You Snooze, You Lose: Insurers Make the Old Adage Literally True
propublica.org
propublica.org
"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."
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.
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.
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-...
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.
On the other side, there’s a revenue maximizination consultant pushing doctors to prescribe unnecessary equipment like inhalers and CPAP.
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 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.
A moment for founders to truly question whether their work will change the world for the better.
There are many countries in the world that are able to service their populations healthcare needs without involving private insurance brokers.
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.
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.
[1] https://ds.ccc.de/download.html (german)
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.
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.
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)
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.
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.
Being an idiot and getting yourself killed is not the doctors fault.
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.
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.
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.
Or you know, get a national health service that treats human beings with dignity and humanity.
>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.
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.
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.
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.
Insurance should be able to do actuarial risk and charge accordingly.
Tell me. Can you explain why that is OK in your narrative?
I haven’t made the choice to look after your parents.
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.
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.
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.
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.
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.
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.
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.
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.
Sure sounds, at least scam adjacent or abusive in the least.
Of course, dealing with insurers is nearly as bad. The US health landscape is broken beyond belief.
Check out their pricing for devices vs. what is listed in the article...
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.
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.
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.
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.
It so happens that antidepressants cause people to gain weight frequently.
Ever tried debugging a program on a machine with bad RAM? It’s kinda like that.
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.
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.
Please don't create HN accounts to abuse the site with.
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.
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.
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.
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".
“... 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.
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.
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.
https://www.ribbonfarm.com/2009/10/07/the-gervais-principle-...
This is an odd thing to say. The ethic of reciprocity is a value. What do you think religious values are?
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.
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.
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.
Traditional religions were aimed at preserving a specific culture, things in line with that were nice, anything falling out of that would be shafted.
>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.