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Comment by twoodfin | Hacker News Reader

This is basically an impossible situation that will have to be resolved by Congress. As sympathetic as you can be to an individual patient, here we’re talking about multiple biologics being used off-label at the direction of a single doctor.

I accept the premise that he’s an expert and the drugs are working, but asking insurers to distinguish this case from any of thousands of desperate patients and less-expert doctors desperately trying to help them with millions in off-label therapy, then pillorying the insurers with bad press and lawsuits any time they get it wrong is a recipe for an accelerating climb in costs.

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> As sympathetic as you can be to an individual patient, here we’re talking about multiple biologics being used off-label at the direction of a single doctor.

But that's being denied by a single doctor, who hasn't practiced in 30 years, and never practiced in the relevant speciality.

"He said his review of McNaughton’s case primarily involved reading a United nurse’s recommendation to deny his care and making sure 'that there wasn't a decimal place that was out of line.' He said he copied and pasted the nurse’s recommendation and typed 'agree' on his review of McNaughton’s case."

"'You are giving zero weight to the treating doctor’s opinion on the necessity of the treatment regimen?' a lawyer asked Cates in his deposition. He responded, 'Yeah.'"

They're also hand-picking doctors to obtain their desired result.

"In a recorded telephone call, Kavanaugh told an MRIoA representative that 'I had asked that this go back through Dr. Pabby, and it went through a different doctor and they had a much different result.' After further discussion, the MRIoA representative agreed to send the case back to Pabby. 'I appreciate that,' Kavanaugh replied. 'I just want to make sure, because, I mean, it’s obviously a very different result than what we’ve been getting on this case.'"

> asking insurers to distinguish this case from any of thousands of desperate patients and less-expert doctors desperately trying to help them with millions in off-label therapy

Nobody (other than their shareholders) is asking the insurers to do that. Insurance customers just want their insurers to pay for the healthcare that their licensed care teams provide. Nobody is asking their insurers to contact strangers who have never personally examined them to overrule their physicians, who have more pertinent data.

In reading the article, I was struck by the number of people employed by UNH whose jobs basically are to deny coverage for which the member has paid.

So any plan-approved doctor can try anything at any expense? Biologics are the accelerant for this problem, given their 6-figure annual costs.

> So any plan-approved doctor can try anything at any expense?

No. A review process of some kind is reasonable. One utilizing hand-picked doctors who haven't practiced in 30 years (see the section with Dr. Nady Cates), and not ever in the relevant speciality, is less reasonable.

For a case this complex, the denials shouldn't take minutes. They shouldn't be able to hand-pick a doc from the supposedly independent review organization. And they shouldn't be able to suppress reports from their own experts that say it's medically appropriate.

> Dr. Nitin Kumar, a gastroenterologist in Illinois, concluded that McNaughton’s established treatment plan was not only medically necessary and appropriate but that lowering his doses “can result in a lack of effective therapy of Ulcerative Colitis, with complications of uncontrolled disease (including dysplasia leading to colorectal cancer), flare, hospitalization, need for surgery, and toxic megacolon.”

> Unlike other doctors who produced reports for United, Kumar discussed the harm that McNaughton might suffer if United required him to change his treatment. “His disease is significantly severe, with diagnosis at a young age,” Kumar wrote. “He has failed every biologic medication class recommended by guidelines. Therefore, guidelines can no longer be applied in this case.” He cited six studies of patients using two biologic drugs together and wrote that they revealed no significant safety issues and found the therapy to be “broadly successful.”

> Gesk discovered it by accident when he was listening to a recorded telephone call produced by United in which Kavanaugh mentioned a report number Gesk had not heard before. He then called MRIoA, which confirmed the report existed and eventually provided it to him.

Put yourself in the position of the patient. Would you want your doctor or your insurance company dictating your treatment?

Yes. How is this so hard to comprehend?

I don't care how much a drug costs and nobody should. The reason we pay for insurance is to use it when we need it. Same goes for disability insurance. All these insurance companies will do anything possible to weasel out of paying.

I don't know a single person happy with health insurance companies that has used them extensively.

If there is a case study that shows a certain drug resolved symptoms that a physician's patient is suffering from, he should be allowed to prescribe them off-label.

US spends 18/% of GDP on healthcare, and we still have to pay into the insurance scam. I would at least expect to get the best care in the world and access to any medication my physicians desires without any bullshit.

If anyone with an MD can prescribe any medicine with any rationale, and biologics stay at these 6-figure costs, you will certainly see more than 18% of US GDP being spent on healthcare.

How? The US govt. won't be paying the bill in most cases.

That's still counted in GDP.

> and biologics stay at these 6-figure costs

High healthcare cost is the entire reason we pay for health insurance. If treatments were cheaper, UNH would not be worth half a trillion dollars.

Put another way, this is exactly what UNH signed up for. They actively lobby against efforts to reduce healthcare costs at the expense of their profits, which largely derive from amortizing the risk that some of their customers will have treatments too expensive for them to afford.

As an analogy, a home insurer doesn't get sympathy when they try to dodge rebuilding costs after a fire or other disaster reduces their profits. The insurer explicitly signed up for the job of paying for the rebuilds, and that was not contingent on the cost of the hypothetical future rebuilds.

They have the scale to influence healthcare costs through means other than denying claims. And they have the financial heft to (for example) buy makers of expensive niche treatments if they dislike other market participants capturing healthcare dollars.

TL;DR; this is a problem entirely of UNH's own making, for which they are well compensated by the markets. Regulators should not allow them to operate in our regulated markets in this manner.

then pillorying the insurers with bad press

>"When the McNaughtons first learned of Opperman’s inaccurate report of the phone call with Loftus, it unnerved them. They started to question if their case would be fairly reviewed."

The insurer lied. What is impossible about this situation. The insurer lied to stop spending money.

>In a deposition, Kavanaugh said that after she opened the Kumar report and read that he was supporting McNaughton’s current treatment plan, she immediately spoke to her supervisor, who told her to call MRIoA and have the case sent back to Pabby for review.

>Kavanaugh said she didn’t save a copy of the Kumar report, nor did she forward it to anyone at United or to officials at Penn State who had been inquiring about the McNaughton case. “I didn’t because it shouldn’t have existed,” she said. “It should have gone back to Dr. Pabby.”

They lied and buried evidence against them. They deserve way more than pillorying by the press.

no pillorying in the press only matter if people can choose to go elsewhere.

They UHC medical staff should lose their licenses: the nurse because she intentionally lied and covered up medical reports that didn't support her claim, the doctor because they were claiming to do a medical review but were just signing whatever was given to them despite not practicing, not having the relevant speciality, and not actually reading into the patient details. That's clearly malpractice: you're claiming to be a medical professional making a medical decision, that means that's what you do.

UHC should be subject to criminal fines and federal oversight. In addition to lawsuit payment. There's malpractice from the above, but that's clearly directed and intentional by the company.

The "independent" review board should be required to provide all reports to the patients as well as the insurance companies, the board should not allow the insurance companies any say in who does the review. In all cases a review should be legally required to be from the appropriate field.

and they should all be pilloried in the press :D

> asking insurers to distinguish this case

It's a strange idea to me. Public insurance in Ontario, Canada makes coverage decisions at a high level, such as whether a drug or procedure will be insured. If it's covered, physicians make the decision. Some medications are restricted to specialists (only infectious disease experts can prescribe HIV antvirals and have it covered, for example). And some are limited use, i.e. for specific indications the physician needs to tick off.

Neither fraud detection nor abnormal prescribing need the power to review and potentially deny individual prescriptions. If a particular doctor is prescribing all weird and not to typical norms, that can be addressed directly.

Neither Entyvio nor Remicade show up in a cursory search of the Ontario-approved formulary[1].

Where does that leave this desperate patient if he lived in Ontario? Should his Canadian doctor be able to prescribe these drugs for Ontario to pay for regardless? Many ITT seem to think this is obviously true.

[1] https://www.formulary.health.gov.on.ca/formulary/

They do forced switching up north AFAIK.

Drugs admistered in hospital are handled separately. A brief search suggests generic infliximab is covered:

> Effective December 18, 2020, Avsola (infliximab) will be added to the Ontario Drug Benefit (ODB) Formulary as a Limited Use (LU) benefit for the treatment of rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), plaque psoriasis (PsO), ulcerative colitis (UC), and Crohn’s Disease (CD).

Drug brand names are often different here, which is confusing.

If it is not covered publicly, you need private insurance, or to pay for it yourself.

Remicade has a generic: https://www.formulary.health.gov.on.ca/formulary/results.xht...

I’m curious if the treatment this patient received would be considered off-label in Ontario. That’s really the issue here. If it were on-label in the US, I’d be taking a very different angle on this!

> only infectious disease experts can prescribe HIV antvirals and have it covered, for example

Jesus fuck Canada is amazingly backwards if that's the case. So if you get stuck with a needle or a condom breaks you need to wait until you can see a specialist to get on post-exposure prophylaxis? Which has a 72-hour window to start, by the way.

Go to the ER. Every hospital will have PEP starter kits, and easy access to an ID specialist.

The biggest barrier to accessing PEP in Ontario in practice is cost. Most working age adults are not covered by public drug insurance.

There should be no such thing as a "coverage decision", outside of you and your doctors deciding on a course of treatment.

The fundamental source of the rot in the healthcare system is that price signals have been utterly destroyed by cartel behavior, leading to an endlessly growing bureaucracy making bespoke decisions about what's "approved". HMOs and provider "networks" should be illegal (straightforward antitrust), every provider should be made to publish straightforward prices (uniform regardless of who's paying), and coverage/copayments should be based only on price. Only then will the market be able to right itself, and develop administrative structures that revolve around providing patient care rather than policing access to it.

The insurance offerings that cover expensive conditions will then end up looking similar to the LTC/life insurance market, rather than this fallacious game of musical chairs that we play every year during "open enrollment". Subsidies for people who can't pay for what they need is an orthogonal topic, and funding for such can only come from the government or private charity. The current system tries to bundle it all together while hoping that corporate charity will magically arise, when the obvious incentive is for health "insurers" to take all the money they can from healthy people, and then drop them once they get sick.

If Congress resolved it, what you’ll end up with is a government agency saying “no” instead of an insurance company.

The government agency doesn’t stand to gain money by denying coverage though.

They will still have a budget, and policies to manage that budget they have to enforce.

In the US, insurers have to spend 80% of premiums on care. The more they spend on coverage (the 80%) the more they get to collect on overhead and profits (the 20%). They can pass the costs on in terms of escalating premiums.

A government agency, by contrast, is on a budget and to get more money it has to get Congress to raise taxes. You think public transit agencies criminally prosecute turnstile jumpers for fun?

So you are saying insurance companies have incentives to drive up the cost of healthcare as part of their business model? That sounds very damaging considering the percentage of GDP healthcare takes up. Might make more sense to scrap that captured industry built on perverse incentives that has only gotten worse and worse during my lifetime. We are now at the point where people refuse ambulance service. This is NOT working.

> So you are saying insurance companies have incentives to drive up the cost of healthcare as part of their business model?

Yes, as part of the ACA. Stories about denied coverage create outrage, but the structural incentive for insurance companies is to cover too much. My dad is a public health expert. He was speaking with a German colleague recently about Germany’s extensive hospice system. He came back asking why we don’t do that here.

> Might make more sense to scrap that captured industry built on perverse incentives that has only gotten worse and worse during my lifetime

Lots of developed countries make their health systems work with a private health insurance based system. Germany, the Netherlands, Switzerland, and Japan all rely on that model. In Japan, for example, 70% of health care spending comes from employer-provided insurance or out of pocket spending.

What’s different in all of those countries is: lower doctor and nurse pay, centralized price controls, greater supply of care providers, and aggressive cost-benefit based control over use of expensive treatment.

Yes, that is exactly the (problematic) incentive insurance companies have.

They still operate on a budget, and have to make decisions to stretch that budget. British NHS, for example, will deny coverage for a lot of procedures that are routinely covered by American private insurers, because they do not consider these treatments good value for the money. If you disagree, tough luck.

But at least the government is a group that can be pressured to improve things. Insurance companies are not. Right now, the US has the worst health care of industrialized nations, unless you're wealthy. I have a hard time believing the government would do a worse job of it than companies we have now.

Yes it will have to be resolved by congress, but not in the way you think.

While you complain about the possibility of some low-skilled doctor using a drug off-label and costing BigInsCo money because it doesn't work, that is actually quite unlikely, and a far smaller harm than what is actually happening.

The insurance companies are overruling the medical judgement taken in the best interest of the patient by some of the highest trained and skilled physicians in THE WORLD, and using low-skilled nurses and doctors to do it.

Your premise that "asking them to distinguish" when the treatment plan is literally designed by some of the best doctors in the world is absurd. You really think that some doctor that couldn't cut actual practice and fell back on InsCo job, and some nurse are on anything like the same level as Mayo physicians? You are literally saying some just-out-of-college junior programmer should be hired to review & reject code over the judgement of Linus Torvalds or Bjarne Stroustrup. It's forking idiotic.

I've got close family members who have gone to Mayo Clinic for help with inscrutable disease conditions. And the insurance companies keep coming up with all kinds of BS reasons to deny. We're literally working with world leaders in the profession, who actually make headway on the disease when no one else can, and the InsCo dolts (who knows if they even have any kind of med license) try to declare some tests "medically unnecessary" or deny on some other pretext (e.g., "you didn't call three days ahead for approval"). Literally, who the f*k are you to question the literal top docs in the world?

In short, insurance companies are systematically scamming, committing fraud, and murder for profit. You can meet all the terms of their contract, make every payment, but if their systematically running software detects that you have a condition or expense profile that puts you in the top 5-10% of expenses, you will get "reviewed". And they will literally do anything possible to deny and delay your payments and therapy, even if you die, just to increase their profits. There was sworn testimony before congress by an insurance employee who "saved" $500k by denying coverage to a patient who died; she was promoted. for that. It is literally defrauding the customer, accepting payments for services you deliberately and systematically have no intention of providing, and denying those services resulting in death, all for your profit.

Putting incompetent gatekeepers in the loop with a profit motive to harm or kill you is at this point, obviously harmful.

It should be up to the physicians alone to determine medical treatment. Period. Full Stop. Insurance companies should be banned from gatekeeping.

If gatekeeping is allowed, it cannot be in the current form of "just deny coverage because we don't like it"; it needs to be at least provide a better treatment plan that produced documentably better results (and no, you can't suggest one that the patient's docs already tried and didn't work). The result would be either no gatekeeping or the ins cos will need to hire actual highly skilled physicians who act as a true 2nd opinion team, which would be a step up from these ignorant gatekeepers.

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