Comment by novok | Hacker News Reader

Comment by novok | Hacker News Reader

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Health insurance's issue is probably how it induces pure waste everywhere as everyone has to play this dance of ever escalating paperwork which consumes a lot of labor. It's not profit, it's waste. Same with the ever increasing amount of admin. Why is that admin increasing? I estimate insurance or requirements created by insurance is part of the cause.

There is also a lot of other smells of a lack of a competitive market. Very opaque pricing, limits to how many hospitals can be opened in a region, needing paperwork to push against that limit, limits in residency slots, the entire hazing ritual of residency in the first place, limits in opening medical schools, ever escalating requirements to become a doctor, restrictions against doctor owned hospitals or clinics, the fact something like an epipen is still not out of patent and not having many clones by now, large barriers to make medical devices and medications, while simultaneously having great issues with generic drug quality, a horrible food system compared to Europe, while simultaneously having a much harder regulatory state medically compared to europe, etc.

This is spot on. It’s not that I think health insurance companies are making insane profit margins. It’s that their very existence in the system is a pure negative and in fact a moral blight. Inflicting profit into a system that is entirely dedicated to human health is by definition a conflict of interest for basically everyone involved, even if it operated at a hypothetical 100% efficiency.

Lots of things necessary for life are run by for-profit businesses — for example, food production. Do farmers have a “conflict of interest”? What about healthcare in particular makes profit immoral?

If the grocery store decides to remove the prices from everything, and require its shoppers to first call its billing department only open until 5pm to receive a set of numbers, then call their third party subscription service only open until 6pm to receive a non-binding estimate, for every item in their grocery list, then wait weeks or months for the grocery store to have its cashiers take time away from checking customers out to petition the third-party subscription service to allow its customers to buy any item deemed to require prior authorization…

You can typically endure hunger for 15 minutes for the time it takes to go to another food store.

On the other hand, if you are bleeding out in the ER, no such luxury exists.

Insurance executives have a fiduciary duty to maximize the profit of the company.

If the company makes a profit off of treating patients, then it has a financial incentive to not approve treatments that would make patients better.

If the company loses money treating patients, then it has a financial incentive to deny treatment as much as possible.

Unless a legal structure is found which scales profit with quality of care, ethical choices will be at odds with the fiduciary duty of the company officers. Having an AI say “no” and putting someone on hold is a lot less expensive than paying out for a cure that cost billions to develop.

In the case of government-run healthcare, the government at least sees the consequence of poor health outcomes in decreased productivity, competitiveness, gdp, and/or tax revenue, as well as increased use of social services.

In other words, if the insurance company refuses to treat you, it costs the government money to pay for welfare indefinitely, not the insurance company.

There are lots of perverse incentives at work, and vanishingly few people even try to understand them, I think because most people simply don’t believe it could possibly be as bad as it is. And by the time they learn otherwise, they care more about getting healthy again than overextending themselves trying to solve a massively complex problem.

> Insurance executives have a fiduciary duty to maximize the profit of the company.

Probably not. Many insurance companies are not "for profit" companies(not a 501c3, something else). Certainly some are, but most of the giant ones, State Farm, etc are not. Most are Mutual Insurance companies: https://en.wikipedia.org/wiki/Mutual_insurance which handily includes a list of them.

I.e. they are operated more like Vanguard, the investment firm than they are Fidelity(a private for profit company) or Schwab a public for-profit company.

Also, this fiduciary duty thing is not really true, but people think it's true. They do have a duty to work in their shareholders best interests. Lately that's been taken to mean profit above all else, but that's a recent(last few decades) interpretation.

> If the company makes a profit off of treating patients, then it has a financial incentive to not approve treatments that would make patients better.

It depends on if they share the cost(s) of keeping patients healthy or not. Incentives matter. If they are incentivized to keep people healthy, instead of just treating X disease today, it would be a different conversation.

> In other words, if the insurance company refuses to treat you, it costs the government money to pay for welfare indefinitely, not the insurance company.

> There are lots of perverse incentives at work

Agreed. But mostly it's just excess waste as far as I know. I'm not an expert in healthcare, so I'm at best a armchair quarterback here.

>If the grocery store decides to remove the prices from everything, and require its shoppers to first call its billing department only open until 5pm to receive a set of numbers, then call their third party subscription service only open until 6pm to receive a non-binding estimate, for every item in their grocery list,

Good point (buying food would be a nightmare if it worked like American health care!) but that's a different argument from the one made above in the thread, that a profit motive in a vital good inherently creates perverse effects.

Oh yes, these things are exactly equivalent. Problem is, nothing about the health system's incentives aligns with consumer benefit. The most profitable outcome for an insurer is that everyone pays premiums and never uses any services. The most profitable outcome for hospitals is that they charge maximum prices for every service and yet don't really fix underlying problems or prevent future problems. Hospitals profit the most off patients that need a ton of care and have deep pockets. They lose money on giving care to people who cannot afford it and won't pay. They lose money in the long run when preventive care prevents later catastrophic (and expensive) conditions later. Pretty much all of the profit-maximizing forces in the for-profit system are deeply unethical.

If you're going to tell us that because health care providers and health insurance companies are some kind of magic counterbalance against each other that benefit consumers, uh, nope.

>Pretty much all of the profit-maximizing forces in the for-profit system are deeply unethical.

Are you talking about healthcare specifically or businesses in general? AMD wants to make the best CPUs for the most amount of money. Is that "unethical"?

> healthcare specifically

Yes, it is deeply unethical that someone can be bankrupted and become homeless because of a treatable condition because the "market" has decided a price for the service that is astronomical without insurance, while at the same time tying insurance to employment, dividing up insurance markets, and making coverage subject to inscrutable, unappealable decisions made by people sitting behind desks in a completely different part of the country, while the leadership of said organizations and investors make higher profits than ever. It is deeply unethical that a CEO can make tens of millions of dollars--which for most regular people is several lifetimes worth of earnings--in a single year, while dealing in a market that regularly denies coverage to people who then suffer, are financially ruined, and die.

It's not the same as making a better CPU for more money. Not. At. All.

You can also become homeless because the market has decided that rent should cost more than you can afford (in a given area). This involves real estate, equity investing, home insurance, zoning, housing regulation, and banking. Is this equally immoral? How many types of business are similarly immoral?

the question sets up a false dichotomy, unless that was your intent?

For profit fire, military, or police departments result in some very obvious issues, and they would simply be causing maximum distress.

For profit / Not for profit, are all serving the same goal - human well being. We choose for profit models where they would result in surplus, and non profit where its more applicable.

at least thats the theory. Reality is more messed up.

> Oh yes, these things are exactly equivalent

A: All men are tall, therefore Giannis Antetokounmpo is tall.

B: Your proof is wrong: see this man here, he isn’t tall!

A: Clearly he has nothing in common with Giannis. He’s not even in the NBA!

I don’t think health insurance is actually insurance, but I have seen little evidence that it has “insane profit margins”. From what I’ve read, ‘health insurance’ has middling profit margins relative to other insurance specialties; where are you getting that view/data?

Honestly, health insurance has a lot wrong. Things like the 80/20 rule can create some weird incentives. Normally an insururer would want to minimize the costs of what they insure, but if non-claim overheads plus profit has reached 20%, then they can't negotiate lower costs without losing profit, and are actually incentivized to either get more claims or negotiate worse prices.

This is besides all the inefficiencies, and nonsense. For example even if a patent hypothetically knew exactly how long a procedure would go, exactly what personnel would be involed and how, exactly how much anesthesia/sutures/other billable supplies were used, and that there were no complications, and even if they know that no denial of coverage would happen, it is not structurally possible for them to know the out of pocket costs, except for the handful of surgeries that get treated as package deals. It would literally take dozens of hours of phone-calls to the hospital's and each provider's billing department to get the exact codes and amounts they would submit, and then trying to get insurance to price the hypothetical bill, or provide you with sufficient information to price it yourself. And obviously a bunch of the information we are assuming the patient has are unknowable until after the fact.

Part of the problem is insurance has a huge rule engine for deciding which line items are covered by not-allowable (meaning they get written off), plus insurance contract rates are only public for hospitals (so no info for providers that bill separate), and even then the data files don't always contain sufficient data to determine which of the multiple allowable rates for this procedure with this insurance at this facility, with these caveats actually applies).

There is a lot of stuff where this is not the case and pricing is still opaque or takes way too much effort. Like if I want to get a well defined CT scan or blood test. It's not as simple as going on amazon or many other retailers.

A few examples: I wanted to get a CAC scan that my insurance wouldn't cover. My insurance website said that a CAC scan would cost this much with my insurance, along with a total price that would be charged, covered or not. It was something like $80 total. I then called the place to get a CAC scan, and they said since the insurance didn't cover it, the price was $300, and there was no cash pay direct price where I could get it at the listed $80 price, even though they could hypothetically bill the insurance, and the insurance could just bill me the full price. The same place does not have a price listing; there is no online ordering I can do for the CAC scan, I needed to go through a permission process by talking to another doctor to even get the CAC scan in the first place. The fact I even needed to call people, and there was all this bullshit, to do direct cash pay for a simple scan is emblematic of a very broken system.

Or I want to get a blood draw for a blood test ordered by a doctor at one medical. They do not list the total price, even though that should be automated and very clear since it isn't a procedure that would have any 'complications'.

Even the simple shit is not clear at all and takes way more work than it needs.

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