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You Snooze, You Lose: Insurers Make the Old Adage Literally True (propublica.org)
235 points by danso on Nov 23, 2018 | hide | past | favorite | 154 comments

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."

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.

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.

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.

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-...

Self-selection ensures that the number is relatively high, the persons who have a problem with the practice tends to quit, persons who don't have a problem stays.

Its the same way open plan offices imposed by building services happen.

The building Services manger gets a bonus or more likely an annual appraisal that saves them from a pip or rif - totally ignoring the cost in reduced efficiency and recruitment costs.

The principal-agent problem. You can notice it everywhere. Every time you hear the word "kickback", you know someone is paying money so that someone else can harm a group of people.

The more infuriating thing is that these cost controls exist because CPAP is a hot prescription that’s being overused.

On the other side, there’s a revenue maximizination consultant pushing doctors to prescribe unnecessary equipment like inhalers and CPAP.

I think that for the people that need it, CPAP is what lets them get a good nights rest (and possibly not die overnight). But looking at all the commercials for the machines - I get the impression that it's the new "Scooter Store", taking advantage of the federal & private money available for durable medical equipment.


Anybody have recommendations for fitness/sleep trackers that respect privacy (e.g. keep data local, doesn't need the cloud)?

Probably not the answer you’re looking for, but the Apple Watch keeps all data on-device until you explicitly opt-in to it being synced to iCloud.

sounds like a torchwood episode

I have nothing to hide! FANG already knows everything about me! /s

> 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.

>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.

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.

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

in the USA

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

Sure, but thats what the situation is.

"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.

Here’s a ‘fun’ anecdote to illustrate this point.

A friend of ours was diagnosed with non-Hodgkins lymphoma a few years ago at 25. Before she was diagnosed, she had gone to the hospital feeling sick and achy. After a full, 12+ hours at the hospital, it was clear she had some kind of cancer. Imaging showed she had a baseball sized tumor in her chest. One more test was needed to confirm which variety so a course of treatment could be prescribed. It was already quite late (after 11pm) and the hospital staff said she could just come back in the morning to finish the one remaining test. The next morning, she went back to the hospital and was denied the test.

Apparently, some inhuman garbage at her insurance company had decided in the middle of the night that they could save a little money by forcing her to do the test in a clinic setting. Since she hadn’t officially received her cancer diagnosis, she had to wait another four weeks to get the required test. Every day the tumor growing a little bigger.

She’s doing fine now by the way! She lost her insurance after turning 26, but did benefit from impeccable timing - she got one of the first Obamacare plans, it probably saved her life.

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.

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.

Insurance companies employ tons of doctors and pharmacists that double check chart notes and treatment plans, especially for expensive treatments and medicines. It’s overall good to have some type of checks and balance system when dealing with market you (I.e. patients) know nothing about, in case the doctor or provider makes a mistake or is compromised in some way.

Hence the EU's GDPR legislation. To forestall exactly this.

A patient sees two doctors for different conditions.

The doctors prescribe different medications.

The patient goes to two different pharmacists to pick them up.

In a victory for privacy, the patient dies from a fatal interaction of the prescribed medications.

In the US there is a strong medical privacy law. And it includes an exception for providers of medical care to share treatment information with each other, for precisely this reason. Even so, every single time you see a doctor in the US, you are handed a notice saying they'll share information for permitted purposes (the triad of "TPO" -- Treatment, Payment, and Operations), and given a form to sign saying you have been made aware of this.

In the UK, the doctor and pharmacist will ask you if you are on existing medication. I know this because a pharmacist refused to sell me Ibuprofen when I told him that was on Ramapril for high blood pressure.

And you can deliberately or accidentally leave something out, yes, or go to other lengths to hide information.

The point was to be an illustrative example of why it can be useful for health-care providers to share information. HN, predictably, took it as a challenge to try to work around and find as many possible ways to hide the information as they could.

Your current system is still broken if say I go to a second doctor and pay with cash, no insurance involved, so it still preferable the doctor and pharmacist to ask you if you have known allergies, other treatment or suffer for some specific illnesses .

You could extend your argument that insurance companies should get access to what food and drinks you buy so they prevent side effects(and not at all tax you more because you drink beer or eat cheap food a lot)

It's clearly the patient's fault here. Every adult knows that in general, drugs cannot be mixed as easily as candy.

Also if you're seeing multiple doctors (like, for example, a general practitioner and a specialist) you should be transparent on what prescriptions you're already taking.

Your doctor is not a third party to your medical information; perhaps you could exclude them from accessing it, but then you'd be the one forcing them to do something dangerous.

Being an idiot and getting yourself killed is not the doctors fault.

Part of the ACA was the consolidation of electronic medical records such that situations like this won't happen.

EU resident here. I am reasonably sure that your doctor has access to your medical records when you hand them your smartcard, regardless of which doctor(s) previously updated said records.

EU resident here. We're not like distinct states in the USA, we're independent countries and each country has it's own systems. Healthcare systems vary dramatically between them.

In one country, I visit any doctor and they have my full medical history, despite not living there.

In another country, every time I visit the same doctor, they somehow don't have any files for me and I have to sign up as a new patient, despite being born and resident there.

It's all shambles, but in both cases, I get healthcare for free so it could be a lot worse.

At least in Germany they don't. You have to take your medical records in paper form from your old to your new doctor.

I think it's non-ideal, but the health insurance should never need to know whether you're using your CPAP. They should only know if the doctor prescribed it.

Information should be shared with the pharmacy and other doctors. That would be helpful and would save lives.

As far as I know, the answer is no. There was an article in "Die Datenschleuder" #98 [1] about it.

[1] https://ds.ccc.de/download.html (german)

> 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.

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

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.


To the contrary I have extensive experience with governments and I happen to live in a country with a well funded national health service. My own mother uses the service regularly (heart / digestive system conditions) and she always receives excellent care.

If where you live has a bad healthcare system or ineffective government, you need to look at the local conditions and please don't generalise. Maybe a positive attitude that government (which is after all, us) can be a force of good would be a good start.

> you need to look at the local conditions and please don't generalise

Presumably, since the context is US healthcare, maybe the commenter meant "governments" inside the US. At the least, it's not worth assuming they meant every government everywhere for all time given the context. Please don't generalize.

> Maybe a positive attitude that government (which is after all, us) can be a force of good would be a good start.

Amusing that such a general statement about government follows a statement about not making general statements about government. Experiences and governments vary wildly. Benefits of support/trust attitudes versus the opposite also vary wildly with differing levels of success.

Have you ever experienced care with the NHS in the UK? Or Australia's public health service? Or Germany's universal health care?

I have, and in all 3 cases, I've seen exceptional care from professional doctors, nurses and support staff delivered with dignity, humanity and care.

Your statement is pure ideology.

No, I've been under government health care for the majority of my adult life in the US. I know exactly how it works, and it's abysmal.

Experience how parts of it works currently in the US is very far from knowing what is possible.

Sorry buddy, lived in Germany, uk, nz, aus and am now in the us dealing with a family member going through terminal illness.

All i can say is you are wildly off base, we're putting my dad on an international flight to save him 200k on treatment costs (immunotherapy). Same shit, different system, fully funded and no out of pocket cost compared to the us of a.

Keep your system, its failing.

No you haven't. The ACA is not government run healthcare by a long shot. Medicare and Medicaid tend to be immensely popular.

Not talking about ACA. The ACA has existed for what, about six years? I've been active duty military my entire adult life, over 20 years, the military healthcare system is the ideal system you're advocating for. I'm an expert in how horrible it is.

FWIW, it sounds like veteran's health care in the us is more top down than most "government" health programs in other countries. All the staff are VA employees, right?

In Canada, by contrast, the doctors and hospitals tend to be private. The government pays, and sets price schedules, but they don't directly control care.

It's obviously a bit more complicated than that, but the public system sounds much less centralized than your VA health system.

You are essentially saying "The US public healthcare system for the military (or veterans?) is terrible". I'm sure most people are more than willing to accept your experience in this.

However, the jump from that to asserting that it's the "public" part of that statement that leads to the "terrible" part is a huge one, and frankly not in evidence.

The statement isn't that all public run healthcare systems are terrible. The statement is the United States governments, either federally or as individual states, are likely incapable of creating or running a non-terrible healthcare system.

We've already got at least a Medicaid system by state, federal Medicare, and federal VA. Are any of these non-terrible? Is there any realistic reform towards making them non-terrible? Is it realistically feasible to scale any of the non-terrible ones up to service the whole US population?

Certainly, it's possible for a government run healthcare system to not be terrible (or at least, mostly not terrible; any healthcare system has to make some hard choices at times, and people don't usually like it when they're the hard choice), and I'm sure you can find examples of that; but it doesn't seem possible with the governments the US has.

I think the "political reality" attitude is an interesting one, but can be used as an excuse.

I'm not convinced that it isn't possible to scale up to the entire US population in a way that doesn't suck, but you could be right. To work well it would certainly involve systemic change across the healthcare industry, and some current players would be hurt. Perhaps it's not politically feasible in the US, but if so that is a pretty damning indictment of the state of things.

I don't perceive Medicare as terrible, based on my relatives' experience. And that's the one most likely to be converted into a universal program.

The VA is not fit for purpose. I don't blame you for thinking that govt. run services suck but frankly how the US treats its veterans (not just medical health but also pensions, etc) is shocking.

> the military healthcare system is the ideal system you're advocating for ...

Hmmm, it sounds more like a terrible implementation, whereas some of the other implementations are generally decent?

That depends on if the implementation details are country and culture-specific.

Knowing what I know of the VA and my former service roommate’s experiences with them, I can’t really blame people for thinking any such system run by our government expanded to more people would never be efficient or better. Something something better the devil you know...

Just to be clear are you unhappy with active duty medical service provided by active service members to other active service members? Tri-Care? VA? It sounds like the first

Both are horrible. Medicare and Medicaid are almost as bad from what I've seen.

It gets dumped on bur the US Veterans Affars system works much better than the rest of the US heathcare system. Vastly lower costs relative to the patient population, heathcare choices based around patient needs not their insurance companies. Doctors are both more efficient and less stressed. It even has vastly less paperwork.

Occasionally people look into replacing it with something else, but it never goes anywhere because it just works even in the US.

How much experience do you have with the VA?

Quite a bit, with people that use the VA and people that work there, and a fair knowledge of it’s cost and performance.

Why, was their something specific you wanted to know? Or was that a low effort attack?

So you know some people who know something about the VA.

That's what I thought.

If it doesn't, it's possible, through voting, to change how that operates. There's absolutely nothing that can be done in the 'free market' which would have any impact on providers/insurance companies.

The United States doesn't have anything close to a free market in healthcare. The industry is heavily regulated (including, of course, regulatory capture that entrenches existing big players).

If you believe voting changes how government operates, you haven't been paying attention.

The powers are entrenched and voting does little to change anything in government anymore.

We don't have a free market health care system anyway, it's a hodgepodge of regulation and absurdity today. Making it single payer would simplify that situation, but claiming it would add dignity to the process is just uninformed.

If you actual compare the data and spout outdated and trite political philosophies, healthcare systems that have significant government involvement tend to be more effective and offer a better quality of care for the money spent than free market solutions. Policies should be made based on data and facts, not sure political philosophy coined years before any of these issues became apparent.

> If you believe voting changes how government operates, you haven't been paying attention. The powers are entrenched and voting does little to change anything in government anymore.

I agree with you there in the context of the US. What desperately needs changing is campaign finance. Lobbying, Citizens United, etc has completely ruined politics in the US.

What needs changing is term limits. One should not be able to spend 40 years in Congress or the Senate.

>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.

> 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.

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

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.

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.

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.

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

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.

The failure of Americans to recognize death panels as a feature rather than a bug are why American healthcare can't be done on a nationalized basis. As to the misunderstanding, I assume that's based either on a misstep in logic, or on moral repugnance for it.

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

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.

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.

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

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

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

A problem is that health insurance as it is organized in the us is not risk management. If you are 20 years old and healthy you get a massive premium to support a 60 year old with obesity and history of drinking.

Insurance should be able to do actuarial risk and charge accordingly.

No, sick people should not be charged more for their health insurance.

I think morally there is a relevant distinction between congenital disease, environmental disease over which you had no control (asbestos, smog), and lifestyle choices (I'm going to eat fast food, lots of sugar, smoke cigarettes, and drink booze as often as possible).

Beriatric surgery should be 100% covered. But if you refuse such surgery and eat yourself into a 400 pound oblivion, then I don't think anyone should have to contribute to managing the ensuing completely predictable problems - insurance is about protecting against unknowns. We know exactly what happens if you drink too much, if you eat too much, if you pickle your organs by eating too much sugar, with 100% certainty.

It is not moral to take resources from responsible people in order to coddle the emotional state of people who want to do what they want because they want to. There's no way to argue it is. Even as an advocate of universal health care I'm hyper aware of the folly that follows which is if I'm paying for you, then I get to have a say in what you consume and your relative activity level, or else you get cut off or sanctioned in some way. The individualism in the U.S., as cowboy mentality as it is, very much expects individual to put in a fair amount of effort in first, in order to get help from others. It's not a ask and you shall receive society, never has been, probably never will be.

Doesn’t really work in practice though, because you rapidly deteriorate into a ludicrously invasive system. Let’s say you drive - why should I, as a non-driver, be paying for your medical care because you chose to drive? You cycle? Dangerous! Wait, you don’t sleep eight hours?? Statistically, you’re doomed!

It doesn’t work. Life is an inherently dangerous environment. Some of the things we do increase our risk of illness massively, but so many things increase our risk in so many ways that it’s surely better to manage this as a public health matter, rather than simply accepting that people will die en masse.

Coordinated and sustained public health programs can reduce the adverse effects of lifestyle choices. But rationing healthcare on that basis is ultimately going to benefit nobody.

I think it works really well: different people do different levels of investment and decisions regarding the personal health. Some to scooter, others to bike, others to walk. Some choose to live in a more crime ridden area, others safer. Some people choose to avoid gluten, others to avoid carbs.

Even on healthcare, in countries were the system is not so busted as in the us, people choose to have premium insurances over regular ones, to get better care ,and others choose not to.

> But rationing healthcare on that basis is ultimately going to benefit nobody.

Its not rationing healthcare: its bearing the burden of individual choices.

> Doesn’t really work in practice though, because you rapidly deteriorate into a ludicrously invasive system

In practice there is a small core group of activities that cause the vast majority of the problems.

> Coordinated and sustained public health programs can reduce the adverse effects of lifestyle

In practice we don’t have the stomach to use techniques that are time tested.

Take obesity - fat shaming works but it’s rough on the people who are being shamed.

Instead of fat shaming though there is a fat acceptance movement.

Healthy young people should not be condemned to economic poverty to maintain sick people.

It's funny then. Why am I, a healthy young person, condemned to economic poverty because my parents have poor healthcare as a result of the sham that is the US healthcare system?

Tell me. Can you explain why that is OK in your narrative?

Because a healthy young person bearing the burden of the parents does not solve the "sham of the US health care system" and shifts the cost mostly from the older to the younger, which with lower incomes are pushed into lower quality labor and lesser jobs, as they cannot be employed with health benefits.

A rich 60 year old man takes 100k medical treatments from medicare and a poor 18 year-old either has no coverage at all or pays an innordinate amount of insurance out of his salary. How can people justify doing such a blatant robbery of the poor.

Because you have made the choice to look after your sick parents?

I haven’t made the choice to look after your parents.

It seems you've managed to miss the point entirely.

Everyone gets older. Everyone gets sicker and medical issues start to crop up as they get older. The people that then have to deal with medical bills are the children and relatives. Meaning you have a choice to make: Go bankrupt helping your family, or maintain your status by abandoning their health.

I hope your family never gets ill because otherwise you'll either end up financially bankrupt or heartless.

> Everyone gets sicker and medical issues start to crop up as they get older.

I disagree. I’m old enough to have been around before we had so many health problems.

It is one of the main drivers of our quickly increasing health costs.

When I was growing up we had smoking and that’s pretty much it.

> It seems you've managed to miss the point entirely.

Most people will change their lifestyle to help their immediate family when they wouldn’t change to help taxpayers as a whole.

> I hope your family never gets ill

It’s far too late for that - I’m an old man and I’ve seen lots of people I love pass away.

In a free market it is, unfortunately US healthcare is too highly-regulated to be a free market, and too badly-regulated to be a working non-free market.

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.

You can totally sell medical equipment online. This sounds like you're getting taken for a ride by a scumbag of a medical equipment company. I don't know about your details but it might be possible to get the insurance company to agree to reimburse a cheaper purchase.

Of course, dealing with insurers is nearly as bad. The US health landscape is broken beyond belief.

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.

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.

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...

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

Catch-22 gets more real every day

Indeed, reminds me of my favourite quote from the book: “When I look up, I see people cashing in. I don't see heaven or saints or angels. I see people cashing in on every decent impulse and every human tragedy.”

Unfortunately, not as funny as the book.

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.

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?


On a practical level you need to accept that most people trying to loose weight fail, succeeding will still take years to lose the weight, and that most of those people will suffer significant medical problems from sleep apnea in the mean time.

> About 80% of obese people with sleep apnea would be asymptomatic if they reduced to a non-obese weight.

Where are you getting this from? I didn't see anything like it in the study you linked, it doesn't match the general impression I've gotten reading other OSA studies, and it's unusual for lifestyle intervention studies to have a large number of people lose enough weight to go from obese to non-obese. Are you sure that you're not neglecting some other qualification of the population (e.g. mild sleep apnea, bariatric surgery)?

> 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?

No, because weight loss takes time, and there's nothing particularly safe about leaving OSA untreated in the interim. Weight loss is a fine thing to pursue for overweight and obese OSA patients, but deciding up-front to do that instead of CPAP is reckless. I agree with the authors of the study you linked when they conclude that "it is clear that treatment of OSA cannot be limited to any single strategy, but rather requires a multidisciplinary approach". Not every patient will respond to or tolerate every treatment approach, and the possibility of synergistic effects should not be ignored.

People have an allergic reaction to the idea that insurance for someone obese should cost more than to someone thats not obese, even though that is actuarially correct.

I feel like there is an obvious reductio ad absurdam. If you are obese, yes, you can expect higher costs. If you are diagnosed with cancer, you can expect higher costs. If you are on your way to an appointment to check for cancer, you are higher risk than someone who has no cause to worry. If we take the idea of discriminating against known risk to an extreme, there would never be a payout at all, because hours, minutes, seconds, or milliseconds before a claim, there is always an indication of elevated risk. If you have full telemetry from all the cars you provide collision insurance for, you can determine that someone is an unacceptable risk moments before impact. "High frequency insurance underwriting" would only be a difference in degree from the sort of discrimination people defend, but it would make the entire industry pointless.

Therefore, I believe that everybody agrees discrimination against known risks must be limited by regulation or other means to make insurance viable; we're just arguing about where to set the boundary. It is generally accepted that race, religion, and so on are prohibited forms of discrimination, but that doesn't mean there is some principle that says all other forms of discrimination are ok. Furthermore, the arguments for discriminating against the obese logically apply to protected categories, so how do you reconcile that?

Apart from logic, I don't understand why anyone would want to argue in favor of discrimination against people who have a tendency to be obese, even if you don't have that particular issue. There are an unlimited number of conditions a person could have that could be similarly discriminated against.

You are describing a world without insurance: where each incident bears its full results on the bearer. This is the situation with almost anything you do everyday: from eating to crossing the street, to wearing helmets on electric scooters.

Insurance as a product is a way to manage that risk, but it doesnt eliminate it, and as a product it makes the total cost higher, as you need to pay to manage the risk. Insurance itself always bears the risk of adverse selections: it attracts those that will have higher tendencies to abuse the insurance.

That is the nature of insurance, what it solves and why it requires human effort to manage, it can't be automated away: it is an economic solution.

Another problem would be: some people have very expensive medical treatment and we should not as a society let them die or suffer death from it. But that problem is not soluble through insurance, that is soluble through charity and charity alone. Using insurance as a mechanism of charity is using a hammer on a screw.

Yes, I was describing a world without insurance. I'm saying a world with insurance and without any of what you call charity is strictly speaking impossible. And therefore the separation between insurance and what you call charity is spurious.

Insurance cannot exist and solve any problem if insurers are able to discriminate perfectly, so it cannot be a matter of principle that they should be able to discriminate to any arbitrary degree.

The idea that insurers are inherently justified in discriminating against poor risks is a nihilistic attack on the idea of insurance.

Total information awareness would lead to perfect discrimination and the annihilation of insurance, so you cannot justify by a principled argument discrimination against those you don't like purely on the basis that insuring them is charity.

> I'm saying a world with insurance and without any of what you call charity is strictly speaking impossible

Truly don't get this. Insurance discriminates before the fact: it's a framework to gauge risk, and collect a premium for managing it. There is no charity involved in that process.

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.

"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".

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

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.

What if your problems are caused by being depressed?

It so happens that antidepressants cause people to gain weight frequently.

How do antidepressants create matter from thin air?

We've banned you again for trolling and using multiple accounts to do it.

Please don't create HN accounts to abuse the site with.

An analogy...people who don't feel pain tend to damage their body. This is mysterious if you think "well, they are not blind, they have free will and the ability to control their body, so why do they let themselves be damaged". But isn't that obviously silly? Pain is very important feedback and if you don't feel it is a disability that you are not at fault for.

Everybody who is naturally not overweight knows that they don't have to rigorously monitor their food intake, because they have an internal thermostat that does it for them. They just eat when they are hungry and stop when they are full.

Some drugs affect that thermostat, and some people have a naturally defective thermostat. It is very very difficult to fight it because the imbalance is very small and the intensity of the output is very high.

The thing that annoys me is, given that I have never been obese, and I assume you have never been obese, we both know from personal experience that people without weight problems do not exert effort to control it. So how can you blame those who need to for being unable? We both know better without needing the least empathy or experience of being obese.

This is an appalling comment that shows you have little knowledge or interest in physiology, and contempt for people who develop obesity as a symptom or a side-effect of medication for serious illness.

A school-friend of mine, who had been an elite athlete during high school and was as healthy and fit as anybody you'd find, developed schizophrenia during his twenties and needed to be put on strong anti-psychotic medication, which caused dramatic weight gain.

He's continued to need various medications for schizophrenia and anxiety ever since, and despite relentless efforts to keep his weight down with the same kind of exercise and diet that kept him in good shape when he was younger, cannot return to an ideal weight.

The reason for this is to do with the way neurotransmitters and hormones alter metabolism, and it's straightforward to understand with a little research.

The question "How do antidepressants create matter from thin air?" amounts to trolling and doesn't belong on HN in my opinion.

"This is an appalling comment that shows you have little knowledge or interest in physiology, and contempt for people who develop obesity as a symptom or a side-effect of medication for serious illness."

I would however, further suggest that not only should we have sympathy for people who have obesity from medication, but those who have obesity without it.

If you take a drug and you perceive God as a result, it is logical to infer that people who perceive God without drugs may be also experiencing something that results from similar brain chemistry.

Yep, that's what I intended to convey; sorry if that wasn't clear.

Sometimes it's a side-effect of a drug. Sometimes it's a symptom of other issues in the body/mind.

My point is that people who are obese (to an extent that causes issues like sleep apnoea or other complications) are not that way because they simply choose to be that way, or because they "just eat too much".

People who can easily lose the weight have already done so. Everyone else is stuck with it, for one or more of any number of complex reasons, and outside observers are in no position to pass judgment.

Don’t be intentionally obtuse. Depression is a bug in the operating system of the mind that impacts everything from motivation to hunger. Pretty hard to lose weight when just getting up in the morning is a feat of willpower and cheap, shitty food is a slightly brighter shade of grey in the dark dull shade of grey that a clinical depression sufferer has as their entire life.

Ever tried debugging a program on a machine with bad RAM? It’s kinda like that.

My point was that regardless of the nature of depression and how well drugs work or don't work, it's well known that psychotropic drugs lead to weight gain and diabetes.

People have an inbuilt homeostatic feedback system which can be naturally out of whack or it can be modified by drugs, and blaming them for not being able to compensate is senseless.

Also, the fact that it can be modified by drugs proves to me that weight gain should not be presumed to be a personal failing. The person who has weight gain didn't become a different person because they took pills.

It's analogous to having a religious experience through electrical brain stimulation - it should make you realize that having such experience is not to your personal credit or detriment.

It's not actually related to anything in the article, it poses a false dichotomy.

That got me.

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.

We detached this subthread from https://news.ycombinator.com/item?id=18504592 and marked it off-topic.

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.

Speaking of "bastards are just bastards" - ever heard of the sociopath|clueless|losers categorisation:


I hadn't heard of that at all. Brilliant read. Thanks for posting this.

The one problem with that categorisation is that once you learn it, it is is pretty much impossible to stop applying it...

> 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?

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.

Religious values are values which already existed but proponents of religion decided to take credit for.

Animals understand reciprocity. These vales transcend human societies let alone religious.

> 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.

You could make a decent argument that religion itself has been problematic. This is a massive can of worms, but everyone's heard all the pieces:

- Gets in the way of progress

- Intolerant of alternative authorities

- Tramples human rights

And so on.

That’s a bit of a rose tainted view I think. Just as any “wisdom” system there is superb and horrible things.

Traditional religions were aimed at preserving a specific culture, things in line with that were nice, anything falling out of that would be shafted.

Religion is as much a societal construct as any other value or system, such as exploitative corporate systems that heavily incentivize this kind of behavior.

Check out humanism: https://en.wikipedia.org/wiki/Secular_humanism

>Secular humanism posits that human beings are capable of being ethical and moral without religion or a god. It does not, however, assume that humans are either inherently evil or innately good, nor does it present humans as being superior to nature.

Hey, we'll be alright friend.

I literally think that some cults are formed for exactly this purpose. "If I could only get people to do what I want, then the world would be a better place!" How do you get people to do what you want? Convince them that there is a higher power that compels them to do that.

It's that benevolent dictatorship kind of thing. If you have a very smart, very selfless and very altruistic leader, then everybody marching to the same drum is a good thing, right? Everyone knows that humans are fallible, so this is the incentive to have an infallible god that knows how to do everything correctly and who is willing to tell your leader what to do. Why have just one leader? Well, it's a matter of trust, of course. If anyone could speak directly to the infallible god, how would we know the tricksters from the true prophets? (I suppose we could ask the infallible god, but it's possible the god is too busy to respond to every request). Better to have only one true prophet, if possible. Even better if they are a god themselves (might as well cut out the middle man).

But even being sarcastic, I think it's really true. It's hard to sway people's opinions because especially in this day and age there are so many opinions vying for your attention. If you are absolutely certain that you could do good in the world, if only people would listen and you were willing to do anything... I seriously think that there would be no more effective strategy than to start your own religion/cult.

Of course, these things get corrupted. Maybe you even start out doing good, but then someone drugs you and stuffs you in your bedroom for years on end and uses you as a puppet figure head because the cult is a good money making opportunity. Maybe, some influential and charismatic person takes your flock away from you (splitters!). Maybe you're not as smart as you thought you were. Maybe after you die, your appointed leaders become more and more corrupt until the organisation you built is just a mockery of what it was supposed to be.

So I think you can't really go that way in the long run. "Just do as I say and believe that it is right", can only lead to corruption because it focuses power too much and there is a limit to what one person can accomplish. Instead, I think you have to create a culture of good. A small post like this is too small to describe how to do it (and besides I have to get some sleep because I have to fight a dual tomorrow -- err just joking... it's really because I don't know how to do it). Anyway, I'm convinced it's about building a culture with a small network of people and growing that culture so that treating people well is a kind of common sense.

Strangely, despite the challenges in today's world of instant communications, I think there is more opportunity to build that kind of global common sense than there ever was. YMMV.

I hope you’re not implying any permanent solutions to temporary problems.

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

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.

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.

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.

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

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.

Medical device, need RX.

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