How often do health insurers say no to patients? (2023)(propublica.org)
propublica.org
How often do health insurers say no to patients? (2023)
https://www.propublica.org/article/how-often-do-health-insurers-deny-patients-claims
102 comments
I worked at a Health Tech Silicon Valley company and our clients were healthcare companies. Our job was essentially to delay and put up barriers to care. So before they could see a doctor they would have to call us, go through the computer system, get routed to a phone doctor who would suggest cheaper things than what they really needed, give them a bunch of hoops to jump through before they could really get the thing they needed.
A big part of my job was to re-route people who needed wheelchairs into getting cheaper things. Our clients were United Healthcare, unions, large health insurers.
It sucked working there it was a total hellhole. I quit when they actually defrauded medicare. Their glassdoor reviews were wild. The owners daughter bragged about dating a glassdoor exec and that he would take down all the honest bad reviews for her.
A big part of my job was to re-route people who needed wheelchairs into getting cheaper things. Our clients were United Healthcare, unions, large health insurers.
It sucked working there it was a total hellhole. I quit when they actually defrauded medicare. Their glassdoor reviews were wild. The owners daughter bragged about dating a glassdoor exec and that he would take down all the honest bad reviews for her.
If it’s not up to health insurers to limit healthcare spending, then which organizational role in the healthcare system do you think is appropriate to place this responsibility with?
More people are employed by health insurance than healthcare. Insurance is the waste.
Elected representatives answerable to their constituents would be a vast improvement in health outcomes.
How would it all be paid for if not by increasing premiums (like what happened with ACA)?
The sheer amount of overhead induced by insurance is staggering. For example, the sum of the net profits of all insurers represents money extracted from the system without contributing to health. And the amount of time doctors spend documenting patient care over and above what’s medically necessary purely to make insurers happy is time not spent seeing patients. Clinic staff spending hours on the phone each day arguing against denials is wasted money. (Anecdote: an insurer refused to authorize an MRI for a patient until my wife xrayed their damaged tendon, which doesn’t show up on xrays. She had to conduct a useless medical procedure on the patient before they’d pay for one with actual diagnostic value.)
The whole overhead imposed by the useless rent seekers is money not spent on making people healthier.
The whole overhead imposed by the useless rent seekers is money not spent on making people healthier.
Have you actually checked any of these numbers?
What do you imagine is the profit margin of a health insurance company?
According to this report by the national association of state regulators, the profit margin of the health insurance industry in 2023 was 3%, or $25 billion.
Compared to over $1T of premiums, and over $4T of total healthcare spending in the US, that doesn't seem "staggering" to me.
https://content.naic.org/sites/default/files/topics-industry...
What do you imagine is the profit margin of a health insurance company?
According to this report by the national association of state regulators, the profit margin of the health insurance industry in 2023 was 3%, or $25 billion.
Compared to over $1T of premiums, and over $4T of total healthcare spending in the US, that doesn't seem "staggering" to me.
https://content.naic.org/sites/default/files/topics-industry...
Profit margin is the wrong metric in this debate. The person you are replying to is saying that the insurance companies as a whole is a waste, including all the salaries paid to their employees.
Yes. I owned a medical practice. These numbers affected how much money we took home every month, and I know them with far more personal interest than almost anyone else weighing in here.
If I can reliably sell people $1 bills for $1.03, in extremely large quantities, I'll be very, very happy.
Low margin, high volume is very different than low margin, low volume. The Walton family is very pleased with their tiny margins and the wealth it has delivered them.
Low margin, high volume is very different than low margin, low volume. The Walton family is very pleased with their tiny margins and the wealth it has delivered them.
Health insurance companies do not provide any medical services. They are the middle man between patients and the places/people that actual do provide medical services. So when they deny coverage, they just keep all the premiums paid by the patient. That money is sucked up by the middle man. So you don't need to raise premiums, you need to lower profits at health insurance companies. Every billion they make in profit is a billion paid by patients and not received in services.
You could say the are negative medical services providers as they remove doctors from practicing medicine in order to have the doctors do non-medical insurance coverage work.
> Health insurance companies do not provide any medical services.
This is substantively not true (though literally true at the level of a company, due to separate companies within the Kaier consortium) of the nation’s largest managed core organization, the Kaiser consortium consisting of the Kaiser Foundation health plans and the Kaiser Permanente Medical Groups.
> No when they deny coverage, they just keep all the premiums paid by the patient. That money is sucked up by the middle man. So you don't need to raise premiums, you need to lower profits at health insurance companies.
Something like limiting retained profits at the plan level to a fixed fraction of costs covered, and requiring refund of excess premiums to members?
This is substantively not true (though literally true at the level of a company, due to separate companies within the Kaier consortium) of the nation’s largest managed core organization, the Kaiser consortium consisting of the Kaiser Foundation health plans and the Kaiser Permanente Medical Groups.
> No when they deny coverage, they just keep all the premiums paid by the patient. That money is sucked up by the middle man. So you don't need to raise premiums, you need to lower profits at health insurance companies.
Something like limiting retained profits at the plan level to a fixed fraction of costs covered, and requiring refund of excess premiums to members?
> requiring refund of excess premiums to members
The solution is to provide the medical services people bought the insurance to cover and not reflexively deny claims counting on at least some people to give up or die.
The solution is to provide the medical services people bought the insurance to cover and not reflexively deny claims counting on at least some people to give up or die.
The waste is not "every billion they make in profit". It's every billion they make.
> They are the middle man between patients and the places/people that actual do provide medical services
This is the same way Medicaid/Medicare works too. Maybe they are the Neutral Good whereas insurance companies are the Neutral Evil.
This is the same way Medicaid/Medicare works too. Maybe they are the Neutral Good whereas insurance companies are the Neutral Evil.
The US could copy virtually any other health system in the world and get lower costs.
Elected representatives should determine what healthcare I get?
Really?
Really?
Irrespective of how healthcare is financed, they are going to do that (well, the government is, it is possible that the government may not be comprised of elected representatives), the question isn’t whether they should, but how many other actors that are neither you nor your doctor should.
All the time. I have a UnitedHealthcare “platinum” plan, and it may as well not include pharmacy benefits because it never covers anything. Generic thyroid meds went from $2/month with Aetna to $70 with UHC. ADHD meds went from $10 to $300.
The threatened “death panels” we heard about when ACA was being debated are actually employees of insurers who decide what they’re not going to pay for.
I was raised a die-hard capitalist and in many ways still am. When it comes to healthcare these days, I’m somewhere to the left of Marx. What we have now is a failed system. It simply does not work. The turnip has been squeezed and there’s no blood left to wring from it.
The threatened “death panels” we heard about when ACA was being debated are actually employees of insurers who decide what they’re not going to pay for.
I was raised a die-hard capitalist and in many ways still am. When it comes to healthcare these days, I’m somewhere to the left of Marx. What we have now is a failed system. It simply does not work. The turnip has been squeezed and there’s no blood left to wring from it.
> The threatened “death panels” we heard about when ACA was being debated are actually employees of insurers who decide what they’re not going to pay for.
The key insight, though, is that this is fundamentally unavoidable. Someone, somewhere has to decide how a limited healthcare budget will be allocated among all the various healthcare it could go towards.
You and I agree that it would be best to have a system where this is never the patient's problem. Someone determines a standard of care that will achieve the best patient results with the resources available, and then any patient can get whatever treatment's best for them within that framework. That's why I have and recommend Kaiser, they do a good job of presenting that abstraction.
Other people are terrified of the idea of having the standard of care determined by some centralized committee, because what if they decide a treatment that my doctor and I like isn't appropriate? I think the fear is wrong, to be clear, but it's genuine and does deserve to be addressed. Thus all the promises about "if you like your plan you can keep your plan".
(A third group of people believe that healthcare is only limited because of shenanigans, and with the appropriate reforms we could build a system where anyone is entitled to any treatment that might reasonably help them. I'm never quite sure what to tell them, since I don't think that's true but I don't know how to prove it beyond the lack of examples.)
The key insight, though, is that this is fundamentally unavoidable. Someone, somewhere has to decide how a limited healthcare budget will be allocated among all the various healthcare it could go towards.
You and I agree that it would be best to have a system where this is never the patient's problem. Someone determines a standard of care that will achieve the best patient results with the resources available, and then any patient can get whatever treatment's best for them within that framework. That's why I have and recommend Kaiser, they do a good job of presenting that abstraction.
Other people are terrified of the idea of having the standard of care determined by some centralized committee, because what if they decide a treatment that my doctor and I like isn't appropriate? I think the fear is wrong, to be clear, but it's genuine and does deserve to be addressed. Thus all the promises about "if you like your plan you can keep your plan".
(A third group of people believe that healthcare is only limited because of shenanigans, and with the appropriate reforms we could build a system where anyone is entitled to any treatment that might reasonably help them. I'm never quite sure what to tell them, since I don't think that's true but I don't know how to prove it beyond the lack of examples.)
For context, I’ve co-owned a medical practice for about 25 years, and spent the previous decade working for a healthcare startup that processed insurance claims to do data science.
The system is broken. It’s useless to extrapolate how things might work based on their current functionality. It doesn’t have to be like this. Everywhere else in the world manages it better than we do, and we’re not special snowflakes who require some hellish mashup out of Cyberpunk 2077 to take our kids to the doctor.
The system is broken. It’s useless to extrapolate how things might work based on their current functionality. It doesn’t have to be like this. Everywhere else in the world manages it better than we do, and we’re not special snowflakes who require some hellish mashup out of Cyberpunk 2077 to take our kids to the doctor.
“Everywhere else in the world manages it better than we do”
If that were true, why do people come to get health care in the US? (Because we have better healthcare and it’s free if you don’t have money or aren’t a citizen.)
If that were true, why do people come to get health care in the US? (Because we have better healthcare and it’s free if you don’t have money or aren’t a citizen.)
1. A properly competitive marketplace
2. Socialized medicine
3. What we have now
I would like to see #1 tried but at this point I’ll gladly accept #2
I would like to see #1 tried but at this point I’ll gladly accept #2
I think the outcome we're witnessing in the U.S. is simply an outcome of an insurance-backed industry. All the market forces conspire for prices to be higher. Insurance companies actually don't care how much healthcare costs because they earn a fixed percentage on premiums. If healthcare costs are higher, then premium costs are higher, so the insurance companies earn more money.
Naturally, hospitals also wants prices to be higher so they can earn more money.
I would expect this dynamic to play out whenever all the buyers in the marketplace are insurance companies.
Naturally, hospitals also wants prices to be higher so they can earn more money.
I would expect this dynamic to play out whenever all the buyers in the marketplace are insurance companies.
I just don't think #1 is possible, how can you have a functioning marketplace for a good when the demand is hard to forecast for an individual, almost completely inelastic and often extremely time sensitive. I'd say the US really tried and the incentives just aren't there for a stable system.
I don’t think we tried.
For a market to work, the buyers have to be exercising their discretion. But most health insurance in the US is provided through employers (whose interests are different from those of the employees). There are a thousand other ways that the US healthcare markets are not free or poorly designed, but this is the original sin that (I would argue) causes most of the issues: the insured don’t choose their insurer, so the insurers are not competing for members, they’re competing for employers.
See Singapore for a place that actually tried. They have a public healthcare but also a well functioning private healthcare market.
For a market to work, the buyers have to be exercising their discretion. But most health insurance in the US is provided through employers (whose interests are different from those of the employees). There are a thousand other ways that the US healthcare markets are not free or poorly designed, but this is the original sin that (I would argue) causes most of the issues: the insured don’t choose their insurer, so the insurers are not competing for members, they’re competing for employers.
See Singapore for a place that actually tried. They have a public healthcare but also a well functioning private healthcare market.
>demand is hard to forecast for an individual, almost completely inelastic and often extremely time sensitive
These don't preclude a free market working well. For instance, they're all apt descriptors of me when I find myself needing an Uber home. I'm not completely inelastic, since I could take a series of long bus rides to get home, or walk, but accepting for the sake of argument those aren't life-threatening, the cab companies more or less have me over a barrel. Or do they? We all know what keeps them from charging me more they do, even given the time sensitivity, lack of prediction, or inelasticity. It's competition.
The USA system doesn't work well, and I'm not necessarily saying that free market is the right solution, just pushing back on the notion that just because a good meets those criterion we are forced to throw our hands up and say the free market could never provide that.
These don't preclude a free market working well. For instance, they're all apt descriptors of me when I find myself needing an Uber home. I'm not completely inelastic, since I could take a series of long bus rides to get home, or walk, but accepting for the sake of argument those aren't life-threatening, the cab companies more or less have me over a barrel. Or do they? We all know what keeps them from charging me more they do, even given the time sensitivity, lack of prediction, or inelasticity. It's competition.
The USA system doesn't work well, and I'm not necessarily saying that free market is the right solution, just pushing back on the notion that just because a good meets those criterion we are forced to throw our hands up and say the free market could never provide that.
Taxi demand is actually usually quite easy to forecast for an individual, which makes planning alternative competition easier, although we often don’t try anymore because we’re used to good app competition. This is before even getting to how much lower the infrastructure and personnel barriers are to competing in the medical space versus the taxi space.
I know that most nights I am going to want to sleep in my own bed, this is somewhat inelastic sure, but not a surprise. The apps can’t raise prices too much however because they are in competition with us making plans to use the bus or call a friend. There is not a good equivalent in the medical world, it’s webmd and herbal compresses versus licensed doctors and prescription only drugs, with your life on the line.
I know that most nights I am going to want to sleep in my own bed, this is somewhat inelastic sure, but not a surprise. The apps can’t raise prices too much however because they are in competition with us making plans to use the bus or call a friend. There is not a good equivalent in the medical world, it’s webmd and herbal compresses versus licensed doctors and prescription only drugs, with your life on the line.
> how can you have a functioning marketplace for a good when the demand is hard to forecast for an individual, almost completely inelastic and often extremely time sensitive.
Most health care is not like this. Most health care is fairly routine: periodic physical exams and checkups, or getting evaluated when you have cold or flu symptoms. These sorts of things are much better provided for in a free market.
It's true that, if you have an emergency, it's probably not something that could have been forecast, and you don't have much of a choice about what care you need. That is indeed the sort of situation that insurance is intended for. But what we call "health insurance" isn't limited to those things. It also covers everything else--all the stuff above that isn't unpredictable or time sensitive. The result is a mess.
Most health care is not like this. Most health care is fairly routine: periodic physical exams and checkups, or getting evaluated when you have cold or flu symptoms. These sorts of things are much better provided for in a free market.
It's true that, if you have an emergency, it's probably not something that could have been forecast, and you don't have much of a choice about what care you need. That is indeed the sort of situation that insurance is intended for. But what we call "health insurance" isn't limited to those things. It also covers everything else--all the stuff above that isn't unpredictable or time sensitive. The result is a mess.
When did the U.S. really try?
Isn’t this just a no true Scotsman? The US claims at least to have built a free market solution, and if nobody else has been able to make it work at scale, why isn’t that enough.
I don’t think so, although that seems like a fair question of you to ask.
I’ve tried on numerous occasions to get pricing quotes for healthcare both paying fully out of pocket, and for getting an estimate for what I’ll be left covering after insurance negotiates ads pays their part.
In every attempt I get absolutely nowhere price estimate-wise and wind get this or that procedure done just hoping and praying that the ultimate bill will be remotely reasonable
We’re so far off the mark for having a healthy marketplace for healthcare pricing that I just can’t see considering it dysfunctional to itself be an appeal to some purity.
Perhaps one might argue that a formerly functional healthcare pricing system will inevitably degenerate into this robber Baron situation that we’ve got currently, but otherwise I don’t see the no true Scotsman.
I’ve tried on numerous occasions to get pricing quotes for healthcare both paying fully out of pocket, and for getting an estimate for what I’ll be left covering after insurance negotiates ads pays their part.
In every attempt I get absolutely nowhere price estimate-wise and wind get this or that procedure done just hoping and praying that the ultimate bill will be remotely reasonable
We’re so far off the mark for having a healthy marketplace for healthcare pricing that I just can’t see considering it dysfunctional to itself be an appeal to some purity.
Perhaps one might argue that a formerly functional healthcare pricing system will inevitably degenerate into this robber Baron situation that we’ve got currently, but otherwise I don’t see the no true Scotsman.
> The US claims at least to have built a free market solution
I don't know that "the US" has actually claimed this, but in any case any such claim is false. There are lots of reasons for that, but the key one is simple: the people getting care, patients, don't know how much it costs. You can't have a free market if the person receiving a good or service doesn't know the cost of what they're getting, and so can't judge whether what they're getting is worth what it costs.
I don't know that "the US" has actually claimed this, but in any case any such claim is false. There are lots of reasons for that, but the key one is simple: the people getting care, patients, don't know how much it costs. You can't have a free market if the person receiving a good or service doesn't know the cost of what they're getting, and so can't judge whether what they're getting is worth what it costs.
> why isn’t that enough.
Because why would you ever only rely on some vague "US claims" instead of looking at reality?
Because why would you ever only rely on some vague "US claims" instead of looking at reality?
How can we have a competitive marketplace? I’m not a doctor (and therefore cannot informed evaluate the services) and even if I was I can’t search for my preferred cardiologist when I’m having a heart attack.
You're not a mechanic, how can you evaluate the services be certain that they didn't oil your breaks instead of your engine?
> can’t search for my preferred cardiologist when I’m having a heart attack.
You can't search for your preferred mechanics when your breaks failed on a highway.
Yet somehow that didn't kill the competitive marketplace.
> can’t search for my preferred cardiologist when I’m having a heart attack.
You can't search for your preferred mechanics when your breaks failed on a highway.
Yet somehow that didn't kill the competitive marketplace.
That’s a bad analogy. If my brakes fail, once I come to a stop there’s no urgency in getting them fixed. I can abandon the care if it’s a lemon. I can have it towed home. I can use Yelp to find a reasonable mechanic. I can rent another car until this one’s fixed. It’s the opposite of “every second counts”.
Meanwhile, this is the only heart I have, and if it’s in danger of stopping, I have approximately seconds to call 911 to get someone to come take me to the repair shop of their choosing.
Meanwhile, this is the only heart I have, and if it’s in danger of stopping, I have approximately seconds to call 911 to get someone to come take me to the repair shop of their choosing.
It could be said that you’re over-generalizing here.
Arguing against any attempt at competitive healthcare pricing because medical emergencies exist is a bit throwing the baby out with the bath water.
Arguing against any attempt at competitive healthcare pricing because medical emergencies exist is a bit throwing the baby out with the bath water.
I wasn’t arguing that. I was pointing out that this was a bad analogy.
I can call a cab or get a replacement car from my insurance to drive around in, and I understand my body a whole lot less than my car. Demand for a car mechanic is nowhere near as inelastic as most of healthcare, so I don’t think this analogy really fits. At most it suggests that private markets can handle ambulances as well as we handle roadside towing.
Is all of your healthcare 100% heart attacks?
But again I don’t have enough education to judge if my doctor is yanking my chain.
In the USA we've been told that the market will sort itself out and give us item 1 any day now...since 1992.
Pricing signals have been blocked from flowing from consumers to providers since LONG before that.
I agree in theory, but I no longer believe #1 is possible in reality. #2 would make tens of millions of lives better than the dystopian nightmare #3 we have today.
These are completely human systems that can be changed any time for any reasons. The current system is achieving exactly what it was designed for: wealth extraction.
There’s no reason why this system has to exist. We can make it better any time we want.
There’s no reason why this system has to exist. We can make it better any time we want.
First they sell you the problem, then they sell you the solution.
There is no emphasis on long term planning or prevention.
Everyone is grabbing with both hands.
There is no emphasis on long term planning or prevention.
Everyone is grabbing with both hands.
There’s a huge reason it continues to exist: exorbitant lobbying from the people profiting from the death panels. Almost everyone supports Medicare, but too many have been convinced that Medicare for all is some kind of nefarious communist plot.
> The threatened “death panels” we heard about when ACA was being debated are actually employees of insurers who decide what they’re not going to pay for.
The employees of the managed care organization are often just using the criteria of the payer (often times the federal or state government for Medicaid/Medicare/federal employee or other large self funded plans).
The US government leaders are in a good spot. They get the managed care organizations (MCOs) to take the heat for denying coverage, while setting the rules to deny the coverage. MCOs even get audited and fined for approvals that don’t meet criteria.
In any case, all systems with limited resources will have to have someone approving or denying payments, whether it be a government employee or someone contracted out by the government.
But the most salient metric here is all the MCOs earn only 2% to 3% profit margins. And their market caps are tiny, and returns abysmal. (Except UNH, but that is due to its significant provider and software business).
Blame MCO employees all you want, but you will be doing exactly what government leaders want you to do.
The employees of the managed care organization are often just using the criteria of the payer (often times the federal or state government for Medicaid/Medicare/federal employee or other large self funded plans).
The US government leaders are in a good spot. They get the managed care organizations (MCOs) to take the heat for denying coverage, while setting the rules to deny the coverage. MCOs even get audited and fined for approvals that don’t meet criteria.
In any case, all systems with limited resources will have to have someone approving or denying payments, whether it be a government employee or someone contracted out by the government.
But the most salient metric here is all the MCOs earn only 2% to 3% profit margins. And their market caps are tiny, and returns abysmal. (Except UNH, but that is due to its significant provider and software business).
Blame MCO employees all you want, but you will be doing exactly what government leaders want you to do.
Healthcare, when you actually need it, is an inelastic demand very often combined with an inelastic supply (or more exactly, an inelastic supply of suppliers) due to IP laws and the realities of specialization.
It is not at all surprising that capitalism fails miserably here, IMO.
It is not at all surprising that capitalism fails miserably here, IMO.
[deleted]
Do Americans think they are special? Do they think that everything gets paid for no matter what? An endless pool of money?
As a Canadian I had the pleasure of my insurer (Canadian government) denying my treatment. Multiple appeals, still a no. My doctor said it was the only thing that would treat my disease. So my only choice is paying for it in cash at $10,000+ per month, which I can't afford.
As a Canadian I had the pleasure of my insurer (Canadian government) denying my treatment. Multiple appeals, still a no. My doctor said it was the only thing that would treat my disease. So my only choice is paying for it in cash at $10,000+ per month, which I can't afford.
I assumed health plans always say "no" the first time you submit, to weed out people who give up too easily.
Are they saying no to patients or are they saying no to providers?
I’ve found numerous instances where providers have billed over $5,000 for procedures that I could get for $250 if I paid cash. They do things like seperating a test panel into 100 different separate procedures, etc.
I think they need some context in the article of the interplay between providers billing practices to maximize their fees and insurer denials instead of just demonizing the insurance companies.
Every denial doesn’t result in a patient not receiving care, but is sometimes pushback against overly aggressive providers/negotiation and some of that can and probably should be automated.
Obviously them denying necessary treatment is really bad, but I find that propublica articles are often highly opinionated against certain interests and leave out a lot of context to create an extreme headline.
I’ve found numerous instances where providers have billed over $5,000 for procedures that I could get for $250 if I paid cash. They do things like seperating a test panel into 100 different separate procedures, etc.
I think they need some context in the article of the interplay between providers billing practices to maximize their fees and insurer denials instead of just demonizing the insurance companies.
Every denial doesn’t result in a patient not receiving care, but is sometimes pushback against overly aggressive providers/negotiation and some of that can and probably should be automated.
Obviously them denying necessary treatment is really bad, but I find that propublica articles are often highly opinionated against certain interests and leave out a lot of context to create an extreme headline.
So far this year I'm seeing basically "We got $100 off! $0 paid by plan. You owe $xxx" I barely use it, but so far insurance isn't covering anything except basic $x refills
You are on a high deductible plan. With those plans you pay the first $X and after that a percentage of costs (coinsurance) up to $Y.
Sometimes certain things are covered before you hit your deductible other times not.
Sometimes certain things are covered before you hit your deductible other times not.
Yes, but you'll often find that in a high-deductible plan the insurance company gets a "discount" of your $1k med down to $200, which they brag about in your EOB… but the medication's cash price for uninsured people would be $20.
You're out of pocket $180 more than you should be, and paying the $20 cash price out of pocket means your deductible doesn't budge.
You're out of pocket $180 more than you should be, and paying the $20 cash price out of pocket means your deductible doesn't budge.
It's straightforward fraud. Both the providers and insurers goal is to mislead people into thinking the "adjustment" represents a payment from the insurance company.
The pattern is even more flagrant when done with post-facto billed services, since the price hasn't even been assented to. The whole medical industry has essentially normalized many different types of fraud against patients, and yet the industry is so entrenched that state/county AGs don't bother going after them.
The pattern is even more flagrant when done with post-facto billed services, since the price hasn't even been assented to. The whole medical industry has essentially normalized many different types of fraud against patients, and yet the industry is so entrenched that state/county AGs don't bother going after them.
As long as it is a legitimate discount (which it legally always is) they aren't lying perse.
After all the discount getting inflated by charging non-insured people ludicrous prices is the real issue but not one you can meaningfully complain about as an insured.
And unfortunately if you ask for pricing they will give you the inflated pricing meaning it isn't necessarily deceptive there.
After all the discount getting inflated by charging non-insured people ludicrous prices is the real issue but not one you can meaningfully complain about as an insured.
And unfortunately if you ask for pricing they will give you the inflated pricing meaning it isn't necessarily deceptive there.
The problem is that it's framed as a payment from the insurance company, so people think the insurance is helping with the bill. What has actually happened is the insurer and pharmacy are cooperating to create sham prices/paperwork and confuse the market.
It's even more glaring for post-facto bills from providers, because those prices are being presented on a cost-reimbursement basis (not contractual). The provider is essentially saying "You owe us $500 because that is what it cost to provide your care". But it obviously could not have cost $500 to provide the service, because they're happy to accept $150 in total.
It's even more glaring for post-facto bills from providers, because those prices are being presented on a cost-reimbursement basis (not contractual). The provider is essentially saying "You owe us $500 because that is what it cost to provide your care". But it obviously could not have cost $500 to provide the service, because they're happy to accept $150 in total.
Providing a discount to insurance companies is not fundamentally bad or nefarious.
Medicare/Medicaid tend to pay less than private insurance, however lots of places accept it because that gives them access to a bunch of potential clients.
Leveraging your user base to get a discount from a provider is normal and expected.
The problem is when insurance companies demand a particular discount and providers given them that discount by raising their prices.
Certainly a 70% discount is a sign of a bad price (assuming it isn't part of a cost normalization scheme where some services get deep discounts and others are paid with little or no discount aka "I get 70% off dangerous surgeries but I will pay 110% of simple ones")
However if instead the normal price was $200 and they accepted $150 to get access to the network that is normal.
Medicare/Medicaid tend to pay less than private insurance, however lots of places accept it because that gives them access to a bunch of potential clients.
Leveraging your user base to get a discount from a provider is normal and expected.
The problem is when insurance companies demand a particular discount and providers given them that discount by raising their prices.
Certainly a 70% discount is a sign of a bad price (assuming it isn't part of a cost normalization scheme where some services get deep discounts and others are paid with little or no discount aka "I get 70% off dangerous surgeries but I will pay 110% of simple ones")
However if instead the normal price was $200 and they accepted $150 to get access to the network that is normal.
It feels like you're just skipping the core of my points and repeating the justification that has allowed the situation to get this bad. The fake prices and 50-100% discounts are indeed symptoms of a pathological behavior that indicates it's not about true good-faith "discounts".
One straightforward healthcare reform that could be done tomorrow would be to mandate that providers must charge the same price no matter who is paying, rather than the current behavior of operating pricing cartels in league with the insurance companies. This would work even if the government kept giving itself a pass by excepting Medicare.
One straightforward healthcare reform that could be done tomorrow would be to mandate that providers must charge the same price no matter who is paying, rather than the current behavior of operating pricing cartels in league with the insurance companies. This would work even if the government kept giving itself a pass by excepting Medicare.
And if a provider keeps charging the same amount only now they actually get it because the law requires that insurance companies pay in certain instances?
My point is just that providers raising their prices to give insurance companies a bigger discount is a problem but getting a discount isn't itself flawed.
My point is just that providers raising their prices to give insurance companies a bigger discount is a problem but getting a discount isn't itself flawed.
You keep outright ignoring my point, and then simply asserting that you don't see a problem. A bill from the provider shows a fake cost that they're demanding you reimburse them, and also a fake payment from the insurance company. Those are lies to make you think you are getting a benefit that you are not actually getting. That's called fraud.
Unless you are comparing a generic to a name brand in a situation where the insurance company forces the name brand that shouldn't be the case.
For better or worse in your hypothetical the uninsured price legally has to be $1,000 for medicine. They can write off part of that but no one would write off 99.8% as the insurance company would sue their pants off.
For better or worse in your hypothetical the uninsured price legally has to be $1,000 for medicine. They can write off part of that but no one would write off 99.8% as the insurance company would sue their pants off.
> that shouldn't be the case
Oh, I agree. But it is.
> For better or worse in your hypothetical the uninsured price legally has to be $1,000 for medicine.
No, it doesn't.
https://www.nbcnews.com/health/health-news/cost-weight-loss-...
"In March, Novo Nordisk cut the price of all doses of Wegovy by 23% for people paying in cash, dropping it from $650 to $499 per month for uninsured patients or those without coverage. (The list price of $1,349 stayed the same.)"
"It follows a similar move from Eli Lilly, which reduced Zepbound’s starter dose to $349 and higher doses to $499 through its self-pay program, Lilly Direct. The discounted doses require patients to manually draw the medication from a vial with a syringe, adding an extra step compared to the prefilled injector pens."
There are entire businesses and apps built around figuring out which is cheaper, paying out of pocket or going through insurance. https://www.healthcaredive.com/news/goodrx-benefits-check-pr...
Oh, I agree. But it is.
> For better or worse in your hypothetical the uninsured price legally has to be $1,000 for medicine.
No, it doesn't.
https://www.nbcnews.com/health/health-news/cost-weight-loss-...
"In March, Novo Nordisk cut the price of all doses of Wegovy by 23% for people paying in cash, dropping it from $650 to $499 per month for uninsured patients or those without coverage. (The list price of $1,349 stayed the same.)"
"It follows a similar move from Eli Lilly, which reduced Zepbound’s starter dose to $349 and higher doses to $499 through its self-pay program, Lilly Direct. The discounted doses require patients to manually draw the medication from a vial with a syringe, adding an extra step compared to the prefilled injector pens."
There are entire businesses and apps built around figuring out which is cheaper, paying out of pocket or going through insurance. https://www.healthcaredive.com/news/goodrx-benefits-check-pr...
Ah yes $500 vs $1,349 is exactly the same as $20 vs $1,000
What if the medicine costs 100$ to produce, should uninsured have to pay that rather than a subsidized 20$?
What if the medicine costs $0.01 to produce and both are getting hosed?
Given US universities did the research for nearly every drug on the market, we've already paid for it.
Universities need to get into the drug production business
Universities need to get into the drug production business
I thought I saw a meme about denail rates when that healthcare CEO got shot? Where did those numbers come from?
That's an estimate, not hard numbers.
https://www.yahoo.com/news/no-one-knows-often-health-2020566...
> At the same time, posts on social media have been claiming that UnitedHealthcare’s claim denial rate is the highest in the industry at 32%. This figure comes from the personal finance website Value Penguin, which said it calculated that rate from available in-network data from plans sold on the marketplace.
https://www.yahoo.com/news/no-one-knows-often-health-2020566...
> At the same time, posts on social media have been claiming that UnitedHealthcare’s claim denial rate is the highest in the industry at 32%. This figure comes from the personal finance website Value Penguin, which said it calculated that rate from available in-network data from plans sold on the marketplace.
FYI the shooter has received $1.2m in donations for his defense fund, and counting.
The accused shooter.
Firstly, Luigi Mangione is presumed innocent until proven guilty.
Secondly, there's a fair amount of real evidence that Luigi is being set up as a scapegoat by the NYPD—a police department with a known history of planted evidence.
Firstly, Luigi Mangione is presumed innocent until proven guilty.
Secondly, there's a fair amount of real evidence that Luigi is being set up as a scapegoat by the NYPD—a police department with a known history of planted evidence.
First part: yes, definitely. That’s a critical part of how the system works.
Second part: I’m not buying that for a moment. It’s way easier for me to believe that an individual working alone, screwed over by a megacorp who earns more based on how many people they can deny healthcare to, had enough and went vigilante. Vigilanteism and cold blooded murder are not OK, but it’s pretty easy to link cause and effect there. That’s vastly more likely than a shadow conspiracy that’s managed to keep its mouth shut so far.
Second part: I’m not buying that for a moment. It’s way easier for me to believe that an individual working alone, screwed over by a megacorp who earns more based on how many people they can deny healthcare to, had enough and went vigilante. Vigilanteism and cold blooded murder are not OK, but it’s pretty easy to link cause and effect there. That’s vastly more likely than a shadow conspiracy that’s managed to keep its mouth shut so far.
Honest question, why isn't vigilantism okay?
What are people supposed to do? Vote? We voted for the public healthcare guy in 2008 and the powers-that-be decided they would rather back "muslim ban" demagogues than let that happen again.
I get this is your corporate-facing persona so you could never actually speak critically to this point, but the health insurance industry broke democracy, and eventually they'll find out what the alternative is.
What are people supposed to do? Vote? We voted for the public healthcare guy in 2008 and the powers-that-be decided they would rather back "muslim ban" demagogues than let that happen again.
I get this is your corporate-facing persona so you could never actually speak critically to this point, but the health insurance industry broke democracy, and eventually they'll find out what the alternative is.
Vigilantism isn't okay because your perception that all would-be vigilantes agree with your politics is terribly mistaken. Many of the people who voted with us for the public healthcare guy in 2008 are now on the side of the "muslim ban" demagogues.
I think you’re right about the FAFO bit. I suspect Mangione will end up being simply the first. I mean that as a prediction, not an endorsement. Anyone who’s studied the French Revolution knows how these things can turn out, for many the same reasons.
But I’ll almost always be against vigilanteism outside extreme hypotheticals (“would you shoot Hitler?”). Even if I were morally ok with a specific instance, some time the person behind the gun might disagree with someone I support, and then where’s my moral ground to oppose their actions?
Edit: Furthermore, as much as I despise UHC and their leadership, I love the notion of our justice system more than I loathe them. When someone decides to be the judge and executioner, society devolves to “might makes right”. I served in Somalia. I don’t want to live there.
But I’ll almost always be against vigilanteism outside extreme hypotheticals (“would you shoot Hitler?”). Even if I were morally ok with a specific instance, some time the person behind the gun might disagree with someone I support, and then where’s my moral ground to oppose their actions?
Edit: Furthermore, as much as I despise UHC and their leadership, I love the notion of our justice system more than I loathe them. When someone decides to be the judge and executioner, society devolves to “might makes right”. I served in Somalia. I don’t want to live there.
Well said, I see where you are coming from.
> It’s way easier for me to believe that an individual working alone, screwed over by a megacorp who earns more based on how many people they can deny healthcare to, had enough and went vigilante.
This does not contradict what I said.
I make no claims about just who or what the actual shooter was. I merely claim that it almost certainly wasn't Luigi Mangione.
This does not contradict what I said.
I make no claims about just who or what the actual shooter was. I merely claim that it almost certainly wasn't Luigi Mangione.
I agree with you 100%.
All the time is not a number but in Germany it's common that your legitimate insurance claim gets rejected at first and then you appeal once or twice and do the paperwork and
document the proof again, citing all terms & conditions that apply and you get what you are
owed or you get a lawyer to do the whole thing again and get what you are owed then.
"Arbeitsbeschaffungsmassnahmen" ( German for "employment creation scheme" ) in an industry where there is not enough actual work for--and or to justify the--number of employees. One of the more useful Ponzi schemes; if you are not a real capitalist, that is. Because if you are, then this shit is just fugly drag.
"Arbeitsbeschaffungsmassnahmen" ( German for "employment creation scheme" ) in an industry where there is not enough actual work for--and or to justify the--number of employees. One of the more useful Ponzi schemes; if you are not a real capitalist, that is. Because if you are, then this shit is just fugly drag.
I have had this experience, but not with healthcare insurers (in Germany). I cannot remember the last time I had to contact them - the last two times they contacted me, was to explain to me, that they have expanded their preventive care offerings and they recommend I go and get them.
Blanket rejections are an extremly efficient measure from the perspective of an entity when the consumer has nowhere else to go and you don't care about ethics. Just tell them no and many people will just give up. If they appeal, you can invest the work to fob them off properly or just pay and not deal with the hassle. I can barely tell the difference with the many public healthcare insurers in germany - if my insurer were to try this nonsense, I would be gone the next month. Universities, some agencies and especially the god-damned GEZ on the other hand...
What frustrates me more, is that it often turns into a class indicator: Do you know how to word your letters or to handle yourself in a way that indicates, that it will be more annoying to not-deal-with-you than to deal-with-you? And if you don't: Do you have a access (network/money) to someone who does?
Blanket rejections are an extremly efficient measure from the perspective of an entity when the consumer has nowhere else to go and you don't care about ethics. Just tell them no and many people will just give up. If they appeal, you can invest the work to fob them off properly or just pay and not deal with the hassle. I can barely tell the difference with the many public healthcare insurers in germany - if my insurer were to try this nonsense, I would be gone the next month. Universities, some agencies and especially the god-damned GEZ on the other hand...
What frustrates me more, is that it often turns into a class indicator: Do you know how to word your letters or to handle yourself in a way that indicates, that it will be more annoying to not-deal-with-you than to deal-with-you? And if you don't: Do you have a access (network/money) to someone who does?
> is that it often turns into a class indicator
Oh, man. One could rant for hours about this. You are absolutely right. But in the end it's not really a class indicator because info about this particular and similar schemes could theoretically be packed into a weekend long workshop. In any small company or big factory, and definitely in schools as early as grade 10.
But it's a matter of character and you have to be damn lucky if you get a teacher who cares that much. Even neighbors will more often than not, NOT enlighten "the less fortunate" about stuff like this. It's pathetic.
But that's why this cascade works so well to keep almost all of the "more fortunate" under perfect societal control by which I don't mean some mythological conspiracy but "Steuerungsmechanismen" (some dude who got out of some cult beautifully explained this but I forgot both his name and the title of the book), keeping almost all of them in line, mostly silent, and alienated from the inter-generational usefulness of critical thinking.
And there is no irony in all this. Too many peoples mindsets never left the modern dark ages. One can only raise a brow and chuckle at all this.
It's a class indicator for sure, but, in my opinion, not class in the sense of hierarchies but of intellectual style, niveau. These tactics are low, like punching drugs.
Oh, man. One could rant for hours about this. You are absolutely right. But in the end it's not really a class indicator because info about this particular and similar schemes could theoretically be packed into a weekend long workshop. In any small company or big factory, and definitely in schools as early as grade 10.
But it's a matter of character and you have to be damn lucky if you get a teacher who cares that much. Even neighbors will more often than not, NOT enlighten "the less fortunate" about stuff like this. It's pathetic.
But that's why this cascade works so well to keep almost all of the "more fortunate" under perfect societal control by which I don't mean some mythological conspiracy but "Steuerungsmechanismen" (some dude who got out of some cult beautifully explained this but I forgot both his name and the title of the book), keeping almost all of them in line, mostly silent, and alienated from the inter-generational usefulness of critical thinking.
And there is no irony in all this. Too many peoples mindsets never left the modern dark ages. One can only raise a brow and chuckle at all this.
It's a class indicator for sure, but, in my opinion, not class in the sense of hierarchies but of intellectual style, niveau. These tactics are low, like punching drugs.
Is there any hope to clean up the US health system in any foreseeable future? How did the health lobby get so much power and get away with all this abuse?
There's a lot of problems you can point at:
- Through extensive lobbying, the US passed the HMO act of 1973 which requires that all employers offer an HMO plan to employees. HMOs were created to keep costs down, but United really took this to the extreme, making it as hard to use your health insurance as possible, and creating vertical monopolies like OptumRX. United takes so long to pay providers for the work they do that they now offer payday loans to doctors offices, which is crazy.
- The US uses a fee-per-service model that priorities procedures over preventative treatment or patient education. Some other countries have moved towards reimbursement based on health outcomes.
- The Affordable Care Act banned physician owned hospitals, which were growing in popularity and had better outcomes for less fees to patients.
- Private Equity is swallowing up hospital systems, emergency departments, etc. The most common seller is another PE firm, so they try to make a quick return through heavy cuts and then flip it 5 years later.
- Through extensive lobbying, the US passed the HMO act of 1973 which requires that all employers offer an HMO plan to employees. HMOs were created to keep costs down, but United really took this to the extreme, making it as hard to use your health insurance as possible, and creating vertical monopolies like OptumRX. United takes so long to pay providers for the work they do that they now offer payday loans to doctors offices, which is crazy.
- The US uses a fee-per-service model that priorities procedures over preventative treatment or patient education. Some other countries have moved towards reimbursement based on health outcomes.
- The Affordable Care Act banned physician owned hospitals, which were growing in popularity and had better outcomes for less fees to patients.
- Private Equity is swallowing up hospital systems, emergency departments, etc. The most common seller is another PE firm, so they try to make a quick return through heavy cuts and then flip it 5 years later.
"vertical monopolies like OptumRX"
This should be illegal. I have read that UNH also owns around 10% of providers so they own the whole chain.
This should be illegal. I have read that UNH also owns around 10% of providers so they own the whole chain.
Yes, they are even buying up therapy clinics.
> and creating vertical monopolies like OptumRX
Aetna "forces" you into using its pharmacy by refusing to authorize any prescription with more than a 30-day supply unless through its wholly-owned pharmacy-by-mail subsidiary.
Aetna "forces" you into using its pharmacy by refusing to authorize any prescription with more than a 30-day supply unless through its wholly-owned pharmacy-by-mail subsidiary.
I’d much rather go to the pharmacy once a month with Aetna than with UHC, because at least Aetna actually pays for things. They’re both awful in their own ways; don’t read that as me endorsing Aetna.
there's a bunch of problems with the setup but a major one is that employer health plans are tax deductible. employees don't really get market choice, and employers really only care about reducing their own expense in regards to healthcare. ending this would be very expensive and disruptive for both employer and employee in the short term, and people have a strong preference for the devil they know vs. the devil they don't (either a public option or fully market-based healthcare)
it's worth noting that the healthcare system has a couple of antagonistic components and right now probably insurers are the only group actually fully happy with the situation. medical providers, pharmacists, and patients are all getting shafted.
it's worth noting that the healthcare system has a couple of antagonistic components and right now probably insurers are the only group actually fully happy with the situation. medical providers, pharmacists, and patients are all getting shafted.
I'm not sure if there's any hope of US healthcare improving for a long while. The ACA was the only recent improvement. It was a small change, but the electorate decided that it was bad, pushed its supporters out of office, and elected a series of people who promised to "repeal and replace" it, but weren't really serious about any improvement. And then when the "repeal and replace" crowd failed, they were not held accountable, but reelected anyways.
There also isn't much interest in improving healthcare from either side right now. The right has nothing. Their current platform is ignorant views about vaccines. The left has a stronger interest in Palestine and housing abundance right now, though all of that is dwarfed by trying to keep the rule of law going, and preventing us from falling out of a democracy. Healthcare is way way down the list for everyone sadly--even Bernie doesn't talk about it much anymore. The electorate has spoken, and they are not interested.
There also isn't much interest in improving healthcare from either side right now. The right has nothing. Their current platform is ignorant views about vaccines. The left has a stronger interest in Palestine and housing abundance right now, though all of that is dwarfed by trying to keep the rule of law going, and preventing us from falling out of a democracy. Healthcare is way way down the list for everyone sadly--even Bernie doesn't talk about it much anymore. The electorate has spoken, and they are not interested.
Very true. Trans athletes in women's sports are way more important than affordable healthcare.
[deleted]
TLDR; 1 in 5
For what it's worth, I've been thrown in society's waste basket altogether on this one.
No insurance, none, of any kind.
I've got a Free h D in hillbilly medicine though. I've accomplished some amazing shit, but it's unraveling a bit now, and I'll be super surprised if I last much longer.
One can certainly say such a hit to morale is just collateral damage in the beautiful face of our wondrous mutant hive, but what are you guys gonna do when we start stinking up your streets en masse? One way or another, you'll be smelling the smoke.
Soylent Green is here. Read your labels carefully.
Proudly Made in the USA with Harshly Sourced Ingredients. I was free roaming though, if that matters.
Edit: returned to clarify that I was pulling myself up by me bootstraps. It's just that it's getting tough to hold on to em tightly enough. No shoes no service though, I guess.
No insurance, none, of any kind.
I've got a Free h D in hillbilly medicine though. I've accomplished some amazing shit, but it's unraveling a bit now, and I'll be super surprised if I last much longer.
One can certainly say such a hit to morale is just collateral damage in the beautiful face of our wondrous mutant hive, but what are you guys gonna do when we start stinking up your streets en masse? One way or another, you'll be smelling the smoke.
Soylent Green is here. Read your labels carefully.
Proudly Made in the USA with Harshly Sourced Ingredients. I was free roaming though, if that matters.
Edit: returned to clarify that I was pulling myself up by me bootstraps. It's just that it's getting tough to hold on to em tightly enough. No shoes no service though, I guess.
1. https://theonion.com/health-insurance-ceo-reveals-key-to-com...