Hacker News Reader

THIS!!

Similar for a close family member with a strange heart and immune condition.

InsuranceCo BCBS had some bureaucrat without even a medical degree directly second-guessing the tests ordered by the literal Director of Cardiology at the world-renowned Mayo Clinic.

All I can think is: "Who the fck are you to even begin to question this expert, and deny his recommendation?". Now, IFF they had some actual peer reviewing it (e.g., the head of cardiology at Cleveland Clinic or Harvard Med School), that might be legit, but this is nothing of the sort. It's like the tech giant's arbitrary terminating accounts with support, except instead of cutting off your livelihood, they are killing you.

It is the death of expertise. It seems like practicing medicine without a license and without even seeing the patient (which is legally required before writing many prescriptions).

Why it is even close to legal is utterly baffling.

(I hope your dad continues to recover)

When Americans style healthcare promoters toss around arguments like “doctors in public healthcare are deciding if treating you is worth it”… I love replying with “at least in public healthcare the doctors get to decide, with only private health insurance paid for by insurance companies, it’s a faceless claims adjuster with zero medical experience who isn’t even deciding as much as they are just telling you that treating you properly would cost the company too much money… I’ll take my chances with a death panel of doctors over the death panel of accountants any day of my entire life”

I think American healthcare is insane… and the slow sliding in the American style healthcare direction I see in the UK and even slower slide here in Australia, this slide is largely borne out of American healthcare business having no more room to expand and trying to export their business model overseas to expand their addressable markets… it’s insane to allow non medical professionals… to allow armies of accountants and actuaries… to decide how to treat patients.

It should be criminal, but it won’t be because the healthcare industry in America is so broken it will lobby till it’s broke to continue to be allowed to remain broken otherwise it might not be as profitable.

> I love replying with “at least in public healthcare the doctors get to decide, with only private health insurance paid for by insurance companies, it’s a faceless claims adjuster with zero medical experience who isn’t even deciding as much as they are just telling you that treating you properly would cost the company too much money… I’ll take my chances with a death panel of doctors over the death panel of accountants any day of my entire life”

I think a licensed doctor/pharmacist employed by the insurance company has to make the decision, although, since they do not have liability exposure, I can imagine metrics can be imposed on them that make the quality of their work less than desirable.

Remember: the doctors working at insurance companies do not need to have a license to practice medicine to do so. In fact an orthopedic surgeon had to fight a denied authorization from a guy who lost his license for surgery for life because he installed a hip backwards!

Yes, that was an egregious example. I think they skirted that one through because that doctor still had a medical license, but not one for surgery? Which, whoever wrote the rules or even just hired him, should have prevented him from being able to be in that position.

And even if you are refused treatment you can always pay out of pocket if you really want to.

Exactly. Another one of the weirdest things in the “healthcare debate” is the idea that it’s public or nothing like a closed border dictatorship that will shoot you before they let you exercise any freedom of choice.

If I don’t want to pay I can have a GP appointment with a short trip and a little wait sometime in the next 1-3 days… if I’m happy paying $40 Australian … I’ve got a GP appointment within walking distance tomorrow, no issues no bullshit, and I’ll even get some of that back from the government if I can be bothered, because anything that urgent is probably worth the money lol.

If I want to pay I can get specialist treatment, I’ve got private healthcare to cover fancy shit like regular physiotherapist sessions due to having an office job which will slowly and stealthily destroy your body no matter how careful you are… and glasses if I eventually need them… and stupid levels of dental because that’s my personal preference, if someone ever smashed out all my teeth I’m just completely covered … and that’s all on top of basically being assured care for anything serious disease or critical injury related by public healthcare… it’s just obviously the better arrangement. The most general risks are shared by the biggest pool of people paying for it… everyone paying for that with their taxes. If you want more… your free to buy it, and a lot of people do! It works great.

It's ironic that certain people claim that socialized medicine results in "death panels" that decide who lives and who dies. Turns out we already have them, in the form of for-profit corporations that have strong incentives to deny treatment.

> The ability of an insurance company to unilaterally deny treatment, or determine what type of treatment a patient receives, is obscene and should be categorically illegal.

I emotionally agree with this, but I don't have a good answer for the following situation:

1) A company develops a new, slightly more efficacious treatment, patents it, and prices it at some completely absurd cost (say, $1 million/month for daily pills).

2) Doctors understandably prescribe this treatment because it's slightly more efficacious than the pills that cost $16/month.

Where would pricing pressure come into play here? If insurance companies can't say "No, that price is ridiculous and we're not paying it." I'm honestly wondering what the solution for this would be.

Don't run your healthcare as a for-profit system.

even a non-profit system has to control costs.

Sure, but single-payer government healthcare has an enormous ability to influence the cost in the first place. Outside of a treatment that demonstrably has a true cost to manufacture (when also accounting for R&D) that is within that ballpark of say, $1MM per dose, I suspect you’d find the government finding ways to bring the cost closer to reality.

Also, rarely is it the case that such expensive treatments are needed by more than a fraction of the population. I’d say there’s an argument to be made that we all aught to be okay with a small fraction of people getting healthcare that far outstrips their contribution via taxes – given that we never know if that one day may be us.

One of the key ways that single-payer government healthcare influences costs is precisely by refusing to offer treatments that are too expensive for the benefits compared to the next-best option. In particular, the NHS in the UK - which is often pointed to by US politicians as an example of how single-payer can save money - refuses to offer treatments that cost more than a relatively low amount per quality-adjusted life year saved, which is specifically illegal for US healthcare providers and insurance companies to take into account.

Yes, I was just thinking of an acquaintance's similar cancer situation in the UK. The NHS denial of the more effective but more expensive treatment was intractable, and so they paid for the treatment out of pocket through a fundraiser and saved her life. Their fundraiser was successful enough that they were able to give some money to other UK residents in the same situation. In the US I think they could have at least switched jobs to get it covered if they couldn't hack the appeals process.

>I’d say there’s an argument to be made that we all aught to be okay with a small fraction of people getting healthcare that far outstrips their contribution via taxes – given that we never know if that one day may be us.

Yes, but that still must have limits. Society certainly should not pay one trillion dollars to care for a single patient. That’s too inefficient.

for every single patient, sure, but if that's the cost of the treating the first patient (it being a revolutionary new procedure and all), and it goes down from there, then why shouldn't we?

Paying to develop and scale a significantly improved treatment for a condition that affects many people is an altogether different proposition.

> then why shouldn't we?

Ultimately, there's only so much economy to go around. What percentage of it are you willing to dedicate to treating that one condition? What about everything that can't be funded or produced as a result of that allocation?

Does co-insurance help with this problem? e.g. if the patient is responsible for 10% of the cost of the pills, then the patient is motivated to choose the cheaper pills without the need for a long bureaucratic process with the insurance company, and the doctor just has to present both options

Healthcare costs for advanced procedures and medicine and equipment are so high that the amount 90% of people can afford to pay is inconsequential to the whole cost, hence the use of insurance companies (which are not just selling insurance, but acting as the healthcare recipient’s agent in negotiating prices and appropriate levels of healthcare, ideally). Obviously, the reality leaves much to be desired.

But that is the purpose of high deductible health plans, to give healthcare recipients an incentive to to visit cheaper healthcare providers or accept generic medicines.

> The ability of an insurance company to unilaterally deny treatment, or determine what type of treatment a patient receives

Technically, the insurance company is denying payment, not the treatment. Also, many times, the prior authorization requirements and formularies are given by the insurance company’s customer, such as the the government (Medicaid, Medicare, employer, etc). But the insurance company will take the heat, because that is part of what they are getting paid for.

Useful for when you need to give a Senator quick access to top tier healthcare, and older people a lower level of healthcare, and poorer people an even lower level of healthcare.

> Technically, the insurance company is denying payment, not the treatment.

For almost every person in this country, for an expensive treatment, this is a distinction without any difference whatsoever.

My point was the insurance company might be taking the heat for denying payment for the claim. For example, the lawyer in the article was 67 years old, and presumably had a Medicare plan sold by BlueCross BlueShield Louisiana (BCBSLA).

Was it BCBSLA that chooses to use Elevance for reviewing claims and the guidelines for those claims? Or does the federal government dictate using Elevance? And are there varying federal government standards for different insured populations?

I have not researched it thoroughly, but I can envision a situation where BCBSLA sells the government a “fall guy” role, and the government (taxpayers) save money by telling BCBSLA to use a more restrictive formulary or prior authorization criteria for certain populations.

unfortunately, I don't think any country in the world has a system where bureaucrats don't have to make decisions about which treatments will and won't be paid for.

I'm sorry to hear you had to deal with that.

My Mum was diagnosed with Stage 4 lung cancer, and they went all out with radiation, chemo, experimental new treatments and a TON of tests and scans. They estimated she had 12 months to live, she made it just under three years and had basically every treatment and scan even conceived to fight cancer.

Money or insurance were never even discussed or mentioned once. It's simply not part of our world.

The US can do better.

I can really empathize with this. My wife fought two brain tumors and was repeatedly denied treatment to the tune of tens of thousands of dollars. Can you imagine going through radiation therapy, chemo, and all kinds of different tests and having extra financial stress dumped on you?

I'm honestly surprised there aren't more cases of violence against Insurance companies and employees.

Why shouldn't insurance companies offer cheaper plans that don't include state of the art treatments?

Not everyone wants to pay top dollar for the most comprehensive gold-plated plans.

So you want to pay $450 rather than $500 a month and in exchange when you get cancer they tell you to just go die rather than getting the treatment your doctor prescribes that could save you? Isn't the whole point of insurance covering that type of situation?

> Isn't the whole point of insurance covering that type of situation?

it is, but i imagine the insurance company is expecting a certain cost for some expected treatments, and use that to calculate your life-time value as a customer. If a new treatment that has better outcomes, but is more expensive comes along, the insurance company may stand to lose money, and thus, they prefer denying such a treatment and only offer the "old" one.

At least, that is how i would rationalize the behaviour. Whether this is actually the reason or not, remains to be seen.

Maybe we just shouldn't allow medical decisions to be made by people whose primary motivation is corporate profits.

Socialized medicine certainly has its issues, but if there has to be a "death panel", I'd rather it be composed of doctors than a bunch of bean counters.

Insurance companies employ lots of doctors and pharmacists to review these decisions. Pretty sure it is a legal requirement, and they have to have active US licenses.

The problem is the word “employ” in that sentence. They are going to do what their boss tells them to.

I don’t think it can be expected to have doctors all the way up the chain. Even in the UK’s nationalized healthcare system, the chief is not a doctor, and I assume many under her are not either:

https://en.wikipedia.org/wiki/Amanda_Pritchard

Even if the chief was the doctor, they would be getting their funds from the political leaders, who are most likely not all going to be doctors.

Huh? I'm not currently planning to purchase health insurance in the US. Are you confused about my comment?

insurance is fundamentally a market of lemons if you allow price discrimination.

For what reasons?