6 ms·

Otoh some medical providers like to over bill and over treat.

drewbug01 2y ago
> Otoh some medical providers like to over bill and over treat. This is true to some extent, but the share of medical providers that over-bill and over-treat really doesn't justify the way the insurance industry does business. It's a false equivalence.
kstrauser 2y ago
Crack down on them, but don’t use it to justify denying healthcare to patients.
harimau777 2y ago
It seems to me that should then be handled by the legal system or perhaps the licensing boards. That is to say, the insurance companies should be forbidden from denying coverage and if they believe that something is going on then they can alert the police or take the doctor to court.
- antisthenes 2y ago
  Will never happen. Doctors have strong lobbying of their own and they really like their second vacation homes and Porsches.
  - joquarky 2y ago
    So are we to just do nothing and die in the crossfire between these two entities?
  - consteval 2y ago
    Most doctors are not very rich at all, upper middle class. I make more than many doctors I know as a software engineer, and this doesn't even take into account their debt. Care is expensive because of insurance. Hospitals needs hundreds of administrators and billing specialists. Very little of that money goes to the doctor.
    - SauciestGNU 2y ago
      Doctors deserve to be rich. They do incredibly specialized work where the outcomes are extremely critical, to put it mildly. I don't want doctors performing unnecessary treatments to line their pockets, but I don't think we're actually in danger of that. The difference between a rich doctor and a rich insurance exec is that the doctor helps people, and the insurance exec makes their money withholding necessary care from people, in effect torturing and killing them.
      - consteval 2y ago
        This is the problem with insurance in general. The incentive of insurance is at direct odds with patients and doctors. It's a tug of war, and even if insurance "loses", it doesn't matter, because you lost trillions of dollars in that tug of war. It's artificial inefficiency caused by privatization, very much a Dark Night burning a mountain of money situation.
        SauciestGNU 2y ago
        Yeah I'm in favor of a single payer system, but I think that's even less likely than adding some guardrails to what we have now.
- nradov 2y ago
  That's simply unrealistic. Medicine is more of an art than a science and most treatment plans fall into gray areas. While insurers do file formal complaints with authorities when there is clear evidence of fraud (like a single provider billing for more than 24 hours of patient encounters in a single day), there is an enormous amount of waste and abuse by providers which can't be proven in court as fraud. The fee-for-service financial model incentivizes over treatment. https://www.npr.org/sections/health-shots/2019/10/22/767376340/the-price-we-pay-argues-rising-health-care-costs-undermine-public-trust-in-medic https://www.npr.org/sections/health-shots/2019/10/22/7673763... The fundamental problem here is that demand for healthcare is virtually infinite while supply is limited. Healthcare already consumes about 20% of the US economy and there is no excess capacity to expand it further without dragging everything else down. We can make some things more efficient and reduce administrative burdens but ultimately we have to draw the line somewhere and ration care. That's going to be true regardless of whether we have commercial insurers or socialized healthcare.
ubnvfft 2y ago
Stop speciously muddying the waters by either intentionally or accidentally making spurious arguments for these unethical sociopaths. I’ve seen this argument made on this website a lot, and it always conveniently omits the vertical integration of these insurers wherein they are the providers too. The DOJ is literally, actively, suing to block a merger between united healthcare and a provider. https://www.justice.gov/opa/pr/justice-department-sues-block-unitedhealth-groups-acquisition-home-health-and-hospice https://www.justice.gov/opa/pr/justice-department-sues-block...
- nradov 2y ago
  It's not clear that vertical integration is necessarily bad for consumers. For example, Kaiser-Permanente is a huge, vertically-integrated "payvider" which both sells insurance plans and also delivers most of the treatment for plan members. They generally do a pretty good job at a competitive price. Both the payer and provider sides of the healthcare industry have been consolidating for years. Insurers merged to gain more negotiating power with providers and drive down costs. Providers responded by merging (or selling to private equity funds) to gain more negotiating power with insurers and maintain high rates. Government mandates on back office technology also incentivized provider consolidation due to economies of scale. In some areas now a few major provider organizations effectively control the market and payers are essentially forced to pay high rates in order to maintain sufficient networks. So, the logical next step is for payers to mimic KP by building their own captive health systems. Every major payer is pursuing this strategy to varying levels; it's not just UHC.
fny 2y ago
Yes, insurance companies deny claims, but this is mostly because they don't have the money to pay for things most of their money is spent on care in the first place: they're forced to optimize and people get hurt in the process. Providers do far more damage. UHCs profit margins are only 6%, their operating costs are extremely low[0], and if you look across G7 insurers in the US pay more than the government does in every country but France![1] Compare this to HCA which makes an average margin of 10% with far higher administrative costs. The CEO of HCA makes $20M, Brian Thompson made $10M by contrast. This is not to say we (and insurance companies) don't spend astronomically more than other countries: providers are to blame for this, and I have seen their nonsense first hand: - They keep people alive overnight to charge insurance more - Some hospitals use ML (!) to optimize ICD codes for billing. Most do this by hand: there's literally a job and training to be an ICD coder. - They allow people to deteriorate (e.g. dialysis) to charge more (no preventative care.) I have seen a hospital only provide preemptive care to patients at risk of dialysis because they were part of their own insurance pool - Their administraive expenses are far higher. - They test and provide unnecessary care. - Physician shortage is in part caused by limited residency spots, a dumb bachelors requirement, and high tuition costs. These barriers to entry are imposed by physicians. - Uneccesary tech and equipment upgrades (e.g. we need to replace your knee with a new knee) - Having to deal with tons of different insurance companies: not their fault but they don't know how to handle this efficiently. [0]: https://www.reddit.com/r/dataisbeautiful/comments/194wucn/oc_unitedhealth_group_just_released_its_income/?rdt=52541 https://www.reddit.com/r/dataisbeautiful/comments/194wucn/oc... [1]: https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fbb8e5dae-6e36-410d-9ce8-47fb6166f21a_1020x720.jpeg https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_pr...
- ethbr1 2y ago
  Underappreciated reality. Because customer-insurer relationships are the only side of the healthcare system that most people see, they're oblivious to what are actually pass-through insurer-provider issues. As you said, the reality is that insurers operate with pretty reasonable margins and incredibly meager per-claim overhead costs. They're stuck trying to make 2 + 1 = 2. If the finger should be pointed at root causes in the US health system, it should be at: - Providers overbilling (particular in certain specialties) - Medical schools, for charging too much and under-expanding capacity - The federal government/Congress, for failing to expand residency funding to increase supply (especially in generalist provider categories)
mancerayder 2y ago
Yes, but in my opinion it falls to the patient to figure out the details and absorb the risk. That's the messed up part. That insurance providers and medical services might disagree on pricing or whatnot is an inevitability. What's not fair is throwing ordinary people under the bus to deal with it, which for many reasons is risky and can ruin lives.

> Otoh some medical providers like to over bill and over treat. This is true to some extent, but the share of medical providers that over-bill and over-treat really doesn't justify the way the insurance industry does business. It's a false equivalence.

kstrauser 2y ago

Crack down on them, but don’t use it to justify denying healthcare to patients.

harimau777 2y ago

It seems to me that should then be handled by the legal system or perhaps the licensing boards. That is to say, the insurance companies should be forbidden from denying coverage and if they believe that something is going on then they can alert the police or take the doctor to court.

antisthenes 2y ago
Will never happen. Doctors have strong lobbying of their own and they really like their second vacation homes and Porsches.
- joquarky 2y ago
  So are we to just do nothing and die in the crossfire between these two entities?
- consteval 2y ago
  Most doctors are not very rich at all, upper middle class. I make more than many doctors I know as a software engineer, and this doesn't even take into account their debt. Care is expensive because of insurance. Hospitals needs hundreds of administrators and billing specialists. Very little of that money goes to the doctor.
  - SauciestGNU 2y ago
    Doctors deserve to be rich. They do incredibly specialized work where the outcomes are extremely critical, to put it mildly. I don't want doctors performing unnecessary treatments to line their pockets, but I don't think we're actually in danger of that. The difference between a rich doctor and a rich insurance exec is that the doctor helps people, and the insurance exec makes their money withholding necessary care from people, in effect torturing and killing them.
    - consteval 2y ago
      This is the problem with insurance in general. The incentive of insurance is at direct odds with patients and doctors. It's a tug of war, and even if insurance "loses", it doesn't matter, because you lost trillions of dollars in that tug of war. It's artificial inefficiency caused by privatization, very much a Dark Night burning a mountain of money situation.
      - SauciestGNU 2y ago
        Yeah I'm in favor of a single payer system, but I think that's even less likely than adding some guardrails to what we have now.
nradov 2y ago
That's simply unrealistic. Medicine is more of an art than a science and most treatment plans fall into gray areas. While insurers do file formal complaints with authorities when there is clear evidence of fraud (like a single provider billing for more than 24 hours of patient encounters in a single day), there is an enormous amount of waste and abuse by providers which can't be proven in court as fraud. The fee-for-service financial model incentivizes over treatment. https://www.npr.org/sections/health-shots/2019/10/22/767376340/the-price-we-pay-argues-rising-health-care-costs-undermine-public-trust-in-medic https://www.npr.org/sections/health-shots/2019/10/22/7673763... The fundamental problem here is that demand for healthcare is virtually infinite while supply is limited. Healthcare already consumes about 20% of the US economy and there is no excess capacity to expand it further without dragging everything else down. We can make some things more efficient and reduce administrative burdens but ultimately we have to draw the line somewhere and ration care. That's going to be true regardless of whether we have commercial insurers or socialized healthcare.

ubnvfft 2y ago

Stop speciously muddying the waters by either intentionally or accidentally making spurious arguments for these unethical sociopaths. I’ve seen this argument made on this website a lot, and it always conveniently omits the vertical integration of these insurers wherein they are the providers too. The DOJ is literally, actively, suing to block a merger between united healthcare and a provider. https://www.justice.gov/opa/pr/justice-department-sues-block-unitedhealth-groups-acquisition-home-health-and-hospice https://www.justice.gov/opa/pr/justice-department-sues-block...

nradov 2y ago
It's not clear that vertical integration is necessarily bad for consumers. For example, Kaiser-Permanente is a huge, vertically-integrated "payvider" which both sells insurance plans and also delivers most of the treatment for plan members. They generally do a pretty good job at a competitive price. Both the payer and provider sides of the healthcare industry have been consolidating for years. Insurers merged to gain more negotiating power with providers and drive down costs. Providers responded by merging (or selling to private equity funds) to gain more negotiating power with insurers and maintain high rates. Government mandates on back office technology also incentivized provider consolidation due to economies of scale. In some areas now a few major provider organizations effectively control the market and payers are essentially forced to pay high rates in order to maintain sufficient networks. So, the logical next step is for payers to mimic KP by building their own captive health systems. Every major payer is pursuing this strategy to varying levels; it's not just UHC.

fny 2y ago

Yes, insurance companies deny claims, but this is mostly because they don't have the money to pay for things most of their money is spent on care in the first place: they're forced to optimize and people get hurt in the process. Providers do far more damage. UHCs profit margins are only 6%, their operating costs are extremely low[0], and if you look across G7 insurers in the US pay more than the government does in every country but France![1] Compare this to HCA which makes an average margin of 10% with far higher administrative costs. The CEO of HCA makes $20M, Brian Thompson made $10M by contrast. This is not to say we (and insurance companies) don't spend astronomically more than other countries: providers are to blame for this, and I have seen their nonsense first hand: - They keep people alive overnight to charge insurance more - Some hospitals use ML (!) to optimize ICD codes for billing. Most do this by hand: there's literally a job and training to be an ICD coder. - They allow people to deteriorate (e.g. dialysis) to charge more (no preventative care.) I have seen a hospital only provide preemptive care to patients at risk of dialysis because they were part of their own insurance pool - Their administraive expenses are far higher. - They test and provide unnecessary care. - Physician shortage is in part caused by limited residency spots, a dumb bachelors requirement, and high tuition costs. These barriers to entry are imposed by physicians. - Uneccesary tech and equipment upgrades (e.g. we need to replace your knee with a new knee) - Having to deal with tons of different insurance companies: not their fault but they don't know how to handle this efficiently. [0]: https://www.reddit.com/r/dataisbeautiful/comments/194wucn/oc_unitedhealth_group_just_released_its_income/?rdt=52541 https://www.reddit.com/r/dataisbeautiful/comments/194wucn/oc... [1]: https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fbb8e5dae-6e36-410d-9ce8-47fb6166f21a_1020x720.jpeg https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_pr...

ethbr1 2y ago
Underappreciated reality. Because customer-insurer relationships are the only side of the healthcare system that most people see, they're oblivious to what are actually pass-through insurer-provider issues. As you said, the reality is that insurers operate with pretty reasonable margins and incredibly meager per-claim overhead costs. They're stuck trying to make 2 + 1 = 2. If the finger should be pointed at root causes in the US health system, it should be at: - Providers overbilling (particular in certain specialties) - Medical schools, for charging too much and under-expanding capacity - The federal government/Congress, for failing to expand residency funding to increase supply (especially in generalist provider categories)

mancerayder 2y ago

Yes, but in my opinion it falls to the patient to figure out the details and absorb the risk. That's the messed up part. That insurance providers and medical services might disagree on pricing or whatnot is an inevitability. What's not fair is throwing ordinary people under the bus to deal with it, which for many reasons is risky and can ruin lives.