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Comment by rqtwteye | Hacker News Reader

The whole system is infuriating. Even when you assume a free market is what you want, it's pretty clear that this is far away from a free market. Unless you view non-competitive monopolies as free market.

I don't understand why vertical integration is not made illegal. An insurer should not own a PBM or providers. They all should have an adverse relationship so they put cost pressure on each other.

Also, providers should charge the same prices for the same procedures no matter who pays. Ideally everybody should be mandated to follow Medicare prices. If these prices are too low to survive, then there should be a discussion about adjusting the prices.

The whole system is basically a huge bureaucracy that wastes a lot of money but some of the waste is enough profit for a lot of people to fight tooth and nail to keep the status quo.

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I can't speak for all providers, but I can say that, in many cases they're getting squeezed by the insurance companies, too. My girlfriend is a provider of services for young people with disabilities. The insurance companies fully dictate how much she can charge (how much the insurance companies will pay) and even what specific services she can provide (what they'll specifically pay for). It's infuriating. Up until about 7 years ago, she was fully funded by the state through the California Department of Education, and it was simple. She met with a single person from the state monthly, they reviewed her billable hours, made some corrections here and there, and she got paid. Simple. When private insurance was introduced it became a nightmare. She had to hire a full-time employee just to manage billing with the insurance companies. One insurer won't even talk to providers at all. Nothing. Nada. She has to fax them. Yes, fax. And their fax machine only answers during business hours; it's powered-off outside of business hours. Why? Because fuck you, that's why. It's obvious that the insurance companies make it as difficult as possible for providers to get paid, which is not too different from patients. Weird...not.

> And their fax machine only answers during business hours; it's powered-off outside of business hours. Why?

In some cases, privacy laws require that fax machines be actively monitored so that sensitive personal information is not just left sitting around in the open for hours.

Yes, there could probably be alleviated with sort form of purely digital fax system, but for regular fax machines, this could be why they are only available during staffed hours.

It's almost the same when you deal with billing departments in hospitals. They give you the runaround, "lose" things repeatedly, ignore you. The whole US health system is abusive but there is so much money flowing around that it's worth it to many participants. I know doctors who complain about their workload but they would never consider moving from 600k salary to 400k in exchange for a straight 40 hour week.

I dunno, I used to have Kaiser which is vertically integrated and the nice thing was there wasn't the thing where the Doctor says we should do X, but your insurance won't pay for it, so we'll do Y. Or my favorite where the doctor writes a prescription, and the pharmacy doesn't fill it because it's not covered, and you have to convey what is covered to the doctor so they can write that instead.

Kaiser would sometimes tell me that we have to try X first before we do Y, but then the X's worked sometimes, so it seemed like they were asking for reasonable things to reduce cost.

I think kaiser is pretty widely regarded as the best experience possible with healthcare in the USA. Unfortunately its not widely available

There are other organizations with the same "payvider" model (combining payer and provider). For example, Geisinger and Intermountain. It's slowly getting more popular.

"Unlike the traditional healthcare model, which often pits payers against providers in a bid to control costs, the payvider model merges these roles..."

- https://www.neudesic.com/blog/the-rise-of-the-payvider/

> I don't understand why vertical integration is not made illegal.

Well I decided that would be extremely inconvenient for me if that was the case, so I’m going to call this “bad regulation”, and say it’s against the “Free Market” so if you support it you are a communist.

If later on I decide this is good for me, then I will call it “good regulation” that supports the “Free Market” and you are in the clear.

All sarcasm aside, if you don’t define what your minimum set of regulations are for you to consider it a “Free Market”, then you are consigning yourself to endless bike shedding over what a “Free Market” really is

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