it hard to use the insurance you're paying for.
Compare to car insurance, where many companies tout how "easy" it is to file a claim, and in most cases it is pretty easy to get your car fixed, get a rental car in the meantime, and get back on the road in a few days. Everybody in the process gets paid, you can shop around every 6 months for cheaper rates, etc. By all accounts, car insurance is profitable.
If healthcare was made simpler, with standard prices for procedures across all hospital systems and insurance carriers, and actual doctors who aren't of the same caliber of the ones prescribing Viagra from some random site in Albania, we could start to fix the system.
As it stands now, and I'm sorry for the people involved who work these jobs, but if health insurance reduced it's bloat of unnecessary workers, many of whom go to work to specifically answer calls from people whose claims are denied, we could lower costs, cover more people's procedures, and keep physician pay the same.
As it stands now, nurses do most of the work in the healthcare system, whether it's in the doctor's office or in the hospital, and unless you're in a niche field of nursing, they get paid less than an entry level PHP developer.
A nurse can lose their license if they make a horrible mistake at work. Hospitals see nurses are replaceable and that's why many of them burnt out during COVID when staffing ratios were thrown to the wayside, raises and department transfers were halted, and techs and other low-skilled nursing positions were eliminated, increasing the burden on RN's.
It's not correct that in order to lower healthcare costs, we have to lower physician pay. Healthcare is just not a business that can be left to the free market.
My Friends, The Revolution is near. There comes a time when the common man can no longer stand idly by and watch as their brothers and sisters (and themselves) continue to be screwed over.
There are many amongst you that fear speaking out in the vain hope that some day that they will get their share of 'the Good Life'. I regret to inform you that if it was going to happen, it would have happened to you by now.
Don't remain silent nor inactive in fear of rocking the boat, the 'they' are mocking you and holding out a carrot on a stick while you blindly plod on in the hope of 'some day'.
Do what you can, when you can. Even the smallest ant can overcome an elephant.
Do not be discouraged nor disheartened if you feel there is nothing you can do. That is what the 'they' count on.
There's no free market for healthcare in the US. What you mean is crony capitalism and corruption. If there was a free market for healthcare and health insurance in the US, it wouldn't be so expensive.
Wow. This is almost the exact plot of The Rainmaker by John Grisham[1] that came out in 1995:
“Rudy uncovers a scheme by Great Benefit to deny every insurance claim submitted, regardless of validity. Great Benefit was playing the odds that the insured would not consult an attorney. A former employee of Great Benefit testifies that the scheme generated an extra $40 million in revenue for the company.”
“Put yourself in the shoes of the insurer,” Howrigon said. “Why not just deny them all and see which ones come back on appeal? From a cost perspective, it makes sense.”
I somewhat get why you'd build such a system when on the other side you've got pharma and labs pulling for useless medication and tests through doctor presents and "seminars". What's beyond me* is how health insurances get to be the deciding entity when there's such a blatant conflict of interest in the matter, which gets abused as it is here demonstrated.
If you get a home insurance claim, at least here in Canada the insurance company has to use an external adjuster. Even though it's not perfect, it seems a widely better solution to handling claims.
* it's not beyond me, it's probably just the result of lobbying
You can attack the management, but also you should look at the people doing the action. If medical doctors participate in such a scheme I feel that the medical schools should strongly consider revocation of degrees as an option. Clearly these doctors are violating their oaths.
That won't help you there. Germany's public healthcare system denies plenty of things too, and will only pay for treatment when you sue (or know someone who works there). Germany's private healthcare system on the other hand is usually better (I'm sure there are exceptions and some insurance company that sucks).
The Norwegian public healthcare is great. The default recommendation to most health issue is to do more sport. Being very physically active usually helps, so it’s not a bad recommendation.
You may experience more pain compared to some other healthcare systems. Like France from my experience and probably USA from what I read.
I had some unforgettable experiences in Norway, such as a colonoscopy without sedation or anaesthesia in case I can tolerate the pain. I didn’t after a while.
Or some little operation that according to the English Wikipedia is done under general anaesthesia in USA. The doctor in my local small emergency room simply told me that the needle for a local anesthesia would be as painful as the operation so it’s unnecessary. She then asked a large nurse to hold me and I was given instructions about how to breathe. I think the doctor may have lied about the pain.
But I pay between $20 and $40 per visit and I don’t have to pay if it accumulates more than $300 per year. It’s also not connected to my work, I can be fired and still have the same healthcare benefits, forever.
> I had some unforgettable experiences in Norway, such as a colonoscopy without sedation or anaesthesia in case I can tolerate the pain.
What pain? I have had a colonoscopy without any sedation, also in Norway. It was uncomfortable, occasionally very, but I wouldn't have called it painful. I think you must have encountered an incompetent doctor.
Can't imagine why you would want general anaesthesia unless it was strictly necessary as it gives an additional risk of dying.
Arguing over whether something is painful or merely very uncomfortable seems like splitting hairs.
That said, I had a colonoscopy with alprazolam and fentanyl, and it was, if anything, a moderately enjoyable experience. There was the odd slightly painful moment as they went round corners, but the drugs made me feel great throughout and I walked home afterwards with a mild afterglow.
However, while I personally certainly wouldn't have requested general anaesthesia, I think it should be down to patient choice. I'm from the UK, and we often take a clench your teeth and bear it attitude to patient suffering, which I think can often be borderline inhumane. Ultimately if a patient wants to accept a 0.001% chance of dying to avoid experiencing pain or discomfort, mental or physical, that is up to them. You also have to consider the second order effects of people avoiding treatment due to fear of pain, as well as people who may have been raped or otherwise have very valid reasons to not want to experience having something inserted into their rectum.
Eh, my experience with health care in Sweden last couple of years is that almost no matter what your issue is, they'll ask what meds you are on, take your blood pressure, and some token blood samples and send you home. This costs $20.
This process obviously does nothing to alleviate any medical issue, so you come back a few weeks later. You pay your $20. New doctor this time, who asks what meds you are on, takes your blood pressure and orders the same tests.
Obviously testing the same thing a second time didn't further the investigation. So you go back. You pay your $20. Yet another doctor this time, who asks what meds you are on, takes your blood pressure and orders the same goddamn tests.
Rinse and repeat. I've had like five of these contacts the last few years. Starting to look like a heroin junkie from all the blood samples. I've never learned of any test results. Just keep taking the same tests over and over. There is just zero continuity.
This anecdote may be true, but Sweden has significantly more favorable health outcomes across most dimensions compared to the US. Infant mortality, in-hospital mortality, etc.
In fact, most developed nations do. But part of what makes it so difficult to have a productive conversation about healthcare is that everyone has experience with the system in every single country, and bad experiences get passed around. So we say X country is doing better, and someone chimes in explaining how that country has its flaws.
They all have their flaws. But the US health system is measurably worse than most other developed nations across most axes that we care about. Though there are interesting questions about how much worse per-capita healthcare spend actually is given the comparatively higher R&D investment in the US.
Infant mortality rates aren't calculated the same in every country. I have no idea if Sweden does it differently than the US, but Cuba's low infant mortality compared to other Central American countries disappears when you calculate them all the same way.
Sure, measurement discrepancies do exist. However, the referenced study is focused almost entirely on Cuba. As a comparison point they use data from PERISTAT which is consistent among countries (or at least that's a goal of the program) for which Sweden is a member.
The point is that, however, you can pick almost any objective health measure and see a similar result. So either all of the measurements are wrong in favor of other nations, or there's a clear problem here.
I think the bigger challenge here is that health in a nation is about much more than just care delivery services. The nations that do better than the US also tend to have significantly greater, and more accessible, social services to the population. Lower income households will have access to higher quality foods, for example. Healthcare services can be rendered even to those who are not actively employed. etc.
Effectively, the US will need to decide if it cares about the health and well being of its population. If it does, we have just about one of the worst ways in modern society to accomplish it. Our method is more expensive, less enjoyable, and has worse outcomes.
> you come back a few weeks later. You pay your $20. New doctor this time,
That's odd. Here in Norway I can always see the doctor with whom I am registered. Very occasionally I'll accept seeing a different doctor in the same practice because that can mean getting an appointment sooner.
I think you should complain to someone because you are clearly getting substandard care.
Every system has a list of approved and unapproved medicines. Every system.
The one benefit (I guess) of universal coverage is that doctors already know the unapproved medicines won't get paid for, so they never try. So you avoid the whole issue of rejections. They just go with whatever the system says it will pay for.
Public healthcare means health care paid for via public funds, nothing more.
Many public health care systems aren't entirely centralized, even though they use public funds. For example even the UK's NHS has regions with allocated budgets they manage based on the number of patients they see, which they then spend as they see fit.
You're trying to attach your biases and assumptions onto an amorphous phrase, and then pretend others are using it wrong because they don't have the same expectations. That isn't reasonable.
I am of Danish origin and stating that the central government has a limited role in healthcare is just downright incorrect. The Ministry of Health (Sundhedsstyrelsen) sets the budget, determines national practices, manages the public health insurance scheme, and manages the list of approved medicines. Yes, execution of healthcare is with the regions, but there has been a significant increase in centralisation of healthcare since the “amter” were disbanded.
Having worked tangentially on AI that approved payments for outpatient ops for one of the companies involved in handling German health system...
The very basic design goal was that the AI system could only approve, not reject. The goal was that obvious cases should be auto-approved, and anything where the AI returned below a certain confidence value was booted back to human to make a decision (same as pre-AI).
There's a viral case going around where a doctor whose lost his license due to replacing a hip backwards is now making his living denying insurance claims. It's not just that claims are being denied unread, but when they are read, it's not exactly the medical cream of the crop doing the work.
But hey: at least they owned the libs this month by passing a disgusting anti-trans bill.
That is what is important right? Not stopping the massive corruption from every mega-corporation in every sector that is making our earth uninhabitable and our lives miserable. Lets hyper focus on people's sexuality.
Permanent measures should be taken very, very seriously and there should be thorough investigation into long term outcomes. This is not at all what the Republicans care about. They aren't doing this because they care about the health of vulnerable kids. They just don't like trans people.
No "thorough investigation" is being done in the US. European countries have halted this treatment because of a paucity of data and evidence of poor outcomes. But the US just ploughs ahead regardless - perhaps a symptom of its for-profit health care system, each transed kid is worth many $$$ in lifetime treatment. So for legislatures to ban this, is the only reasonable path forward to save kids from this type of medical abuse.
> “Put yourself in the shoes of the insurer,” Howrigon said. “Why not just deny them all and see which ones come back on appeal? From a cost perspective, it makes sense.”
This is more or less how the UK government handles benefits (welfare) applications.
It’s cruel and demeaning and damaging to health in many many cases.
What would be the problem with requiring all healthcare to be non-for-profit? You can still have it privatized, but you can’t ever be in a situation where you’re trying to maximize profits. Someone poke holes in the idea…
The incentive to maximize profits (i.e. minimize costs and maximize number of customers) is the benefit of a privatized market. The profit-minimizing mechanism is supposed to be competition, because then people switch away from plans that have a poor balance between price and rejecting claims. But because most plans are tied to employers, that part doesn't work.
If you had a non-profit with no competition it would be little different than the government, i.e. susceptible to regulatory capture and with poor incentives to constrain bureaucratic inefficiency.
Non-profits in a competitive market would be better, but so would for-profit insurers in a competitive market. The problem isn't that somebody is making money -- a service is being provided and somebody is getting paid one way or another -- the problem is it's too hard to switch so bad providers proliferate.
I understand what you’re saying but I don't think it’s so simple when you involve human lives. When you have shareholders and a board demanding profits, fucked up things happen like you don’t get the new MRI machine because it’s bad for the bottom line. Or you pass on the state of the art surgical robot because it won’t pay for itself quick enough. Both examples would increase outcomes for patients but don't happen because the board chooses profits. I am from a family of primarily doctors for multiple generations so I have 2nd hand experience with this crap.
I think as a society it would be totally reasonable for us to say “we don't want profiteering in healthcare”. If you set out to take care of people then your business may only cover costs, which includes reinvesting into the business and your employees. You can never be in a situation where you’re weighing profits against patient care because the conflict of interests is considered unacceptable. I would love to see more people advocate for that stance.
If you have multiple non-profits competing with each other for price-sensitive insurance customers, they have the same incentives. The new MRI machine will require them to raise premiums which will lose them customers, so the providers with the most customers will be the ones that cut costs. Unless customers can measure and prioritize service quality over price, but if that was possible it would also be possible with for-profit insurers.
If you have no competition, the problem shifts the other way. The MRI machine is ten years old, so buy a new one even if it still works, because there is no competition so nothing stops them from raising premiums to pay for it. Then the MRI manufacturer declares that they're only supported for five years and by the way the price has gone up, because they know the non-profit isn't price-sensitive and the patients have no other choice. (Unless you put government pressure on them to keep costs down, and then you're back to cost cutting.)
The underlying problem is that you need an objective way to measure whether some cost is worth incurring. The best metric we have for that is whether the patient is willing to pay that amount of money for it, having been informed of the consequences by their doctor. Sometimes the answer is no -- it really might not be worth spending a million dollars to extend the life of a 78-year-old by six months.
But it probably is worth spending $100,000 to extend the life of an 8-year-old by 70 years, even if the 8-year-old doesn't have $100,000. Which is where you want some kind of insurance.
Where we screwed up is in making "insurance" cover minor procedures that really ought to only cost tens to hundreds of dollars out of pocket, because then the insurance causes those costs to balloon up to thousands by providing a deep pocket that can fund excessive bureaucratic inefficiency. (It also doesn't help that the AMA engineered a doctor shortage so now doctors are overworked, patients are less informed and prices are higher because of supply and demand.)
I guess I'm okay with costs increasing if it means the quality of care is increasing and it's going to care providers not to shareholders. That's the implication of a non-for-profit, that all costs go back into employee salaries or equipment overhead. I'm okay with a good medical team making bank or with pricier but stellar facilities justified by results. I'm sure no system is perfect, but if we'll get the same results removing the profit motive, why not eliminate that potential conflict?
> Where we screwed up is in making "insurance" cover minor procedures that really ought to only cost tens to hundreds of dollars out of pocket, because then the insurance causes those costs to balloon up to thousands by providing a deep pocket that can fund excessive bureaucratic inefficiency. (It also doesn't help that the AMA engineered a doctor shortage so now doctors are overworked, patients are less informed and prices are higher because of supply and demand.)
This is 100% true and concurs with complaints I've heard from doctors (both bits, the broken model and artificial doctor shortage). Insurance isn't the right model for baseline healthcare. People should be willing to pay for routine care like they pay for anything else (food, TV, movies, games, etc.). It should cost $30 to get a physical because it takes a doctor 15 minutes, not $300. Insurance should kick in for absurdly expensive "disaster scenario" procedures that nobody can be expected to afford.
> I guess I'm okay with costs increasing if it means the quality of care is increasing and it's going to care providers not to shareholders.
Shareholders aren't some distinct group. One of the big "providers" of MRI machines is General Electric. Are the shareholders of that conglomerate more honorable than the shareholders of some insurance conglomerate?
Somebody is the beneficiary of any given inefficiency and they're the bad guys regardless of what kind of labels you put on things.
> I'm okay with a good medical team making bank or with pricier but stellar facilities justified by results.
The "justified by results" thing is the whole problem. What do you want to do when the system is pricey but the results are still mediocre?
> I'm sure no system is perfect, but if we'll get the same results removing the profit motive, why not eliminate that potential conflict?
If you set up the incentives in the same way (e.g. by making non-profits compete for customers) then you'll get similar results, but the existing system is bad. The problem with that is we need something better, not something the same.
And it's not impossible to end up with something worse, e.g. a non-profit with no competition that allowed healthcare costs to go up when we need them to go down because people can't afford the cost as it is.
> People should be willing to pay for routine care like they pay for anything else (food, TV, movies, games, etc.). It should cost $30 to get a physical because it takes a doctor 15 minutes, not $300. Insurance should kick in for absurdly expensive "disaster scenario" procedures that nobody can be expected to afford.
There is a case to be made that it should cover an annual physical and routine diagnostics, because early diagnosis lowers costs and you don't want people to skip their checkup to save $30 and then need a $500,000 heart transplant that could've been prevented with a $5 bottle of pills.
What it shouldn't cover is e.g. most prescription medications, because then the $5 bottle of pills goes up to $500 when the insurance is covering it, or patients request $5000 patented drugs that aren't materially better than $5 unpatented ones but the patented ones have better marketing and they stop caring about the cost when the insurance is paying.
That was how we got the "people can't afford insulin" problem IIRC. Insulin isn't patented but there was a patented form of it that was somewhat more convenient, which everybody with insurance gets. There weren't enough people without insurance to justify anyone making the generic stuff anymore, so the super expensive patented stuff was the only thing available, which the minority of people without insurance can't afford.
> Shareholders aren't some distinct group. One of the big "providers" of MRI machines is General Electric. Are the shareholders of that conglomerate more honorable than the shareholders of some insurance conglomerate?
I wonder what it would look like to mandate that suppliers must also be non-for-profit. Companies would all have to spin up non-for-profit divisions (if they don't already have one) and sell to hospitals through them. I imagine it would be massively disruptive in the short term.
Anyway I agree that healthcare should be competitive regardless of whether it's for profit or not.
My wife and I just looked into genetic testing for our child-to-be and Natera bills insurance multiple thousands but only charges people $250 or so if you pay out of pocket. The hilarious part is they bill insurance so much that it would have cost us more to have them bill insurance ($650 would have been our cut of the like 3-6k bill) than if we had done it out of pocket. Ultimately we didn't do it at all because the whole thing seemed sleazy. It's just so fucked up.
Sounds great, but to make it happen on a legal level, the public would have to mobilize enough money to out lobby the vast interests already enjoying complete regulatory capture.
Also every advertisement block would have a 2 minute propaganda segment showing a grandmother suffering due to 'sclerotic non-profit ineptitude' that is inevitable when the god given American profit motive is stripped away.
I keep and keep saying that health insurance is a scam. Paying to a company for a service when their explicit objective is to AVOID providing that service or to minimize the money they spend is plain wrong.
Even medical professionals are angry at the system (check r/medicine) . We are two parties in a transaction being screwed by a third party which only value is to extract profit as an intermediary... even a lending setup (instead of a insurance) would be better. Or imho better yet, socialized medicine.
Problem is that neither the patients nor the doctors choose health insurance so they both get screwed over. Your company CFO chooses your health insurance and the hospital managers chooses what health insurances to collaborate with.
This reminds me of the US patent approval system. There are too many claims to properly vet them all, so just "click and submit" and only put effort into the ones that come back to complain. (Except the PTO is biased toward approval and not rejection, of course.)
Not exactly. The US PTO rejects a large proportion of patent claims. It can be quite expensive / time consuming to get a US patent as an individual inventor. But you can appeal the rejections, and large corporations and patent trolls have staff attorneys who do that all day long, so then tons of garbage patents get approved too.
In Germany blood test for vitamine D are also not covered by the insurance. But they cost 16€. I believe the algorithm might be right in the example given in the text. The costs for such a simple test are excessive and the case should be rejected.
It sounds to me what is described here is simply an algorithm for fraud detection, which many companies use.
I am a T1 diabetic, and worked for UnitedHealth Group. During that time they decided to stop paying for my insulin with no substitute for it, in spite of several cheaper substitutes existing. Thank god for Canada mail pharmacies.
No amount of oversight of health insurance is too much. Health insurance companies should be forbidden from owning or otherwise influencing any health care provider (sounds like a RICO thing now that I type it out). Mandatory prison time for CEO's and any other corporate officers if they knew about the offense and failed to notify authorities. Also fines base on gross revenues, at least 10%. Make shareholders pay as well. Also mandatory incarceration of corporate officers while investigations take place.
I worked customer service for years with a cell carrier in the US. It was tiring hearing everyone's problems with their luxury devices(at that time). I left and got a job at Aetna customer service 6 weeks of training and I walked in the first week on the job. After getting off a call with an elderly gentleman trying to figure out why we weren't paying for his wife's medical care. And all I could say was the plan you have well not cover that because you didn't jump through some ridiculous hoop. A hip that as a young adult I would have struggled to complete let alone a very old person who doesn't understand what is required and there is no one to help him.
>As a physician, van Terheyden said, he’s dumbfounded by the company’s policies.
>“It’s not good medicine. It’s not caring for patients. You end up asking yourself: Why would they do this if their ultimate goal is to care for the patient?” he said.
Because their ultimate goal is to make money, as with the entire health "care" system in the US.
In addition, states (as the pirnary regulators of insurance) should adopt a rule that if an insurer has a policy which directs, incentivizes, or which managenment knows or should reasonably know results in denials without good faith review, the state then has a cause of action against the insurer for damages of equal to triple the amount originally denied without appropriate review (whether or not later paid), and will, if necessary, pierce the corporate veil to recover it and, separately, each medical reviewer who is found to have denied a claim without good faith review shall be fined an amount equal to the value of claims so denied and prohibited (regardless of whether their medical license may later be restored) from being responsible for medical review of insurance claims in the state in the future.
The USA medical insurance system is missing a "stick" for such bogus rejections. Unduly denying a claim should result in a fine big enough to be felt in the company balance sheet, that is the only way to change companies' behaviours.
What if we just don't have a stick. The government or a company they hire is the party that reviews claims. The insurance contacts must have standardized terms and conditions.
This probably wouldn't even really hurt the insurance companies. They would not need to compete with each other by denying claims on the backend to provide lower prices on the frontend.
So the law says a Doctor must review the claim. An algorithm does what effectively is a pre-review of each claim and the Doctor just clicks accept without even checking a single sample in each batch of pre-reviewed claims. This cannot possibly be legal.
Insurance companies deny medical necessity claims because the procedure and diagnosis code combinations don't align with what is pre-determined to be medically necessary. One of the big reasons why this happens that nobody ever talks about is because the doctors office does not code the claim correctly and it gets denied. The patient is pissed and blames the insurance company, the doctor is pissed and blames the insurance company, but in reality its the biller/coder in the back office who screwed it up.
If all insurance companies published all the code combinations covered for every procedure/diagnosis, I might buy this argument. But they don't. I've asked Blue Cross and they said they don't disclose those details. Many billing codes are open to some interpretation. So if insurance companies aren't transparent about what codes are or are not covered, why are the doctors' offices at fault when something is denied? Why isn't the default response from every insurer "code X isn't covered in combination with code Y. <some clarifying questions, explanation, and related codes>"? Why is it a black box?
All right, US insurance companies deny millions of valid claims not because of greed, but because "the doctors office does not code the claim correctly". It's just an unforeseen side effect that said insurance companies end up with billions of annual profits and patients sometime die...
Your post remains me of how Russians often react on their forums to posts regarding the corruption in Russia. There are undeniable proofs of how corrupted Putin regime is. All ministers, members of president administration, local administration, judges, generals, etc. end up owning multi-million properties both in Russia and Europe/USA, but many regular people find the stupidest excuses of how the system is fair and just, but "the doctors office does not code the claim correctly".
I’ve worked in healthcare revenue cycle management for over a decade. If you don’t accurately tell the insurance company what you’re doing and why you’re getting denied. Doesn’t matter if it’s health, auto, home, etc. There are thousands of codes, millions of combinations, and all being mostly hand coded by minimum wage workers. There are constant fuck ups most of which don’t require anyone but a computer to review to know it’s wrong. But okay cool conspiracy.
Even if we assume you're right, the way that the system is setup and the fact that there are constant fuck ups, but no effort to fix them are not accidents. Yes, there are conspiracies out there (surprise, most people are not angels) and the US health system is definitely one.
Check out the insurance companies profits. Those are directly linked to denied customer claims. Claims are not denied en-mass, by accident obviously - unless you're a complete fool.
The constant billing and coding fuckups are because the government forces providers to use them. HIPAA requires the use of the x12 standard which is woefully broken. Speech between provider and payer is completely regulated. Nobody is doing anything to address it because they are prohibited by law.
Oh and by the way: health insurance company profits are essentially capped by the government via medical loss ratios. They don’t make more money the more they deny otherwise they will be forced to send rebate checks (like what happened during Covid)
For anyone who is against government regulation... this is another perfect example of the kind of perverse financial incentives unregulated capitalism results in.
Blanket denial without consideration lowers your costs as an insurance provider, because it acts like a filter on people who care enough to appeal repeatedly.
This is not unregulated capitalism. This is crony capitalism or corruption. It is government regulation that allows a monopoly of large corporations to remain the powerful health insurance companies they are, and ObamaCare gave them even more power.
If this was a free, unregulated market, healthcare in the US would be cheaper.
There is a curious irony regarding retirement funds that invest in health insurance companies: if one is healthy and pays into the system, the insurers will reap ample profits, and one's retirement plan will reap the benefits. Get sick, and one may never make it to retirement....
Insurance companies are scum of the earth. A relative, who's a Prudential agent, bragged that Prudential had billions in their war-chest. I replied that's because ya'll don't payout any claims.
Somebody should make an AI service that automatically files appeals. I suspect that the cost of the appeals process would negate the savings they make from auto-denying claims.
Privatized health care as a person's sole option for care is an absolute dystopian nightmare. Any system that requires balancing human suffering against profitability is inevitably going to optimize for profitability.
The fact that this is even a thing is mind boggling.
All claims being reviewed by big health insurance conglomerates is the antithesis of privatized healthcare. It incorporates the worst part of public healthcare and destroys the best potential benefit of privatized healthcare.
I would say that there can't be any market without the government creating it (what does a contract or deed mean if there's no authority that recognizes it?), so there's a bit of "no true Scotsman" in trying to call it anything else besides a private market.
This is not properly referred to as health insurance. It is a sickness, aging, and death payment plan. There's no such thing as major medical anymore.
It was private healthcare that backed public law forcing minimum coverage. Why? Because their pool was shrinking. They were getting sick people who needed care, but with premiums skyrocketing, what benefit is there for healthy people to buy in?
But I agree that the private for profit health care system is an abomination only made much worse by making it public law requiring we buy into it. Instead of Medicare for all.
What part of public healthcare is incorporated into health insurance conglomerates? And what potential benefits of privatized healthcare are we missing out on?
The person I was responding to was suggesting it was a connection to public programs that made private health programs so stingy in denying claims, and I don't see how your answer gets me any closer to understanding what that means.
I'm also not sure what you mean when there's plenty of other examples. Examples of what? I'm still trying to figure out what the "what" is. Private health insurance companies in America ruthlessly deny claims, this is supposedly because of something about public administration of healthcare, and I'm still waiting for an explanation of how that works.
IMHO in privatized healthcare you are not the patient, you are the customer. As such, you should be having a better "customer journey" than in public healthcare: more immediate test/diagnostics, better experience in the hospital (like a room for yourself). And that's it. As a counterpart, it's not clear you are receiving the best medical attention. And of course you (through your employer) are paying for something that can be denied.
Note: I happen to have private healthcare with Cigna in a country with a reasonably good public health system (Spain, though it varies between different autonomous communities), happy to pay the taxes and will defend that public health systems are a staple of any modern country.
"Being the customer" doesn't matter one bit to most modern megacorps, because people are fungible to them. We constantly hear about big money screwing over little money.
Small-time capitalism is quite good. Make a few millions, sure. I have no problem with that. But when the amounts concerned are in the billions? There needs to be massive oversight and regulation, regardless of the relevant field.
To be clear, we are talking about benefit to the patient; there's lots of reasons concierge doctors may not be the best benefit for society at large. But that's immaterial because this is just one example; if we hadn't gone for the worst possible way to scale private medicine, then there could be better examples.
But the point is that you can't seriously look at concierge doctors and say that public healthcare would be better for those patients! And therefore this refutes any claim that public healthcare is the best system overall.
This is a great example. Alas, I'm pretty sure I disagree.
I am an early adopter of concierge care. It's been tremendous.
I had a bone marrow transplant +30 years ago. Continuity of care has been an ongoing challenge.
From my reading and my own experience, having a patient advocate greatly improves outcomes. Someone who just keeps everything on track. Could be family member, friend, or a nurse / case worker. For me, it's now my concierge doctor. (Over the years, I've served as advocate for other patients many times.)
My current issue with concierge (patient advocates) is that it's rare. Everyone should have this. In times past, it was a family's doctor. But as everyone knows, that relationship is no longer stable, due to how healthcare in the USA has been commodified and "optimized".
Further, according to the research (like what Atul Gawanda has written about), specialty "wrap-around" practices greatly improve outcomes. Like for diabetes, cystic fibrosis, and other chronic life threatening conditions. Most all of a patient's care is done by these multidisciplinary primary clinics. One stop shopping. Instead of bouncing patients around, delegating the coordination and whatnot onto the patients themselves.
Again, thank you for this example. It's an interesting edge case. Today, I think most concierge arrangements are private. Whereas it should be the default, public or private.
FWIW, maybe about 10 years ago, Medicare and the VA had started to adopt the capitation model (preventative care vs fee-for-service). Now I'm curious what they (or any other large orgs) are doing wrt concierge (patient advocates).
> A key component of the free market is the ability to say "no thanks" to an offer to do business.
So a free market in health care is not possible because you can't consider your options and say "no thanks" when you need emergency treatment. Whatever the government does or does not do, you can't really get around the fact that at a moment of crisis health care providers have you in a coercive situation and could charge life changing amounts for care if they were permitted to.
My dad used to tell me there are 2 types of jobs, jobs where you use your hands or intellect to make something more valuable from less expensive constituent parts, and jobs where you skim off the top of people doing #1
> Privatized health care as a person's sole option for care is an absolute dystopian nightmare.
Dont exaggerate. I've lived in 3 European countries and Australia. My American healthcare is easily better than those. Sure I'm lucky to have a good job that pays for it, but you can't say its terrible without looking at how those public systems are really struggling right now.
The article suggests that your health care isn't as good as you think it is. You never know if you'll be one of those cases where they make you fight for every bit of care you get.
Some Americans do get excellent care with a minimum of grief. Others think their insurance is fine while they're healthy and only discover later that it doesn't really cover what they imagine it does. And the difference is entirely arbitrary.
The fundamental problem of health insurance is that you cannot know what you will need, and there is no way to make an informed consumer choice, but your need when you have it is absolute. It's pathologically pessimal as a free market. And you usually don't know until it's too late.
You cannot know what you will need, but to leap from that and say that you cannot make an informed consumer choice is a huge and incorrect leap.
Actuaries know, in aggregate, what specific demographics will need. Insurance companies use those statistics to make profit. The view that consumers cannot make informed choices on healthcare needs is incompatible with the fact that risks are not perfectly and uniformly random. Unless, by “informed choice”, you mean one that is correct in hindsight, in which case, I agree.
> How can you smugly dismiss their point like that?
Because "it's fine if you're rich" is a shitty place to terminate the matter. It's not a useful counterargument in any sense. Of course it's fine if you're rich, that's why people want to be rich. What about, you know, the rest of the planet?
Having lived the opposite, I have to strongly disagree. I lived the nightmare of US healthcare, where my provider decided to stop working in my state, which meant that I no longer had access to any doctors under health insurance despite it being paid for by my company.
The UK was amazing - no questions asked care for my health was a massive improvement over what I had in the US. Free access to a doctor at any time is more life changing that you can think - every health issue I had I could talk to a medical professional and get guidance. Even free mental health care.
Moved to Ireland last year, with a mixed public/private system, and my health is now slipping a bit. Going to a GP, trying to file for reimbursements, and knowing that every time I have a health concern, it will cost me money, is a powerful suppressing force. I miss the NHS.
Do you think your health care experience represents the median healthcare experience in all 5 countries?
If we divide up people into percentiles based on wealth, 25, 50, 75, 95, how do you think people fare in the different countries? How do you think they the median experience is in America?
Totally if you're poor in the USA the healthcare medicaid is OK not great. If you have a little bit of money so dont get medicare its an expensive disgrace.
> Sure I'm lucky to have a good job that pays for it,
That is not where you are lucky.
You are lucky to be healthy enough that you can hold on to that job. Once your health takes a bad turn, and you are unable to work, when you really need your healthcare, that's when you are better positioned to judge the quality of healthcare.
My personal healthcare in Sweden has been higher quality (considering both personal cost and state cost) than my healthcare in US. I have heard complaints the other way of course.
Regardless of our personal experiences, the US spends so an enormous amount on healthcare and gets very little in return by basically all international measurements. Americans who think American healthcare seem to me too insecure to accept that their system is just plain bad. But yes Americans with a lot of money have access to better healthcare than average Americans. That said, this is essentially true in all countries so it's not that relevant really.
Technically, you just need money to pay for it. However, buying the employer’s choice lets you pay for premiums with pre tax funds, and the employer usually subsidizes 70% of the premiums.
So for an individual, it is roughly a $10k per year benefit to get it via employer and for a family of 4, $40k per year benefit.
That's not true. As I discovered when my COBRA ran out recently, finding individual plans that match the coverage of employer plans is very hard or impossible, regardless of how much you're willing to pay.
You’re telling me a mega-corp buying coverage for 10000+ employees might have an advantage in negotiating price that a single “rugged individual” doesn’t?! But that sort of thinking could burst the whole “pull yourself up by your bootstraps” thinking that fuels the American dream! Clearly all individuals (both single citizens and corporate entities)are the same other the law!
I’ve always been able to find the same or similar BCBS plan my employers offer on healthcare.gov. If it has the same metal level (platinum/gold/silver/bronze), it should be the same actuarial value.
In terms of general benefits, maybe. In terms of provider coverage - I couldn't find an individual plan at coveredca.com that was accepted by doctors at Stanford Hospital.
The important question is: have you ever made a large claim for a serious long-term illness? If not, you aren't yet in a position to judge the two systems.
Yeah this is a very common sentiment. I feel like most people in the US haven’t actually talked to someone that has experience with socialized healthcare at scale. I had a German professor that was very clear about just how much better healthcare is in the US.
I am from Germany and agree that US healthcare is very shiny. But once you get sick it’s very easy to get stuck in an extremely expensive bureaucratic nightmare between hospitals and insurances. I prefer the German system where I can go to a doctor or ride an ambulance without the fear of having to pay tons of money.
The German healthcare system was surprising to me. It was affordable, it was fairly honest, and our anecdotal experience was not as good as most experienced we’ve had in the USA.
A few examples for those wondering:
* the total cost for over a week stay was a couple hundred dollars - very affordable!
* certain painkillers banned in the USA were the first line of defense there
* getting very strong pain killers was next to impossible - I think we probably only got it because we were family members of the anesthesiologist, and he knew we needed it. And it took nearly 24 hours of agonized pain before we could finally get them
* nurses are not trained to put in IVs - we needed an MD for that. And the MD had a lot of things to do and we had to wait quite awhile even though there were many nurses around. In the USA, I think most people with the title of nurse can do that
In the US people with the title of nurse can be someone who is highly skilled and is playing an important hands-on role in major and complicated surgeries.
I think some other places around the world use the title nurse for what may be a medical assistant in the US. (No clue about Germany though)
Healthcare in the US can be higher quality, but you never know what you’re going to pay for it.
When I was starting my career, I had to go to an ER that was out of network, I checked with my insurance and they said they would cover it. They decided after all not to honor their word and charged me 10’s of thousands of dollars.
Being young and independent, this was devastating, despite having a good job, good insurance, etc.
I largely credit this with my push to move to Europe, and have never looked back.
Sometimes knowing you can get any healthcare you need without it potentially a bankrupting you is it’s own reward.
"I checked with my insurance and they said they would cover it. They decided after all not to honor their word and charged me 10’s of thousands of dollars."
That's the insanity here. You simply can't protect yourself reliably from overcharging. Hospitals and insurances do whatever they want and good luck to you fixing mistakes. I find it really hard to understand how people can be defending such a system.
As someone who has lived in the US, UK, and NL. I'll happily take the UK (pre-running it at such a budget that it fell apart) or NL systems over the US anyday.
There is no fun surprises like finding out that while your surgeon and hopsital were in-network your anaesthetist was out of network.
Eh. I did in Poland, but, admittedly, it is a poster child of how to do it so badly that people opt for now existing separate private care. It is, however, definitely a negative example of socialized health care.
MRI accessibility is regulated at the state level, which determines the number of MRI machines available to the public. I was able to obtain an MRI while on vacation in Europe without any appointment or referral from a physician. The process was straightforward; I explained my needs to the receptionist, and a technician conducted the MRI. The cost was 180 euros.
My family has received multiple radiology procedures including x-ray, MRI, and ultrasound from private radiology businesses (I.e. not the hospital). They are typically 10x give or take less expensive. Last MRI was $600.
Doesn't help if you are stuck in the hospital. But, it's an option otherwise.
I know it's still not cheap, but I needed an MRI a few years ago and it was $350. Talk to your doctor and let them know you want to pay cash. Mine suggested a place.
Don't get one in the hospital if you can help it. They charge 1-2k because they have a full set of people who can't go anywhere else.
That MRI would probably bill out at >US$ 1000 in most urban areas in the US. I've been billed $300 for a simple shoulder X-ray.
The real kicker is that you generally can't even find out this price until you have the procedure and receive the bill. It's become almost akin to a legal mafia cartel. In my area, a majority of the urologists have become part of a medical group that now dictates pricing for related procedures. Most of the major insurance carriers don't want to pay this pricing so this group is not a covered provider, so finding a urologist that is covered entails sometimes waits of months for an appointment.
It's the worst parts of socialized and for-profit health care assembled into one system.
> The real kicker is that you generally can't even find out this price until you have the procedure and receive the bill. It's become almost akin to a legal mafia cartel. In my area, a majority of the urologists have become part of a medical group that now dictates pricing for related procedures. Most of the major insurance carriers don't want to pay this pricing so this group is not a covered provider, so finding a urologist that is covered entails sometimes waits of months for an appointment.
I find the American healthcare system pretty atrocious, but I've never had issues getting upfront costs when scheduling non-emergency procedures using cash. Then again it's probably been a good 8+ years since I've done that in the US.
The trip to the EU, a vacation, and the MRI itself would be cheaper...
I was actually planning on getting it done on my next trip to China, which is about the same cost wise, and the doctors are good as they see so many people lol
I get a screening in India when I visit some family there. Full blood work, you call in the morning, they come by the house and draw it, results in the next morning. It's faster and cheaper to do that, including the flights, than to try and get this done through my doctor in the US.
Not sure what you mean here. Services like Personalabs or just scheduling straight through Quest Diagnostics cost a couple hundred bucks for blood & urine tests on most things, there's probably a facility near you, and you get your results in a few days. I do it every few years with zero issues.
Though sometimes the price the consumer pays isn't reflective of the true cost.
Sometimes the public health system does buy/subsidize the machine for the provider and a private client isn't charged some chunk of the amortized cost of the machine because the public system (rightly) assumes that 99% of the work is going to be for their residents. The clinic can profitably just charge for their professional/office use.
Here's a Bucharest Romania MRI clinic with tariffs:
I may be completely wrong, but I understand in the US normally people have health care through their employer? so they are not themselves paying the insurer, and cannot change insurer.
If this is the case, then it is no wonder the insurer has no particular care for them. It is the power of the consumer to change provider which gives them influence over the provider.
This is the case, and is, IMO, the central problem with American healthcare. Folks in both political parties argue for or against socialized healthcare, and ignore that a huge amount of the problems could be solved by having an actual free market.
My opinion is that providing healthcare as a benefit should be banned. Employees who have healthcare today should be provided the amount the employer would have spent on health care in wages/salary. The fine details are hard to work out, but I think it is a good starting point.
I agree, an important component though is that insurance premiums are pretax, so you’d need to expand HSAs to be large enough to pay insurance premiums.
> so you’d need to expand HSAs to be large enough to pay insurance premiums
I don't think that's the problem so much as 1) IIRC you simply can't use them for premiums in the first place and 2) you need a high deductible plan to be eligible for an HSA in the first place
Public health care can be similarly dystopian in other ways: Very long wait times due to limited resources, subpar medical care, limited prescription options and drugs, beauracracy.
No matter what society you live, the advice is the same: try not to get sick.
This might be true, but as someone who has lived in the U.S. and Europe I can say utterly unequivocally that I preferred Health Care in Europe. I wasn't even in one of the European countries with a great reputation for Health Care.
Health Care in the U.S. isn't just bad, its outright fucking brutal. An elderly friend of mine recently fell and went to an urgent care where they couldn't get him into the x-ray machine. They told him to go to an emergency room where he waited for _13_ fucking hours with a broken pelvis. I'm basically 100% sure that such emergency room bullshit literally kills people from stress or exposing them to other sick people. You can't even wait in your damn car and just have them text you - they just force you to sit in this horrible room with a ton of sick people for hours on end.
The U.S. Health Care system absolutely fucking blows.
I’m fully insured and have always been well taken care of in the United States health care system. Never wait more than 30 minutes if I were in an emergency room, and usually I’m attended to within 10-15. Doctors appointments are easy to get, never paid much for prescriptions.
If I was in a public system, I’d fear I’d be fighting for attention alongside the general public, so I’m not convinced it would be better.
Don't you think it's a worthy goal to strive for this for all people in your country? Would you really try to block progress towards that goal due to your fear of being treated as they are right now, instead of putting your energy towards nobody being treated that way?
Sincerely, if anyone can explain to me - how can we as a species both have figured out game theory, AND consider this as a position that is in any way acceptable?
The current situation is that the parent poster has preferential healthcare access, and other people that they do not care about do not. The alternative is equal treatment which might mean the same access, or worse access as they are forced to "fight for attention alongside the general public" as they so blithely put it.
Given the option between the status quo, or a change which can only ever be the same or worse for you personally (regardless of the broader impact), of course someone self-centered would choose the former.
The best insurance I've seen in the US is Medicaid.
It's people in the middle who are getting squeezed by HDHPs, mostly not the poor, who have access to Medicaid (exact qualifications vary by state) or Medicare (everyone 65+).
I'm fully insured and healthy but still just paid almost $3000 in deductubles for a single upper endoscopy (common procedure for 40+ folks). Cigna. In Italy last summer I received a dental xray and diagnosis as a walk-in, for FREE.
Just adding that in Lombardy, the region around Milan who have a bad case of parochial wanna-be NYC, local (right wing) government is pushing towards private health care with lavish subsidies for privates and a grossly underfunded public health system. To get an MRI via public you can wait 1k days, invia private is a next-day appointment although you must be ready to pay thousands EUR. frankly it’s obviously deliberate
That's disappointing to hear. My experience was in Brescia. I'm from NYC so I can say that if they're charging thousands of euro for a scan they're right on the money.
Where is the wait only 30 minutes? Every time I've been to the emergency room the wait has been 6+ hours. I think the only way it would be that fast at the hospitals I've been to is if you'd die waiting longer, otherwise it's a long wait.
Everywhere and nowhere it can be 30 minutes. Every competent ER on the planet triages patients. Come in with crushing chest pains and it should be 30 minutes everywhere 99% of the time. Broken arm? You might wait hours if people keep coming in with crushing chest pains.
"Wait" can be defined very differently. Wait time to get triaged by a nurse? An ECG for chest pains? Initial physician assessment? Entry-to-exit? Lab results? Time to X-Ray if needed?
Lots of directives may be in place too. In an efficient system, the nurse is empowered to "order" many procedures that screen out serious things that require immediate physician intervention. Or just to save time like ordering an X-Ray first instead of waiting to see a doctor to order it and then waiting again for it to come back to review.
I've waited less than an hour in New Jersey and Connecticut.
When I still lived in NYC, I resolved that if I needed a hospital but I wasn't in extremely bad shape, I would drive an hour into an adjacent state's ER rather than wait in NYC.
Post COVID hospital in Ohio, limped in with severe ankle sprain, got doctor in less than 15 minutes and out within an hour with splint and crutches. Even got X-Ray.
What city? Most of us in this thread live in larger cities. When I lived in LA and had to go to the ER, the wait was 5 hours and they literally rolled a cart over and made me prepay my insurance deductible (several hundred dollars) before a doctor even saw me. Helped a friend get to the ER in Phoenix and it was about 3 hours.
Only ~8% of people are uninsured so I wouldn't be so quick to distance yourself from being "the general public". Besides, you don't need insurance to be stabilized in an ER that only comes into play after (or if you enter with a non-emergency). 30 minutes is pretty good though, especially if it's the latter type of visit, it'd be about 3x better than the best state average https://www.beckershospitalreview.com/rankings-and-ratings/e.... Specific location and severity have more to do with ER wait times than your insurance. Travel can often be a "spin the wheel" type situation. I'm lucky to have short wait times near where I live but on some work trips I haven't been so lucky.
I am fully insured in the United States. An appointment with my primary for something urgent is typically a week out, if I can't wait a week I am advised to go to an emergency room. An appointment with a specialist, if I can get one, is typically six months out. An average emergency room visit is typically a three hour wait to be triaged, additional multiple hours to talk to someone about my condition.
I live in Massachusetts. I would take a public system over what we have now, no questions asked.
How old are you and what are your insurance premiums and deductibles? Generally the US healthcare system works better the more money you have and the less risk you have.
> I’d fear I’d be fighting for attention alongside the general public
Are you not a part of the "general public"? If it is true that there is a class of people who don't have your advantages and therefore have worse medical care, is that a situation that you see as acceptable?
It always seems strange to me when people argue this about this issue from a hypothetical perspective, when we have a wealth of actual data that we can use to compare health outcomes. We can just look at the results and see what works better!
(TLDR: the US spends much more per capita on healthcare, especially in administrative costs, and has worse health outcomes than most wealthy countries).
> If it is true that there is a class of people who don't have your advantages and therefore have worse medical care, is that a situation that you see as acceptable?
The answer is obviously yes, given that they don't want the "general public" to have the same level of access and make them potentially have to endure any longer waits. Their convenience is more important than the health of others.
People love feeling like they're better than someone else, that's an ideal that's been floating around the US for quite some time. Ingroup outgroup stuff, great way for capital owners to keep the workers fighting amongst themselves and keep the attention where they want it
To me this is similar to being "stuck in traffic" as if it is something that you are experiencing. No, you ARE the traffic. The congestion didn't come to ruin your day. You contributed to it too.
I find it hard to believe you have never waited more than 30 minutes in an emergency room. I can't ever remember waiting less and I've always had pretty good insurance.
ERs, even in US, will triage patients by need, not quality/quantity of insurance. If they're seeing insured ankle sprains before uninsured strokes/heart attacks, they're going to get sued to dust.
As someone who has dealt with many folks suffering from AIDS, I can say that it may even rise to the level of crimes against humanity.
It's a well-known trope (probably proven, but I don't know the studies) that insurance companies routinely delay healthcare to AIDS and other patients with terminal diseases, in the direct hope that the patient dies.
With AIDS patients, there's a big moral component to the diagnoses, and companies can "get away with it," because there's such stigma to the disease, but I have also heard of the same thing happening to cancer patients. In fact, it can sometimes be a matter of life and death. If a treatment is delayed enough, it can change the outcome.
I have been told (but don't know it for a fact) that this is actually the point of the delays, and that the delays are triggered by the diagnosis.
In many cases, delaying payment, also delays treatment. Most patients don't have an extra 500K, floating around, that they can pay the hospital for a procedure, in the hope they get reimbursed. No promise of payment, no treatment.
So that means that refusal to pay is the same as withholding treatment, and these companies know it.
I think that AI is likely to make this worse, as they will probably give these decisions to an AI, thus removing any hope that there may be a caring human in the process that could possibly feel shame.
I moved from a third world country with both socialized and private healthcare, to the United States. I pay vastly more for worse healthcare than anywhere I've lived.
The fact that you, your doctor can agree that a certain procedure is required, only to be denied by a third party with no medical qualification is absolutely dystopian.
I also came to the US from a country with a good hybrid public/private system and my experience in the US had been different.
So I guess it depends on where (city/state) you live and also what type of insurance you have.
Where I live I have access to a SOTA network of hospitals with great technology and some practices amount the best in the world (people come here from other states and even countries for treatment) and I use their own insurance, so it's been great so far, never dealt with any issues having medical care rejected.
I pay $350/month (self employed) and I have a very reasonable deductible, $60 copay to see specialists and many preventive procedures such as cancer and heart disease screenings (which I use), blood work and some PT sessions completely free.
I even get discounts on fitness centers and health tracking apps which helps offset part of the premium.
My shoulder was actually spared from a very invasive surgery thanks to a doctor top of his field (he sees olympic teams) who was able to treat me with only PT.
I don't think I paid more than $1000 out of pocket for everything including several MRIs and multiple visits to his practice, plus several sessions of PT and medications.
It could have been free back in my country, I guess, but I could have also been screwed for life due to an unnecessary surgery.
The article is not about death panels run by doctors, they are run by insurance companies. The doctors in this scenario are workers given bounded instructions on how to operate by the ones running it, without autonomy on how to organize the death panel decisionmaking. It's in the title - the "having" shows who is in control. These are not worker owned cooperatives. Nor are most state owned death panels.
Is American healthcare a patriotic issue or something, that's why criticizing it warrants a "don't come here"? Where the hell does your comment come from?
Americans who are unable to listen to critiques of their system are frankly an embarrassment for the country. Their insecurity is kind of pathetic. They hold us back in development as a nation.
Not everyone came to this nation due to capitalism. My parents partially came here to be free to say whatever they wanted and not disappear, for instance.
It doesn’t mean healthcare is done right; just as using TP to wipe one’s ass is 100 years backward.
I sometimes wish they stayed back, because my own life and theirs would’ve probably been much better in the long run.
You’re always free to go back. Unlike many collectivist countries, we won’t stop you from leaving, or try to force you to do things in general. So it’s not unsurprising that your attempts at forcing others to pay for your things is met with hostility when you and others that share your views don’t even want to face those policies themselves.
> You’re always free to go back. Unlike many collectivist countries, we won’t stop you from leaving, or try to force you to do things in general.
No, I won’t be forced. I’ll just get shouted down by anonymous accounts just like the cancel culture of the left.
You think complacency is patriotism. I actually would prefer to improve my country.
> So it’s not unsurprising that your attempts at forcing others to pay for your things is met with hostility when you and others that share your views don’t even want to face those policies themselves.
“My attempts”? Your response is indeed hostile, but you have it backwards.
My family and I have been directly paying for and subsidizing for your own care and other Federal entitlements for decades.
Your response is also irrational to the core. We collectively pay for law enforcement, the military, highways, etc.
Why is it suddenly taboo to consider whether we’d actually save money if we had a baseline?
Why is the worst of socialized medicine and the worst of market-based medicine an acceptable status quo?
Law enforcement and military exist to prevent you from using force on others, and others from using force against you. You're absolutely correct, I'm in favour of forcing you to not use force on others. The only positive right I believe in is the enforcement of negative rights.
Alternatively, I simply state that we both agree on law enforcement and military but not healthcare, so at a baseline you want to force others to pay for more things than I do.
I don't support the US healthcare system, but I won't support socialized healthcare because of that. The government can follow the rules it enforces onto private companies by operating its own healthcare service without forcing those that did not choose to use it to pay. Problem?
> Law enforcement and military exist to prevent you from using force on others, and others from using force against you. You're absolutely correct, I'm in favour of forcing you to not use force on others. The only positive right I believe in is the enforcement of negative rights
I specifically also mentioned highways. How does that fit into this narrative?
> Alternatively, I simply state that we both agree on law enforcement and military but not healthcare, so at a baseline you want to force others to pay for more things than I do.
I’m already paying for your care, so I’m paying for more than my fair share.
Highways are no different from healthcare. I don't care if the government does them. You use it you pay for it.
You have no idea how much I make, which your claim entirely depends on. You also don't seem to be reading very carefully, I'm stating what I believe should happen. I would like people to be forced to pay for less things. You would like people to be forced to pay for more things. Simple as that.
> Highways are no different from healthcare. I don't care if the government does them. You use it you pay for it.
So you’d pay for law enforcement and a military, but without roads and highways they would be ineffective.
What is your proposal? Do police and soldiers have to pay money for its use?
> You have no idea how much I make, which your claim entirely depends on
And you have no idea whether I’m overpaying for healthcare to subsidize your care.
Those services you’re enjoying now and the professionals you’re relying on? Those are costs far beyond just the single treatment and whatever private insurance you’re paying for.
The government already operates roads. Nothing would change. The people that use it (ie. most people including myself) pay for it. I like the idea that part of the police and military budget be put towards the highways they use.
You made the claim, the burden of evidence is on you. All I said is that you wish people be forced to pay for things they don’t use and I do not, which you conveniently ignored after asking me to address every bit of your comment.
People like you always pull this “indirectly use” argument to justify making people pay for things they do not use. I don’t pay for the gym membership of the delivery guy, this is no different.
> Highways are no different from healthcare. I don't care if the government does them. You use it you pay for it.
…
> The government already operates roads. Nothing would change.
Okay. So we established that you don’t mind if the government runs the roads as long as they pay for it (tolls, gas tax).
I’ll go out on a limb and say that until the Federal stepped in, our road system was haphazard and ineffective. Having standards and an interstate system was crucial, and only possible with government.
Now given that law enforcement and military can incur injuries, can we have an effective law enforcement without the medical support to get them back up when injured or sick?
Now for this portion:
> So it’s not unsurprising that your attempts at forcing others to pay for your things is met with hostility when you and others that share your views don’t even want to face those policies themselves.
Why would you assume the worst ? This goes against Hacker News’ core principles.
> People like you always pull this “indirectly use” argument to justify making people pay for things they do not use. I don’t pay for the gym membership of the delivery guy, this is no different.
I help pay for all of infrastructure, the building safety codes that ensure the gym doesn’t collapse or electrocute me, that the machines aren’t death traps, etc.
It’s great that I don’t have to pay for a membership or other services if I don’t want it, but the foundation that makes these services even possible or reliable costs money.
Having these services on standby also costs money, even if you don’t use it. So yes, I’m already paying more than I’ve ever received in healthcare.
Back to healthcare. What I find frustrating is that your kneejerk reaction is neither unique nor uncommon, yet it
never comes with a workable alternative and solution.
> Very long wait times due to limited resources, subpar medical care, limited prescription options and drugs, beauracracy.
those are all there because the people that created the system did not think paying for it was good enough. it doesn't have to be that way. and even with wait times being long you still eventually get it. in the privatized system if you are poor and have bad health care you don't get it at all.
Ah, yes, have a privatized public sector, use the gained funds to lobby in other countries, pushing a ideology that destroys public sector/services, use the result of ones own actions to push the conversion to more privatized public sector. The ultimate glider gun ideology.
That just shows that the us has good medical treatment for people with essentially infinite money who don't have to worry about cost or insurance coverage so they can bypass the kind of issue the article is talking about entirely.
For normal Americans who actually have to worry about these things, healthcare in the us is a nightmare.
You can't just ignore insurance and judge the us healthcare system based on the best hospitals and doctors when most Americans aren't going to have access to that.
> That just shows that the us has good medical treatment for people with essentially infinite money who don't have to worry about cost or insurance coverage so they can bypass the kind of issue the article is talking about entirely.
No, that shows that even in places with public healthcare, there are issues.
Universal public health care is not the utopia that its proponents religiously advocate for.
> You can't just ignore insurance and judge the us healthcare system based on the best hospitals and doctors when most Americans aren't going to have access to that.
Most Americans have insurance. You can't ignore real data. Are you from the US?
> Most Americans have insurance. You can't ignore real data. Are you from the US?
If you're judging the quality of healthcare based on whether people from the US have insurance or do not have insurance it shows that you're fundamentally failing to understand the type of problem the article is discussing, which in this case is specifically that insurance is broken and insurance companies will refuse to pay for treatment even when people have insurance. The people having Cigna refuse to pay for medical treatments as in the article obviously have insurance or they wouldn't be dealing with Cigna in the first place, so I'm not sure how "real data" on the percentage of americans who are insured could possibly refute that.
> Compared to the rest of the world? It is not.
Yes, US healthcare providers are capable of providing very good care. However, it doesn't matter if the US healthcare providers theoretically provide the best treatment in the world if that treatment is now so expensive and the insurance system is now so broken that a huge percentage of the people can't afford medical treatment even with health insurance (e.g. most americans on bronze/silver health insurance plans).
I think this is something that gets missed in a lot of statistics.
The reality is that once you factor in the insurance system, and not just healthcare providers, the US healthcare system does not look so great anymore for average americans.
If they are paying out huge sums to their c-suite, giving them stock left and right, and enriching the company through stock schemes or dividend payouts, unjustly, perhaps their compensation shouldn't be so rich?
C-suite, board members, a bunch of "foundations", probably some for-profit contracting services for IT and accounting (also managed by the c-suite, probably). Unraveling health insurance admin costs is probably similar to Panama Papers level of financial engineering, especially after the ACA capped profit margins, the companies just turned to malicious compliance.
If you look at the 10-K for any of the 7 publicly listed health insurers, administrative cost increases are minuscule compared to healthcare expenditures.
You can get rid of half the employees and cut everyone’s pay by half, and it won’t make much difference.
I think the US’s biggest problem in healthcare is liability. Every entity is spending so many resources on making sure that they do not get blamed in the event there is a lawsuit, because the damages are huge.
In countries with taxpayer funded healthcare, this liability issue is much less because you are dealing with the government only and suddenly liability and damage amounts are reduced.
I think we can just go a step further and kill their entire toxic business model. After decades of observing how it behaves, it should be pretty clear that it's always going to devolve down to privately-ran death panels.
Is their pay out of line with executives in any other similar sized businesses?
As far as I can tell from the financial reports, profit margins are so low simply because expenses are that high, and its across at least 7 publicly listed health insurers.
The main cause of low profit margins that I can tell is high healthcare expenses (and lots of competition and state regulation so they cannot increase premiums more).
For all the crappy stuff insurance does, their medical loss ratio for group insurance is pretty good. The actual problem is that healthcare costs way more in the US than most other countries. Health insurance just ends up getting the blame for that.
I tend to agree. People love to blame insurers for the difference in price between US and (other country) healthcare prices, without any mention of facts like US nurses earning 4 to 8 times as much as an average NHS nurse, or that half a trillion dollars goes to end of life care in the US every year, i.e. spending $70,000 to extend an 85 year life 3 more months.
Income = expenditure. They are one and the same. Every dollar spent on healthcare in the US is someone else's income and looking at the profit margins, 'someone else' doesn't seem to be the insurers.
IMHO, the push-and-pull between insurance companies and hospitals is a big problem here. They seem to be in a co-dependent battle to consistently raise the costs of everything. I don't think any solution to managing cost will succeed unless we're altering the incentives for both insurance companies and hospitals.
15 years ago I worked for a "non-profit" health insurance company that was a Blue Cross Blue Shield affiliate/franchise. The CEO made $2.1m/year while the other VPs were raking in > $1m. The IT organization was as backward as they come - 200+ full time employees. I got in trouble for trying to introduce using source control to their developers. Beyond that, they used Excel spreadsheets as the source of truth for their healthcare plans...and the spreadsheets fed the claims processing system. There were 20 dedicated employees to managing Excel spreadsheets.
I am surprised commenters here did not read into the nuance:
> A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments. Company doctors then sign off on the denials in batches, according to interviews with former employees who spoke on condition of anonymity.
Before grabbing the pitchforks, it is important to be sure if their policy is reasonable or not. Whose fault is it if doctors ask clients to perform expensive tests, because they can't be bothered to actually think and figure out what test would be the most optimal?
Now even if the doctors really overprescribe tests, I don't think the client should be responsible. Instead, the insurance should pay, but kick the doctor out of their network.
I don’t think we should trust the soundness of their algorithm. I’ve worked in the healthcare space before, and the perverse incentives involved should make everyone extremely skeptical of insurance companies’ motivations, procedures, and algorithms.
From the description it sounded like something trivial. E.g. given the diagnosis, there might be a cheaper known way to get to it. I am a layman, but for instance that could be ordering an MRI when an ultrasound would suffice.
It’s insane to trust an insurance company to make healthcare decisions. I was denied an MRI when I tore my hamstring off the bone, and so my doctor had zero info on what my treatment options should be. I went to physical therapy when I possibly should have had surgery.
I’d so much rather 10% of people overpay for unnecessary tests than the other 10% of people be denied potentially necessary care.
Not testing at all. You know what that leads to? Bad outcomes. I'm all for selection pressure toward more efficacious, less invasive, less dangerous tests. Writing an insurer a blank check to blanket deny millions of claims without checking or reading up though? Nah. That's profiteering.
You want to run that algo in parallel and dift through the claims that would change, individually weeding out the actual false positives? Kosher. Just YOLO'ing it on prod and trottingbit out in front of investors? Hell no.
