5 ms·

What a poorly designed system. If the insurer truly prioritizes client care as they claim, why on earth would the doctors contracted to review the treatments of

by lijok 2y ago

What a poorly designed system. If the insurer truly prioritizes client care as they claim, why on earth would the doctors contracted to review the treatments of the insured, have access to the insurance policies? Shouldn't the output of their review simply be whether or not the treatment seems appropriate, period? Why are the doctors weighing their review against the insurers policies? Honestly, this just seems like incompetence at multiple levels in a highly complex system. All it takes is one bad apple paying more attention to the bottom line than client care, for the entire system to magnificently cascade into an absolute shitshow. If you read through the entire article without prejudice, most of the decisions made along the way make sense, with a couple of process failures and incompetent or indifferent individuals sprinkled in along the way, and the end result is a client who has to plan bathroom stops for a 5 minute walk, being told to take a treatment they know will kill them, or pound sound. This is the kind of systemic cascading failure that can only be addressed by the person at the top having a come to jesus moment.

peitho_pls 2y ago
The insurer is a business, its ultimate priority is the make money. Same as the hospital, the drug producer, etc. I am sure they all want to prioritize client care but that have to ration it by cost at some level.
- lijok 2y ago
  Insurance firms have the unique benefit of being able to offload their costs to their customer base in the form of premiums. That and excess would be the appropriate level to ration in the cost. Is that not verbatim how insurance works?
  - peitho_pls 2y ago
    I look at it as Insurers generate float from upfront premium payments to invest in the market and generate returns and also cover future payouts. Then an insurer can go about negotiating the prices of treatment with health care providers to determine payouts.
SpicyLemonZest 2y ago
> What a poorly designed system. If the insurer truly prioritizes client care as they claim, why on earth would the doctors contracted to review the treatments of the insured, have access to the insurance policies? Shouldn't the output of their review simply be whether or not the treatment seems appropriate, period? Why are the doctors weighing their review against the insurers policies? All healthcare systems ultimately have to make cost-benefit tradeoffs, and in the US system those tradeoffs are generally represented as insurer coverage policies. I don't mean to suggest that this justifies the story in the article, where it really sounds like the treatment did fit the policy and UHC worked hard to avoid seeing that. But there's no system where a doctor dreams up an arbitrarily expensive treatment protocol and a patient gets it with low out-of-pocket costs and no questions asked.
- lijok 2y ago
  So are you saying the doctors contracted to review the treatments need access to the clients insurance policies in order to make a decision on whether the treatment is appropriate? For what purpose? My, arguably naive, understanding is that the reviewer should only need to provide two things for the adjuster to take it from there; whether the treatment is appropriate, and alternative potentially cheaper treatment options. If there are alternative potentially cheaper treatment options available, those should be discussed with the care provider and ruled out. I just don't understand why the reviewing doctors report is required to take into account the policies of the contracting insurance firm?
  - SpicyLemonZest 2y ago
    The policies consist largely of guidelines regarding what the most cost-effective treatment option for a condition is likely to be. Good insurance companies do try and discuss with providers rather than firing off denial letters willy-nilly, but of course that still ends up being a conflict where your insurance might not let you have the treatment your doctor thinks is best. This conflict is why I've always subscribed to Kaiser when I have the option. It's much less headache for me if there's no distinction between what a doctor wants to prescribe me and what they're allowed to prescribe. (Would I feel differently if I needed some crazy custom treatment protocol? Perhaps.)

by lijok 2y ago

peitho_pls 2y ago

The insurer is a business, its ultimate priority is the make money. Same as the hospital, the drug producer, etc. I am sure they all want to prioritize client care but that have to ration it by cost at some level.

lijok 2y ago
Insurance firms have the unique benefit of being able to offload their costs to their customer base in the form of premiums. That and excess would be the appropriate level to ration in the cost. Is that not verbatim how insurance works?
- peitho_pls 2y ago
  I look at it as Insurers generate float from upfront premium payments to invest in the market and generate returns and also cover future payouts. Then an insurer can go about negotiating the prices of treatment with health care providers to determine payouts.

SpicyLemonZest 2y ago

> What a poorly designed system. If the insurer truly prioritizes client care as they claim, why on earth would the doctors contracted to review the treatments of the insured, have access to the insurance policies? Shouldn't the output of their review simply be whether or not the treatment seems appropriate, period? Why are the doctors weighing their review against the insurers policies? All healthcare systems ultimately have to make cost-benefit tradeoffs, and in the US system those tradeoffs are generally represented as insurer coverage policies. I don't mean to suggest that this justifies the story in the article, where it really sounds like the treatment did fit the policy and UHC worked hard to avoid seeing that. But there's no system where a doctor dreams up an arbitrarily expensive treatment protocol and a patient gets it with low out-of-pocket costs and no questions asked.

lijok 2y ago
So are you saying the doctors contracted to review the treatments need access to the clients insurance policies in order to make a decision on whether the treatment is appropriate? For what purpose? My, arguably naive, understanding is that the reviewer should only need to provide two things for the adjuster to take it from there; whether the treatment is appropriate, and alternative potentially cheaper treatment options. If there are alternative potentially cheaper treatment options available, those should be discussed with the care provider and ruled out. I just don't understand why the reviewing doctors report is required to take into account the policies of the contracting insurance firm?
- SpicyLemonZest 2y ago
  The policies consist largely of guidelines regarding what the most cost-effective treatment option for a condition is likely to be. Good insurance companies do try and discuss with providers rather than firing off denial letters willy-nilly, but of course that still ends up being a conflict where your insurance might not let you have the treatment your doctor thinks is best. This conflict is why I've always subscribed to Kaiser when I have the option. It's much less headache for me if there's no distinction between what a doctor wants to prescribe me and what they're allowed to prescribe. (Would I feel differently if I needed some crazy custom treatment protocol? Perhaps.)