Feds help health insurers hide their dirty secret: denials on the rise
nypost.com
nypost.com
Additionally, it reports that denial rates have increased 10x in 10 years, based on the following chain:
- "UnitedHealthcare nixed 1.1%, Humana 1.9%, Aetna 1.5% in 2013, per the American Medical Association."
- "By 2022, major insurers were refusing to pay, on average, 15% of claims, according to a national survey of hospitals and health-care providers by Premier, an insurance consultant."
- "The figure continues to shoot upward, with some companies today denying almost _half_ of all claims, according to researchers at the Kaiser Family Foundation."
Furthermore, "few people appeal, but of those that do 41% obtain a reversal", which suggests the denials may be unfair.
I certainly would like to know the denial rates when selecting an insurance provider. As the article says, "You aren't really insured if your insurer can deny valid claims with impunity."
Given that the ACA requires this information be provided, it certainly ought to be provided. Then we'd have a much clearer picture.
It's an opinion piece on a news site known for inflammatory articles but it reports some interesting information. It would be much nicer if it included references to the research it's based on, but it seems pretty reasonable to me.
As the article says: "No industry malfeasance could ever excuse murder."
With that in mind, we should remember that every death that happens because a valid lifesaving claim was denied is a kind of murder, and no amount of fraud could ever excuse denying valid lifesaving claims.
The stakes are too high: all claims should be approved, then adjudicated later. Fraud should of course be punished severely (with prison, not merely returning the money), but no one should die to protect insurance companies from fraud.
Fraud is only a small part of the systemic problems. There is an enormous amount of waste and abuse by providers who deliver treatments that are ineffective or unnecessary or excessively expensive. The dominant fee-for-service financial model incentivizes over treatment. We can argue about where to draw the line but payers (whether commercial or government) have to push back on this to keep the system from collapsing. Healthcare is already ~20% of the US economy. It can't continue expanding, we simply don't have the resources to pay any more. Every other country rations care in some way; no country delivers unlimited lifesaving care to everyone.
https://peterattiamd.com/saumsutaria/
https://www.npr.org/sections/health-shots/2019/10/22/7673763...
A site properly presenting the facts is due for launch in the lead up to Germany's upcoming federal election. Until then, you can find a teaser here:
Any claim related to outpatient treatment which outside the ordinary requires prior approval there. You cannot opt to pay in advance and seek reimbursement later.
In the state of Bavaria the doctors at a government agency have been practicing without a medical license going back many years because their supervisor let this slide. I discovered her problem randomly in the course of litigation and it impacts probably a million case.
The person responsible for her staff of hundreds lacking a current medical license was later hired to lead the qualifications department at the medical board. That is, after I got her fired from her position and then from a job at a hospital (a felonious psychologist is unacceptable risk for patients). Politics would prefer to see her problem covered up.
The relevant metric to customers isn't "What percentage of claims are denied?" given the substantial amounts of medical claim fraud.
It's "What percentage of claims are denied... that should have been approved?"
So you regularly audit a random sampling of denials, publish the results of that audit transparently, and provide a financial incentive for insurers to keep their numbers below a certain threshold.
It's worked pretty well for FEP -- to the extent that FEP insurers typically have segregated operations from the rest of the company and do much better on denial accuracy and other metrics.
[0] https://en.m.wikipedia.org/wiki/Federal_Employees_Health_Ben...
I think the biggest barrier is that it inconveniences the powerful to benefit the masses.
And now, we also pay to audit insurance? It's too much money burning.
This shouldn't be done by the private sector, period. The reason our costs are so insanely high is because of insurance the sheer inefficiency it brings to care.
Obviously they'd be lower with single payer, especially on the provider side, but outside of that the system runs pretty efficiently for what it is.
On the provider side, they're going to have to code up a claim.
But once they're submitted, the majority of claims automatically flow through the rest of the system with low human touch.
That's literally the only way insurance companies can function under ACA admin cost caps.
When that generates a denial... then obviously there's a lot more touch during the back and forth.
But to expand, the US has, by far, the highest cost per capita for healthcare at just a bit over 12,000 dollars a year when compared to similar countries. A large part of this is due to our inefficient system, in which administrative costs are astronomically high:
"administrative expenses account for approximately 15% to 25% of total national health care expenditures, an amount that represents an estimated $600 billion to $1 trillion per year of the total national health expenditures of $3.8 trillion in 2019."
https://jamanetwork.com/journals/jama/fullarticle/2785479
There's multiple fundamental problems with the healthcare system that causes this. Again, these problems are fundamental, meaning they cannot be resolved within the constrains of a private sector insurance industry:
1. Insurance billing complexity is extremely high. There are thousands of insurers nationally, and providers are forced to navigate through that to provide adequate care. As a result, many private practices have gone out of business, because doctors spend more time managing insurance than patient care.
2. Insurance has an incentive to deny as many claims as possible. There's simply no way around this fact - the only way to remove this incentive is to remove insurance.
3. Insurance is not transparent to consumers and consumers typically have little to no choice, killing competition and allowing price gauging.
4. Providers are incentivized to charge as much as the most premium insurer in their area allows. For example, if insurer X covers 650 dollars for a treatment but insurer Y only covers 150, then the provider must charge 650. Otherwise, they leave money on the table for patients with provider X. This means that competition in the insurance space doesn't lower prices - it can only raise them. Yes, as boutique plans for employees such as CEOs gets better, your care gets more expensive.
A denied prior auth results in no unexpected costs but perhaps a change or delay in care.
A denied claim to an in network hospital may result in the provider losing revenue but nothing for the claimant.
In my experience, I've seen some denied claims, because the provider submitted a wrong code. Then the provider submits a new claim with the correct code and it goes through.
Given the proliferation of plans, and their sometimes conflicting requirements on medicial coding, I could see that being a big driver of denials increasing over time. As well as a driver of increased administrative costs for providers and insurance companies.
https://www.propublica.org/article/cigna-health-insurance-de...
Acupuncture has a CPT code and can be billed; do you think a patients file is required to deny it?
Removing a skin tag is considered cosmetic unless it's causing significant issues or is suspected to be cancerous.
It sounds like the insurance companies have a strong incentive to make their coding and requirements as complicated as possible to increase the error rate so they can deny coverage. I don’t think they should get a pass for those denials.
What I want is a sense of what the breakdown of the denied claims.
Ex: company sends a list of all denied claims. Auditor picks 100 randomly, gets the files for each and researches those denials to classify the denial as reasonable or not and whatever other categories apply.
UHC subsequently reversed itself and delayed the plan for 6 months. That was in 2021-2022. It's now 2024-2025.
Around that time many insurers, not just UHC, began implementing AI-assisted claims adjudication. It was a bumpy ride with a steep learning curve and probably took a couple of years to fine-tune the algorithms and learning models.
Especially as the Covid-19 claims tsunami subsides.
No matter tho', every claim paid is considered a loss by insurers. Every claim denied is considered a small step towards mitigating those losses.
In the U.S., medical reimbursement is a push and shove, shove and push battle fought inch by inch with high-speed data systems. It has been that way for a long time.
[0] https://www.aha.org/special-bulletin/2021-12-29-aha-expresse...
https://www.cms.gov/marketplace/private-health-insurance/med...
If anyone wants to see real reform then eliminating employer sponsored health plans is one potential way to get the incentives more properly aligned.
All three systems get better health results than the US, by measures like survival time after diagnosis of major disease. And all three spend a significantly lower percentage of their GDP on healthcare.
Source: The Healing of America by T.R. Reid.
So no, it obviously doesn't go without saying. If we want to cut overall health system costs or improve access then we might have to accept some reduction in service quality, at least for the most expensive stuff.
Not to mention, your comparison on cancer survival rates is flawed. The US system drives many people with cancer to be completely unable to afford treatment, which I doubt you've factored into your survival rate number.
https://www.npr.org/sections/health-shots/2019/10/22/7673763...
The fundamental problem here is that demand for healthcare is virtually infinite while supply is limited. Healthcare already consumes about 20% of the US economy and there is no excess capacity to expand it further without dragging everything else down. We can make some things more efficient and reduce administrative burdens but ultimately we have to draw the line somewhere and ration care. That's going to be true regardless of whether we have commercial insurers or socialized healthcare.
Care is expensive because of insurance. Hospitals needs hundreds of administrators and billing specialists. Very little of that money goes to the doctor.
The difference between a rich doctor and a rich insurance exec is that the doctor helps people, and the insurance exec makes their money withholding necessary care from people, in effect torturing and killing them.
It's a tug of war, and even if insurance "loses", it doesn't matter, because you lost trillions of dollars in that tug of war. It's artificial inefficiency caused by privatization, very much a Dark Night burning a mountain of money situation.
UHCs profit margins are only 6%, their operating costs are extremely low[0], and if you look across G7 insurers in the US pay more than the government does in every country but France![1] Compare this to HCA which makes an average margin of 10% with far higher administrative costs. The CEO of HCA makes $20M, Brian Thompson made $10M by contrast.
This is not to say we (and insurance companies) don't spend astronomically more than other countries: providers are to blame for this, and I have seen their nonsense first hand:
- They keep people alive overnight to charge insurance more
- Some hospitals use ML (!) to optimize ICD codes for billing. Most do this by hand: there's literally a job and training to be an ICD coder.
- They allow people to deteriorate (e.g. dialysis) to charge more (no preventative care.) I have seen a hospital only provide preemptive care to patients at risk of dialysis because they were part of their own insurance pool
- Their administraive expenses are far higher.
- They test and provide unnecessary care.
- Physician shortage is in part caused by limited residency spots, a dumb bachelors requirement, and high tuition costs. These barriers to entry are imposed by physicians.
- Uneccesary tech and equipment upgrades (e.g. we need to replace your knee with a new knee)
- Having to deal with tons of different insurance companies: not their fault but they don't know how to handle this efficiently.
[0]: https://www.reddit.com/r/dataisbeautiful/comments/194wucn/oc...
[1]: https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_pr...
Because customer-insurer relationships are the only side of the healthcare system that most people see, they're oblivious to what are actually pass-through insurer-provider issues.
As you said, the reality is that insurers operate with pretty reasonable margins and incredibly meager per-claim overhead costs. They're stuck trying to make 2 + 1 = 2.
If the finger should be pointed at root causes in the US health system, it should be at:
- Providers overbilling (particular in certain specialties)
- Medical schools, for charging too much and under-expanding capacity
- The federal government/Congress, for failing to expand residency funding to increase supply (especially in generalist provider categories)Because anecdotally, among my friends, I’ve never known someone to not make it through the system to practicing medicine who wanted to, but I do know several who persevered despite being real idiots. I don’t see how opening the pool wider would lead to better care.
2. There are limited spots in certain residency programs due to how competitive they are. Ergo those specialties are artificially more lucrative. Dermatology is a good example.
3. Becoming a doctor is temporally arduous: 11 to 15 years! Why the hell do people need to spend four years of time and money on a bachelor's degree instead of entering a medical program directly?
4. Becoming a doctor is financially arduous. You will be in debt for four years of undergrad, then four years of medical school, and then you'll be paid garbage for 3-7 years of residency. High interest rates exacerbate this.
5. Residency is hell.
6. Working in a hospital is often hell. Burn out is very real.
7. There are many, many professions which provide a far better standard of living.
[0]: https://www.aamc.org/news/press-releases/new-aamc-report-sho...
https://students-residents.aamc.org/medical-school-admission...
We can also expand access to affordable primary care by shifting routine services to physician assistants and nurse practitioners. Physicians should be reserved for more complex or higher risk cases.
You’ve restated the old joke, “That restaurant is terrible —- the food tastes bad and the portions are so small!”
TLDR 1. Society is getting older demographically.
2. Physicians are getting older demographically and have stopped working.
3. Many rural areas and minorities are already underserved.
1. This is true sometimes, but still privatization and insurance's fault. Hospitals have a motive to charge insurance more money. Public healthcare doesn't have this problem.
2. Administration and billing is ludicrously expensive because of insurance. Thousands of insurers with their own processes breeds the most inefficient and broken system you could possibly imagine. The solution is removing the market, i.e. having a single payer. Boom, administration costs disappear.
3. Preventative care is rarely paid for by insurance. In addition, many patients simply don't do it. It's easy for a smoker to get treatment for COPD, it hard for a smoker to stop smoking. That's just how it is.
No matter how you slice the healthcare problem in America, it undebatable that private insurance must go. The inefficiency it creates is absurd and it's why our healthcare costs are through the roof.
Not only do we pay much, much, MUCH more per citizen for care, but our care is also lower quality as compared to the rest of the west.
https://www.newsweek.com/how-medicare-advantage-scams-senior...
Most provider costs are obscured / complicated by insurers sitting in the middle of transactions.
If they weren't, providers wouldn't do some of the all-but fraudulent coding shenanigans that have become normalized. But overbilling a faceless insurer is fine.
And likewise, patients would have an incentive to shop around for the most cost effective services, instead of no one in the system being able to proactively say how much something would cost until the insurance claim is submitted and processed.
Wealthy lobbyists for providers and health insurance companies prevent any change basically.
Also misguided American exceptionalism whereas people think the healthcare standards will go down significantly if there is a public option (as if they weren't already down for the things people can actually afford).
Doctors in Canada went on strike when nationalized healthcare was pursued by the government in the 60’s.
The government broke the strike by importing foreign doctors.
https://en.m.wikipedia.org/wiki/Saskatchewan_doctors%27_stri...
In those other countries doctors power was significantly curtailed long long ago.
I mean, actually it makes sense. Their job is to pay for expensive procedures, sometimes quite urgently needed. They can’t really ethically insert themselves into the decision making process, so if these companies were run ethically they’d be signing themselves up for unlimited risk.
Maybe they shouldn’t exist.
- The ACA limits the amount of money, as a percent of revenue, that insurance companies collect as profit. If they wish to increase profit, their primary option is to collect higher premiums and pay more benefits.
- (No experience with keeping someone alive overnight. I'm sure it's happened and couldn't disprove it in any case.)
- Of course they have optimized billing. The current fiasco has byzantine rules for payment. For instance, you know how your dermatologist offers you smoking cessation and weight loss classes? That's because if they offer it to you, insurance rules allow them to bill the encounter as an enhanced care visit which pays more. This isn't an exaggeration. The insurance rules say "we'll pay you an extra 30% if you ask about their smoking and weight". The doctor can earn more simply by following those rules. Again, of course providers do this! If my boss gave me a 20% raise for asking him each morning if he'd like me to make him a sandwich, even knowing he hates breakfast sandwiches, you bet I'm doing it.
- That's complicated. If a hospital violates the insurer's rules, they don't get paid for seeing the patient. Yes, the situation you described is horrid, but no provider can afford to write off every patient. It's the insurers who said they wouldn't pay until the patient is seriously sick.
- Surveys have shown that as much as 60% of small practices' management overhead involves staffing people to deal with insurance companies, process claims, optimize billing (see above), negotiate pre-approvals, and so on. They have higher overheads because the insurers require it, not because they want to.
- Well, according to the insurers trying to weasel out of paying for it. For example, a patient came to my wife with an obvious soft tissue injury. She ordered an MRI to diagnose it. The insurer refused the approval until my wife took an X-ray first because it's cheaper. X-rays also don't show soft tissue injuries. (Don't correct me; I know the exceptions here and they're not relevant to this.) So it was the insurer who demanded my wife perform a wholly useless test before they'd pay for the effective one.
- I'm not willing to lower the quality of physicians. Other studies have shown that the lack of upcoming doctors is due to fewer people willing to put up with the insane stress levels for mediocre pay. The stereotype of a doctor heading out at noon for an afternoon of golf are largely over for nearly all specialties. Frankly, there are many jobs that pay better with less stress and less personal responsibility.
- That's laughably wrong. No one gets a new knee for the fun of it. It's a major surgery with long and challenging recovery that people get because they're otherwise unable to function normally.
- There is no way to handle this efficiently. It's an utter morass.
This assumes that the things being done now are meaningfully contributing to the quality of physicians vs various proposals.
It's also probably a mistake to measure the quality of the doctor vs the quality of the care that is delivered. More doctors that are less stressed and can spend more time on each patient could easily outperform a smaller group of "better" doctors.
This is true to some extent, but the share of medical providers that over-bill and over-treat really doesn't justify the way the insurance industry does business. It's a false equivalence.
I’ve seen this argument made on this website a lot, and it always conveniently omits the vertical integration of these insurers wherein they are the providers too.
The DOJ is literally, actively, suing to block a merger between united healthcare and a provider.
https://www.justice.gov/opa/pr/justice-department-sues-block...
Both the payer and provider sides of the healthcare industry have been consolidating for years. Insurers merged to gain more negotiating power with providers and drive down costs. Providers responded by merging (or selling to private equity funds) to gain more negotiating power with insurers and maintain high rates. Government mandates on back office technology also incentivized provider consolidation due to economies of scale. In some areas now a few major provider organizations effectively control the market and payers are essentially forced to pay high rates in order to maintain sufficient networks. So, the logical next step is for payers to mimic KP by building their own captive health systems. Every major payer is pursuing this strategy to varying levels; it's not just UHC.
Plenty of healthcare is not covered by insurance. Cosmetic procedures are healthcare and not covered.
Not to mention errors in claims, claims that include care well outside guidelines, etc.
You’d expect a pretty consistent level of denials even if all medically necessary claims are approved.
I think it's a sign of deep American corruption that we can't even have this public debate without a salacious murder occurring.
The problem today is the insurers, hospitals and doctors put the patients at the center of the fight.
Insurance denied? You pay patient.
Insurance didn’t pay doctor enough? You pay patient.
Hospital not in network? You pay patient.
I think patients would see it as an improvement if hospital said upfront to go somewhere else as insurance won’t pay. If they knew insurance would pay at the right hospital than it would be better than today’s situation.
Someone comes to you saying they need a website. You say "absolutely ... clearly you need one!". So you build it.
The decision to pay you however comes from some 3rd party who says "denied". Now the customer keeps their site and you don't get paid.
Will you stay in this coding business?
The real solution is a public health system. Which has issues (apply queuing theory, because you will have to wait for the limited resources you are niw denied) overall it is better though since it can in theory be optimized as a whole.
AND YET
The hospital where I receive my cancer treatments once told me "don't worry, our Denial Team is handling this."
They have a Denial Team. That is to say, insurance companies are imposing cost overheads on providers and patients due to their illegitimate profit boosting tactics. And our government can't be bothered to enforce the ACA's basic requirement to track and report denial rates.
>"No industry malfeasance could ever excuse murder.
"Period."
And yet, that's what it took for our media to start reporting on this? We have some real problems in this country, and a corporate news media asleep at the switch, or at worst complicit, is one of the most serious.
IED airbags, HIV injections, babies without limbs, etc. are industry malfesance.
So the phrase implies:
No acts of corporate greed including profiting by killing people could ever excuse murder.
If you're seeking coverage for lung cancer, but you chose to smoke, denied.
If you're seeking coverage for type II diabetes, but you weigh 400lbs, denied.
If you're seeking coverage for cancer because you got unlucky with a cosmic ray incident on your DNA, approved.
If you're seeking coverage for a liver transplant because you refused to put down the bottle, denied.
If you're seeking coverage for injuries from an auto accident that was not your fault, approved.
I will NEVER understand why this type of blanket policy is so controversial. Cover bad luck, do NOT cover personal choices. It will fix not only costs, but the moral hazard endemic to the current system.
Or, AT THE VERY LEAST, allow prejudicial adjustments to premiums for fatties, smokers, and alcoholics.
- Health "Insurance" middleman mafia should not be the default b/w me and my doctor - Health Insurance should only exisit for Catastrophic events (big surgery, cancer etc) - Get rid of the regular Premiums, CoPays, Deductible, CoInsurnace, In network/Out network Bullshit. - For catastrophic events, we pay a premium (much smaller than now) - All hospitals and Doctors must offer an advertised/displayed Cash Price. No exceptions. Fine heavily if they hide - Let me pay cash for a regular doc visit. - Govt can subsidize for poor people (exdtension to medicare etc ??)
That's it. Problem Solved. This will remove so much BS, middleman stuff, overhead and with a competitive market, prices will drop significantly. Doctors will be happy not dealing with Insurance for everything.
Tell me why I am wrong.
In 2022 I was denied full insurance payment of a routine, preventative echocardiogram at Stanford Healthcare to monitor my heart issues. I was balance billed $5000+. The insurance company was HealthNet. The policy clearly indicated full coverage of preventative procedures, without a deductible. They said they did not recognize the procedure as preventative. Fuck them, I know better about what's preventative and what's not than them.
I argued the shit out of it, dozens of e-mails, hours of phone calls, and it was eventually sent to debt collectors. I wrote back to the debt collectors that it wasn't my debt and to stop contacting me. I reported it to a couple of government agencies as well to give them more headaches. I did not pay.
In 2024 it was written off as uncollectible.
(a) Use a virtual mailbox with your health provider so that they don't send debt collectors to your residence. Do not give them your residential address.
(b) Use a virtual phone number with your health provider so that the debt collectors can't call you. Their only option will be mail and that leaves a paper trail which you DO want. NEVER communicate with a debt collector by phone.
(c) Freeze your credit reports with all 3 bureaus so that they cannot use your mailing address to find your residential address.
(d) If they do somehow find your residential address, do NOT answer. Only communicate by mail.
Disclaimer: IANAL, account of personal experience only
https://www.healthcare.gov/coverage/preventive-care-benefits...
In your particular case it might have been medically necessary, but not legally classified as preventive. This is a huge hassle for patients because the nuances aren't obvious or clearly documented. It's likely that Stanford Healthcare erred by failing to obtain the necessary prior authorization from HealthNet before performing the procedure.
Since 2022 there are some legal protections against balance billing. Although those might not have helped in your case.
https://www.cms.gov/newsroom/fact-sheets/no-surprises-unders...
I do have a question about one thing you said:
> I know better about what's preventative and what's not than them.
How is that? From your profile I don't see any medical training.
Doctors and medical research may supply me with additional medical knowledge, but the insurance company can go to hell. They don't know a damn thing about any of this.
Remember that.
I also wasn't too concerned about that because
(a) I believe medical debts don't affect credit scores for a long time.
(b) I believe medical debts are required to have complete erasure from a credit report if cleared so if I actually needed my credit score to buy a house or whatever I could take the $5K hit to restore the credit score at that time.
(c) I sent them a formal letter disputing the debt, which I assumed means they can't just take it to the credit agency, they'd have to go to court with me first. (Again IANAL, I don't know how accurate this is.) In any case I was mentally prepared to spend $10K on lawyers and court and give them a absolute hell of a time than pay $5K to pay for healthcare I shouldn't need to pay for. I made it VERY CLEAR to the debt collectors that I was ready to pay for lawyers.
(d) For the forseeable future I don't think I need my credit score for anything. I don't plan to borrow money.
New York's law focuses on prohibiting healthcare providers and related entities from reporting medical debt, while California's law directly restricts credit reporting agencies from including medical debt in credit reports.
Many online papers have pay walls. There are similar articles criticizing health care denials from other sources, feel free to post them. They're not all discussion material nor even readable.
And if the writer did a poor job, poke a hole in the argument.
When I called to refute the denial, which was denied, I asked them to find the person, if it was a person, who denied it and shove a tube up their ass without anesthesia and then reassess whether it's medically necessary to have a colonoscopy without it.
I'm 45. Colonoscopies are a thing. I had a friend die at 52 two years ago after he was diagnosed with stage IV during his first colonoscopy. I spent many of his last days watching him struggle to survive; I don't want that to happen to me just because UHC charges me $2000/month in premiums and denies basic service because they need to pay their executives too much money.
Patients strongly prefer having what amounts to a general anesthetic; your chances of recalling anything are low either way, but propofol results in a much faster recovery to full consciousness afterward.
Go gain 100 pounds and develop sleep apnea. Then they'll approve it.
Note that they approved the colonoscopy, just not the anesthetic. Also, to get approval for a colonoscopy, one just needs to have persistent intestinal pain or note that they have a history of polyps.
It is almost universal that hospitals pay from their fees for part of the anesthesia services because the direct reimbursement we get is so low.
You can get one at 45, no questions asked, or you can claim you had a bloody stool.
As far as pain, that’s hard to measure. Procedures that are done under sedation or anesthesia in the US are done in other countries with little or nothing. I had all of my wisdom teeth extracted and all of my dental fillings done under local anesthesia only. It was fine. I don’t need gas, I don’t need sedatives.
It sounds like something is getting lost in translation. Presence or absence of anesthesia does not change the medical necessity of the procedure.
> I'm 45. Colonoscopies are a thing. I had a friend die at 52 two years ago after he was diagnosed with stage IV during his first colonoscopy.
Without wading into the specifics of your situation, there's not great evidence justifying colonoscopy for normal people without family history at age 45. The USPSTF just kinda lowered the threshold based on crappy (pun not intended) observational data. And if you look at their recommendations, they actually don't recommend colonoscopy, specifically -- they just recommend "screening" [1] which includes FIT, DNA testing (again: not great evidence here), or flex sig, which is done without anesthesia, and all of which are cheaper than colonoscopy. It's a huge debate.
Anyway, I absolutely don't want to reflexively defend the health insurance industry in the US, but one the reasons we have skyrocketing health care costs in this country is because people are doing expensive procedures when cheaper ones would suffice.
[1] https://www.uspreventiveservicestaskforce.org/uspstf/recomme...
No regrets about getting screened though. It saved my life.
Well yeah...it isn't screening then. It's a treatment. So the question becomes whether or not the treatment is necessary. If the prior "screening" didn't show definitive evidence that the treatment is necessary, then...what are you doing, exactly?
I understand that colonoscopies mix up the notion of treatment and screening, but the doctor is basically saying "our screening tests don't work very well, so we should just do the treatment without evidence because they'll pay for that."
At some point, after so many failures and edge cases, the least they can do is be actual humans and ask themselves "are we the baddies?"
A lot of health care is just really expensive superstition. For a more extreme version, consider the phenomenon of "preventative MRIs", which are just lighting piles of money on fire for no reason at all.
I replied to colonoscopy specifically here because the general public has been conditioned to believe that these screenings are medically necessary at increasingly younger ages for everyone, despite the fact that this is not the standard at all in most other countries.
I am glad you are able to recognize behaviors that you don't like doing, as that's the first step in not doing them.
It's it usual to be asleep? I've not really heard of that. Is it a US thing?
Without any real evidence except a hunch, I think it's because I've already met my deductible for the year and they don't want to pay for the entire thing and they'll do anything they can to avoid having it happen this year and hope I just go away or do it in another year when I haven't hit my deductible.
> Anesthesia or anaesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia, paralysis, amnesia, and unconsciousness.
"General anesthesia" is probably what you're thinking, which is a specific form of anesthesia where someone is put to sleep.
Also UHC fwiw, but went through my local provider group, etc...
We have people - covered in tattoos - who insist that they are terrified of needles. And that they want drugs before any even mildly painful procedure, like placing an IV.
It depends on what they do while they’re in there. If they’re just taking pictures then it’s fine. If they find anything they usually cut it out immediately. I can tell you from experience that having a piece of inflamed colon cut of and cauterized while you’re conscious isn’t a “non-event” as cool as it might be to watch on the monitor.
Requiring people to be awake is a good way to guarantee they don’t get the procedure. Which mathematically makes it far more likely for the insurer to incur enormous colon cancer treatment expenses, erasing their profiteering.
Just find an excuse to deny those claims, too!
This presupposes the insurer isn’t going to deny claims for that treatment, too.
signed up for an account with my real name to share a doc i've been working on for a long, long time now - i've had UC since high school, and have written an extensive guide of what i've learned, if it helps you or anyone else you know who might be getting scoped:
https://docs.google.com/document/d/1bTW2rdF744woSPpFsUeSaFYa...
Given those numbers, how often should everyone get a colonoscopy?
That's before we get on to the potential harm from a false diagnosis (which is much higher without additional priors).
Yes, absolutely people should pay attention to their bowels and get a colonoscopy when it's indicated. Let's not all rush to get one though unless there's some reason for it.
i also believe pre-screening (stool sample testing, mostly) is getting better, which would potentially help categorize who does and does not need an actual colonoscopy in the future
these are all US stats[0], which i'd imagine is a broadly worse-off group than the UK in terms of like, ultraprocessed foods and other risk factors, but this stood out to me:
> Lifetime Risk of Developing Cancer: Approximately 4.0 percent of men and women will be diagnosed with colorectal cancer at some point during their lifetime, based on 2018–2021 data, excluding 2020 due to COVID.
anecdotally, i think with gastro problems there's a lot of individual latitude where serious problems might go undetected, under-reported, or assumed to have a less serious cause - i also think (but do not know) that colon cancer develops slowly, which may mean there's a long potential where it could be caught, detected, or risks flagged early by a colonoscopy, which, to me, outweighs the risks of "serious complications" from the procedure
1: https://www.mayoclinichealthsystem.org/hometown-health/speak....
I haven't heard of any jurisdiction where putting someone under for colonoscopies, outside of extreme cases, is the standard expectation.
Not even for fancy private hospitals, way too high of a risk-reward ratio.
Anesthesia in many cultures is seen as a "drug use" and avoided. It has several risks, including death. In many cases it includes needle into backbone.
Period."
Murdering a murderer to save many innocents could be considered ethical by some?
(Not saying that's the case here, but nypost made an interesting categorical statement.)
But a murder carried out by a random citizen is still worse than a death sentence after a fair trial and convicted by a jury of your peers.
For example, we can go into treacherous schemes that pushes our neighbors into paths where the only obvious option they can still perceive as a way to escape our shenanigans is an attempt to kill us, and as they come with this very real intention to kill us, press the button we had prepared to trigger some mortal trap.
Considering that a lot of innocent people are murdered by the state via jury and trial in the US the distinction isn't very clear imo.
~211 people were killed via trial sentence in the US in the last 10 years [0]. Presumably some of them weren't innocent. In the same time period (conservatively) 8500 were killed by law enforcement outside of the legal process [1].
Both are problematic, but calling <20 people/year (out of a third of a billion people) "a lot" is missing the forest for the tiny sprig of moss.
[0] https://deathpenaltyinfo.org/database/executions?year=2024&y...
[1] https://en.wikipedia.org/wiki/Lists_of_killings_by_law_enfor...
Is 5 a lot?
Depends. Potatoes? No. Murder? Yes.
It's quite possible for someone to hold that a killing in self-defense is much more defensible than the deliberate execution even after a conviction and trial of someone who is "no longer harmful to society" because they're locked up.
Making prevailing the idea that some humans can reach a level of certainty that is high enough to put a death sentence on some people they didn’t even knew before that is telling a lot. Like, we humans never make errors, we don’t have any kind of cultural and idiosyncratic biases, we never have conflict of interest and we can’t be manipulated by miscellaneous social forces.
Murder is bad, and murder en masse committed through institutionalized legitimating mechanisms is thus extremely bad, as as many times as bad as how many people it kills.
Legal murder through institutions never prevented a society to have "random" citizen going awry and kill other people, but it never missed to add supplementary threats to all their citizen.
A more constructive observation would be to consider the overlap in groups of people who (1) hold that murder is indefensible in any case, and (2) hold that death sentences are appropriate for crimes. While not sharing that view myself, I could think of a few factors that may lead others to espouse it, such as:
- an implicit trust in authority and deterrents (follow rule, "or else");
- feeling of being mostly immune to errors in the justice system ("this would never happen to me");
- a propensity to desire revenge but only when it pertains to "others" ("I'm a good person, we must punish the bad people")...
The concern is not whether laws are rights or wrongs, but which privileges and which hurts they reinforce for which classes in the society where the national myth is eager to present them as the applied rules.
There's Switzerland.
https://www.swissinfo.ch/eng/democracy/swiss-democracy-in-an...
First, direct democracy is kind of a pleonasma, that is in its core democracy has to put equals duties and means to all its citizens. It's clear probably why such a system can easily attract masses, as it promises to maintain political power in the hands of those who have to obey it. Note that this definition insist more on duties and means, which is a very different promise from a populist statement on "righteous rights for everyone thanks to a turn key plan you don't even need to investigate on applicability". People certainly are interested with more democracy, so their slavers scam them with all kind of system under the label democracy which never give them these duties and means that you can expect to see attached to an effective democratic citizen.
The question is not so much the quality of the US democracy but to what extend it can even be classified as a well functioning democracy.
The US resembles an oligarchy, and when the laws are written by the rich and profit seeking that will affect how killings are perceived such as killing in the name of corporate profits will become alright.
So expressing the sentiment that nothiong excuses murder and still having a death row is just I congruent and wrong.
And yes, both the will of the people and tradition can justify capital punishment.
But then again, the society apparently defines the quality of a killing - only future history will tell if this is a murder, and thst can go back and forth a lot depending on public sentiment.
Everybody knows that plenty excuses a murder, we live in murderous states and in murderous times. The question is whether this murder is excusable, and one's opinion on it is probably dependent on whether one wishes they had that guy's job. Most people wouldn't do it for any price, but plenty would.
A claim denial that results in denial of life-saving treatment could never be counted as either of those charges.
First-degree murder is when you willingly, and with forethought, plans and carries out the killing of a human. Which seems to me to be 100% what you described.
It is surprising if insurance companies what to sign themselves up for this sort of obligation. But obviously they’ll take all the privileges of the decision making process if we don’t also hold them to the responsibilities.
For profit medicine and for profit health insurance is just riddled with moral hazard.
I suspect that all modern legal systems have the concept of negligence which could result in someone being considered guilty for someone's death. I imagine in that case whether that's "murder" would come down to whether you mean a legal definition (which might call it something else like "manslaughter") or the colloquial definition.
Why wouldn't they do their part as a news org, and why did they wait for the murder to publish such an article, if that murder was not "needed" for things to change, then?
In the US it’s insurance companies (or the government through Medicare or Medicaid) but in the UK it’s NICE, in Canada it’s CADTH and the provincial health authorities.
Since there are finite resources spent on healthcare, trade offs are made all the time. If spending $10M on treatment A saved 10,000 lives and $10M on treatment B saves 1,000 lives, then treatment A gets funded and treatment B doesn’t.
The difference is that patients in the US have an up close and personal experience with denial.
In Canada and the UK they don’t because doctors knows what is covered and what isn’t so never bring up life saving options if they aren’t paid for.
In rare circumstances like cystic fibrosis in the UK, patients become aware that they are being denied a life saving drug and protest, but generally it’s pretty rare because patients just don’t know the option exists.
https://www.cms.gov/marketplace/private-health-insurance/med...
If employers wanted it, insurers would be happy to offer health plans that fully paid every claim with zero denials. This would be enormously profitable for the insurers because they could run those health plans with minimal work. But instead, most employers are constantly looking for ways to cut employee health benefit costs. This means incentives aren't aligned.
The person at the insurer who denies a claim is not making more money because they denied it. The company as a whole might, but not the person denying it.
There are numerous stakeholders who setup the rules - the government, insurance companies, hospitals, doctors, billers, etc.
All of them profit from the current system, but there is no single stakeholder who decides the overall rules.
Fixing it is another matter. Of course that’s not easy.
Medicare per-capita spending is more than NHS per capita spending, but the NHS covers everyone.
Of course healthcare is denied in any system (in other systems this is triage), but nowhere to the level United Health does it: over 30%, it's on a completely different scale.
Plenty of treatments are denied in other countries. Not to mention most other countries have private insurance layered on top of public and it’s the same issue - private insurers denying a treatment through their own process.
If US insurers are guilty of murder than most of the worlds insurers are too.
Violence works.
Are you saying this as an opinion, or is this an established thing? I thought murder was an "unlawful killing without justification or valid excuse" (paraphrased from Wikipedia), whether one finds it ethical or not is sort of beside the point. Especially because there is no objectively correct ethics.
But, I'm not a lawyer, this is just my understanding.
It's quite easy to come up with situations where the law declares a killing as unequivocally murder yet everyone agrees it was ethically justified. The opposite can happen too.
The point is also orthogonal to what the insurance industry does.
This is a heavy statement.
More I read, heavy it gets.
Kill people it never the answer. The ideia that "I" have the power is weak. People, together, have power, however they don't know what to do. In his case the easiest way to win is pressuring the government, with the people, for clear changes.
Perhaps n = 1 is too low of a value? We should research this field more, some people may die but it's a chance I'm willing to take
https://www.vox.com/policy/390031/anthem-blue-cross-blue-shi...
So Anthem based on the article it might be overpaying for at worst 5% of the operations BUT the big but is that in some hospitals it is routine to round digits. So paying less workers for some rounding operations? It doesn't look as bad to me. It might be because of reasons, or might be due to media backslash.
I think it's safe to assume we definitely need more research into healthcare companies rules after healthcare companies ceo related killing
I worry that the future for the U.S. is the malaise that appears to have taken hold of the Russian people.
It worked beautifully
The media pearl-clutching is extremely heavy this time around, painting Luigi as an unhinged lunatic and all the rest. It feels incongruent and purposefully dismissive to equate this to something like the Oklahoma City Bombing.
Media seems to be on an agenda setting tear to disavow the murder, but I think it’s a frankly boot licking response to what is going on here.
I think this spooked a lot of executives (re: “elites” if you will) and there is pressure to ignore the nuance of what the murder means to people and why it isn’t the same as say, stabbing a tech CEO in SF like what happened last year
https://www.opensecrets.org/orgs/unitedhealth-group/recipien...
Unfortunately, it’s easy for them to create conditions to perpetuate and widen the American political schisms. And they’ve convinced both sides the common historical solutions (nationalism, limited democracy, religion) are for low IQ bigots. Things are likely too far gone.
That does not look to me like both sides are at fault and we need to think of it differently. That looks to me like Democrats are imperfect but largely aligned with what I want, whereas Republicans are resolutely in opposition.
"Give me universal health care...but don't increase my taxes!...and don't take away my current insurance plan!"
Every year for 10 years, reduce the age of eligibility by 1 year. At N+10, it will cover 55+.
For the next 10 years, reduce the age of eligibility by 2 years per year. At N+20, it will cover 35+.
You can also set up Medicaid to cover all children in a similar way (after all, most children have no income, so should qualify if judged on personal income rather than family income). Set a date and if you're born after that date, you get medicaid until you're 20.
At year N+20, there will be a 15 year gap for young people. Which is hopefully time enough for them to earn enough social security credits to qualify for Medicare.
And yes, medicare and medicaid taxes would have to go up. But private healthcare premiums should go down.
Rolling it out over 20 years allows for adjustments to be made as things go along. Criteria based on years is for simplicity... A better method would be increasing eligible population by 1% the first year, 1.1% the second, and so on until you're done.
If people really don't want to just pay for it socialized. Just make it possible to self pay for medicare at more ages; this is something that seniors without enough social security credits can already do. Again modulating the eligible age over time to allow for a transition without overwelming the system.
Yeah, why not? The US already spends more tax dollars per person in healthcare. The excess gets funneled to the insurance companies. There's no reason why we can't implement universal healthcare without increasing taxes.
Civil disobeyance is nothing new. The fact that is is so little pronounced currently is probably a signal that there has been alignment for quite a while.
Bit when politicians do not take their jobs seriously, change finds other ways.
[1] https://www.theguardian.com/world/2009/dec/16/joe-lieberman-...
Obama campaigned for Joe Lieberman afterwards as an independent against Ned Lamont, who had won the Democratic primary. Lieberman tanked the public option for the Democrats, and Obama was paying his debt.
Democrats would have paid the price at the polls for getting rid of the public option. Lieberman took the hit for the rest of them; he was the cheapest, because he already publicly held right-wing positions. If they had needed another vote, they would have had to find another Democrat to risk their political career to do it. Probably with a cushy lobbyist job at a health insurer after getting voted out.
I don't know a single person who ENJOYS going to the doctor, or needing medical treatment.
What are you on about?
Everyone knows Americans pay the most for medical treatment, but the life expectancy is not that high. If you know your behavior isn't good for you, but you can't stop yourself, well, that's an addiction.
But many people don't, because visiting a primary care / walk-in clinic / urgent care is expensive, so they ignore it, until it becomes un-ignorable. Now it's an ER visit.
Sure.
> If you know your behavior isn't good for you
This doesn't follow. Our healthcare system might be worse than some but that does not imply it's bad for you. That same logic would imply getting punched in the face is good for you because it's better than getting shot.
Well, if you have that mindset, then you'll never achieve anything better, will you? It's not necessarily bad for us, so we'll just keep doing it.
It's like the people who vote for the same set of loser politicians every 4 years and then complain that nothing ever changes.
I was thinking about condensing my thoughts into a post, but I'll make one point on the issue of premiums. In the article, it says the cost of insuring a family of four is $25,000 a year. That sounds accurate to me.
I know from experience (being self-employed for a period of time and having to figure this all out myself) that if your family is healthy, you can replace all 4 full-term plans with 4 short-term plans and pay about $4,000 a year for the same coverage. The only difference, really, is that your insurance coverage ends after one year and you have to apply for it again. This used to be seen as risky, but with the ACA, someone will always be forced to insure you. So, it's not the same anymore.
That's not even all we could collectively do to solve this problem. Just imagine if all the healthy people in America just did that. I know, there aren't many healthy Americans left. And a lot of people have health insurance as part of their benefits package.
But many of those people are paying their dependents' insurance out of pocket. So, someone on a full-term plan could switch all his dependents to short-term and save about $5k per year per person. And it doesn't cause any noticeable difference to someone's coverage.
Imagine if only 1 million healthy Americans went from full-term to short-term. The health insurance industry would lose 5 billion dollars of income a year. That's not huge for a $500B industry, but it's not nothing. Corporate America sits up and starts paying attention to what's going on at ANY loss of revenue.
This is not insurance advice, but just thinking out loud. Verify everything yourself, but my point is that there's a lot everyday Americans could do to hurt these companies in their wallets. We just need to come together, share ideas, and trust ourselves and each other more than nameless, faceless companies.
Here's a goalpost for you: a healthy person should not spend more than $2,000 a year, total, on any health care related expenses. Even that number is ridiculous. But it's probably about half of what people are paying. If we all focused on that, and helped each other achieve that totally achievable goal, we'd change a lot about this rotten system.
I’m against vigilante killings because I don’t want to live in that kind of a society. But a couple days later, Anthem decided to end their insane time limits on anesthesia. I’m hoping the public’s reaction to all these events has put a bug in the ear of politicians who ran partly on the idea of “repeal the ACA”: maybe this isn’t a great time to start slashing coverage. People seem pretty upset about it right now.
> “Say there is a contract between an insurance company like Anthem and an anesthesiologist,” Garmon told Vox. “What is always in that contract is a clause that says, ‘You, the provider, agree to accept the reimbursement rules in this contract as payment in full.’ That means the provider cannot then turn around and ask [the patient] for money.”
There was also a process for anesthesiologists to apply for extra payment if surgery went extra long.
https://www.vox.com/policy/390031/anthem-blue-cross-blue-shi...
They make a larger point that the main reason Americans pay so much more for healthcare is that we pay our providers a lot more. Nations with more reasonable costs and high-quality results have controls in place to keep costs down at the provider level.