Before I worked in healthcare, it all seemed so easy. The doctors were the good guys, and the insurance and drug companies were the bad guys. Now I see it differently.
Healthcare companies are massive bureaucracies because there are people at every end trying to scam them. All that redundant paperwork is for a reason.
You wouldn't believe some of the things that people try to get away with. Plastic surgeons billing tummy tucks as emergency C-sections. People pretending they were the hospital so they can get the insurance company to reimburse them for the IV "hangover cures" they got every morning while partying in Vegas. People walking into office buildings and play-collapsing in the lobby so they can get an ambulance ride to the hospital across town, then once they arrive they run out of the hospital and down the street because all they were really looking for is a free ride. People who have six or seven dependent children from multiple partners on their insurance, then yell at us because the partner they're living with didn't know about all those other children from all those other spouses until they opened some piece of mail from us.
I'm not saying that insurance companies are all good. IME, most are not. But if people were just honest and decent, a large part of the healthcare system dysfunction wouldn't exist.
In my view, a broader observation is that every group claims to be protecting us while accusing every other group of gouging us. This leads me to suspect that they are all gouging us. The system is so labyrinthine that literally nobody can figure out where the money is going. And many of these groups have ownership stakes in the other groups. For instance, doctors are prominent owners and investors in clinics, providers, and even malpractice insurance companies.
It's attributed to Abe Lincoln, that in order to get down to the truth, you have to get all of the liars in the room together.
In my imagination, a potential benefit of a government health care system is that it could eliminate this rat's nest of business entities by paying directly for the things that are needed. And we'd know who is getting paid how much by just publishing the government's checkbook register. Doctors can attend medical school for free, and then work for the government, for a good professional salary. They don't have to engage in all sorts of monkey business with LLC's and insider investments to earn a living.
Block chain should be used to provide a legit health history on a per person basis ... It's all about trust ... Similarly insurance and healthcare businesses must also be on a transparent block chain ... As is it's only benefitting lawyers
He might just mean "Merkle tree with digital signatures", which most people intimately familiar with block chain won't distinguish from block chain, despite the former being in general use in the software industry and the latter in general use by Ponzi schemes.
I firmly believe blockchain is over hyped, but that doesn’t mean it doesn’t have its potential use cases. Medical payers/providers are in fact giving it serious consideration.
Second this! My gf used to do part-time work (before she started her residency) for a couple of doctors doing mostly data entry works (to eClinicalWorks and whatnot). She would always tell me how these doctors instructed her to add more diagnosis codes so that they can get paid more (esp. from medicaid/medicare patients).
My host family father is a doctor in the US. He said to me once something like, "Be prepared to be scammed by people whether it is a brain surgeon or a carpenter. Never ever trust the original price they quote on you and be critical of their output."
Have you seen how pharma reps treat doctors? I have. Hundreds of dollars worth of dinners/lunches (one of the dinners my gf and I were invited to, it served unlimited Wagyu beef for bbq; of course, we had to sign in before the dinner). I am disgusted by how cozy the relationship between pharma companies and docs are.
The more I talk to and observe doctors, pharma and healthcare industry in general, the more I lose respect to the parties involved (of course, there are a few respectable professionals, but they are a minority because of the sheer amount of money to be made in that industry).
> Have you seen how pharma reps treat doctors? I have. Hundreds of dollars worth of dinners/lunches (one of the dinners my gf and I were invited to, it served unlimited Wagyu beef for bbq; of course, we had to sign in before the dinner). I am disgusted by how cozy the relationship between pharma companies and docs are.
In France (and California), there's a website where you can see how much your doctor got from pharma.
I found out that one of my doctors received $200K for the last reporting year from the manufacturer of my medication. The medication is $600/month. Granted the medication does work for me and insurance picks up most of it, but it still seems like a massive conflict of interest. I honestly have half a mind to switch doctors.
I have an anecdote:
I had a small fat cyst near my eyelid and the doctor removed in less than 45 seconds.
I later got the bill for multiple cyst removals in both eyes, granted it was only $75, it still was wrong. I contacted the office and said that this is simply not true and if they don't remove this from the bill, I would contact the insurance company. They argued with me saying that they had in fact removed many of them in both eyes.
If you look at it from the Doctor's POV, he is lying because there is a low risk of getting caught. The penalty for getting caught is probably not high enough.
This happened to me as well but with a dentist. When I first moved to Boston I had never had any cavities but my new dentist kept remarking about how great my dental insurance was - I was in the insurance sweet spot of under 26 so I was covered by my mom's policy as primary and had secondary coverage through my dad's policy and my school's policy. Well wouldn't you know, I averaged two cavities a year during law school even though my brushing & flossing habits were unchanged.
When I finally graduated and switched to a dentist closer to my office I insisted to my new dentist that I had had six cavities filled and he insisted that I most definitely hadn't. There wasn't a single filling to be seen on my x-rays. Dentist #1 had been scheduling me to have a cavity drilled after every regular visit. Apparently he was just giving me a shot of lidocaine and pretending to drill in my mouth for an hour so he could bill my "great" insurance.
I did actually but I never heard anything back, though the dentist retired about a year later. I always wondered if it was related to my complaint or just a coincidence.
I worked out an out of network surgery center which targeted high reimbursing insurance companies. The standard tact is to lie to patients, telling them not to worry about high deductibles because the surgery center won’t collect on them.
I seen an endoscopy be reimbursed $28,000 from a major county’s government employee insurance program in CA. At a hospital, it would cost around $2,000.
I heard established surgeons say that some surgeons would purposely perform shoddy hernia surgeries to require further surgeries. Or add more procedures etc to inflate the charges.
They’ll bill as much as possible, using billing codes in the most strategic ways. Insurance companies would then reimburse 15-20% on average.
The entire system is flawed and opaque so it’s hard to know who is exploiting who.
>The entire system is flawed and opaque so it’s hard to know who is exploiting who.
Doctors are by far the highest paid career in the USA. Surgeons are paid enormous salaries. Its pretty clear who is winning.
I know there is a complaint that medical school is very expensive. If we offered free medical school for cutting salaries in half, I'm pretty sure doctors would prefer to keep as it is.
> Doctors are by far the highest paid career in the USA. Surgeons are paid enormous salaries. Its pretty clear who is winning.
Right. People talk about drug company executives. There are a few hundred at most. We have hundreds of thousands of specialist doctors making hundreds of thousands of more dollars a year than their counterparts in other countries.
Exactly! Medical training in the US is unnecessarily long. The med students don't need 4 years of undergrad studies on top of another 4 years of med school. In my home country, 5 years of med school and 2 years of residency is sufficient to train a competent generic physicians (not brain surgeon). Physicians from my country, when they came over to the US to be trained in the residency programs here, found that the medical exams and residency training to be not that difficult (it is extremely difficult to get into one because they are foreigners, but once they get in, almost every one of them become multi-millionaires by their 40s).
My gf externed at a hospital just outside of LA in California. The attending physician there earn ~300K/year for a total of 14 days of work per month. She met two physicians (both from my country again), who work at two hospitals near that area as attendings; they go to one hospital for one week; then work at another the week after; and the cycle repeats. Each of them makes easily >$500K/year (one of them said so to my gf).
Despite majority of Americans are led to believe by doctors, born and trained in the US, that they are the most hardworking folks out there doing 70-hours/week shifts, it is simply an exaggeration. Sure there are some outlier residency programs that made its first or second year residents work maybe 60-hours/week, but 70 to 80-hours? I know so many former and current residents in a the biggest metro area in the US (and another one who just finished her residency at JHU), and asked them about their working hours. NONE of them had to work that much. The average for first year residents is ~50 hours. Then it drops off to normal 40-hours/week starting second year and third years.
Spouse of young doctor here. I have worked in tech for two decades. During that time, my spouse did 12 years of post-secondary pre-med and medical training. Undergrad, postbacc, med school, and residency; she is now in a fellowship.
You said (paraphrasing): “despite majority of Americans being led to believe doctors are doing 70-hour shifts per week, it is simply an exaggeration.” First, most Americans don’t believe it. Second, my wife worked 60-100 hours per week for her entire 4-year residency. That included month-long stretches on nights doing 6pm-6am shifts, 6 days per week. That included more 24-hour (or, even 28-hour) shifts than I could count. I know the hours precisely because I worked from home the entire time for my tech startup job, and we lived a 5 minute walk from the hospital. It’s a top academic hospital.
I once attended a wedding where all her med school friends were guests, all in their 3rd and 4th year of residency. Polled them about work hours. All similar. Group of 7 or 8 residents at programs all across the US, mostly top programs. Some exceptions in residencies like geriatrics and pediatrics, but any surgical or specialty residency is brutal. The happiest resident had recently quit medicine altogether — to go into tech.
They work that hard whilst earning essentially sub-minimum-wage. The contrast couldn’t be greater vs tech. My company employs over 50 people, mostly college educated, and it is not even remotely comparable. Residents get paid less than our lowest paid staff, and work twice the hours, with higher stakes, a higher emotional toll, and worse working conditions. And it just gets more unequal from there.
She is now in fellowship and the hours are slightly better. But she is now in a more urban area with a longer commute, higher taxes, higher cost of living, and debt hanging over her. As a fellow, she only makes marginally more money for her 13th and 14th years of post-secondary training. This week she worked approx 55 hours so far (if you don’t count the 4 hours of “journal club”, also required), and will need to commute an hour by car on her Sunday morning to round on a single patient — part of her unscheduled, but required, call.
If she becomes a multi-millionaire in her 40s, as you suggest is inevitable, I will be pleasantly surprised — but considering fellowship, for her, ends at age 37, I think it unlikely. First, she has to pay down over $300k of student debt, since none of the journey was paid by her parents. Then she has to earn for awhile, and make up a little for lost time, since she doesn’t have decades of savings behind her, living right at the breakeven mark for cost of living for so many years. And even if it does happen, I’ll think it a justified renumeration for her countless sleepless and low-paid nights saving lives in her 30s, not to mention the opportunity cost (and real cost) of educational years. After all, should we expect the personal sacrifice of one’s 20s and 30s have no reward at all?
Doctors should be paid much more, sleep much more, and they should suffer much less ire from people like you. As someone with two decades in tech and first-hand, concurrent experience of the contrast, I feel that much more now than ever.
I think you're agreeing. The 10+ years of doctor training is too much, too long and too expensive. But I think you're double counting the residential years as medical training as well as an underpaid job.
Yes I agree software developers are currently overpaid as well.
"Yes I agree software developers are currently overpaid as well."
This reminds me of an old Romanian joke a family friend once told me, translating to English.
Two pig farmers, one Romanian and one Bulgarian, live across from each other along the countries' border. A genie magically arrives on the Bulgarian side and says to the farmer, "I can grant you any wish in the world." The humble Bulgarian farmer thinks on it for awhile and says, "I wish for 10 beautiful and healthy pigs, so that my farm may thrive for the coming years." The genie grants the wish and the pigs appear.
The genie flies over to the Romanian side. He says to the Romanian farmer, "I can grant you any wish in the world." The Romanian farmer thinks pensively for a little while, and then it comes to him. He points to the Bulgarian side and says, "Kill his pigs."
Doctors are the highest paid career, if you have no concept of opportunity cost. To earn a surgeon’s salary, you need a surgeon’s training. In the US, that means 4 years undergrad, 4 years of medical school, 4 years of medical residency, and often a few more years of specialty fellowship. My wife will have racked up $300k of debt and done 14 years of training before earning her first year of a “surgeon’s salary”. I suspect a tech salary earned 10-14 years earlier, and earned for 10-14 years running, without debt, combined with smart savings and the miracle of compound interest, will beat her every time.
The training requirements aren’t much different in other OECD countries. Their med schools and residencies are still at capacity. Their outcomes are better and their doctors are paid much less, but still more than most others.
I doubt the outcomes being better has much to do with the lower physician pay. But it wouldn’t surprise me that you can “get away” with paying doctors less, while maintaining outcomes above some level.
My question is: why bother? Or, put another way, what if we paid them more, reduced their hours, and had more of them? What might that do for outcomes — especially since physician salaries are a rounding error of total healthcare system costs, and since the best and brightest working in medicine means more patient lives saved and more physician happiness?
1) is it a rounding error? There are a lot of doctors, every one of them making a lot of money. I don’t know but every doctor making a lot more every year has got to add up.
2) Doctors are overtrained. This is by design, to keep salaries high. Nothing about their job demands the salary they command other than the artificial scarcity imposed by regulation.
How about: streamline the process of becoming a doctor; remove 4 year degree requirement, lower cost of med school or make it free. This has the benefit of both improving care (more doctors/patient) and making care cheaper (fewer ludicrous salaries).
Absolutely I believe doctor pay is a big part of the racket on the hospitals end. A fair amount of it goes to the higher education racket via student loans, but I guess that is a different problem.
"There are a lot of doctors, every one of them making a lot of money."
So what? That's the way it is supposed to work for highly skilled jobs adding tons of societal value in our capitalist society. What, sacrificing your 20s and 30s isn't enough for you? You also want doctors to sacrifice their future, their comfort into adulthood, and their retirement? All the while keeping a steady hand on the scalpel while they operate on you and your children?
There is nothing wrong with well trained and well skilled people getting paid to do what they love -- especially if that hugely benefits society. Go looking for overpaid waste in leech sectors like finance and insurance instead.
I agree with you on the rest.
Doctor pay isn't a "racket" though -- you are seeking the wrong boogeyman. Remember, in the healthcare system, they are the ones adding so much of the value, at the cost of personal time, training time, opportunity cost, and emotional cost. Can the same be said by the millions of administrators in the back office of highly profitable private insurers?
But not for FFS. For the most part i believe that is nonsense. Instead it was SOP. Like doing blodletting on a sick patient. You did it because it qas the thing to do.
>Healthcare companies are massive bureaucracies because there are people at every end trying to scam them. All that redundant paperwork is for a reason.
And what about other countries with way lower healthcare expenditures (by % of GDP)? Are people scamming the healthcare system an American problem?
> Are people scamming the healthcare system an American problem?
Definitely not. In Poland we have public healthcare, and the stories I hear from my doctor acquaintance still reveal ridiculous levels of fraud, mostly the usual scams against large bureaucracies.
Public healthcare may be more efficient, but is still full of bureaucratic scars.
One of the major savings is single payers have more data on each provider. This means they can randomly audit a lower percentage of cases and become just as likely to spot fraud.
Maybe, maybe not. In France all my information is in EMR in my Carte Vitale. The US I have to fill in a paper questionnaire every fucking time. They may have more data, most likely it's redundant.
Feedback loop. The more expensive healthcare gets, the more money you can get by scamming insurance companies, which in turn increases costs even more.
NHS and other nationalized healthcare providers, doctors and nurses working in hospitals get salaries, so they could scam some overtime but that's about it. I think local primary physicians get paid per visit, but most are way overworked anyway so kinda hard to fake extra visits.
True, but most other industries have effective, scalable mechanisms to clamp down on such blatant fraud and dishonesty; health care in the US just isn't using the appropriate mechanisms, it seems.
Like a basic one I see lacking is, checking the patient him/herself. I have never gotten contacted for any kind of follow up about "did you actually receive this health care", which would eliminate fraud related to the tummy tuck/C-section you mention.
Or why aren't they keeping track of that person that's constantly calling the ambulance?
Furthermore, where is the crushing power of the state to recover from such people? If you find systemic fraud, why aren't the regulators able to recover a big chunk of the money?
I feel you. A lot of anger in the world comes from this, I think, and I want to push back because it can lead to dangerous conclusions. I'm not arguing you would use it as such, but others do. I.e. see xenophobia, religious persecution, violence against LGBTs, etc.
How much of what you say is due to a lack of honesty and decency on behalf of the rich and powerful? How many people have "abandoned their decency" because the system is just fucking impossible to overcome? It's not how I reacted, but some friends did - faced with the often impassible barrier between poverty and the lower-middle-class, they threw their hands up in the air and turned to crime, or vagrancy, or just general dickishness towards the rich ("civil disobedience" they'd call it, as they spraypainted a dick onto the rich neighborhood's entrance sign").
If people were just honest and decent, we wouldn't need jails, because nobody would commit crimes. But if people were just honest and decent, people wouldn't be going to jail because a rotten cop planted drugs on them (https://www.youtube.com/watch?v=UANRvFNc0hw) or because they smoked a plant in the privacy of their own home. People wouldn't get shot for being black.
If people were just honest and decent, other people wouldn't feel the need to squeeze every drop of support out of a system beleaguered by a warring two party system to fund and defund it at the same time. "Hell yes I'm going to abuse food stamps, republicans just got a majority, they might take it away next month!"
If people were just honest and decent, we wouldn't have a rapidly escalating war between tolerance and intolerance. Antifa vs fascists. Nazis vs liberals. Friends in Texas wanting to ban transgenders from public restrooms while LGBT friends arguing "it has gotten to the point where punching nazis in the face is acceptable dialogue."
The "if people were just honest and decent" argument keeps cropping up over the centuries, and I think we should work around it. Moral superiority, it doesn't work. Catholics trying for 1000 years to get people to stop getting pregnant before marriage - a multigenerational failure to understand that that strategy just doesn't fucking work. It takes a bit more creativity.
So, I sympathize with your urge to throw your hands up and say "can we just stop being fucking assholes and taking advantage of eachother?" I agree. I try not to be an asshole. But there are tons of assholes in the world, and some of them, when I sit down to think about it, are kinda justified in their assholeness, because they're in shitty situations that would really stress my ability to not be an asshole. Long story short, it's not a helpful attitude - creativity is needed, alongside sympathy. Acknowledge that helping people will come with shortcomings (free riders), abandon pride, and accept that it's better than the alternative (a war of assholes undercutting eachother at every opportunity).
There are two ways to deal with it, either universal healthcare which is a proven and working system in most of the western world or free market where every procedure has a price tag attached to it and people pay knowing what they pay in advance and for what exactly they pay, like a normal shop in a free market.
The weird hybrid system in the US is like communism, it doesn't work, we can see it doesn't work, it costs more than any other place on earth, both for the government and the people. The US should just scrape it and choose some working system. Until then leave us alone every second week with your horror stories, it is not interesting anymore.
I know a fellow that got a bill a drug testing company didn't mean to send him. He was meant to check for a single restricted medication because of some treatment regimen he was on. Instead, it checked for pretty much everything and automatically rechecked both positive and negative results.
Long story short, a $50 test turned into a $2500 test, invisible to all but the testing company and the insurance company.
The testing company told him to ignore the bill and, indeed, he wasn't charged that amount. It piqued his curiosity and offended his sense of fairness and it led him down a disturbing rabbit hole of uncovering some very bad behavior and desperately trying to get folks to do notice what was happening and do something about it.
Basically, this company seems to be in the business of bribing doctors through ridiculously priced leases in their medical office that they pay for to house their 'testing advisors'. We're talking on the order of $15K a month for a broom closet. In return, doctors use the testing company's pre-filled documents for requesting testing -- standing orders for the whole suite of tests with re-checks rather than just what is needed.
By the time the insurance companies caught on they'd amassed a huge war chest and were more than happy to tie up the courts fighting claims that they're doing something wrong.
One reason I support universal healthcare even though, generally, I'm a free-market proponent, is because it would make this kind of fraud a lot easier to spot and the federal government has a lot more tools to bring to bear to stop it.
I agree that if we are to maintain this opaque system where customers (patients) pay a flat rate for ludicrously overpriced insurance, and then have no insight into prices nor ability to reduce them because they don’t pay for the actual services, then universal healthcare is better.
However, universal healthcare is not a panacea as evidenced by many angry patients waiting for procedures in Canada and the UK - although they are leaps and bounds better off than many in the current USA system.
An alternative would be to have transparent pricing and open the market much more to for-profit businesses. Notice how vasectomies and laser eye surgery, 2 procedures not typically covered by insurance, have become safer, cheaper, and more effective over the past 20 years as they have been forced to advertise directly to consumers and compete with other vendors. This is the opposite trajectory of almost everything else in the healthcare system. I’m not saying all procedures can become like this - obviously a heart attack is a heart attack - but there are many other specialist procedures that are indeed scheduled in advance that could benefit from a heavy dose of transparency and competition.
As another example, I’ve been on the same medication for the past 8 years. I get the same dose, and it’s never changing. Yet my provider makes me visit every 3 months for a refill. They put me in a room and “check up” to make sure the meds are "going well". Often this 30 minute scheduled meeting is less than 5 minutes because my doctor just hits a button on the computer to refill it. Yet insurance pays 4 times a year for this unnecessary visit to a specialist doctor. It doesn't cost me anything (other than deductible) so I'm most annoyed about the time wasting, but I also know that the system is being bilked for thousands of dollars.
Multiply that anecdote by a million other situations. I should just be able to buy my meds without being forced to go through a doctor.
> I agree that if we are to maintain this opaque system where customers (patients) pay a flat rate for ludicrously overpriced insurance, and then have no insight into prices nor ability to reduce them because they don’t pay for the actual services, then universal healthcare is better.
How do you square free-market ideals in a price-inelastic market? If my life is on the line, do I really decline the $10k required treatment?
> However, universal healthcare is not a panacea as evidenced by many angry patients waiting for procedures in Canada and the UK - although they are leaps and bounds better off than many in the current USA system.
This needs a cite. Most folks I know in Canada and France are satisfied with a wait time for non-urgent procedures, knowing that at least they won't be potentially getting bankrupted like folks in the US for random billing.
Consider, perhaps, the alternate case: where your medications are not going well. Tons of people people will power through feeling awful and won't go see a doctor until they're half-dead.
Is it not a societal good to make sure somebody at least gets eyes on a patient? To me, the failing here is the cursory lack-of-care of your doctor, not the notion that you should see a doctor to check in on your meds.
The trope that waits are materially worse in single-payer systems is precisely that: a trope. I have had to wait "until some time early next year" to get a diagnostic procedure scheduled (my consult was in September), and the wait for, e.g., an initial visit with a dermatologist where I live is measured in months, for everyone. Just as a couple examples, which abound.
The trope comes partly from some of us who have lived in both and saw the difference first hand. It also depends on where you are (eg: Im told Quebec is a lot worse than Ontario, though I've never gotten the chance to compare them).
But when I lived in a single payer system, the thought of going to the ER was -terrifying-. Go in at 6am in excruciating pain, still waiting by 10pm unless you're spitting blood all over the place.
The first time I went to the ER in the US, I walked straight by it because all I saw was a bunch of nurse looking bored and no one around...because it was empty. Subsequent time it was a bit more crowded, but never the horrors that I saw in my childhood.
Now that Im older, for fairness reason I'd still take single payer any day. While I'm quite privileged, others are not, and I rather wait all day at the ER than knowing some people can get bankrupted by it. But the difference in wait times are still front and center in my memories.
I saw someone get an MRI inside of three hours in a Montreal ER for an injured ankle and comparing it to America for cost and turnaround time was pretty impressed
For the most part, I agree with you. But we need a fix and we need it yesterday. I think it is much more likely that we can implement Universal Healthcare than implement reforms that would bring transparency and other reforms that we'd need for a fully functional free market to the healthcare sector.
Also, I have serious concerns about whether a purely profit-driven market system can even work when people are negotiating agreements with their lives and physical well-being on the line.
I think the anomaly might be that the largely-free-market healthcare system in the US worked as well as it did for so long rather than the other way around.
Truly, I think we owe a debt of gratitude to the people running healthcare businesses for the last hundred years, and those still trying to today that let some form of ethics beyond how much profit they can extract from desperate people guide them. Unfortunately, they are working at a severe disadvantage.
> As another example, I’ve been on the same medication for the 8 years. I get the same dose, and it’s never changing. Yet my provider makes me visit every 3 months for a refill.
Know the feeling, my girlfriend has to get pap smears every 1 or 2 years in order to get birth control and she despises those checkups. Yeah, let's put more barriers to women getting birth control... Fortunately, I only have to deal with yearly eye exams to get contacts which are still super annoying but the pap smears sound awful.
It's ridiculous that birth control even requires a prescription in the US but it's not an issue you ever hear debated or discussed. The reason? If it were OTC (and no longer covered by health insurance) it would be prohibitively expensive for many of the young women who need it the most. So instead we end up getting annual pap screening even though it's only necessary every 3-5 years. Quite a corner we've painted ourselves into with this whole health insurance mess.
Birth control can safely be prescribed without a pap test. A pap test is merely a screening for cervical cancer. The fact that a medical provider would require a pap for a birth control prescription when that's not medically necessary is a problem. Overscreening for cervical cancer is also a big problem. Once every year is an inappropriate screening interval for most people.[1]
In some states pharmacists can prescribe birth control pills after a consult.[1]
There's no reason why we can't require insurance to cover birth control pills even if they are OTC. We can still have a pharmacist run it through insurance, you just don't need a doctor's note.
>All women should begin cervical cancer testing (screening) at age 21. Women aged 21 to 29, should have a Pap test every 3 years. HPV testing should not be used for screening in this age group (it may be used as a part of follow-up for an abnormal Pap test). Beginning at age 30, the preferred way to screen is with a Pap test combined with an HPV test every 5 years. This is called co-testing and should continue until age 65.
Another reasonable option for women 30 to 65 is to get tested every 3 years with just the Pap test.
FWIW, the Centers for Medicare & Medicaid Services makes the entire National Provider Identifier database searchable [0] and downloadable (6M rows, 7.25GB)[1], in which you can find all of the story subject's many fraudulent entries. Interestingly, even though CMS tracks and disseminates a file of deactivated NPIs, several/many of this guy's entries are still "Active" [2]
I've never really liked the "the business screws up and you pay for it" narrative so common in articles like this. I don't remember my microeconomics class too well, but the inefficiency affects the supply/demand curve, and I believe that the business and the consumer both typically take a loss. Not really so simple a story as "they just raise the price by the amount they lost and take it from you easy-peasy" like the line makes it sound, like consumers have just simply absorbed all cost/risk on the company's behalf.
At any rate, fraud like that should increase the inefficiency of the business, and in a competitive market, companies handling fraud better should get an edge, then we end up with a bunch of companies doing the optimal amount of fraud policing. Of course, we have the real problem of not having real competition in the US health care market.
It seems pretty obvious the cornerstone of that narrative is a poorly functioning market, lacking competition, price transparency, freedom of choice, etc.
Maybe 40 years ago only MD doctors were qualified to perform medical procedures and thus to have NPI's, but things change. Now states are all over the place on what professional is qualified to provide what service. Most states probably require some kind of registration, but I also wouldn't be shocked to learn some ancillary physical therapy or acupuncture or chiropractic service can be billed somewhere by someone who only has a PhD. Not in Texas apparently, but somewhere.
The article was about a brazen 'slam dunk' fraud, but for the 99% of other schemes that inflate a bill 5%, 10%, 15%, the blame is laid more correctly at the feet of the AMA and it's CPT Codebook (the 99215 in the article) which at once makes billing for things an awful chore and makes prosecuting less brazen schemes a total headache.
Look up 99215, for example. First of all, the description is copyrighted IP not freely available for use. Second, if you find it, it's a timed procedure that doesn't have a specific time attached to it. Just proving 'you billed for a long examination and didn't actually spend much time with the patient' generally will not suffice to prove fraud. Instead you need to delve into medical notes, interviews and compare the lengths of other examinations, just to demonstrate falsity for one occasion, one exam. This, and all the secrecy attached to medical records, is a big reason why medical billing anomalies are so unlikely to generate legal department responses.
A bit unrelated, but states make it easy to scam unemployment insurance too!
I've had a rando collecting unemployment benefits from my company's account for a year now because my company's name is similar to a grimy company that hires contractors and operates in a different industry. I've never had a relationship with the claimant and don't even know who they are.
My theory is: The scammers search for businesses with similar names to whom they contracted for and submit unemployment claims to whomever looks similar on the state business registration website. The state doesn't check to see if there was actually a record of employment and just puts the burden of proof on the business. If the response by the business isn't timely or things get lost in the mail, the state pays out whatever they claim.
At this time the risk appears small to the scammer as our fraud reports went nowhere, the cost to my business is large as it screws our UI experience rates up and has now lead to having to change/rebrand the business's name.
The scammer ended up with $4M in his pocket, for providing personal training services to 1000 people. Now, it sounds like he would also fraudulently bill the insurance companies for exercise sessions that didn't happen. But let's say only 800 people got personal training: that's $5000 per person. That's not an absurd amount for personal training over a long period of time. And their health was surely improved by the exercise.
Then someone with a personal vendetta against him got his business records because of bad OPSEC. I'm sure a lot of other people involved (clients, business associates) also knew it was a questionable operation, but they were probably pretty happy to have health insurance actually pay for things that improved their health for once. I don't feel like this type of fraud would increase healthcare costs in the way many other actors in the system (who are not about to go to prison) increase them.
If this guy had been ordained as a doctor and was just a little more careful with the billing, he'd be hailed for getting insurance companies to pay for exercise treatment. "You say you have pain? I prescribe 'physical therapy' where you work out with one of my assistants for an hour and I talk to you at the end." Easy as that.
It's kind of a stretch to say that this guy Williams was a hardworking health provider who just wasn't lucky enough to have an approved degree and good opsec. According to the story, his first felony conviction came from using his son's autism to submit fake invoices to get gov't reimbursement (nevermind the felony child abuse that landed him in prison).
And then there's the allegations that he highly exaggerated his services (describing "typical fitness exercises" as treatment for "lumbago and sciatica"). And then there's the several examples of clients who did notice and call out the egregious mis-billing:
> Another client texted Williams with concerns that her United insurance plan had been billed for 18 workouts in December 2015. That couldn’t be accurate, the woman wrote. “I had to take December off due to my work schedule and family in town,” she wrote. “I understand that people need to be paid but this seems excessive.”
The guy is a grifter, no doubt. But the general tone of the article implies that I should be concerned about some random sleazeball for raising my healthcare costs, rather than the insurance companies themselves (who in this case basically administered the defrauding of their client, Southwest Airlines, by not having proper vetting procedures), the MDs who undoubtedly commit the vast majority of insurance fraud, or policymakers.
I think this is a fair point, that the headline suggests a systemic problem, but its narrative is highly focused on one bad player, albeit someone who took advantage of highly exploitable weaknesses. Full disclosure: I used to work at PP years ago and my time overlapped with the author's, so I'm obviously biased. One takeaway I got was that the system is easy to game – particularly in applying to CMS for a NPI number. And apparently, insurers just assume or don't care that CMS does minimal vetting to stop fraudsters. And currently, it seems insurers are optimized to eat the costs (and ostensibly, pass it on to customers) than to actively root it out, which has its pros and cons ("cons" including being overaggressive and making it harder for regular people to get treatments approved.
While the system overall seems ripe for abuse – the story says CMS officials can't recall any instance in which someone has been sanctioned for applying w/ fraudulent credentials, and it's hard to believe that Williams is the first to discover the vulnerabilities – the story ultimately doesn't know the total costs of this kind of fraud.
Ah, true. But they had lots of family sources and court records for Williams, and I suppose no spokesperson from the insurance companies wanted to talk, so most of the article is just about him. I wish journalists would develop some more sources inside insurance companies, PBMs, etc. How they operate internally is just like a void that nobody wants to look in to, apparently. Like how do they decide what they'll pay for? Or how do they decide who gets to be part of their network? How long will they let a doctor send in fraudulent claims? There are probably 1000 analysts or programmers inside UHC alone who would happily help answer these.
Or the entire article. Sure, the foreground story is about a serial fraudster, but its substance is the cavalcade of systemic failure to do anything about him, or, by implication, any of the innumerable others like him, bilking the system.
If a system shrugs at fraud, what fraud it suffers is substantially that system's fault, IMO. Obviously, mens rea is a thing, but if you're cultivating an environment where bad actors can act badly, you own a heap of that bad.
Several years ago I wanted to learn Olympic Weightlifting. So I hired a trainer and have made good process considering that I was in my mid 30s and have never been active in my life.
These folks are gaming the system and getting something for free, that I've paid thousands of dollars for. That really grinds my gears. As far as I'm concerned his clients are just as complicit in this fraud as he is.
The thing to take away from this: Doctors, Insurance companies and big and small Pharma (small meaning pharmacies) are in cahoots with each other. Doctors charge for unnecessary operations and insurance companies don't care because they can pass on the costs to people who must have insurance.
But then why doesn't competition keep insurance companies more alert? Is it because it is really oligopoly, a bit like either you use Spectrum or Verizon there's really other choice?
Hospitals in California now requires Chinese patients to pay upfront, and from what I gather, you don't even need to ask the doctors and hospitals for them to unknowingly sign you up various healthcare benefits.
Some birth tourists in fear of immigration policy changes need to specifically stress and request to not being signed up.
A lot of this would be solved by knowing how much people make, what they spend it on and where the money came from.
If you want democracy, let people vote on who is a scumbag, investigate those people's financial history and if it's confirmed, ex-communicate them from society.
That'd border on real democracy however, so I don't see it taking place anytime soon :)
> A lot of this would be solved by knowing how much people make, what they spend it on and where the money came from.
> If you want democracy, let people vote on who is a scumbag, investigate those people's financial history and if it's confirmed, ex-communicate them from society.
I may be reading your point too narrowly but it sounds like you are advocating for a judicial system.
We'll always have scumbags who twist the law in ways to profit themselves.
This system is so broken we even have names for sub-categories of scumbags who literally abuse the law - one of them is called patent trolls!
That's why we need democracy - to vote on ex-communicating scumbags that try and do that. Law alone is not enough - I don't know why that's not immediately obvious.
There's also the question of incentives - if you can't spend money you steal without getting caught, you're far less likely to be a scumbag and steal in the first place. These seem like incredibly obvious things.
Healthcare companies are massive bureaucracies because there are people at every end trying to scam them. All that redundant paperwork is for a reason.
You wouldn't believe some of the things that people try to get away with. Plastic surgeons billing tummy tucks as emergency C-sections. People pretending they were the hospital so they can get the insurance company to reimburse them for the IV "hangover cures" they got every morning while partying in Vegas. People walking into office buildings and play-collapsing in the lobby so they can get an ambulance ride to the hospital across town, then once they arrive they run out of the hospital and down the street because all they were really looking for is a free ride. People who have six or seven dependent children from multiple partners on their insurance, then yell at us because the partner they're living with didn't know about all those other children from all those other spouses until they opened some piece of mail from us.
I'm not saying that insurance companies are all good. IME, most are not. But if people were just honest and decent, a large part of the healthcare system dysfunction wouldn't exist.