Comment by doctorpangloss | Hacker News Reader

Comment by doctorpangloss | Hacker News Reader

Wellness programs don't need to have positive outcomes to make sense for insurers. Instead, they need to use enough superfluous technology to discourage older people from signing up for them.

Hence, from a linked point in the article:

> AARP, the consumer advocacy group for older Americans, sued the federal government in 2016, arguing that the rules governing the [wellness programs] violated anti-discrimination laws aimed at protecting workers’ medical information.

That lawsuit against Kaiser was over individual coverage. Kaiser realizes all its savings by carefully maintaining very health (i.e., young) pools. The medical information stuff is the legal argument, but it was really a lawsuit about making people do stuff that disproportionately negatively affects old people.

If you try the wellness program for people whose enrollment is through their employer, and your employees are disproportionately not college educated or young, the wellness program of the kind you and I are familiar with will not be effective at either lowering costs or improving health outcomes. That's why this program was sort of doomed to fail.

There exists an as-of-yet unobserved program that gives people money in exchange for behavior modification with positive health and cost savings outcomes. It will probably look more consuming entertainment--stuff that has evidence people will do over long periods of time. We're a long ways off from finding the appropriate design of such a program.

I've seen it done in a much more brutal (if less discriminatory) fashion - everyone who doesn't get a full fluids screening in done 2 months sees their premium jump.

Employees are responsible for booking their lab appointment, receiving the lab sample, and then submitting it manually. So that's 2-3 weeks to schedule and make an appointment, followed by at least 4 weeks for the lab's turnaround, followed by time to submit the paperwork from the lab.

Great way to raise some rates.

That is pretty harsh. I'm personally scared of the future liability and privacy implications of deep screens, especially if it's employment related. Is that irrational or justified?

On the other hand, my life insurance company asked for an update on my health, and after I had a blood test, they came back and said I was so healthy they were going to have to cut my rates, and they did massively, by like half. They weren't threatening to raise rates or offering to reduce them, so I guess it felt like a very positive thing. Still worried that somehow the data will be used against me to reject claims when I get old.

The good news is that all the solutions are systemic, relying on individual heroic actions to preserve privacy won't work for society at large.

The bad news is that we hate each other and don't like systemic solutions, even if they are easy (and it is comparatively easy to specify what information private insurers can use when setting premiums and then audit the premiums).

I think it's justified. I felt lethargic so I got my testosterone tested. Came back low. But now that's a pre-existing condition so if the ACA is overturned I'm SOL.

It will probably return to the pre-ACA regime where maintaining continuous coverage of SOME sort will preclude an insurer from using "pre-existing conditions" to deny coverage. COBRA is useful for this especially for those who lose their jobs, albeit at immense cost.

I'm not saying everything's fine, but you do have some options.

I've never been without health insurance and I was rejected from several insurance carriers pre-ACA. I was on cobra at the time but trying to switch because it was so expensive. But luckily Cobra got me through until the ACA kicked in.

Tangental question - how did you get your testosterone tested? I'm curious to do the same thing. Do you just book a meeting with your PCP? Ask them for it? Is it more practical to do a number of different blood tests at once?

Sorry if this is an obvious question

I just went to walkinlabs and got it tested. It's usually much cheaper than going to a doctor for lab testing.

They pitch it as a “discount” if you complete it and meet goals.

Yes, but that actually works and makes people generally happier with it than if it were pitched as a penalty.

A good case study of this is world of warcraft's rest system when it was first introduced in beta vanilla back in the day. Initially it was called a penalty for playing too long; you would begin to receive less XP. Players didn't like this, so they rereleased the system and called it a rested XP bonus. Players loved it.

It may be manipulative, but if it makes people happier and results in higher usage rates for the system, then why not?

What about countries with mandatory health insurance. How should it be handled here?

First thing we can do is to call the health insurance mandate penalty a deduction.

With no opting out because it would affect lifestyle choices? There actually are some programs to get boni, but I am mostly against this. Public health insurance is a system based on solidarity. I would like the option to opt out of Public health insurance.

Yeah, they pitched it as a discount but they also raised the base rate at the same time so the framing rang a little hollow.

Yep. My employer lowers my premium and awards us with Amazon gift cards if we earn a certain amount of points each year. You earn points by completing a full blood test, visiting the dentist, etc. It's a significant enough amount that everyone is motivated to do it.

It would require probably hundreds of thousands of dollars of extra salary before I would consider sharing that info with my employer, possibly millions (not exaggerating). Trading that info even for tens of thousands of dollars (let alone peanuts like gift cards) seems deeply unappealing to me.

We would get $500, $1,000, or $2,000 if we met certain criteria, deposited into our HSA

Wait would they get the details or just the information that you went and did it?

If they needed a digital version of a doctor’s sign off, that’s enough for me to say no thanks. I don’t want them knowing when or where or how frequently I check off their particular health checklist items. Giving them any more details, such as the result of tests, would be an astronomical violation of trust, no way.

I even hate it that my insurance company generates paper _or_ digital records stating the exact application of my benefits (resulting in a copay, etc) for individual appointments, even if I already paid the relevant bill onsite at the doctor.

It just creates a data exfil / hacking risk if it’s digital, or a risk someone (China) will pick through trash or recycling and get it, when there’s literally no need to create the record (they’d already have the claims record from the doctor making a claim, this is a separate thing they generate to send to me redundantly describing the applied benefits... note: it’s not a bill (and very clearly says it’s not)).

That's pretty crazy because outside of cholesterol and A1C using blood tests for screening in asymptomatic populations has little proven benefit.

EDIT: And there's no benefit in testing cholesterol or A1C every two months unless you're actively tinkering with medication doses for people with high cholesterol or diabetes respectively.

It doesn't matter if the test does anything, if the main aim is price discrimination.

A company can boost profits by raising prices and offering a discount for anything inconvenient. Increase the price by $250. Then offer $50 off for spending an hour in a phone queue. $50 off for clipping a coupon out of a newspaper. $50 off for faxing us a photo of you with a shoe on your head. $50 off for making a pilgrimage to the hermit who lives on top of the mountain. $50 off for filling in a form only available on Flash on Konqueror on KDE2 on FreeBSD.

Price-sensitive customers will go through the hassle to get 5x$50 off, price-insensitive customers will pay the extra $250. Thus, more profit from the latter without losing the former.

Sorry if it was unclear - this was a large battery of tests, run one time.

at least 4 weeks for the lab's turnaround

4 weeks??? Aside from a handful of tests which need cultures to be performed, I would be shocked if tests took more than 4 days. When I have my HbA1c, TSH, lipids, CBC, and electrolytes checked, I normally have results within 12 hours.

What do you mean premium jump? You guys pay individual rates for health insurance rather than a flat % of your income? How odd.

The last place I worked before moving away from the states had different rates for different folks. It was not a percentage of income, but rather a flat fee.

So if you did your physical, you got a discount. Non-smoker? Charge less. (They'd only pay for smoking cessation program once, though). Not meeting company wide health numbers (blood sugar, cholesterol, etc)? You get charged more unless you have a doctors note saying it was medically impossible for you to meet the numbers.

Not only that, but Americans have a concept of "pre-existing conditions" -- that is, your medical history -- so that a health insurer can refuse to cover you on the basis that it might not be profitable for them.

Americans have the concept of a death panel, which is theoretically some sort of government entity that decides whether you get medical care, but actually exists as a profit motive for health care.

Pre-existing condition exclusions no longer exist. Although Trump wants to overturn the ACA and bring them back though. Death panels exist in the abstract: they are largely republican politicians who want to bring back pre-existing conditions and otherwise strip people of insurance and remove specific coverages as well. Fox News and Murdoch have really done a lot of damage to the country.

> ... so that a health insurer can refuse to cover you on the basis that it might not be profitable for them.

Or rather, on the basis that known expenses are not something which ought to be paid for through insurance. Which is completely correct: Insurance exists to mitigate risk. Once something becomes a pre-existing condition it is no longer a risk.

The problem with the pre-ACA system was not that insurers sometimes wouldn't cover pre-existing conditions, but rather that the insurance you had at the time the risk was realized (when the condition was discovered) didn't cover the full lifetime cost of treatment for that condition—it was dependent on maintaining the same insurance plan. That implies that the insurer, and perhaps even your employer, has every incentive to drive you off your current plan once your condition is discovered and thus make your treatment someone else's problem.

Whether we're talking about a broken bone or discovering that you have leukemia, once it's been established that the condition is covered by your insurance plan the cost of treatment should continue to be paid by that insurance provider—perhaps via a trust—even after you've switched insurance companies or dropped health insurance altogether. Having the payments for your treatment pass to the new insurer when you switch insurance providers is a unearned windfall for the original provider and an unfair (and ultimately unsustainable) penalty for the new insurer forced to take over treatment of your pre-existing condition.

Hang on, so the clock ticks until the lab sends it back, rather than the time submitted to the lab? And the lab is associated with the insurer/health provider? So all they have to do is delay everything for 3 months?

The clock ticks from announcement until the employee submits the results received from the lab. The lab is selected from a list of approved labs, but is otherwise unaffiliated.

Collecting behavior data is important to insurers as they can profile customers based on public data.

For example, if you work out 4 days a week, and have back pain diagnosis, you might be a different risk for recovery complications than a guy who doesn’t work out.

There are folks looking at using consumer behavior and habits to predict health outcomes.

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