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Medicare Advantage plans use algorithms to cut off care
- jjoonathan 4y agoPrivate, for-profit death panels. Innovation!
- LorenPechtel 4y agoThis sort of garbage will not be fixed until there's a real penalty for denied claims. Not merely pay the claim, but enough to deter misbehavior.
- whoomp12342 4y agoThere is a real penalty? I mean, even if you implemented this, they would fight the penalty just like all the claims they fight today
- mywittyname 4y agoRight now, there's no cost to blanket denials, but there's a huge incentive to do it. My partner works on the hospital side of things, and several major insurance providers deny literally every claim. And why not? At worst, it just means that the insurance company can wait a year or more before paying. At best, they never pay. Of course, it's also the insurance companies who are adjudicating the claims.
- elliekelly 4y agoIt reminds me of this thread[1] from a few weeks ago. The article was so infuriating to read. [1]https://news.ycombinator.com/item?id=34639988 https://news.ycombinator.com/item?id=34639988
- darkarmani 4y agoMake the penalty increase exponentially each time they lose. Eventually, they will stop fighting it all.
- LorenPechtel 4y agoSo long as the penalty is higher than the percent of claims they get out of with their improper denials it would be enough to deter the behavior. You just need to tip the balance to making proper behavior cheaper.
- Wingman4l7 4y ago
- ImHereToVote 4y agoThe advantage is for the shareholders. Keep up poors.
- mikece 4y agoDeath Panels via "AI" processing of approval for service?
- r00fus 4y agoYes, the "health insurance" industry funded backlash during 2010 against Obamacare was most definitely "projection" in the classical sense. They most definitely did that for private plans - by recission (kicking expensive people off the plan) or simply the "pre-approval" BS where they keep expensive people but decline specific (and possibly needed) care. That's the only way private health insurance can both cover (most) in a cost effective way AND be profitable for their hedge fund masters.
- nine_zeros 4y agoPlain and simple regulation - Coverage cannot be defined by insurance. It has to be defined by providers. But what about fraud? Well, maybe don't start a health insurance company if you can't deal with it.
- fallingknife 4y agoWhat do you mean don't start an insurance company if you can't deal with it? Your first sentence says they shouldn't be allowed to deal with it.
- ceejayoz 4y agoIf an insurer believes a provider is committing fraud, that should be between the two of them. The patient shouldn't have to be the negotiator in the middle; they have zero power over either side. Too many fraudulent/suspicious claims from a provider? Cut the provider off, not the patient.
- macinjosh 4y agoThey would deal with it by passing the cost of the fraud onto the patients paying principles. Now you have more problems. There is no such thing as a plain and simple regulation.
- HDThoreaun 4y agoThe issue with this is that there is absolutely gigantic amounts of over prescription of care in the US because of the payment structure. Many common procedures not only aren't helpful but are commonly actively harmful, but the surgeon who recommends it gets paid so they'll keep on signing people up.
- fortran77 4y agoThe problem is people duped into switching into Medicare Advantage, which they can’t undo. See https://www.newsweek.com/how-medicare-advantage-scams-seniors-opinion-1759368?amp=1 https://www.newsweek.com/how-medicare-advantage-scams-senior...
- tpmoney 4y agoWhat do you mean you can’t undo it? https://www.medicare.gov/sign-up-change-plans/joining-a-health-or-drug-plan https://www.medicare.gov/sign-up-change-plans/joining-a-heal... >Medicare Advantage Open Enrollment Period. From January 1 – March 31 each year, if you’re enrolled in a Medicare Advantage Plan, you can switch to a different Medicare Advantage Plan or switch to Original Medicare (and join a separate Medicare drug plan) once during this time. Note: You can only switch plans once during this period.
- erentz 4y agoSomething to be aware of is that when using Original Medicare you will want to also get a Medicare Supplement (Medigap) plan. Medicare only pays 80%, the Medigap pays the extra 20% (no questions, anything approved by Medicare they cover the gap on). But you are only guaranteed to be able to join Medigap during your initial enrollment at 65. If you switch back from Medicare Advantage to Original Medicare you are not guaranteed to be able to get Medigap. This can leave you stuck. It will possibly vary from state to state so it pays to get up to speed with the rules in your local state. If you're expecting to be sick in old age or if you get Medicare due to a disability that is likely to have a lot of expensive treatment or require you to see different doctors in different areas it is best (IM-somewhat-experienced-O) to take Original Medicare.
- tpmoney 4y agoThis sort of crap is part of why so many people are scared of the idea of a national healthcare plan. You would think Medicare would be easy, medical coverage for people over 65 or the disabled, paid for by the taxes you (and others) are paying your whole lives, simple and done. Except it isn't easy at all. Only Part A (hospitalization) is covered by the taxes. And it only only pays 80% of costs, with no annual out of pocket max (remember how having that was a huge selling point for ACA plans?). Oh and there's also a PER INCIDENT deductible for each in-patient hospitalization. And you better hope you don't need a visit longer than 60 days in the hospital, or 20 days in a skilled nursing facility or you're going to start paying for that too. Then if you want to, oh I don't know, see a doctor so you don't go to the hospital in the first place, that's Part B, but now you're paying a premium, and also have a new deductible (thankfully only once per year for this one). Still only covers 80% of the costs, still has no out of pocket max. And all that "in network / out of network" crap you have to deal with in private insurance? Yeah that's still a thing, they just call it "participating" and "opt out" providers. Only unlike a lot of private plans where at least there's some (crappy) out of network coverage, if you see an "opt out" provider, medicare won't pay at all, no matter if you submit the claim yourself or if the service was a medicare approved service. So that's nice. Oh and if you don't sign up for part B What's that you say? You'd like to be able to take life saving medications and prescriptions that could also keep you out of the hospital? Why that's yet ANOTHER plan (Part D) you need to sign up for, with yet another premium (medicare currently claims between $4 and $150 monthly in my state). And then like always, drugs tiers with co-pays and then the infamous "donut hole" (I worked IT for a pharmacy, the number of their patients who just... stopped being patients when they hit that donut hole every year was disturbing). Don't worry though, Medigap is here, an insurance policy you can buy to pay for the stuff your national insurance that you're already buying doesn't pay for. For a mere $200 - >$1000 / month, some or all of those deductibles listed above can be covered. Oh and did we mention that if you fail to sign up for part B or part D within 60 days of being eligible you might have to pay an additional penalty on your premiums for life? And as you pointed out, you might never be eligible for medigap if you don't get it the first time around. And none of that includes vision or dental coverage. So how much does it cost to be covered by medicare? Well with all the plans and a medigap plan as well, anywhere from $200 - $2000 / person / month just in premiums. Yeah ...
- MilnerRoute 4y agoEarlier discussion about "Medicare Advantage" plans. https://news.ycombinator.com/item?id=35001728 https://news.ycombinator.com/item?id=35001728
- gaterin 4y ago[flagged]
- swayvil 4y agoI live in a town that has offered a novel answer to the riddle of "low value humans". The homeless. The head-injured. Low income families. Recently released prisoners. The impoverished elderly. My town has arranged itself to serve that population. Or more specifically, my town receives money from the state for providing these services. It's our #1 industry. All the other towns bring their "problem people" here. It's probably the most efficient approach (within legality). We've concentrated them all in one place. (It's gotten kind of dangerous and filthy.) It used to be a nice college town.
- l_theanine 4y ago[dead]
- tmpz22 4y agoSo ghettos?
- poorbutdebtfree 4y agoThe decision makers never live with these decisions. Sound the bell and you're a white nationalist transphobe.
- InCityDreams 4y agoExamples?
- danielrpa 4y agohttps://en.wikipedia.org/wiki/Escape_from_New_York https://en.wikipedia.org/wiki/Escape_from_New_York
- DrThunder 4y agoYou could just become Canada and have the government offer to help the old/disabled people end their lives "painlessly" because your socialized medical system can't keep up.
- msm_ 4y agoI hate when people use the word "algorithms" like that. Which algorithms? Dijkstra? I know this is the way non-technical people refer to the spooky AI action at a distance happening in social media to maximise engagement, but in my opinion it just makes everything confusing when actually trying to understand the argument.
- WediBlino 4y agoalgorithm /ˈalɡərɪð(ə)m/ noun plural noun: algorithms a process or set of rules to be followed in calculations or other problem-solving operations, especially by a computer. "a basic algorithm for division"
- whitemary 4y ago> like that. Like what? Correctly?
- lcnPylGDnU4H9OF 4y agoI didn't go through academia for my computer science knowledge so I may be wrong about the definition of "algorithm". I understand it as a series of steps to accomplish a task (e.g. a food recipe is a list of ingredients and an algorithm for rendering something delicious). If that's not mistaken, then the algorithm is something that's being used to make decisions. A different term to use could be "machine-made decisions", which I personally think describes the issue better. Still, (and unless my understanding is mistaken) the word algorithm is technically accurate to this kind of decision-making.
- sdfghswe 4y agoWe already knew these were bad people from the fact that they use the name to confuse. After that, this is no surprise. What surprises me is how long most people take to pick up on the pattern. They see person X do bad thing, shocked. Then they see same person X do a different bad thing, shocked again. I say arrest the executives and charge them with fraud. Hopefully that will send a message.
- twawaaay 4y agoWhen finally an AI will become sentient and gets access to all our infrastructure, it won't need to nuke us, it won't need to wage war with us. It will just locate everybody who is trying to fight it and block their credit cards, Internet access and repossess their cars.
- nostromo 4y ago> repossess their cars In other news: Ford Motor Co. has filed a patent application for technology that would allow autonomous vehicles to repossess themselves if drivers miss payments. https://thehill.com/homenews/3880884-future-fords-could-repo-themselves-if-drivers-miss-payments/ https://thehill.com/homenews/3880884-future-fords-could-repo...
- pc86 4y agoThat's almost certainly what the comment is referencing.
- netsharc 4y agoA nicer AI would just get their targets addicted to... something and make them mostly hate themselves instead of the attacking AI. For "something" you can substitute drugs, or social media, porn, or calling others idiots on the Internet. Wait a minute...
- mywittyname 4y agoSo, do we train AI on Brave New World or 1984?
- jmugan 4y agoDidn't read the article and don't know about what nefarious things may be going on, but we need to think broader about these issues. There's lots of articles here on hacker news about how the vast majority of medical expenses come at the end of life and how we do too much to keep people alive against their wishes.
- kerkeslager 4y ago> Didn't read the article Then don't comment. It's not complicated. > There's lots of articles here on hacker news about how the vast majority of medical expenses come at the end of life and how we do too much to keep people alive against their wishes. Jesus Christ. Let me get this straight: you're saying the solution to medical expenses is "let old people die, they don't want to live anyway"? There are certainly cases where people are kept alive beyond what's compassionate, but that's a pretty separate cultural problem from the situation at hand, which is people who need basic care and can't get it because of capitalism being involved where it shouldn't be.
- jmugan 4y agoCome on, we can't be children. I'm saying we need a conversation as a society about how we are going to handle end of life. We can't lurch form unthinking outrage to unthinking outrage.
- kerkeslager 4y agoTrue, but I'm not interested in hearing the opinion of companies in that conversation. When I and my loved ones are reaching end of life, what decisions we make should be a conversation between me, my loved ones, and my doctor. Whether it's humane to pursue life-extension should be a part of that conversation, sure, but I trust my doctor to present that viewpoint: people who profit from that viewpoint and don't know anything else about the situation (such as Medicare Advantage providers) are welcome to fuck right off. The reason our society keeps lurching from unthinking outrage to unthinking outrage is that people like you who can't be arsed to read an article and respond on topic keep proposing outrageous changes to our society. If you don't like unthinking outrage, maybe be more thoughtful and stop saying outrageous things.
- denton-scratch 4y agoAs far as I can see, this isn't news; medical insurers (and really any kind of insurers) use rules (algorithms) to decide which claims they should pay out on. Even if they could evaluate each claim completely individually and personally, they'd get sued for not treating all claimants equally. They have to use rules. And saying it's "AI" when it's just an algorithm (or even just a checklist) is getting annoying. I started getting annoyed when game developers called the algorithms used to control NPCs and so on "AI", when it's actually hand-made rules, finely tuned. Nowadays, if it's been anywhere near automation, then it's OK to call it "AI". A calculator could be called "AI" (if they still made them).
- gwright 4y ago> They have to use rules. There are rules and then there are rules. It is the details of the particular rule that is of interest. The use of "AI" in that article seems like clickbait to me. The article seems to suggest that predictions based on aggregate statistics are being applied to implement strict coverage approval for individuals. That seems like a complete misunderstanding of predictive value of those statistics for a particular individual. Not sure if that is gross incompetance or malfeasance. Either way, a problem.
- nerdponx 4y agoWhenever money is involved, invert Hanlon's razor. High prior on malice, low prior on ineptutide. Some well-meaning team of data scientists might have produced this model originally. But its employment in this manner cannot be assumed to be anything other than malfeasance, except in the face of significant evidence to the contrary.
- bandofthehawk 4y agoI think it's just a simple profit motive. If the insurers can minimize the amount of care while also minimizing the risk of getting sued, why wouldn't they do that? The algorithm/rules can be tweaked to minimize costs while protecting themselves from lawsuits when the algorithm "accidentally" drops coverage for someone who still needs it, as described by the examples in the article.
- NovemberWhiskey 4y agoAny time I see the output of a statistical model like "estimated length of stay" that gives a number like "16.6 days" without also saying something like "with a 95% confidence interval of -5.1 / +20.9 days", I get pretty confident the goal is not actually to help decision-making.
- Espressosaurus 4y agoIt's to launder guilt. I'm not denying the benefit. It's "The Algorithm" (TM). Nobody can change "The Algorithm" (TM), we'll just have to live with it. Sorry, but you're on your own.
- NovemberWhiskey 4y agoOr, as the TV show Little Britain put it: "Computer says no"
- LocalH 4y agoIt's wild how rigid society has become since computers became dominant. I read an article once that discussed how people who emigrated to the US prior to computers were generally unconcerned with making sure their name was romanized the same on every document, as all the humans involved were smart enough to understand "this is the same person even though the name is spelled slightly differently". Once computers took over, those people have had to "unify" their name across various documents, otherwise the computers do a literal comparison and reject it since clearly, the names are not the "same".
- CatWChainsaw 4y agoComputers are math machines. Everything has a procedure, an answer, a quantity, a yes or no. When people are determined to put computers and AI in everything, everything will naturally reach a computer-like end state; the world becomes a set of algorithms: no deviation, spontaneity, choice. How is that "wild"?
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- thinkingkong 4y agoThere's a war being waged on whether or not we're going to allow certain institutions to belong to the commons. If certain industries had their way, every sip of water and every breath of air would have an associated cost and market value. Can't afford to pay? It's unfortunate, but that's your own fault. Every time we encode and reinforce these systems through laws, market mechanisms, and now AI, we tacitly agree that people who cannot afford such things do not deserve them. If you can't afford private healthcare before the 0 cost system was implemented to decide that well... best of luck!
- philjohn 4y agoIf you haven't, check out the musical "Urinetown". Private toilets are banned, and all of the public conveniences are owned by a megacord - the UGC (Urine Good Company).
- mort96 4y agoI love that pun. It's pronounced exactly the same as "you're in good company".
- to11mtm 4y agoTBH The ending of that musical ruined it for me; The people 'take back control' only to squander the water and die of thirst. Sooo... Corporations are bad, but people are bad anyway so it doesn't matter? IDK. Might be a product of it's age (bitter endings were big back then, right?)
- philjohn 4y agoI read the ending differently - it's got two distinct parts. The first is a warning on populism - it falls apart quickly in the face of reality. Promising easy solutions to hard problems. The other is the Malthusian trap (explicitly nodded to with the "Hail Malthus") line.
- CWuestefeld 4y agoIn principle, if we paid MORE attention to property rights around these resources, we wouldn't be in the situation we find ourselves with respect to air and water pollution, carbon emissions, and so forth. If there were an owner, somehow, of the air, or the air over my house, or something, then when other entities are trying to externalize their own costs (by way of dumping carbon into the air, say), then we'd be able to use vanilla tort law to recover those costs as damages. I'm not saying we should necessarily do that - obviously there are big questions about just whose bit of water this is, and how to determine who's causing the damages. But if we could somehow answer those questions, it seems like the market could supply the answer. That, to me, suggests that moving in the opposite direction is not obviously the best answer.
- originalcopying 4y agothey're there to run a business first, and look out for your health second; budgetary constraints permitting, of course.
- steve76 4y ago[dead]
- dianeb 4y agoMedicareAdvantage is one of those things where people say, "Oh. It's Medicare and it has all this extra stuff!" because living on basic Medicare is expensive and finding appropriate physicians can be daunting because of high deductables and low cash to practitioners. It's not a scam but an attempt to provide better care. The problem is that it's almost always run by insurance companies and they're concerned about profit rather than the individual. Think of it in the same way as you would a PPP or basic HMO plan from your employer. Other than the oddities such as money to pay for over-the-counter medication (limited to $40 per quarter) there's little-to-no difference. It's not the government limiting the care but rather the insurance companies protecting their profits. It's capitalism in action. Deal with it.
- jalapenos 4y agoThese things are why I really like the US legal innovation of bad faith failure to insure, which makes a failure of an insurer to pay out when they reasonably should a tort rather than just a breach of contract.
- lysp 4y agoIn Australia, I believe private health insurers use a shared-risk model. Basically, they cannot deny anyone insurance based on health/age. Once a year, all insurers submit their claims data to a central pool. They will then need to pay a certain amount to the pool, or get a refund based on their claims vs the rest of their providers. That means risk is shared between all companies, and they don't need to deny people plans like in this case on the chance they get too many "bad customers".
- DavidPeiffer 4y agoI believe this is part of how the Obamacare marketplace works. I networked with a team from a major insurance company who exclusively worked with marketplace plans. They all said "I morally wouldn't work here if we were optimizing plans to avoid paying, like happened before Obamacare" and went on to explain a similar setup. In the scheme of things, it's a relatively small part of the overall population, but still very important.
- more_corn 4y agoAnd kill people. My father in law was killed by a Medicaid Advantage company canceling his skilled nursing. They admitted to doing it routinely. “You just have to call and appeal” only while his skilled nursing was denied the nursing facility “downgraded his care” which apparently means “we’ll park you in a hallway till this gets sorted”. He was in the ER within 72 hours of being discharged from the hospital. ER doctor said “cardiac arrest due to low electrolytes” the man was on an IV. Know how low electrolytes happens when you’re on an IV? They don’t fill the bag. Why didn’t they fill the bag? Downgraded from skilled nursing. Know why he was downgraded? Because his claim was denied. What was it denied? “They’re all denied. You have to call and appeal” This country is so fucked. Our plan for elder care is to literally kill them with paperwork.
- paxys 4y agoDon't blame the technology, blame the institutions using it. And blame the political system that let these health insurance companies have this extreme a level of control over our lives.
- CatWChainsaw 4y ago"Don't blame technology" sounds a lot like "don't blame religion". You're not allowed to do it, because... reasons... It's just a tool, bro. It's the people using it that are bad.
- desireco42 4y agoAlmost gotten a job in UnitedHealth... and I was looking forward to it, thinking I will improve experience for users trying to find and get services. I am really naive.
- PaulHoule 4y agoMedicare ‘Advantage’ is a scam transparent to everyone except your congressman.
- treeman79 4y agoYou’re giving many congressmen too much credit. Many believe the scam they perpetuate.
- whitemary 4y agoIronically, this is the most naive comment in the entire thread. The many private corporations who profit from Medicare Advantage know exactly how it works. In fact, they hired the congressmen! The Libertarian Fallacy is a stubborn one!
- nkrisc 4y ago> everyone except your congressman. Oh, your Congressman knows. It's not members of Congress they're trying to deceive with that name.
- christophilus 4y agoIs it? My dad absolutely loves it, but I don’t think he’s faced its limits. How is it worse than plain Medicare? (Asking seriously as a mostly uninformed non-participant.)
- ineptech 4y agoIt might be helpful to read this recent HN submission and its comments: > Stop the Medicare “Advantage” Scam Before Medicare Is Dead https://news.ycombinator.com/item?id=35001728 https://news.ycombinator.com/item?id=35001728
- wombatpm 4y agoWhen you really need it, say dialysis for kidney damage after years of high blood pressure, then you will realize how screwed you are. My mother-in-law had four years of dialysis. Monthly cost was 70k according to the insurance statements. Between her Medicare and supplemental plan she paid 1000 a year. But your dad gets vision and dental now, so that’s nice