> Their doctors are left to walk a tightrope trying to convince insurers that patients are making enough progress to stay in treatment as long as they actually need it, but not so much that the companies prematurely cut them off from care. And when insurers demand that providers spend their time justifying care, it takes them away from their patients.
I don't know how this isn't considered the insurance companies practicing medicine without a license.
> Insurers most often turn to two sets: MCG (formerly known as Milliman Care Guidelines), developed by a division of the multibillion-dollar media and information company Hearst, and InterQual, produced by a unit of UnitedHealth’s mental health division, Optum. Insurers have also used guidelines they have developed themselves.
Presumably, the guidelines were written by medical professionals.
> In interviews, several current and former insurance employees from multiple companies said that they were required to prioritize the proprietary guidelines their company used, even if their own clinical judgment pointed in the opposite direction.
In medical care, the attending doctor should be the one taking final call. Otherwise, we'd all be receiving medical treatments based on a bunch of flowcharts.
>A few hours after the session, Moore drove herself to a hospital and was admitted to the emergency room, accelerating a downward spiral that would eventually cost the insurer tens of thousands of dollars, more than the cost of the treatment she initially requested.
Is the issue here that most patients in this slot would have just made-do with the lower level of care, so the insurance company is saving money even if a handful end up in the emergency room? Or is it that the insurance company is inept and is not even saving money in expectation?
I'm not sure whether "is too cut-throat at saving money" or "is too incompetent at saving money" is the worse problem to have, but they probably have different solutions.
It just means that rather than "trust doctors" or "evaluate care" it's cheaper to hire a random doctor who evaluates and sets limits based on arbitrary reasoning about "excess" and that reasoning follows from what crimes they've gotten way with previously (lawyers).
This is not a system of care; it's a system of squeeze the turnip, with a parade of MBAs who constantly need to turn the screws to ensure they can climb the latter.
It's sociopathy, like the entire business capitalism. It's just that in this case, the consumers arn't directly the costumers.
William Mayo said in 1910, "The best interest of the patient is the only interest to be considered." If we would design a healthcare system to follow this ONE PRINCIPLE, there would be no healthcare problem.
With the horrible reputation US insurance gets, is there some reason why smaller insurance companies aren't popping up to deliver better quality (i.e. less denials)? Is the field simply heavily protected by lobbying and regulatory capture?
In addition to the other responses, I'd add that I don't believe the "free market" adequately incentivizes insurance companies to "deliver better quality". If it did, I don't know that we would've seen a collective, "Oh, yeah, we get it," response to the recent shooting.
My faith in things is so entirely shot that if I saw a company like the one you suggested, my immediate, heels-dug-in assumption would be, "That's cute, and in five years they'll be just like the rest of them".
Well there is also the fact the calling the US healthcare market a "free market" stretches the term beyond all comprehension.
Due to a weird, historic tax incentive, people get mostly get insurance through their employers. Their interests are not in opposition to, but are still different than those of the people actually being insured. So you have a situation where the people doing the insurance "shopping" aren't the ones using the insurance.
Then on the actual healthcare side, for no coherent reason, almost all prices are hidden from the patient, totally inscrutable, or highly variable. Providers and insurers collude to keep these prices astronomically high so the providers they can overcharge medicare (which is not allowed to negotiate prices) and the insurers can "give" their customers "negotiated prices."
A more normal free market would be something like: people buy their own insurance or pay providers out of pocket. This would incentivize people to make price conscious decisions and evaluate insurers and providers for quality. Providers would need be required to set and publish fixed prices for different procedures and services so the market could actually function, but this seems pretty simple.
As a cherry on top, prices also aren't visible to the doctor, aiui. Doctors also can't really tell in advance if something is going to be covered or not.
Doctors seem to me like deer caught in the headlights of an oncoming train that is the medical system. My wife just lost her third primary care doctor because of turnover. When I was a kid we had family doctors we had known and visited at their office for twenty years and one doctor would stop by our house to visit and check in on my brother whom he diagnosed and treated as a cystic fibrosis patient for over a decade. We were just an insignificant middle class (working class) family in Cincinnati.
These days the bedside manner is trash. Though I don't blame the doctors. And they are little more than privileged employees...if that. The real service they provide, and the service people are growing to expect, is to navigate the insurance system to wrangle out some semblance of coverage. Being employees the most you are going to get is a wink and a nod because as employees they cannot speak freely.
Systems drive human behavior and determine human performance. Individual exceptionalism doesn't scale. The default of course is ineptitude, which is why it's so important to design systems that yield exceptionalism.
In the case of healthcare I don't think we are capable of building a system this large, prescribing every detail, while getting it right. It's like trying to plan an economy.
> why smaller insurance companies aren't popping up to deliver better quality
I am no expert, but my impression is that it would be very hard for the insurer's customers (e.g. employers) to know an insurer was better, and many might not care. There's so much opaqueness and indirection in the system, it's not surprising it's both inefficient and heartless.
That said, all systems ration in some way or another. We need to come to grips with that.
And you might hope that reviews or consumer surveys might help, but all health care companies seem to provide the same mostly mediocre, unpredictably terrible service.
Probably a combination of heavily regulated, the lack of choice for employer provided plans, and the difficulty in building out a network of doctors and other facilities. Would you sign up for an upstart health insurance with a tiny network?
If those providers were local to where I live and I don't travel much or at all, yes I would - if I were an American that is. I'm a Dutchman living in Sweden so I'm used to two totally different systems.
Insurance is made in the margins of charging a healthy population more than you will use for them in the year. The reason "Single-Payer" is "the answer" to everyone's woes, is that in order to make anything close to a reasonable amount of money on insurance you need to have an actual population to insure. This typically works because insurance companies are big.
This also means that any new insurance company needs to pick up a ton of customers. This is really hard to get off the ground in a way that will make you money. You would ideally pick up a healthy population (younger folks), and then you'd have to get lucky on your actuarial tables for the population of people you pick up insurance plans for.
like all the other capitlism things, monopolies drive the wheel, and because no one typically shops for it but rather has to take whatever companies give them.
Because insurance is one of the most nakedly capitalist business models around. The goal of of insurance companies is to make as much profit as possible by paying out as few claims as possible.
>A few hours after the session, Moore drove herself to a hospital and was admitted to the emergency room, accelerating a downward spiral that would eventually cost the insurer tens of thousands of dollars, more than the cost of the treatment she initially requested.
I don't mean to diminish the struggle that Moore went (is going?) through, but at least there was some kind of karmic retribution here.
Europe here. It is sad to see the results of the EEUU healthcare system. I still do not get why people do not vote for a more rationale and public service. I guess the EEUU media have brainwashed their people into thinking that a private health system is better. People do not see the problem until it affects them ... until it is too late...
In Mexico that's the US, so maybe the poster is from Spain.
The doubling of the letters (e.g., "EE." for "Estados" and "UU." for "Unidos") follows a convention in Spanish where plural abbreviations are indicated by duplicating the letters. The correct form would be "EE. UU." This practice aligns with historical Latin abbreviations (e.g., "SS." for "Sancti" (plural) or "S." for "Sanctus" (singular)).
Suppose insurance company doctors could lose their medical license if too many of their decisions are reversed in court. I imagine these doctors would command higher pay for their increased level of personal risk, but would end up making better choices for the insured. What does HN think?
What about if we instead of building more levels on top of this already falling building we build a new one a few blocks over. With blackjack, hookers, and free* and humane health care.
* not really free of course, but you pay less on average than you do today and you do it on your taxes instead of to some profit chasing private company -- and most importantly those who don't pay today will have equal access to it as well.
There is no excuse for insurance fraud like this. C-Suite and board of directors must be held criminally liable much like drug overlords are held criminally liable.
The CEO is primarily responsible to [maximize profits for] shareholders, not necessarily to benefit patients. If shareholders wish for better care to be provided to patients, I’m sure they would be happy to accept a lower rate of return on their investment.
It's almost like profits shouldn't be part of the equation when we are talking about humans lives and health.
Noone should enrich themselves on others not getting the health care they need, and those who do it today are morally bankrupt -- and society should fight back.
Shareholders of publicly traded businesses have governance power; they can vote for or against board members and policy documents.
Perhaps this is one of the concerns with the rise of index funds— fewer investors make use of their governance power and the index funds just vote according to the recommendations of the current board.
I don't know how this isn't considered the insurance companies practicing medicine without a license.
reply