5 ms·

My best understanding is that if patients use insurance to pay for the device/visits, payment to the Drs office is predicated on the patient following the presc

My best understanding is that if patients use insurance to pay for the device/visits, payment to the Drs office is predicated on the patient following the prescribed treatment. In our case, we actually bought the cpap out of pocket. But because this is unusual (It cost us about 800 dollars) the doctor we went to pays a company that does treatment monitoring. This company is paid based on the number of patients that are "in compliance" with their treatment plan, because this makes it easier to bill against insurance for the Drs office. The monitoring company has a financial incentive to make sure patients are in compliance. The Drs office has a financial incentive to make sure patients are in compliance. --- Ironically - the thing that was actually needed was additional monitoring to tune pressure: it takes several readings over a few nights to manage pressure and keep bloating down and make sure it's not hard to breathe, while still ensuring that apnea events are in the acceptable range. But additional monitoring is expensive - it requires clinician/doctor time. So there is little incentive to actually do this, in favor of forcing plan compliance. Basically - My read of the situation is that the whole thing was rotten to the core. It had very little to do with patient comfort or health, and everything to do with maximizing insurance based revenue.

matheusmoreira 5y ago
> maximizing insurance based revenue That seems to be the state of US healthcare unfortunately. What used to be an ethical doctor-pactient relationship has turned into a doctor-insurance-patient monstrosity. Doctors actually have limited autonomy. They can't always do what's best for the patient, only what the insurance company agrees with.
- lotsofpulp 5y ago
  The patient and doctor are free to negotiate a deal that avoids third parties such as the insurance company. The patient chooses to hire an insurance company (better labeled a "managed care organization") to manage their care, because they do not know what they are buying, or how much it should cost. >They can't always do what's best for the patient, only what the insurance company agrees with. Because that is what the patient can afford. Note that when the previous commenter states this: > everything to do with maximizing insurance based revenue. They are referring to requirements frequently set forth by the government or their employer. Some of them are called "star ratings", and the government goes to managed care organizations (who also sell health insurance), and task them with implementing standards of care and star ratings and a very complex system that determines who gets paid how much and who is incentivized to do what. It is very naive and counterproductive to label insurers as the bad guy because "insurers maximizing revenue", because it lets go of the real issue, which is that A) healthcare is hard, and measuring results even harder B) supply of healthcare is low relative to demand C) the limited supply of healthcare has to be allocated in some manner It is a very complicated subject, that involves many players, incentives, opportunities for corruption, people with good intentions, and no easy answers.
  - nescioquid 5y ago
    >> They can't always do what's best for the patient, only what the insurance company agrees with. > Because that is what the patient can afford. What is the point of paying for insurance, then? Nothing legitimizes for-profit insurance companies having any role or prerogative in health care, other than the status quo.
    - lotsofpulp 5y ago
      The point of insurance is to protect against unaffordable losses. An insurance business only works if the losses are, by and large, randomly distributed and unexpected. The more predictable the losses, the more an insurance offering resembles a payment plan where you are simply setting aside money with a third party to save for the eventual loss. This is because as losses become more probable, the insurance company has to increase premiums eventually to the point where the sum of the premiums is equal to the losses if the probability of loss is 100%. This is the current state of health insurance in the US. It is not what would normally be called an insurance product. In fact, quite a few of the stipulations of ACA make health insurance premiums explicitly a tax from the young/healthy to the old/sick. Therefore, the industry term is to refer to health insurance companies as "managed care organizations" (MCOs), some of whom sell health "insurance". In the US, when you pay health insurance premiums, if you are young/healthy, you are mostly paying for the treatment of the old/sick, and only minority paying to protect against the risk of you breaking your arm. The profit that MCOs earn is actually more like an administration fee. The US could have implement an NHS style taxpayer funded healthcare system, but the politically viable option in 2010 was to outsource the administration of healthcare (pricing negotiations, healthcare rationing, auditing, etc) duties to MCOs, hence we have a system where the government (or employer) sets the rules, that abide by ACA rules, and then the MCOs execute them. For example, nearly half of Americans' healthcare is paid by the government, but it is administered by MCOs. The MCOs are not setting the rules, just carrying out the stipulations of their contracts with the government: https://crsreports.congress.gov/product/pdf/IF/IF10830 https://crsreports.congress.gov/product/pdf/IF/IF10830 Finally, to answer this question: >What is the point of paying for insurance, then? If you have future earning potential, or a little bit of wealth saved up, then health insurance in the US is valuable because your out of pocket maximum is capped. https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/ https://www.healthcare.gov/glossary/out-of-pocket-maximum-li... This is one of the policies that also helps make health insurance premiums more akin to a tax, along with, but not limited to, the following policies: Age Rating Factors (adds cost to young people's premiums and lowers old people's premiums) https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/state-rating https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-In... And insurance cannot be denied to someone for any reason, and has to only be based on age/location/tobacco use: https://www.healthcare.gov/how-plans-set-your-premiums/ https://www.healthcare.gov/how-plans-set-your-premiums/
pvaldes 5y ago
Looks a lot like an octo telematics device spying your activity when you drive your own car.

matheusmoreira 5y ago

> maximizing insurance based revenue That seems to be the state of US healthcare unfortunately. What used to be an ethical doctor-pactient relationship has turned into a doctor-insurance-patient monstrosity. Doctors actually have limited autonomy. They can't always do what's best for the patient, only what the insurance company agrees with.

lotsofpulp 5y ago
The patient and doctor are free to negotiate a deal that avoids third parties such as the insurance company. The patient chooses to hire an insurance company (better labeled a "managed care organization") to manage their care, because they do not know what they are buying, or how much it should cost. >They can't always do what's best for the patient, only what the insurance company agrees with. Because that is what the patient can afford. Note that when the previous commenter states this: > everything to do with maximizing insurance based revenue. They are referring to requirements frequently set forth by the government or their employer. Some of them are called "star ratings", and the government goes to managed care organizations (who also sell health insurance), and task them with implementing standards of care and star ratings and a very complex system that determines who gets paid how much and who is incentivized to do what. It is very naive and counterproductive to label insurers as the bad guy because "insurers maximizing revenue", because it lets go of the real issue, which is that A) healthcare is hard, and measuring results even harder B) supply of healthcare is low relative to demand C) the limited supply of healthcare has to be allocated in some manner It is a very complicated subject, that involves many players, incentives, opportunities for corruption, people with good intentions, and no easy answers.
- nescioquid 5y ago
  >> They can't always do what's best for the patient, only what the insurance company agrees with. > Because that is what the patient can afford. What is the point of paying for insurance, then? Nothing legitimizes for-profit insurance companies having any role or prerogative in health care, other than the status quo.
  - lotsofpulp 5y ago
    The point of insurance is to protect against unaffordable losses. An insurance business only works if the losses are, by and large, randomly distributed and unexpected. The more predictable the losses, the more an insurance offering resembles a payment plan where you are simply setting aside money with a third party to save for the eventual loss. This is because as losses become more probable, the insurance company has to increase premiums eventually to the point where the sum of the premiums is equal to the losses if the probability of loss is 100%. This is the current state of health insurance in the US. It is not what would normally be called an insurance product. In fact, quite a few of the stipulations of ACA make health insurance premiums explicitly a tax from the young/healthy to the old/sick. Therefore, the industry term is to refer to health insurance companies as "managed care organizations" (MCOs), some of whom sell health "insurance". In the US, when you pay health insurance premiums, if you are young/healthy, you are mostly paying for the treatment of the old/sick, and only minority paying to protect against the risk of you breaking your arm. The profit that MCOs earn is actually more like an administration fee. The US could have implement an NHS style taxpayer funded healthcare system, but the politically viable option in 2010 was to outsource the administration of healthcare (pricing negotiations, healthcare rationing, auditing, etc) duties to MCOs, hence we have a system where the government (or employer) sets the rules, that abide by ACA rules, and then the MCOs execute them. For example, nearly half of Americans' healthcare is paid by the government, but it is administered by MCOs. The MCOs are not setting the rules, just carrying out the stipulations of their contracts with the government: https://crsreports.congress.gov/product/pdf/IF/IF10830 https://crsreports.congress.gov/product/pdf/IF/IF10830 Finally, to answer this question: >What is the point of paying for insurance, then? If you have future earning potential, or a little bit of wealth saved up, then health insurance in the US is valuable because your out of pocket maximum is capped. https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/ https://www.healthcare.gov/glossary/out-of-pocket-maximum-li... This is one of the policies that also helps make health insurance premiums more akin to a tax, along with, but not limited to, the following policies: Age Rating Factors (adds cost to young people's premiums and lowers old people's premiums) https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/state-rating https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-In... And insurance cannot be denied to someone for any reason, and has to only be based on age/location/tobacco use: https://www.healthcare.gov/how-plans-set-your-premiums/ https://www.healthcare.gov/how-plans-set-your-premiums/

pvaldes 5y ago

Looks a lot like an octo telematics device spying your activity when you drive your own car.