3 ms·

Aside from someone being denied life-saving medication, the most awful thing for me in these stories is the relentless Kafkaesque quality. We never get any answ

Aside from someone being denied life-saving medication, the most awful thing for me in these stories is the relentless Kafkaesque quality. We never get any answers to our basic sense-making questions about the bureaucratic process: - What did the insurer expect to happen, in order for this person to keep getting their medicine? - Why did those things not happen? - Whose job was it to make sure those things happened? - Did that person know it was their job? - ...etc. I get that it was about prior authorization, but whose job was it to make sure the prior authorization happened? Why didn't that person do it in a timely fashion? Why isn't there an understanding within the insurer's system that Type 1 Diabetes is a life-long condition and not something that will just go away when the insulin runs out? Was there a "happy path" here or does a scenario like this invariably degenerate into a scramble involving dozens of calls and day-destroying last-minute errands?

lotsofpulp 5y ago
I find the article written in a circuitous way, that does not clearly lay out the timeline. This statement about what a prior authorization is is also incorrect: > They’re essentially requirements that a physician get approval from an insurance company before prescribing a treatment. Doctors need no approval from anyone to prescribe. A prior authorization is approval from the insurance company that they agree with the treatment option and will pay for it (subject to deductible/copay/oop max). The theory here is that the end user has no idea what they are getting since they are not knowledgeable about medicine. Doctors could be prescribing unnecessarily expensive medicine or treatment, so the managed care organization (MCO, or insurance company) “manages” the healthcare for the uninformed buyer by having the healthcare professionals employed by the MCO double check things. In this specific person’s case, it looks like the biggest delay was in getting a doctor’s appointment when he needed both a new MCO and a new doctor. Technically, you can pin this on undersupply of doctors, MCOs tied to employer, MCOs not hiring good people and causing unnecessary delays, incompatible electronic documentation systems that do not talk to each other, and I could go on and on. Ideally the doctor should be able to see what medications the MCO will cover on their computer while the doctor is seeing the patient so before they even leave the doctor’s office. Another concern in the long list of concerns is the MCO is not necessarily the one deciding the rules for what treatment/medications to pay for or not. Many, many times it is state government (e.g. Medicaid), federal government (e.g. Medicare/Tricare), or other entity that is actually paying for the healthcare who will hire the MCO and give them the rubric on how much to pay for people’s healthcare/what treatment courses or brands of medications will be covered. This is how poor people (Medicaid) can be restricted access to healthcare by limiting the reimbursement for their healthcare so fewer doctors accept it while older people or members of military get access to better healthcare because their healthcare gets reimbursed at higher prices (Medicare/Tricare). The system allows for a lot of opacity to allow for a lot of price segmentation while also providing political cover for such decisions due to the complexity of understanding it.
- stefan_ 5y ago
  None of this is making any sense. There is no cure for T1 Diabetes and it is lifelong. There is no reason to have any of these requirements, middlemen, authorizations or whatever.
  - lotsofpulp 5y ago
    There are many different kinds of insulins at different prices, and apparently, in the US there is not though political will to pay for any choice of them as even the federal government restricts which one it pays for. https://www.healthline.com/diabetesmine/new-medicare-program-caps-insulin-prices-at-35 https://www.healthline.com/diabetesmine/new-medicare-program...
- deleted 5y ago
  [deleted]
- civilized 5y ago
  We went through this with a relative recently. She needed a surgical operation. We were asked to either 1. Wait for prior authorization and allow our appointment to be canceled and rescheduled (for the fourth time, having already wasted several weeks) 2. Pay out of pocket We decided to pay out of pocket, since we knew that the prior authorization could delay us by an arbitrary amount of additional time and had recently read that the insurance might not even help us anyway. The twisted thing is that you can't just get the operation done and let the prior authorization work itself out later. It truly has to be prior or you get stuck paying out of pocket, even if the operation is obviously medically necessary. This structure seems expressly designed to screw the patient over. Maybe it doesn't prevent the doctor from prescribing, but it has a similar impact in the end. And regardless of my anecdote about prior authorization, there is the question of why someone with Type 1 Diabetes is being denied their medicine. I feel like the only potentially valid excuse would be if the insurer literally didn't know the person had Type 1 Diabetes.
  - lotsofpulp 5y ago
    > The twisted thing is that you can't just get the operation done and let the prior authorization work itself out later. It truly has to be prior or you get stuck paying out of pocket, even if the operation is obviously medically necessary. I have had doctors collect payment, and then refund me once they get paid by the MCO. One more thing that would help here is decoupling employers from your MCO. That way, when you change employer and location at the same time, it does not mean you change your MCO. If the person who wrote the article had the same Blue Cross Blue Shield MCO (or other MCO part of a nationwide network) with old and new employer, then he would have had no reason to seek out a new doctor and new medication.

lotsofpulp 5y ago

I find the article written in a circuitous way, that does not clearly lay out the timeline. This statement about what a prior authorization is is also incorrect: > They’re essentially requirements that a physician get approval from an insurance company before prescribing a treatment. Doctors need no approval from anyone to prescribe. A prior authorization is approval from the insurance company that they agree with the treatment option and will pay for it (subject to deductible/copay/oop max). The theory here is that the end user has no idea what they are getting since they are not knowledgeable about medicine. Doctors could be prescribing unnecessarily expensive medicine or treatment, so the managed care organization (MCO, or insurance company) “manages” the healthcare for the uninformed buyer by having the healthcare professionals employed by the MCO double check things. In this specific person’s case, it looks like the biggest delay was in getting a doctor’s appointment when he needed both a new MCO and a new doctor. Technically, you can pin this on undersupply of doctors, MCOs tied to employer, MCOs not hiring good people and causing unnecessary delays, incompatible electronic documentation systems that do not talk to each other, and I could go on and on. Ideally the doctor should be able to see what medications the MCO will cover on their computer while the doctor is seeing the patient so before they even leave the doctor’s office. Another concern in the long list of concerns is the MCO is not necessarily the one deciding the rules for what treatment/medications to pay for or not. Many, many times it is state government (e.g. Medicaid), federal government (e.g. Medicare/Tricare), or other entity that is actually paying for the healthcare who will hire the MCO and give them the rubric on how much to pay for people’s healthcare/what treatment courses or brands of medications will be covered. This is how poor people (Medicaid) can be restricted access to healthcare by limiting the reimbursement for their healthcare so fewer doctors accept it while older people or members of military get access to better healthcare because their healthcare gets reimbursed at higher prices (Medicare/Tricare). The system allows for a lot of opacity to allow for a lot of price segmentation while also providing political cover for such decisions due to the complexity of understanding it.

stefan_ 5y ago
None of this is making any sense. There is no cure for T1 Diabetes and it is lifelong. There is no reason to have any of these requirements, middlemen, authorizations or whatever.
- lotsofpulp 5y ago
  There are many different kinds of insulins at different prices, and apparently, in the US there is not though political will to pay for any choice of them as even the federal government restricts which one it pays for. https://www.healthline.com/diabetesmine/new-medicare-program-caps-insulin-prices-at-35 https://www.healthline.com/diabetesmine/new-medicare-program...
deleted 5y ago
[deleted]
civilized 5y ago
We went through this with a relative recently. She needed a surgical operation. We were asked to either 1. Wait for prior authorization and allow our appointment to be canceled and rescheduled (for the fourth time, having already wasted several weeks) 2. Pay out of pocket We decided to pay out of pocket, since we knew that the prior authorization could delay us by an arbitrary amount of additional time and had recently read that the insurance might not even help us anyway. The twisted thing is that you can't just get the operation done and let the prior authorization work itself out later. It truly has to be prior or you get stuck paying out of pocket, even if the operation is obviously medically necessary. This structure seems expressly designed to screw the patient over. Maybe it doesn't prevent the doctor from prescribing, but it has a similar impact in the end. And regardless of my anecdote about prior authorization, there is the question of why someone with Type 1 Diabetes is being denied their medicine. I feel like the only potentially valid excuse would be if the insurer literally didn't know the person had Type 1 Diabetes.
- lotsofpulp 5y ago
  > The twisted thing is that you can't just get the operation done and let the prior authorization work itself out later. It truly has to be prior or you get stuck paying out of pocket, even if the operation is obviously medically necessary. I have had doctors collect payment, and then refund me once they get paid by the MCO. One more thing that would help here is decoupling employers from your MCO. That way, when you change employer and location at the same time, it does not mean you change your MCO. If the person who wrote the article had the same Blue Cross Blue Shield MCO (or other MCO part of a nationwide network) with old and new employer, then he would have had no reason to seek out a new doctor and new medication.