
You Snooze, You Lose: Insurers Make the Old Adage Literally True - danso
https://www.propublica.org/article/you-snooze-you-lose-insurers-make-the-old-adage-literally-true
======
throwaway5752
In case someone doesn't read all the way through (and you _should_ and you
should donate to propublica):

 _" Umansky was bewildered. He hadn’t been using the machine all night because
he needed a new mask. But his insurance company wouldn’t pay for the new mask
until he proved he was using the machine all night — even though, in his case,
he, not the insurance company, is the owner of the device.

“You view it as a device that is yours and is serving you,” Umansky said. “And
suddenly you realize it is a surveillance device being used by your health
insurance company to limit your access to health care.”

Privacy experts said such concerns are likely to grow as a host of devices now
gather data about patients, including insertable heart monitors and blood
glucose meters, as well as Fitbits, Apple Watches and other lifestyle
applications. Privacy laws have lagged behind this new technology, and
patients may be surprised to learn how little control they have over how the
data is used or with whom it is shared, said Pam Dixon, executive director of
the World Privacy Forum."_

~~~
SOLAR_FIELDS
The most infuriating part of all of this is that you know it was some middle
project manager who got some minor bonus in the grand scheme of things
(probably in the tens of thousands) for introducing some practice that is
literally ruining people’s lives. It is absolutely maddening to look at this
entire system and see what it has become because of above happening tens of
thousands of times over.

~~~
newsbinator
I wonder how often that middle manager looks back and regrets the move. Or how
often he/she doesn't.

It might be the reality that those people in society who ruin 9/10 lives are
amorally oblivious, and stay that way through long, comfortable lives of their
own.

~~~
hrktb
Actualy if the life of that middle manager is mildly miserable they won’t have
the time to look back or regret, or really think about what they are doing for
a living.

And by definition they’re sandwitched in a hierarchy, that can be a hell of
its own.

I’d argue the health of our society could come from healthier life for these
corporate workers.

~~~
lazulicurio
I don't know if you've seen The Gervais Principle[1] before.

It's a cynical but interesting way to think about some of the amoral behavior
you see in corporations.

It touches on how middle management gets stuck with the short end of the stick
between upper-level management and lower-level employees.

I'm not really sure how you could change the incentives to make things better
for mid-level employees.

[1] [https://www.ribbonfarm.com/2009/10/07/the-gervais-
principle-...](https://www.ribbonfarm.com/2009/10/07/the-gervais-principle-or-
the-office-according-to-the-office/)

------
JumpCrisscross
> _When his doctor prescribed a CPAP, the company that supplied his device, At
> Home Medical, told him he needed to rent the device for $104 a month for 15
> months. The company told him the cost of the CPAP was $2,400.

Levy said he wouldn’t have worried about the cost if his insurance had paid
it. But Levy’s plan required him to reach a $5,000 deductible before his
insurance plan paid a dime. So Levy looked online and discovered the machine
actually cost about $500.

Levy said he called At Home Medical to ask if he could avoid the rental fee
and pay $500 up front for the machine, and a company representative said no._

This looks an awful lot like fraud. Remarkably, the mark-up disclosure and
best-pricing rules required to fix this could be largely copy-pasted from the
securities industry.

~~~
carlmr
>This looks an awful lot like fraud. Remarkably, the mark-up disclosure and
best-pricing rules required to fix this could be largely copy-pasted from the
securities industry.

This is something that bothers me a lot about the American health care system.
It's not that costs are exorbitant. It's patients being defrauded every step
of the way. Most medical procedures, devices and pharmaceuticals would be dirt
cheap if there was a) price transparency and b) competition.

That not everybody is insured is one problem, but that most people need
insurances just to have someone negotiating on their behalf is not
sustainable. Especially when there's a quid pro quo between insurances,
devicemakers and hospitals.

------
yesimahuman
This is going to get so much worse. There’s a whole category of health tech
startups chomping at the bit to help insurance companies and billing
departments instead of patients.

A moment for founders to truly question whether their work will change the
world for the better.

~~~
conanbatt
Its just really hard tending to patients without insurance: you would niche
yourself on rich and wealthy people exclusively.

~~~
oarsinsync
_in the USA_

There are many countries in the world that are able to service their
populations healthcare needs without involving private insurance brokers.

~~~
conanbatt
Sure, but thats what the situation is.

------
mrhappyunhappy
"Monitoring patients also helps insurance companies advise doctors about the
best treatment for patients"

Since when did insurance companies become doctor advisors? That's very
alarming.

The whole concept of unsuspecting data sharing is wrong, disturbing and should
have everyone concerned.

~~~
ubernostrum
_Since when did insurance companies become doctor advisors? That 's very
alarming._

If you want to, you can make this sound sinister. But it's pretty common, and
the reason behind it is simple.

Many people who need medical care do not see a single doctor for all of their
needs. They have a primary doctor, but also see one or more specialists,
perhaps have occasional visits with a nurse, deal with a pharmacist, may
sometimes need to go to a clinic that's open on a day they can't get an
appointment with their regular primary doctor, etc. etc.

Out of that potentially large pool of providers, how many do you think are
automatically and quickly sharing full records with the primary doctor? How
many others of them receive that level of records from the primary doctor and
from all the other providers? How many of them even know about all the others'
existence?

This is a genuine problem, because it means that _none_ of them see the full
picture of the patient's health. They see isolated bits and pieces of it. And
that's dangerous. Pharmacists get a reputation as the last line of defense for
many people against different doctors -- ignorant of each others' existence --
unknowingly prescribing badly-interacting and possibly fatal combinations of
medications to a single patient, for example.

In the US system (and this is not an endorsement of it), there is exactly one
entity that sees everything: the payer (i.e., insurance). All of those
providers want to get paid for their services, so every one of them submits
claims to the payer, including details of diagnoses, procedures, and so on.

Given this status as the only entity which actually sees the whole picture, it
makes a lot of sense to be sharing that information with the medical providers
who see the patient. This is part of the original idea behind the HMO model of
health insurance (where all the providers are a single super-entity
coordinating with each other), though it comes with the widely-hated downside
of being unable to see a doctor who _isn 't_ part of the HMO. And for many
years, even PPO-model insurance plans have introduced more and more active
collaboration with providers.

~~~
mrhappyunhappy
That makes sense though I still feel there is a huge conflict of interest and
the system is broken. I do see your point regarding insurance being the all
seeing eye so to speak. Thank you.

------
howard941
> supplies would be substantially cheaper if they didn’t have insurance at
> all.

Imaging is another area with altered pricing and lessons to be learned. I had
a lumbar MRI at an imaging standalone and asked about cash pricing. The
procedure costs $295 when paid in cash or $395 if paid in cash and counted
against my high deductible insurance policy.

------
a_c
So the patient rent a device for a price higher than retail, got personal data
collected so to be denied for medical treatment and trust some device
manufacturing company for transmitting data securely. It is eyeopening on so
many level

------
noir-york
What the article described is just one device. With all the sicknesses and
ailments that afflict people, the insurance companies must have a very
extensive playbook...

Or you know, get a national health service that treats human beings with
dignity and humanity.

~~~
dsfyu404ed
>national service

>treats human beings with dignity and humanity.

Anyone who's been to the RMV knows you can't have your cake and eat it too.

------
daveFNbuck
> insurers may agree to pay higher prices for some services, while negotiating
> lower prices for others, to achieve better overall value

That would make sense if they were paying everything. It's a really nasty
trick when they negotiate for higher prices on things they don't cover in
exchange for lower prices on things they do.

------
Endy
People wonder why I loathe insurance companies. It's really upsetting how our
modern world has gotten, thanks to legalized protection rackets.

~~~
kstrauser
I'm very pro-capitalism. I love it. I think it's great. But no matter how
terrible I was raised to believe that socialized medicine would be, it simply
cannot be worse than what we currently have.

~~~
eric_h
The thing is that some problems are not solved by an immediate profit driven
market. Healthcare, education and public transportation all suffer when the
required payback periods are relatively short.

A good healthcare system will pay itself back by adding to the next 50 years
of economic output. Good, accessible education will continue to improve the
economy over generations. Good transportation increases the mobility of the
entire population which allows for more competition over longer distances in a
given region.

By no means should we socialize everything, but we should certainly socialize
the things that the free market has been failing at for decades.

------
herodotus
Tracking... seems to be everywhere. Yesterday, I discovered that the head of
fund raising of a group in my city gets an email whenever a donor's concert
ticket is scanned at the door. Presumably this is one of the "compelling"
features that the ticket-company offers its clients. (It may be Ticketmaster,
but I am not sure). I have asked the group to send me their privacy policy.
Maybe someone here can confirm that online ticket companies routinely offer
such a feature.

------
isostatic
I thought it was the UK that had things like 'Death Panels'.

~~~
tialaramex
Because healthcare requires resources and resources are inherently finite,
rationing is inevitable. This means there have to be policy decisions. If you
want to, you can label the policy decisions over rationing "death panels", or
you can say it's just "market forces" or "God's will" or whatever turn of
phrase suits your pre-existing position. Obamacare as originally designed
would have such a policy setting panel, now it does not so you're at the mercy
of whatever for-profit insurance companies decide.

In terms of the specifics, the UK has an public body named NICE that makes
decisions about how to spend limited resources in the NHS, it uses a model
called Quality Adjusted Life Years, in which it tries to spend no more than a
certain amount of money to buy people healthcare that will improve the amount
of "quality adjusted" life they get, where e.g. "Give blind toddler normal
vision" would be a big boost of quality even though it doesn't actually
increase their lifespan, whereas often cancer treatments have a headline boost
to lifespan but quietly admit you spend the extra time crippled by pain or
other health problems the treatment does not fix or even exacerbates, so NICE
would discount those extra months accordingly.

But NICE does not directly mandate patient care, they're like the legislature
making a sentence guideline, not the judge passing sentence on a specific
criminal. NICE provides guidance, individual doctors can override that
guidance, although where it's very expensive they may need clearance from
somebody controlling the purse strings. For example NICE guidance might say
Drug A is recommended because although Drug B has slightly better outcomes in
most respects, Drug B causes incontinence in most patients and the loss of
dignity from being incontinent makes for poor quality of life. Your doctor
sees you're incontinent anyway for other reasons, figures you may as well have
Drug B and suggests you have Drug B. They're the one signing a prescription,
not NICE.

------
cyborgx7
Isn't the profit motive a great driver of I N N O V A T I O N

~~~
Delmania
Health INSURANCE should not be profit driven as it's a risk pool, and profit
driven means they will charge high premiums and attempt to deny as much as
possible. Health CARE should be driven in part by profit.

~~~
ams6110
Insurance is a business, and of course it should be profit-driven. Competition
should keep excessive profit-taking in check. A problem with health insurance
is that regulations prohibit very much competition.

~~~
hedvig
An insurance company is incentivized to NOT provide service, so no, it doesn't
make sense to be profit-driven.

~~~
ams6110
Not in the face of competition. Better service is a competitive advantage.

~~~
Delmania
And yet that hasn't worked so far at all.

------
DanielBMarkham
The CPAP business has been a scam for many, many years. As more people use
them, it's just getting worse.

I think the crux of the problem is the intersection between a large population
in need, the ability of the machine to keep people alive, and the machine's
foray into into what once was well-marked regulatory territory, the
respiratory therapist.

I expect it to get worse.

I need my CPAP to stay alive. I have severe, obstructive sleep apnea. So
there's no option for me except "do whatever it takes to keep and maintain a
CPAP"

That tends to be a powerful motivator to separate people from their money. And
the machines themselves, even with the cost of regulatory compliance, aren't
extremely expensive. Retail they're 500-1200 bucks. From the parts involved,
manufacturing costs are probably a tiny fraction of that.

I've had my CPAP for years, and I was burned by the system getting it. My wife
was prescribe a CPAP as well about a year ago and had an even worse
experience.

She was told to go down to the local CPAP shop and pick out a unit. Her
insurance would cover it after her deductible.

When she got there, they gave her the nicest one. Then they told her because
of compliance worries, she would be paying only so much every month. If she
decided she didn't want it? She could take it back in the first month or two.
Makes sense, right? Then if she wanted to file with the insurance company to
cover her rental, that was up to her.

Flash-forward six months. The insurance company refuses to pay. She's not
using it enough (even though she needs to. Long story.) So she calls up the
CPAP folks. No, they will not take it back. And guess what? If you stop
payments, you now owe us for the full cost of the CPAP. Not the cost you could
get online. Nope. The "cost" we've put on our special price list for insurance
companies.

She's now in a spot where she's paid about twice the cost of the machine in
"rent", _plus_ the CPAP folks want her to pay twice the cost again -- or
they're taking her to court.

Try to sell it online? Great idea. They won't let you. You can't sell medical
equipment online!

The best part is that the manufacturer of the CPAP now bugs the hell out of
her to buy all sorts of replacement parts. And why not? They're all covered by
insurance!

She finally gets them to shut up and leave her alone. Decides to pay off the
CPAP dealer. Yet again. She goes back to the machine, more out of anger and
spite than anything else.

The machine refuses to work, makes you screw around with it. It's nagware,
reminding her about all the supplies she needs to keep ordering.

It's a fucking scam. God only knows how many billions of dollars they're
screwing people out of.

~~~
driverdan
Why didn't she read the contract before signing it? She's the one who signed
it and is responsible for fulfilling her part. That doesn't make it a scam.

~~~
rileymat2
From the Original Post: "Not the cost you could get online. Nope. The "cost"
we've put on our special price list for insurance companies."

Sure sounds, at least scam adjacent or abusive in the least.

------
patrickg_zill
Just a quick plug for cpap.com. I am a satisfied customer and have no
financial interest in them.

Check out their pricing for devices vs. what is listed in the article...

~~~
NedIsakoff
Wow, that's still over priced. I'm in Canada, check out
[https://www.monstercpap.ca/](https://www.monstercpap.ca/) \-- remember that
1USD = 1.32CAD

------
nimish
Catch-22 gets more real every day

~~~
myle
Unfortunately, not as funny as the book.

~~~
milesvp
Try rereading the catch 22 in your 30’s. I laughed at it in college, I wept at
it after being an adult for a decade.

------
rustcharm
About 80% of obese people with sleep apnea would be asymptomatic if they
reduced to a non-obese weight. For this subset of people, shouldn't insurers
(and often the Public) encourage the patient to use the free, safe, and
natural solution (eating less) before being dependent on an expensive machine?

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3021364/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3021364/)

~~~
driverdan
Not sure why you're being downvoted. If your problems are caused by being
overweight you should be incentivized to lose weight and do so.

~~~
tomhoward
"Just lose weight" is not that simple and it's unhelpful and cruel to imply
that it is.

I personally haven't been seriously obese - moderately overweight at worst -
but even then I've experienced how difficult/impossible it is to get down to
an ideal weight when also dealing with health complications like auto-
immunity, stress/trauma/anxiety/depression, or hormonal issues.

I do know others who struggle with more serious obesity, along with some
combination of the aforementioned issues, which when you pay attention turns
out to being almost always the case with obesity.

"Just lose weight" is simply not possible.

"Just overcome all your auto-immune, hormonal and emotional issues" is really
what you're saying, in which case the response must be "OK, give me about 15
years and a ton of support and patience along the way".

~~~
driverdan
No one said "just lose weight." I'm not sure where you got that from.

~~~
tomhoward
The parent to your comment said patients should:

“... use the free, safe, and natural solution (eating less)”

Your comment said:

“you should be incentivized to lose weight and do so”

I’m not sure where the nuance is that my paraphrasing failed to capture.

It’s not as if people don’t already have huge incentives to lose weight. Those
that have not lost weight are likely unable to for complex physiological or
psychological reasons. Telling people to “eat less” amounts to trolling.

If you or the parent commenter have insights on what methods of weight loss
could work for people who have yet to find an effective solution, then there
might be an interesting discussion. I do have some insights on this, for what
it’s worth.

The parent commenter signaled that they have no such interest, hence the
downvoting and the ban after their blatant troll comment downthread.

------
jmnicolas
Even though I'm an atheist, the more I see this kind of shit, the more I see
wisdom in traditional religious values.

Thousand years ago they (the people that "created" religions) already knew
that humanity left to it's own wouldn't grow in a positive way.

I'm not far from opting out completely from this inhumane society.

~~~
setquk
Random crazy rant there. Even as a militant atheist, this is nothing to do
with religious values. It’s the ethic of reciprocity. But bastards are just
bastards and that’s life. Holding people accountable for being a bastard and
saying “no that’s not ok” is what we should be doing, not try substituting
value systems trying to find a less cruel one.

~~~
thaumasiotes
> this is nothing to do with religious values. It’s the ethic of reciprocity.

This is an odd thing to say. The ethic of reciprocity is a value. What do you
think religious values are?

~~~
setquk
The ethic of reciprocity is a simple logical construct which defines a
survival advantage for the adherents to it.

Religious values are merely an abstraction over that which define a lot of
specific super-rules, some based on faith and some on opinion but rarely on
logic. Fundamentally the only reason there are "religious values" is so that
the idea survives as well as the people.

It's difficult separating the two concepts.

To note I have no problem with people believing what they want but I think the
universe is simpler than we like to make it out to be. That might be a little
scarier than god though.

------
k__
I read EPAP should be a viable and cheap alternative, why aren't many people
using it?

~~~
joveian
My understanding is that it is usually better than nothing but not nearly as
effective as well adjusted CPAP or Bilevel PAP even in relatively mild apnea.

------
blisterpeanuts
An obvious question: why aren't more CPAP machines generally available for
sale to end users? Amazon and Ebay mostly sell accessories. Maybe there's a
business opportunity here.

~~~
wmil
I believe that's partly a government issue. They're considered a prescription
medical device. So they can only be sold by specialty stores that can validate
the prescription.

~~~
ams6110
I wonder why? Are they significantly risky if used without medical
supervision?

~~~
Karunamon
The definition of medical device is terribly non-granular, classifications
notwithstanding. Something like an IV pump which directly literally kill you
if it breaks or is misused is subject to the same kind of sale prohibitions as
a CPAP whose absolutely worst failure case is giving you a shitty night’s
sleep.

