Using AI to fight insurance claim denials
sfstandard.com
sfstandard.com
https://fighthealthinsurance.com/scan
Specifically laying out what and how everything is stored. Hahah. Probably overwhelming to a non-dev, but Kudos either way!
However, it would mess with mobile?
It exposes part of how the health insurance industry works:
"Out of roughly 40 denials, she won more than 90% of her appeals, she estimates"
Most people don't have the stamina to dig in when this happens, so my guess is the entire insurance industry is designed around the assumption that a lot of valid claims won't be paid out.
It's obviously disgusting that the industry has incorrect denials baked into their business model.
If we fix that with LLMs, what happens? It's going to have knock-on effects, since it could eliminate the profit margin these companies have right now.
Once they eliminate all competition the next target for optimisation is between the company and hospitals. They realise its cheaper, with better margins, to run primary care facilities rather than hospitals. The government see that they are a monopoly and force them to provide coverage for a minimal monthly cost. It seems like such a good idea that eventually the government agrees to give them a set amount each month for universal coverage of citizens.
They rename themselves as the National Health Service.
Hospitals and insurances should be fined if they have a high ratio of claims that get rejected first and reversed after appeal. Patients simply shouldn't have to go through this. The whole system is set up to profit from wearing down patients by attrition.
They'd just invest more in not having to reverse on appeal. Handling these kinds of incentives with rules and strictures gets messy fast.
Too often, we throw our hands up and declare legislation impossible "because companies will just get around it in ways, X, Y, and Z". The solution is to write better laws that also remove X, Y, and Z as options. And also X0, X1, Y0, Y1, Y2, Z0, Z1, Z2, Z3, and Z4. The world is complex and regulation can be complex, too. You'll never fix things by giving up and saying "We can't write the perfect law--oh well, let's just let companies do whatever they want!"
I think the letter of the law should stipulate the spirit of the law (almost a TL;DR right at the beginning) so that jurists can later take that into account when deciding if the law was broken.
That happens a lot with finding loopholes in housing related legislations. If there is a proposal that would hurt investors, they lobby against it for a while, buying time to figure out an alternative method, and by the time it passes, they don’t really care because they’ve circumvented it anyways.
I see why it would also suck if we fast tracked most of the legislations though.
That happens anyway though, as much of law in Common Law systems is only settled by precedents, jurisprudence, etc. Even the US's Constitution interpretation is up to the courts when questions arise, that's the courts' job anyhow.
At least working with the spirit of the law allows ways to prevent loopholes in a way that the letter of the law process only allows if new legislation is passed to cover those loopholes.
Judicial review of the constitutionality of laws is itself an invention of the courts, in fact. (And probably a good idea, but it’s something the courts had to decide they had, not a role or power plain in the law). So that specific thing being their job is… something they decided was their job, which is kinda funny.
1. Interpretation should not be limited to the letter of the law but should reconstruct the legislative intent from the texts, taking into account the unity of the legal system, the circumstances in which the law was drafted, and the specific conditions of the time when it is applied.
2. However, the interpreter cannot consider a legislative intent that does not have at least a minimal verbal correspondence in the letter of the law, even if it is imperfectly expressed.
3. In determining the meaning and scope of the law, the interpreter will presume that the legislator has adopted the most appropriate solutions and has expressed their intent in suitable terms.
It doesn't help make the meaning of the text more determinate, but it may shift where the battle is fought.
The theory of strict construction is a protection in our legal system. Otherwise you'll end up with a system similar to the insurance you're complaining about - generalized rules, you won't know the outcome going into it, and they can find ways to make the rules for the desired outcome. (This stuff happens in the legal system today, it would just get immensely worse)
Real talk, the US spends more on socialized medicine per capita than all of Europe, nobody should get reelected, no foreign aid rendered nor bombs dropped until we receive what has been long paid for.
They want you to focus on the former sort of "solution" than the one I provide and that's why you probably are first hearing of mine now.
Funnily enough, as far as I have been able to figure, this is basically the unifying element of all developed-country healthcare systems outside the US, which have a lot of variety but all seem to do this, one way or another.
Some do it with comprehensive direct price controls that are pretty much exactly “it’s illegal to charge too-high prices” (Japan), some through state monopsony (Great Britain), some through limited price controls but the very-credible threat of adding more if providers get too greedy (Singapore), and many through some combo of the above, but the effect always boils down to price controls.
If that buyer decides your price is too high, you sell around 0 units.
You can often receive these treatments if you wish to pay privately. Only the very wealthy do this, a small market.
Drug companies in the US prefer to sell units at the prices that the buyers in those nations are allowing them VS not selling them at all. That's why they do it. Then turn around and say they can't do the same in the US as it would bankrupt them.
The difference is in the US, Medicaid is quite happy to pay prices that are multiples of what other nations are paying. They sort of pretend this is all some sort of accident or due to some complexity that you wouldn't understand but it's just theft.
[edit] apologies if I’ve misunderstood, though—the above is not intended as one of those “rephrase your point into something you definitely weren’t saying” sarcastic things people do sometimes, I’m really trying to follow along.
Reimports of drugs produced in the United States back from Canada are prohibited for safety reasons. You know because those Canadians are famous for tampering with drugs for unclear reason and benefit. It's all a farce.
That would be the goal. Get it right first time around.
And to the extent that costs do go up for appeals processes, there's no guarantee that the resulting setup has margins that incentivize doing right by customers at all.
I got a $150k bill for emergency care for my daughter once; it wasn't too bad because they denied it as "uncovered elective procedure" which was trivial to show it wasn't, but it was still a tense month for me waiting. The punchline, of course, is that the insurance company and the provider agreed upon $30k.
Doctors' offices can't tell you what a procedure will cost ahead of time, and the amount they bill you afterwards is completely fictitious (because if you don't have health insurance you probably can't pay 5x what the insurance companies pay, so will be bankrupted anyways).
Or it could go the other way depending on arbitrary factors. Nobody knows.
Disputing charges, small claims court or simply never paying bills is the better option because the good faith channels are rigged.
This project is helpful and is going into the case management workflow right away. Fight slop with well crafted, guardrailed slop.
Out of curiosity, does ACA require coverage if the doctor refuses?
ACA coverage is for the procedure, doctors who won’t refuse can be found at https://childfreefriendlydoctors.com/
If you want kids, Godspeed. If you don’t, I am building systems to radically empower that outcome. “Build something people want.” or something like that. Essentially a suffering reduction flywheel.
how many are unwanted though? unintended doesn't necessarily have the negative connotation that /r/childfree folks make it out to be.
That said, I do take umbrage with people using suspicious statistics in unusual ways to push an agenda. If your cause is just, there is no need to use misleading statistics to inflate its importance. I argue this for causes I support as well as those I don't support.
> If your cause is just, there is no need to use misleading statistics to inflate its importance.
I absolutely love this, and appreciate you calling it out. We need more of this.
https://www.axios.com/2024/07/25/adults-no-children-why-pew-...
> 64% of young women say they just don't want children, compared to 50% of men.
Unfortunately, the dataset for unintended pregnancies doesn’t also ask if it was unwanted, leaving us to infer preferences via various datasets.
I suspect there’s often an anti-natal bias at work: unwanted children have a very low negative value (like toxic waste), while wanted children are a luxury good.
You mentioned a cost-benefit ratio. How does this calculate the pain of not being able to have more desired children?
People who want kids are not my TAM, I cannot speak to their unmet desires. We all must grieve that which we want but cannot have. Life is inherently unfair. I can speak to the burden of unwanted children though.
I am sorry to hear of your struggle and wish you well.
The morally correct choice is to just not pay.
Personally, I just don't trust companies to not put that sort of thing in a credit report. Do we actually audit for that sort of thing? And what if they do? Assuming anyone finds out, they get to drag the punishment out over the span of years, and if they do get punished, it's probably only a fraction of the money that they earned by reducing risk.
[1]https://www.consumerfinance.gov/about-us/newsroom/cfpb-propo...
Debt holders can (and will) sue to collect, win, and take the money by court order. Depending on the state they will take the debt, then take the amount it cost to collect the debt.
Do people live in some kind of alternate reality USA where poor people who can't pay extortionate medical bills don't have their checking and savings accounts wiped out by private equity firms pretending to be healthcare providers?
In my state over the past ten years 14,000 civil suits have been filed to collect medical debt. Up until last year it was legal for debt holders to place liens on debtor's houses, often their only remaining asset after being wiped out by an illness. It was only made illegal after a particularly aggressive private equity-backed firm cosplaying as a healthcare provider started relentlessly pursuing their debts, putting liens on elderly people's homes, and then aggressively pursuing judgements on the liens, and-- get this-- SNIPING THE HOME DURING THE LIEN SALES.
A person cancer would not show up to court due to being a person with cancer, the private equity firm pretending to be a healthcare provider would get a default judgement, and then immediately start hammering on the courts to get dispositions and final judgements in order to add the person with cancer's house to their real estate portfolio.
The state legislature made it illegal to garnish the wages of someone living below the poverty level at the same time because medical debt collectors were specifically targeting patients who could barely pay their mortgage due to not working due to being sick by garnishing what wages they were able to earn, if any, to the point that the debtor went into foreclosure (in order to facilitate the confiscation of their home).
Please try, for just a few hundred milliseconds, to imagine losing your paid-off (or almost paid off) house, a scant few years before retirement age, because you got cancer.
Your choice, but don't act like you have some kind of moral high ground here.
I remember Google denying coverage after a surgical procedure that they approved during the prior authorization period, and then running out the clock on my appeal. That's on them, no evil insurance company to blame, just my employer. And, the market decided... I don't work there anymore.
There are other hidden costs, too, like government employees who have to deal with private insurance issues for purposes of sorting out benefits and child support and all kinds of things, but aren’t primarily involved with healthcare so I’m sure those hours aren’t counted among costs of our healthcare system. Not sure about the hours (and hours, and hours) HR at entities public and private lose to dicking around with insurers and brokers and HSA providers and such. Doubt that’s counted, but it’s real and significant. Healthcare providers waste lots of money on similar things from their side, but I expect those figures make it in to even fairly naïve system cost estimates.
Yes to the first two, but the latter is a good way to get your credit score destroyed for a few years, and plenty of insurance companies are willing to send unpaid bills to collections agencies which are very aggressive about collecting.
Not necessarily or at all - in California there are a bunch of laws about what healthcare debt can even be reported on your credit score. I routinely let things fall into collections and maintain a very high credit score because I ironically gain more negotiation power occasionally with the debt collector than whatever service I was charged for - often this happens as a result of over-billing. Dispute it enough times and they can just disappear. The credit hit is/should be minor. They use "credit" as an intimidation tool to coerce people into paying bills they don't actually owe.
Classic example - I get a procedure. Doctor submits a claim that is pre-authorized (I don't know the exact term). You receive procedure, insurer later denies claim. The doctor then passes the bill to you. Later, the doctor and insurer may come to an agreement, and the doctor is paid - but sometimes/often this is never communicated back to the patient, effectively "double billing." In these cases the only sane way to navigate it is by simply allowing it to fall to collections.
Just this morning I was thinking how every single streaming service pushed out a version with ads and a more expensive ad-free version recently. It just comes to ~$20/mo to upgrade them all, but how much more can they pile on before people just have nothing left?
The end result is that there is less slack in the economic system. There are fewer and fewer opportunities for individuals to leverage inefficiencies. It means there is less room to be human. Less room to make mistakes.
It is just the latest way of transferring wealth from the many to the few.
It's like Gaben said, piracy is a service problem, not entirely a cost problem. The same 20 euro subscription would've gotten be 100x more movies and shows a few years ago, whereas now it's split to a million random services. Sometimes one season of a show is on 1 service, while the next one is on a different one. You also can't get 4K anywhere, every service has shit quality.
So why bother paying, when radarr lets me get 4k content of anything I'd ever want to watch, completely for free?
I would like to see some data actually about each streaming service content availability in a chart by country with over time changes.
What I DO mind is how shitty it all is. I don't want to search through 8 apps just to find what I want. I don't want to open something called Super Freebie Movie to watch season one and then go to Amazon Prime Video for season two. I don't want to have some that inexplicably only play at low quality and there's no settings to turn the quality up.
I mean, the apps suck ass. We need a common interface for this, like we had with TV. If we're gonna be breaking up the content into a million different places I should damn well be able to see it all with 1 interface, 1 website, that's fast, reliable, and easy to use.
They already do, and it's pretty obvious.
It's clear the people adopting the AI systems are the big co's -- we've been battling half-assed phone navigation agents for a decade now, and more recently chatbots (often with humorous results -- see the "No Backsies" car dealership chatbot). AI always favors the one with more resources.
When you have AI's battling AI's, rather than making progress, I suspect it'll actually result in confusion, more delays as tighter roadblocks pop up, and probably some humorous events like the infamous Dominos-vs-Papa-Johns prank call https://www.youtube.com/watch?v=ALnPVybD9X8 but darker because it'll be about cancer treatments instead of pizza prices.
The only winners will be data center operators, and the losers will be everyone without access to the AI tools. In an arms race, everyone loses in the long view.
In other words "suspicious bot activity detected, start over" and "account suspended for security reasons" will become new crappy barriers to claims and appeals.
I've always wondered why don't we have companies that "equalize" that fight, with some kind of subscription or other revenue model that aligns with the consumer. They could also have armies of lawyers fighting on the side of the claimer.
> She began helping friends file appeals, too, then asked herself a question that’s typical for engineers: Could she figure out a way to automate the process?
> After a year of tinkering, she just launched her answer: Fight Health Insurance[0], an open-source platform that takes advantage of large language models to help users generate health insurance appeals with AI.
Next thing you know the entire system is just a bunch of large language models shooting email at one another and it becomes even more unwieldy and irritating to engage with.
What will happen to insurance companies (and policies) once they can no longer rely on flippant violations to pad their profits depends on other factors.
And I mean, it could be, the history has yet to be written for AI in terms of it's long-term effects on industries, but I think as I said it's very generous on your part to preemptively assume that it will benefit the customers.
Prices is a purposeful word choice. I don’t mean costs, or your costs. I mean agnostic to who is paying - whether it’s a compulsory non tax payment via insurance and hence the price the insurer sees, or the price you pay for insurance, or the price that CMS pays for an appointment, whatever.
It seems like these industries are ripe for AI-based startups whose job is basically to be an asshole to corporations on behalf of customers, the same way that corporations are assholes back. If anything, at least consumers will be able to say "Have your AIs talk to my AI."
As if that's any less of a complicated technical solution.
Meanwhile, how often has a company in the US been reigned in by another company?
Disruptive services dramatically impact companies at scale
The Credit Dispute industry radically lowered the aggressive dark patterns of credit score companies like Experian, as an example.
Law being on the books does not resolve the central asymmetry here. Again, their full time job is bleeding you. You getting your rights asserted comes at the expense of your time.
Hell, when was the last time you got to negotiate a EULA with $BigCorp's legal group? Odds are, never.
The NLRB will work to represent your interests. They are doing their job. Go to them if you have a dispute to resolve.
As an example, insurance covering trans care is required by state law in my state. Is it any easier to be trans in New York than other states? Yes. But you still get very familiar with your insurance claims process and the documentation hurdles. ("We need a letter from your therapist, not your doctor." This exists nowhere in WPATH8, but it does delay the money going out of their bank account while a therapist copy-pastes the form letter. One week to wait for your appointment. One week for them to turn it around. 2 weeks of interest earned by the insurance company. And that's the best case for the patient that already has the necessary support network.)
Correct, this is how it works in many other countries.
> [Some stuff about health insurance documentation being complicated]
Almost every developed country except the US has settled on some model of a single-payer system with universal coverage. This whole thing with private insurance companies and documentation requirements doesn't have to be a thing.
This is not amazing. The single-payer model is unfortunately too political, and somehow being trans is a hot button political issue right now. It really, really sucks for these kids.
Meanwhile in the US, there is a lot of hate, but a lot of insurance companies do cover the necessary care. They even pay for flights/hotels in other states when care isn't available in your state because of political issues. We all like to hate insurance, but seeing those things commonly available in private insurance policies is ... refreshing. You are still going to have to file appeals, but it's better than "the government doesn't believe in trans people so fuck you".
> The government passed a law banning prescription of puberty blockers for kids
This is completely independent of how health care is paid for. It might happen that a similar law is passed in the US, and the same would apply over there, private health insurance or not.
Those parents should be investigated by social services for this abuse. Destroying a crucial stage in your child's developmental process to adulthood is awful, deleterious, terrible parenting which shouldn't be enabled by anyone and needs to be urgently prevented.
It's quite a stretch to call this abuse, and I know you know it, because you created a brand new throwaway account to make your comment.
The point is that laws are useless without enforcement. There's a wide body of civil law that depends upon the plaintiff to assert their rights. The government isn't going to go monitoring every private transaction to ensure it conforms to every applicable law. We don't want them to do that - in general the government should stay out of private transactions, that's what makes them private. And the law usually requires multiple attempts and back-and-forths to ensure that everyone has had a chance to rectify the situation before it goes to the court system. Again, this is a good thing.
But one side of the transaction is much more able to put up with convoluted processes and paper trails than the other. A corporation can amortize the cost of the paper trail across many customer interactions and build systems to handle it automatically. It can hire employees to do nothing but sit on the phone, and build delays into business processes that will make most customers give up.
These sort of LLM startups just give the same economies of scale to customers seeking redress. Yes, it'd be easier if the whole process didn't exist - there's an old joke about LLMs generating e-mails to sound longer and more impressive than they need to be, and then another LLM summarizing the e-mail back into one sentence that isn't really what the original person meant. But the problem is that each incentive along the way makes the company better off if they get the customer to go away, while each incentive for the customer makes them better off if they don't go away, and so you get an arms race between them.
So many of our consumer-protection laws are written by a tremendously adversarial system: one side does its level best to get solid, genuinely-effective protections in place, and the other side won't let them happen at all until they're hamstrung almost beyond their ability to function.
It'd not wrong to view "the government" as something that is run by a small group whose interests are not congruent with the majority of the population, and experience shows this.
That's one of the hardest things for STEM types to learn, not everything can or needs to be solved with a complicated technical solution. You see it with HR and interpersonal type things all the time, where some minor communicator could solve the issue, but people start suggesting overly involved technical processes instead.
And insurance doesn't want to pay out, that is their business, which actually goes against the whole idea of healthcare. You need to spend money now to prevent higher cost later.
(on the other hand, car insurance weirdly doesn't penalize you for buying cheap tires, even though the difference between 4 cheap tires and 4 Michelin tires is less than the cost of a deductible for you when miss out on those 10 ft of breaking distance).
I'm about to switch healthcare plans and I'm already mentally preparing (i.e. stressing out) to file appeals for some medications I need that they will deny-by-default.
This isn't strictly true. We insure against the unexceptional as well. With regards to your specific example, I think refunding the flu shot is perfectly reasonable and an elegant solution to solving the social problem of getting people to be healthy. We all pay higher premiums but only those that actually do the preventative stuff get any benefit. Put another way, if health care plans were $1/month cheaper and the cost of the flu vaccine was $12, I'm pretty sure we'd see our already lackluster yearly vaccination rate plummet.
Ideally this sort of routine "maintenance" work would be affordable and accessible to anyone, but we have layers of middlemen in the way because the entire healthcare industry in this country is designed to run everything through insurance.
So you go and take personal responsibility for your liver and take the Hep A shot yourself. One wishes the government supported life, liberty and happiness of its people and offered labour protection, sick leave and healthcare to its weakest citizens.
Vaccinations are a few hundred per shot, and the part-time worker hasn't got insurance or the spare cash.
I knew this in theory, but never really thought much about it.
I need a flu shot, so the company that makes the flu shot needs to be compensated (paid), and the nurse that knows how to inject it into my arm needs to be compensated, and that's it. The manufacturer and nurses provided a sufficient infrastructure to administer flu shots.
But in America, I also have to pay a bunch of insurance companies. I used to make 6 figures as a programmer in the insurance industry. I knew my salary ultimately came from the high medical bills everyone pays, and while I didn't blame myself personally for a nation wide problem, I would have been happy to see my job and my company rendered obsolete and all of us move onto more useful jobs.
I want to see a political cartoon where someone gets a flu shot and then does their patriotic duty, opens their wallet, and starts handing out money to half the nation. In the end, there's even a few bucks left for the nurse.
I exaggerate a bit. In truth I think about 20% of US workers are involved with the healthcare industry and the surrounding insurance and other supporting industries (if I remember correctly). I really do have to pay all those people every time I have a medical bill.
Fixing healthcare costs will require a lot of people losing their job, and that wont be popular.
And going to a 'single payer' model would also reduce jobs. And the whole "they want to get rid of your insurance and raise your taxes!".
Well, the taxes would be raised, but almost certainly to a smaller extent than the price of the insurance policy you pay for. A middle of the road health insurance policy for me right now is around $1k/month. Whether I pay for it, or an employer offsets some of it - it's beside the point. That's $12k/year that is effectively a 'health tax', it's just not called a 'tax'. Somehow, weirdly, we use the term 'benefit', without with I may more easily and quickly die or languish in pain. Some benefit ;)
But yes... if my taxes go up by $10k year, but I don't have to pay for a health insurance policy... I'm still ahead. If I pay for it all, and the employer is out of the loop, it'll feel 'wrong' to many employed folks, but the employer will have more money - they should either pay people more, or hire more people (who used to work in private insurance companies).
I think if it's politically untenable to go single-payer then every employer must instead be required to give you a stipend every month to buy your own insurance. Then make it illegal for a company to offer insurance for their own employees. If everyone saw what it really cost and what they were really getting there would be a lot more impetus for changes.
You dont need to pay that much. You can halve that.
https://en.m.wikipedia.org/wiki/List_of_countries_by_total_h...
Not dying or languishing in pain sounds like a pretty awesome benefit. And indeed, that’s the problem with health care: when one needs it, one will pay almost anything to the provider.
Prices are a communication: they signal customers how to ration goods, and producers how to produce them. The higher the price, the fewer the customers but the more the producers; the lower the prices, the more the customers but the fewer the producers. In a free economy, it is possible to say that the work output of one FAANG engineer is economically worth that of 5 New York City garbagemen or 10 Podunk, Idaho janitors or 35 burger-flippers.
How many rolls of toilet paper is one vial of insulin worth? Infinitely more, to someone who doesn’t need insulin. Some fraction, for someone who does. Some really small fraction, for someone who needs it right now. It doesn’t make any sense for all three of those people to pay the same price, for either the toilet paper or the insulin.
In a single-payer system, how much does the single payer pay? How much do the producers of health care (e.g., physicians, surgeons, nurses, medical researchers, pharmaceutical factories) get paid? It ends up being based on the whims of the people setting those prices (a wage is just a labour price), not on any fundamental voice of the market — and thus it is either too high, or too low, and there is no feedback mechanism to constrain it. And that means society will produce either too little or too much health care, which means it will produce too much or too little of other things.
> not on any fundamental voice of the market ... > And that means society will produce either too little or too much health care
Are we producing 'too little' or 'too much' in the US right now? How would one tell?
> It doesn’t make any sense for all three of those people to pay the same price,
It doesn't many ANY sense at all? I produce an item and can make ... say, a 20% profit on it by selling at a standard price with my customer base. I could possibly make more with some form of dynamic pricing, but... to say my current approach doesn't make ANY sense seems a bit much, no?
> Are we producing 'too little' or 'too much' in the US right now? How would one tell?
Probably both, in different circumstances. Not being able to tell is the key thing: without the constant negotiation of prices, there is no way to tell how much is too much or too little.
That’s why command economies fail so badly: they do things like multiply the average monthly usage of toilet paper by the population, and then issue it uniformly to everyone monthly, not realising that some people have digestive issues and use more than average, while others live remotely and need to get a season’s supply at once.
> It doesn't many ANY sense at all? I produce an item and can make ... say, a 20% profit on it by selling at a standard price with my customer base.
I don’t think so. The value of a thing to a customer, or across all customers, is not determined by its production cost. Prices have to increase as demand goes up, and have to decrease as demand goes down. That’s what keeps the guy who doesn’t need insulin from stockpiling ‘too much’ of it just in case (because the price is higher than the marginal utility he would have for it), and ensures that there is some insulin available in some store for the guy who will die without it (because the price there is high enough that some remains unsold; he may not like that high price but he is glad to have the insulin).
I don't think we should be organizing our society in such a way that "staying alive" is considered a "benefit" that is largely at the whim of employers who can revoke that "benefit" at any point.
The corporate world has bugged me for years with the "get a good job with good benefits!" then people somehow thinking they "deserve" those "benefits" from an employer. The employer relationship has amplified the brokenness of the insurance systems in place (however useful they may have originally been).
I've got a similar bugbear with the word "scholarship" as a shorthand for "money" when... there's usually nothing "scholarly" about it. Yes, it's typically used for attending a university with nominally scholastic aspects to it, but "getting a scholarship" because... you hit a baseball X number of times, or what not... the language bugs me more than anything (as with "benefits").
One’s employer literally pays one the money one uses to feed, clothe and shelter oneself. And — in the U.S. — often the money one uses to insure oneself against certain risks.
Employers don’t do it out of the goodness of their hearts, of course: they want one’s labour. In exactly the same sense, one doesn’t labour out of the goodness of one’s heart: one wants that money, insurance and other benefits. Likewise, the farmers who grow food, the truckers who transport it, the grocers who stock it, the tailors, the weavers, the cotton growers, the builders, the electricians, the plumbers: everyone trades what he has for what he wants more, and in every single one of those trades everyone gets better off. Your employer is richer with your work than if it just kept your salary and benefits, while at the exact same time your are richer with your salary and benefits than if you kept your work. Likewise for all the other participants in the economy.
Your proposal appears to be single-payer health insurance. If you pay doctors more than you should, your proposed economy will get more doctors and less other things than it should; if you pay them not enough, you will get a shortage of doctors and too many other things. You don’t know how much is fair to pay a doctor (neither do I). We don’t know how much is a fair price for a painkiller. None of us knows how much a heart operation should cost. None of us can make the right call for someone else when a procedure is worthwhile or not.
But they don't deal with everything. They have to interact with upstream providers! And they have to pay somebody to negotiate with them. So another 30%, and add 5% just to pay somebody to bargain the price with the Flu Shot Distributor.
But the flu shot distributor has to interact with yet more upstream providers - the flu shot packager, who interacts with the flu shot pharmaceutical company, and the syringe company. Everybody adds their overhead and then their premium; "Price signals" become exponentially complex and more a matter of the mood of the negotiation than anything else.
This is all an externality of a non-vertically-integrated capitalist system, which is somehow, somewhy, supposed to be regulated by your desire to get a flu shot relative to your ability to pay; It is not at all optimal in the market system for everybody to get a flu shot, that defeats the fundamental mechanism of the supply-demand curve.
https://siderea.dreamwidth.org/1179450.html this essay series offers some of the better hypotheses on cost disease that I'm familiar with.
Agreed, but I also don't think it _has_ to be this way. First and foremost, a switch to single payer would mean that a lot of the infrastructure that's currently in medical insurance industry would need to shift towards being government employees. While there'd be massive administrative savings with single payer, there wouldn't be zero administration at all.
I'd also posture that the US would never go full single payer, and that there'd be supplemental plans similar to the German model (and Medicare, to be fair), so while private insurers would still exist, the administrative burden would significantly lower.
In the end, you'd still end up with a lot of people losing their job, but it wouldn't be a complete wipe out of the industry. Certain areas would get hit harder than others with the insurance brokers likely getting cut out big time.
> In truth I think about 20% of US workers are involved with the healthcare industry and the surrounding insurance and other supporting industries
That seems pretty high to me. I wonder what made you come up with those numbers.
I'm looking at my EOBs for this year, and all insurance has done by their own documentation is negotiate discounts for care I've received. I think they have paid $0 of their own money. Meanwhile, I'm still paying premiums, but I don't know for what!
1. health care is a mixture of the predictable and the utterly unpredictable. It is vaccines, regular exams, and minor trauma care. But it is also cancer, severe trauma, rare diseases.
2. insurance in its purest form is not a business but a way of pooling resources and distributing risk. Even in some countries with socialized health insurance, it is still called "insurance" for that very reason. We could get rid of every for-profit health insurance company in the USA tomorrow, and we'd still want something that is in every way just like "insurance" and would likely still be called that.
To add another data-point: In the US, the real name for the law behind "Social Security" is "Old-Age, Survivors, and Disability Insurance".
That said, it is frequently mis-characterized in our political discourse, with people making apples-to-oranges comparisons to investment accounts. I blame that on bank lobbyists' attempts to take the money for themselves. Anyway, if one views it as "old and unable to support yourself" insurance, many of its "weird quirks" make perfect sense.
If someone gets a chronic condition while covered the company isn’t paying out a lifetime benefit, so they soon need to renegotiate rates while sick even though they had insurance while they got sick.
That's not weird; it's essential for the system to work, because you can rapidly move from "never go to the doctor" into "seven figures of healthcare spend" without much warning.
We used to have "high risk pools"; it was horrific. https://www.kff.org/affordable-care-act/issue-brief/high-ris...
It would be sensible if we were talking about one society-wide pool (ie single payer), since those younger people would end up being subsidized as they developed health conditions. But as it stands having many pools run by independent companies is fraught with perverse incentives, since an "insurance" company is quite happy to have you as a customer when you're paying in, but much less happy when they're paying out.
You get a high deductible catastrophe plan, and bolt on a Direct Primary Care provider for simple things. The DPC is a doctor who you pay a small retainer (My guy is $70/mo) and the main reason that the cost is so low is that he does not need to staff a billing department due to simply not integrating with insurance at all. I keep $10K in an HSA to cover my deductible if I need to.
DPC doctors also keep a much smaller patient roster so it is pretty easy to book time with him and he isn't being pressured by some middle manager to keep every interaction at 10 minutes or less. Once you see how this all works it's easy to become singlepayer-pilled because wow the whole medical scene could pay providers better, offer higher quality services, and have competitive pricing if we could just get around to deleting the billing department and insurance company.
https://www.investopedia.com/articles/personal-finance/12071...
Setting aside the reality of the system which will happily collect premiums for 40 years and then use any slightest technicality to avoid paying in the end, ie like changing jobs or providers and it's like you were born on the day of that switch and haven't been paying in your whole life. That is a seperate issue from the simple concept that the young somehow "don't need" to be contributing to the health care pool because they "don't need" to dip from it.
In this, there are no individuals and it's not some elective luxury like how much you want to blow on toys.
Merely in the US, we have been treating it like it was, except even worse, because when I buy a fancy over the top steak, I know the price ahead of time and get no surprises after the fact either. I don't just get hit with $500 steak bills with no warning or choice or recourse and thank god my boss takes $12k out of my salary so that I only have to pay a $50 deductible and fill out 3 forms correctly for that $500 steak I didn't ask for...
I treat it more like a subscription. I pay a little over $100 a month for health insurance. A doctor visit would cost around $10-20 out of pocket, so it wouldn't be worth it. However, the insurance also costs with 50% discount on medicine, which ends up right about $80 a month (in discount), so it pays itself back more or less.
Sorry friend, your total comp likely something like $800~$1400 lighter per month due to health insurance. The fact is that your company is paying the vast majority of your actual premium and you just never see that money as coming out of your paycheck.
https://www.completepayrollsolutions.com/blog/how-much-does-...
Somewhat similarly, car insurance will often give discounts for completing defensive driving classes, and home insurance for having an alarm system.
What's weird about health insurance in the US is that it's often tied to an employer, and you can't freely switch between insurance providers on a whim. It's a way worse experience than insuring a car, which can be done on a phone in a few minutes.
In effect this is how home appliances are regulated. You have companies like ETL Intertek and Underwriters Laboratories performing fire and electrical safety testing of home appliances, originally on behalf of homeowner's insurance companies(See the definition of "Underwriter"). It's effectively self-regulating because the Intertek or UL stamp implies a certain degree of care. And based on some lease provisions I've seen the insurance companies for buildings do require use of certified equipment as a condition of coverage in many cases.
Auto insurance doesn't pay for your gas because they don't have to pay a claim if you run out of gas.
This is often repeated, but it's simply not true. Preventive care is better for patients in the long run, but at a population scale it is more expensive than foregoing it.
And that is before you account for the fact that patient churn is quite high (especially since most plans are linked to employment). An intervention that cost money today and may increase costs within the next few years (due to followup care) is much more expensive for insurers if the savings will only be realized in 10+ years, when the patient has moved on to another job and so is no longer on their plan.
Very few medical interventions save money in the short- and medium-term at a population level. That's reflected in the fact that health insurers didn't cover most preventive care until required to by law (the ACA), and even then they routinely simply ignore this provision of the law. If it were profitable for them to follow the law, why would they go out of their way to break it?
Take, for example, PrEP for HIV prevention. Costs about 5,000 dollars a month - insurance is forced to cover it. Sure, you could say HIV is very expensive, but few people at risk of HIV actually get it. If it were up to insurance companies, they'd rather just pay for HIV treatment or even better - just drop customers with HIV. The ACA prevents the latter, and the former was the case for 15 years since Truvada was introduced. Of course, now that's changed too, and they have to pay for Truvada.
Except, many (most?) insurers straight up ignore this requirement and charge people for PrEP, even though it's illegal. The ACA is very clear that preventive care is required to be covered in full with no cost-sharing or out-of-pocket cost to the patient, even if the deductible has not been met.
https://kffhealthnews.org/news/article/prep-hiv-prevention-c...
Granted, the comparison is imperfect. Medical insurance won't pay for a healthy diet (another way to reduce health problems) and replacing the brakes on a car would reduce the chances of an accident causing thousands of dollars of damages ... but we are human, and sometimes it is a miracle that we even take half measures.
But it's not weird that the insurance company wants you to get a flu shot or exam, since those things prevent them from paying out more money later.
In reality there is some cross over point, where the flu shot isn't worth it for younger people, and is for older people. If you are young/healthy, get the flu and totally recover with a few Tylenol, and no insurance claims, then it clearly wasn't worth a $10 vaccine to prevent. That's the analysis for the insurance company. Depending on how you value your time, and time spent sick, your individual analysis may be different.
Health insurance is new, because until the 1920s/30s the salary loss from sickness was more expensive than medical care, so that's what was insured against.
But no sooner was demand for health insurance created than it was pushed into groups. In America, there's never been a time where non-group insurance was the norm.
The reasons is clear: healthy people would not get coverage, but sick people would.
Insurance makes it free to get a flu shot because it makes everyone healthier and lowers their expenses. Similar to how you get a discount on car for installing a theft prevention device.
Insurance isn't just about insuring for exceptional events either. It results in a better allocation of resources. By incentivizing reducing risk to reduce premiums. Insurance is also a huge boon to providers who would otherwise need to spend much more time pursuing non payment, or entirely deny services to financially risky patients. And then this goes back to the outcomes for society at large.
Half-disagree: "Health insurance" is a big group that includes a whole ton of things, and only a subset of those don't make much sense.
There are plenty of other maladies/treatments which should be insurable because not everyone will get/need them but everyone has a risk that can be understood mathematically.
> Yet we use insurance for our yearly flu-shot, hardly exceptional.
In isolation, no, but "unusually extreme case of the flu" is something that can be insured because it is a rare stochastic problem.
So out of enlightened self-interest, the regular boring preventative measure gets insured as a way to reduce the odds of the exceptional case occurring and needing a payout.
Yes. The problem here is that (in the US) the "insurance" part is combined with the "price negotiating power of an association with lots of members" part.
I think it is well known that the non-insurance "list price" for a procedure is many times higher than the actual price that should be paid. Witness the comment here about the $150k bill for a procedure that was settled for $30k once insurance admitted they had to pay.
This is one of the reasons that you really can't be paying for medical expenses without the weight of the insurance company behind you - your bills will not be (what I consider to be) fair at all.
instead of describing the process in plain language, everything is wrapped in so many layers of legalese that even the 'happy path' becomes impentrable.
i particularly hate the 'EOB' which they tell you 'this isn't a bill' but then they make it look as much like a bill as possible and don't really tell you what its for other than to show off that insurance is... around
A company owes you something and doesn't promptly pay. If you prevail in the end and the original problem wasn't on your end what they owe gets a multiplier and then a high interest rate.
Several years ago I got totaled. The woman came up with a few bits of nonsense that clearly didn't match up with reality but the woman from the insurance company saw right through that and knew there was no possible way I contributed to it. Then they ghosted me until I filed a complaint with the insurance regulator.
Make that say 50% or 100% higher, then maybe a couple percent of interest from the date that they should have paid. This would make such tactics not in their interest because failure doesn't mean just doing what they should have anyway.
But yeah, if some farmer has to sue John Deere to be able to fix his tractor or whatever, that's going to take a ton of his valuable time to deal with. Why shouldn't he be compensated in the event he was correct?
Hope it ends up working out, and makes it sustainable. Although one thing about insurance companies is that they have made the rules of this game.
Some sources indicate there is some legal requirement or right granted to patients for these internal reviews. But I can’t find the exact law.
If this service takes off, I wouldn’t be surprised if the language of this law changes over the years to make it more difficult to file patient appeals (or make it outright impossible).
Also, not living in US, I wouldn't be surprised to learn that:
- any attempts to implement this will be met with weapons-grade lobbying on all levels to make it illegal
- it was attempted and litigated to hell and back and hence forced to shut down
- this business model is illegal already, neither lobbying nor litigation necessary
It would be nice to see more research into the role of “payor harm” in patient outcomes.
How many people lack that? And how many companies have the resources to take things even further? I wish there was another way to get this outcome. Baby steps, I guess; and this platform in particular sounds like a good step.
In my opinion, if an insurance company ends up paying a claim that was denied, they should be forced to compensate the person for all the time spent, including wait times on hold, at 5x the equivalent hourly wage that person would have earned.
First, insurance and everything else (including your job) should be strictly decoupled.
Second, health-insurance and life-insurance companies should imho be required to be cooperatives. That makes it so that incentives are aligned.
That the instance company is denying certain claims (both wrongly and rightly) is perfectly fine. In fact, that is good. It's part of the core business to protect against abuse. The balance is important here and will reflect in the premiums.
Those two things should already fix most major issues in insurance in a working market with competition.