11 ms·

Go after all the healthcare giants. If people knew even half of how consolidated their treatment was, they would riot. For those who don't know about the signi

Go after all the healthcare giants. If people knew even half of how consolidated their treatment was, they would riot. For those who don't know about the significant conflict of interest present here: 1. United is a health insurer that has to make payments for people's 2. United owns several physician networks (totaling 90,000 physicians), who then determine what your care should be—no conflict with the fact that they pay the bills... 3. United owns Optum, which determines how much your drugs are going to cost, and of course, who makes them—brand vs. generic, etc. 4. Optum runs its own mail order and specialty pharmacies. Optum also writes your care plans for many chronic diseases and ships medications all over the country. 5. Optum could require their own customers to use their care plans and software in order to receive medications at all, or mark up the price for anyone who doesn't. Let's step through a workflow. You, a patient on United, go to a physician for treatment. Later on, you get referred to a specialist, then get diagnosed with a chronic disease and need medication that you receive delivered monthly. That pans out to: United pays United, who refers you to United, that forwards you to Optum (owned by United), who gets paid by United. Each and every month. Let's say you find a better deal for your medication at another pharmacy. Too bad, its not going to be in your network and Optum will no longer cover it. How is a health system or an independent supposed to compete with that level of integration? This, of course, does not result in any savings or quality of life improvement for the patient or the physician. United and Optum charge the same prices as everyone else, or more.

yborg 3y ago
You didn't even mention Optum Bank, which they use to also sponge up that sweet HSA cash lest any drop of healthcare spend somehow escape UHG's toll.
sensanaty 3y ago
Imagine if the useless governments actually broke up these behemoth megacorporations that control the entire vertical and horizontal slice of industry they operate in. What a crazy concept, right?
rapatel0 3y ago
> 2. United owns several physician networks (totaling 90,000 physicians), who then determine what your care should be—no conflict with the fact that they pay the bills... I disagree that this is necessarily a bad thing. One of the critical problems with our current model is the Fee-For-Service. When the insurance company is separate from the payer, then the incentive is to treat patients like revenue. A significant part of our ballooning costs are due to this fundamental miss-incentive. When the payer and provider are the same entity, that is the one of the only effective mechanisms to control costs. I've thought about this a lot and I think that there are 3 critical changes that would fix the whole fucking thing: - Insurance being one country scale pool of capital - Actually average out the risk across lifetime - Every provider must be the payor - Incentivize hospitals to manage costs - Individual vouchers to join a network - Give the patient agency to join a care network that manages their health well.
mywittyname 3y ago
> If people knew half of how consolidated their treatment was they would riot. My partner deals with claims denials for care providers and if someone wrote a book on the stuff she's seen happen, I genuinely think it would be akin _The Jungle_ for modern audiences in terms of cultural impact.
- oogali 3y ago
  I’ve been getting exposure to this space and the backend systems that drive it. It is mind-bogglingly dysfunctional. Aphyr recently provided a limited window[1] into the level of dysfunction that happens with one of these behemoths that are the result of 100+ mergers, acquisitions, spinoffs, and joint ventures. I feel terrible for the providers who have to try to navigate these antics. In my opinion, all of this contributes to two primary “bad” things: 1) increased rates of retirement from older physicians who don’t want to deal with this anymore (despite wanting to continue practicing for 5-10 more years), and 2) consolidation of physician practices into larger entities as a way of coping which inevitably leads to the entity being acquired by a hospital and absorbed into another behemoth of an organization. Both make it hard for individuals to receive consistent, quality care. 1: https://aphyr.com/posts/368-how-to-replace-your-cpap-in-only-666-days https://aphyr.com/posts/368-how-to-replace-your-cpap-in-only...
not2b 3y ago
Yep. I have UHC through work. I'm on an expensive medication and UHC requires that I order it through Optum, so they keep more of the money. At least neither of the doctors I usually see work for them, so I don't have that conflict.
- joncp 3y ago
  And has Optum conveniently forgotten to ship refills, but only for the expensive drugs? That happened to my wife on multiple occasions. Or maybe they've rejected refill requests until right before your supply runs out, such that you have to go days without your meds while the new supply is shipped? Optum is the shadiest shitshow I've ever dealt with.
  - not2b 3y ago
    They make it extra painful sometimes when it's time to refill, requiring re-authorization every year. My doctor has a woman working for his practice who spends almost full time battling insurance companies so that patients can get their meds, and she's been my ally at managing these fights.
    - khuey 3y ago
      > My doctor has a woman working for his practice who spends almost full time Yep, and this is the sort of make work that the health care system is full of that drives up costs for everyone.
      - ChrisMarshallNY 3y ago
        Every doctor has one of these people, and they are probably the most valuable member of the practice, after the doctor, themselves. Most of them (in my experience) have been middle-aged women, hard-nosed, cynical, and no-nonsense. They can easily be abrupt and cranky. It's a real good idea to ignore that, and make them your friend. They can do miracles.
      - silverquiet 3y ago
joe_the_user 3y ago
If people knew half of how consolidated their treatment was they would riot. Most Americans experience first hand how horrible health care here is. No one can get upset at whatever little details are involved, however 'cause it's beyond them. Especially, you won't get people excited about more competition in a field where markets and competition seem neither logical nor have shown any benefit. The complex referral system you describe basically results in turning regulated monopoly behavior into unregulated monopoly behavior. And this is the upshot of breaking up the original, regulated monopoly Blue Cross/Blue Shield, which provided adequate insurance in America's "Golden Era". Which to say that, imo, "restoring the free market" isn't a useful action in this mess. State controlled medicine is essentially the only solution to the already partly collapsed US health care system.
- cyanydeez 3y ago
  the healthcare complex employs millions. all these people would lose jobs. so there's really zero political will to crack the monolith, and why things like Obama care go forward, because they're bandaids. then there's the who employer leverage that businesses live having to immobilize a significant portion of their work force. it's absolutely not complicated to understand why nothing has moved the needle.
  - SteveNuts 3y ago
    Right. If these huge insurance companies had to "compete" with a real universal system, there's no way they could even exist. All they do is scrape profit off the top of every healthcare procedure in the US. The most useless middleman to ever exist, in my opinion.
    - vinay427 3y ago
      I agree with your broader point, but it’s worth noting that insurance middlemen exist in many European countries with universal health insurance, so surely some form of this can exist in a more regulated health insurance/provider market.
rainsford 3y ago
That kind of extractive, anti-consumer business model would be worth going after in any industry, but it feels especially bad in health care. Most health care isn't optional for the patient, and of course the more non-optional the care is the more expensive it tends to be. And serious health problems are both rare and incredibly stressful for the patient. Someone with cancer is going to have no experience shopping around for oncologists and will be willing to pay almost anything not to die. It's almost the worst possible scenario for consumer driven free market dynamics. My personal opinion is that giant health-care conglomerates probably shouldn't exist at all. But if they do, they should be subject to much higher standards when it comes to things like antitrust than regular companies.
oogali 3y ago
Wait until people catch on to the behemoth that is CVS Health…
- FireBeyond 3y ago
  Oh, and I love where my insurance would cover my prescriptions from CVS in Washington, but when I was down in California needing steroids and anti-inflammatories urgently for my gout, they would not cover them there (and I'd made the apparently idiot assumption of having the urgent care physician send the scripts to a nearby CVS because I thought they'd be covered. Nope. Not even "out of network" - I ended up paying out of pocket and arguing for reimbursement.
  - vundercind 3y ago
    For non-Americans: US health insurance is often bound to a state or even a region of a state, paying only for emergency care (and that, only because they are required to) outside that area. We basically need travel insurance to safely travel in our own damn country. Add it to the list of crazy features of our system, any one of which would cause riots in another OECD state if not fixed promptly. And we’ve got several.
tacticalturtle 3y ago
Isn’t this just how HMO’s work? It’s not a PPO, you’re supposed to have the majority of your care managed within the large organization. Kaiser Permanente is another one. In theory it makes sense - by keeping everything in network there’s no constant negotiation over reimbursement rates. But the problem is there aren’t many competitive HMOs, and we have a healthcare system driven by employment, so you can’t switch to a new HMO if you’re unsatisfied by your current one. Edit: My point is that it’s not a conflict of interest to be routed through the UH network - that’s the entire point of an HMO vs a PPO. The idealized goal is that you have a coordinated team of providers across the organization.
pierat 3y ago
Basically, most forms (including ours) of capitalism turn into a oligopoly where each oligo-member is highly vertical and controls the whole narrative. Another word for this would be corporation-states. Amazon is another example of this. So is Google. So is Apple. It's high time that government steps in and breaks these 'too big to fail' corpo-states up into actual competing interests that, in the end, do better for the citizenry. Cause each corporation is a dictatorial 'state' acting in opposition to our elected government, and much of our monopoly laws, either in spirit or in application.
deleted 3y ago
[deleted]
akeck 3y ago
This is like Luxottica owning optometrists offices, eyewear providers like Lenscrafters, and Eyemed vision insurance.
earth2mars 3y ago
Feel like you also explained the Apple walled garden. You pay 30% tax or no entry. Regulation need to be passed to change adapter port. Things won't work if you aren't in the ecosystem. And they cost a buck for Mediocre service
earth2mars 3y ago
Feel like you also explained the Apple walled garden. You pay 30% tax or no entry. Regulation need to be passed to change adapter port. Things won't work if you aren't in the ecosystem. And they cost a buck for Mediocre service.
biggc 3y ago
On paper this seems similar to how Kaiser operates. AFAIK Kaiser is generally well-liked by its members, why is UHC so terrible? I guess UHC doesn't own the hospitals?
- markus92 3y ago
  Kaiser is non-profit, that might change the incentives?
fnordpiglet 3y ago
Rioting isn’t covered under the insurance terms and conditions so no one can afford to do so.
ars 3y ago
Isn't this basically how an HMO works? I've heard those have lower costs and patients seem to like them. What's different with United?
- toast0 3y ago
  I've been with Kaiser in Northern and Southern California. But not really with other HMOs. I think the difference is Kaiser (in most places) is really a closed system; if you're with Kaiser, you go to Kaiser facilities for everything, as long as you're in the service area. If you're not with Kaiser, you don't go to Kaiser facilities, other than the emergency room maybe. Everyone you interact with is a Kaiser employee or contractor. You don't get recommended care that won't be covered, you don't get treated by someone who isn't in network, you show up, you pay your copay, and that's it, you're done. For HMO plans with other providers, it seems like the doctors are often independent; you have to stay in network, but you still have to deal with network BS like this office is in network, but only some of the doctors. There's not a Blue Shield medical center with doctors, specialists, and a pharmacy at one location.
  - lotsofpulp 3y ago
    Because Blue Cross Blue Shield is neither a healthcare provider nor a managed care (health insurance) seller. BCBS is kind of like a franchising business, where the franchisors get access to other members’ negotiated pricing and administrative services to create a larger (nationwide) network. For example, your employer could purchase managed care from Horizon BCBSNJ, and if you get into trouble on vacation on the west coast, then they coordinate with Elevance or BlueShield California or Regence in Washington/Oregon to figure out how much they are paying providers. And this way Horizon BCBSNJ does not have to do all the legwork of negotiating with every healthcare provider in the country. I’m sure it is quite a bit more complicated in practice though. > if you're with Kaiser, you go to Kaiser facilities for everything, as long as you're in the service area. Kaiser also sells PPO plans where you do not have to see a Kaiser employee for covered healthcare.
nradov 3y ago
It's important to understand the factors driving consolidation in the healthcare industry as this goes beyond UnitedHealth Group. Everyone is sort of gradually converging on a "payvider" model like Kaiser Permanente with everything under one parent corporation. Payers and providers have been merging for years in order to gain more negotiating power over claim reimbursement rates. Regulatory compliance issues and IT costs are also killing off small, independent medical practices. In many regions a few large health systems now dominate the market. So, the only way for payers to hold down costs is to build up captive provider organizations where they can drive some operational efficiencies and economies of scale.
bogota 3y ago
I’m sick of paying 5k a year myself and close to 20k counting my employer for a doctor to see me for 20 minutes, ignore everything i say, and then prescribe some shit without explaining anything. Additionally seeing how my wife is treated by doctors makes me feel physically sick. I have no respect for the medical field
garyiskidding 3y ago
Thanks for breaking it down, especially for people outside America.

yborg 3y ago

You didn't even mention Optum Bank, which they use to also sponge up that sweet HSA cash lest any drop of healthcare spend somehow escape UHG's toll.

sensanaty 3y ago

Imagine if the useless governments actually broke up these behemoth megacorporations that control the entire vertical and horizontal slice of industry they operate in. What a crazy concept, right?

rapatel0 3y ago

> 2. United owns several physician networks (totaling 90,000 physicians), who then determine what your care should be—no conflict with the fact that they pay the bills... I disagree that this is necessarily a bad thing. One of the critical problems with our current model is the Fee-For-Service. When the insurance company is separate from the payer, then the incentive is to treat patients like revenue. A significant part of our ballooning costs are due to this fundamental miss-incentive. When the payer and provider are the same entity, that is the one of the only effective mechanisms to control costs. I've thought about this a lot and I think that there are 3 critical changes that would fix the whole fucking thing: - Insurance being one country scale pool of capital - Actually average out the risk across lifetime - Every provider must be the payor - Incentivize hospitals to manage costs - Individual vouchers to join a network - Give the patient agency to join a care network that manages their health well.

mywittyname 3y ago

> If people knew half of how consolidated their treatment was they would riot. My partner deals with claims denials for care providers and if someone wrote a book on the stuff she's seen happen, I genuinely think it would be akin _The Jungle_ for modern audiences in terms of cultural impact.

oogali 3y ago
I’ve been getting exposure to this space and the backend systems that drive it. It is mind-bogglingly dysfunctional. Aphyr recently provided a limited window[1] into the level of dysfunction that happens with one of these behemoths that are the result of 100+ mergers, acquisitions, spinoffs, and joint ventures. I feel terrible for the providers who have to try to navigate these antics. In my opinion, all of this contributes to two primary “bad” things: 1) increased rates of retirement from older physicians who don’t want to deal with this anymore (despite wanting to continue practicing for 5-10 more years), and 2) consolidation of physician practices into larger entities as a way of coping which inevitably leads to the entity being acquired by a hospital and absorbed into another behemoth of an organization. Both make it hard for individuals to receive consistent, quality care. 1: https://aphyr.com/posts/368-how-to-replace-your-cpap-in-only-666-days https://aphyr.com/posts/368-how-to-replace-your-cpap-in-only...

not2b 3y ago

Yep. I have UHC through work. I'm on an expensive medication and UHC requires that I order it through Optum, so they keep more of the money. At least neither of the doctors I usually see work for them, so I don't have that conflict.

joncp 3y ago
And has Optum conveniently forgotten to ship refills, but only for the expensive drugs? That happened to my wife on multiple occasions. Or maybe they've rejected refill requests until right before your supply runs out, such that you have to go days without your meds while the new supply is shipped? Optum is the shadiest shitshow I've ever dealt with.
- not2b 3y ago
  They make it extra painful sometimes when it's time to refill, requiring re-authorization every year. My doctor has a woman working for his practice who spends almost full time battling insurance companies so that patients can get their meds, and she's been my ally at managing these fights.
  - khuey 3y ago
    > My doctor has a woman working for his practice who spends almost full time Yep, and this is the sort of make work that the health care system is full of that drives up costs for everyone.
    - ChrisMarshallNY 3y ago
      Every doctor has one of these people, and they are probably the most valuable member of the practice, after the doctor, themselves. Most of them (in my experience) have been middle-aged women, hard-nosed, cynical, and no-nonsense. They can easily be abrupt and cranky. It's a real good idea to ignore that, and make them your friend. They can do miracles.
    - silverquiet 3y ago

joe_the_user 3y ago

If people knew half of how consolidated their treatment was they would riot. Most Americans experience first hand how horrible health care here is. No one can get upset at whatever little details are involved, however 'cause it's beyond them. Especially, you won't get people excited about more competition in a field where markets and competition seem neither logical nor have shown any benefit. The complex referral system you describe basically results in turning regulated monopoly behavior into unregulated monopoly behavior. And this is the upshot of breaking up the original, regulated monopoly Blue Cross/Blue Shield, which provided adequate insurance in America's "Golden Era". Which to say that, imo, "restoring the free market" isn't a useful action in this mess. State controlled medicine is essentially the only solution to the already partly collapsed US health care system.

cyanydeez 3y ago
the healthcare complex employs millions. all these people would lose jobs. so there's really zero political will to crack the monolith, and why things like Obama care go forward, because they're bandaids. then there's the who employer leverage that businesses live having to immobilize a significant portion of their work force. it's absolutely not complicated to understand why nothing has moved the needle.
- SteveNuts 3y ago
  Right. If these huge insurance companies had to "compete" with a real universal system, there's no way they could even exist. All they do is scrape profit off the top of every healthcare procedure in the US. The most useless middleman to ever exist, in my opinion.
  - vinay427 3y ago
    I agree with your broader point, but it’s worth noting that insurance middlemen exist in many European countries with universal health insurance, so surely some form of this can exist in a more regulated health insurance/provider market.

rainsford 3y ago

That kind of extractive, anti-consumer business model would be worth going after in any industry, but it feels especially bad in health care. Most health care isn't optional for the patient, and of course the more non-optional the care is the more expensive it tends to be. And serious health problems are both rare and incredibly stressful for the patient. Someone with cancer is going to have no experience shopping around for oncologists and will be willing to pay almost anything not to die. It's almost the worst possible scenario for consumer driven free market dynamics. My personal opinion is that giant health-care conglomerates probably shouldn't exist at all. But if they do, they should be subject to much higher standards when it comes to things like antitrust than regular companies.

oogali 3y ago

Wait until people catch on to the behemoth that is CVS Health…

FireBeyond 3y ago
Oh, and I love where my insurance would cover my prescriptions from CVS in Washington, but when I was down in California needing steroids and anti-inflammatories urgently for my gout, they would not cover them there (and I'd made the apparently idiot assumption of having the urgent care physician send the scripts to a nearby CVS because I thought they'd be covered. Nope. Not even "out of network" - I ended up paying out of pocket and arguing for reimbursement.
- vundercind 3y ago
  For non-Americans: US health insurance is often bound to a state or even a region of a state, paying only for emergency care (and that, only because they are required to) outside that area. We basically need travel insurance to safely travel in our own damn country. Add it to the list of crazy features of our system, any one of which would cause riots in another OECD state if not fixed promptly. And we’ve got several.

tacticalturtle 3y ago

Isn’t this just how HMO’s work? It’s not a PPO, you’re supposed to have the majority of your care managed within the large organization. Kaiser Permanente is another one. In theory it makes sense - by keeping everything in network there’s no constant negotiation over reimbursement rates. But the problem is there aren’t many competitive HMOs, and we have a healthcare system driven by employment, so you can’t switch to a new HMO if you’re unsatisfied by your current one. Edit: My point is that it’s not a conflict of interest to be routed through the UH network - that’s the entire point of an HMO vs a PPO. The idealized goal is that you have a coordinated team of providers across the organization.

pierat 3y ago

Basically, most forms (including ours) of capitalism turn into a oligopoly where each oligo-member is highly vertical and controls the whole narrative. Another word for this would be corporation-states. Amazon is another example of this. So is Google. So is Apple. It's high time that government steps in and breaks these 'too big to fail' corpo-states up into actual competing interests that, in the end, do better for the citizenry. Cause each corporation is a dictatorial 'state' acting in opposition to our elected government, and much of our monopoly laws, either in spirit or in application.

deleted 3y ago

[deleted]

akeck 3y ago

This is like Luxottica owning optometrists offices, eyewear providers like Lenscrafters, and Eyemed vision insurance.

earth2mars 3y ago

Feel like you also explained the Apple walled garden. You pay 30% tax or no entry. Regulation need to be passed to change adapter port. Things won't work if you aren't in the ecosystem. And they cost a buck for Mediocre service

earth2mars 3y ago

biggc 3y ago

On paper this seems similar to how Kaiser operates. AFAIK Kaiser is generally well-liked by its members, why is UHC so terrible? I guess UHC doesn't own the hospitals?

markus92 3y ago
Kaiser is non-profit, that might change the incentives?

fnordpiglet 3y ago

Rioting isn’t covered under the insurance terms and conditions so no one can afford to do so.

ars 3y ago

Isn't this basically how an HMO works? I've heard those have lower costs and patients seem to like them. What's different with United?

toast0 3y ago
I've been with Kaiser in Northern and Southern California. But not really with other HMOs. I think the difference is Kaiser (in most places) is really a closed system; if you're with Kaiser, you go to Kaiser facilities for everything, as long as you're in the service area. If you're not with Kaiser, you don't go to Kaiser facilities, other than the emergency room maybe. Everyone you interact with is a Kaiser employee or contractor. You don't get recommended care that won't be covered, you don't get treated by someone who isn't in network, you show up, you pay your copay, and that's it, you're done. For HMO plans with other providers, it seems like the doctors are often independent; you have to stay in network, but you still have to deal with network BS like this office is in network, but only some of the doctors. There's not a Blue Shield medical center with doctors, specialists, and a pharmacy at one location.
- lotsofpulp 3y ago
  Because Blue Cross Blue Shield is neither a healthcare provider nor a managed care (health insurance) seller. BCBS is kind of like a franchising business, where the franchisors get access to other members’ negotiated pricing and administrative services to create a larger (nationwide) network. For example, your employer could purchase managed care from Horizon BCBSNJ, and if you get into trouble on vacation on the west coast, then they coordinate with Elevance or BlueShield California or Regence in Washington/Oregon to figure out how much they are paying providers. And this way Horizon BCBSNJ does not have to do all the legwork of negotiating with every healthcare provider in the country. I’m sure it is quite a bit more complicated in practice though. > if you're with Kaiser, you go to Kaiser facilities for everything, as long as you're in the service area. Kaiser also sells PPO plans where you do not have to see a Kaiser employee for covered healthcare.

nradov 3y ago

It's important to understand the factors driving consolidation in the healthcare industry as this goes beyond UnitedHealth Group. Everyone is sort of gradually converging on a "payvider" model like Kaiser Permanente with everything under one parent corporation. Payers and providers have been merging for years in order to gain more negotiating power over claim reimbursement rates. Regulatory compliance issues and IT costs are also killing off small, independent medical practices. In many regions a few large health systems now dominate the market. So, the only way for payers to hold down costs is to build up captive provider organizations where they can drive some operational efficiencies and economies of scale.

bogota 3y ago

I’m sick of paying 5k a year myself and close to 20k counting my employer for a doctor to see me for 20 minutes, ignore everything i say, and then prescribe some shit without explaining anything. Additionally seeing how my wife is treated by doctors makes me feel physically sick. I have no respect for the medical field

garyiskidding 3y ago

Thanks for breaking it down, especially for people outside America.