4 ms·

That would be awesome, especially if we could get rid of the yearly Open Enrollment period. We could finally dump insurance providers that don't provide good se

by throwway120385 1y ago

That would be awesome, especially if we could get rid of the yearly Open Enrollment period. We could finally dump insurance providers that don't provide good service or who have bad networks without having to change jobs.

mrguyorama 1y ago
And in the years it would take for a new system to shake out of this disruption and chaos, most people would be unable to access healthcare for basically anything. Isn't that just great? I too would love to disconnect healthcare from employment, but good god is this the wrong way to do it. But the current administration has shown for over 20 years that it is utterly incapable of building a solution, so they will just keep tearing down what little of this system is effective while pocketing billions.
- franktankbank 1y ago
  If you had 20k extra in your pocket to cover regular shit and 10k to pay for a private health insurance covering catastrophic shit all the while regular hospital expenses went down (cough diagnosis, broken bones, etc etc) I think that would be a good thing. Right now you can see the effects of taking insurance out of the system by going to private practice that doesn't accept insurance. These fuckers way overstepped, not only are you paying several 10K for insurance you pay more when you go for minor issues.
coredog64 1y ago
I can't speak to smaller employers who actually use the insurance capability, but larger employers (e.g. 500+ employees) are almost certainly self-insured. They bring the money for the loss pool and use the insurance company for claims service and network. On it's face it might seem like this isn't related to your complaint, but one of the consequences of self-insurance is that the employer essentially has a dial that they can turn that influences what level of service you get from the provider. If the pool is okay, then your employer might spring for additional benefits like free telehealth. If the pool is marginal, they might force you into a pharmacy plan. And if the pool is completely hosed, then the provider can get aggressive about requiring documentation to bring pool spend back in line.
- nradov 1y ago
  Exactly right. Many consumers naively blame their health insurance company when they have trouble with a denied claim or prior authorization. What they don't realize is that in most cases the "insurance" company isn't actually providing insurance (bearing financial risk) at all and is simply acting as a third-party administrator for a self-funded employer. It's ultimately the employer that decides what to cover (within legal limits). Insurance companies are happy to offer plans that pay 100% of every claim for everything no questions asked if that's what an employer wants.
  - FireBeyond 1y ago
    Yes and no (and I worked for a company that built software for administrating all that). You are right, the insurers in a sense don't care about specifics - you can say "everyone gets 52 massage visits a year covered 100%" and they'll do that for you. But when you talk about TPAs, realize too that those self-funded employers obviously haven't done the actuarial work, so they'll by and large follow an insurer plan because that's had a lot of effort put into balance, optimization and such. Otherwise it's like "I don't know, how much -should- we pay for X?"
    - nradov 1y ago
      Sure, I understand that. Health insurers and TPAs all have standard offerings that they'll sell off the shelf to any customer that wants one. But the point is that they're happy to build a custom product with better benefits for any large customer that asks. When consumers aren't happy with their coverage it's pointless and counterproductive to complain about "greedy" insurance companies: any major improvements will have to come from employers or government. (I suspect that some large employers are secretly happy to take advantage of public ignorance and let insurers take the blame for everything.) Of course if we take a step back it's crazy that the current system of tax incentives and penalties essentially forces most large employers to do some level of healthcare actuarial work. There's a whole niche industry of consultants who assist self-funded employers with this. But we'd all be better off if access to affordable health coverage wasn't tied to employment.

mrguyorama 1y ago

And in the years it would take for a new system to shake out of this disruption and chaos, most people would be unable to access healthcare for basically anything. Isn't that just great? I too would love to disconnect healthcare from employment, but good god is this the wrong way to do it. But the current administration has shown for over 20 years that it is utterly incapable of building a solution, so they will just keep tearing down what little of this system is effective while pocketing billions.

franktankbank 1y ago
If you had 20k extra in your pocket to cover regular shit and 10k to pay for a private health insurance covering catastrophic shit all the while regular hospital expenses went down (cough diagnosis, broken bones, etc etc) I think that would be a good thing. Right now you can see the effects of taking insurance out of the system by going to private practice that doesn't accept insurance. These fuckers way overstepped, not only are you paying several 10K for insurance you pay more when you go for minor issues.

coredog64 1y ago

I can't speak to smaller employers who actually use the insurance capability, but larger employers (e.g. 500+ employees) are almost certainly self-insured. They bring the money for the loss pool and use the insurance company for claims service and network. On it's face it might seem like this isn't related to your complaint, but one of the consequences of self-insurance is that the employer essentially has a dial that they can turn that influences what level of service you get from the provider. If the pool is okay, then your employer might spring for additional benefits like free telehealth. If the pool is marginal, they might force you into a pharmacy plan. And if the pool is completely hosed, then the provider can get aggressive about requiring documentation to bring pool spend back in line.

nradov 1y ago
Exactly right. Many consumers naively blame their health insurance company when they have trouble with a denied claim or prior authorization. What they don't realize is that in most cases the "insurance" company isn't actually providing insurance (bearing financial risk) at all and is simply acting as a third-party administrator for a self-funded employer. It's ultimately the employer that decides what to cover (within legal limits). Insurance companies are happy to offer plans that pay 100% of every claim for everything no questions asked if that's what an employer wants.
- FireBeyond 1y ago
  Yes and no (and I worked for a company that built software for administrating all that). You are right, the insurers in a sense don't care about specifics - you can say "everyone gets 52 massage visits a year covered 100%" and they'll do that for you. But when you talk about TPAs, realize too that those self-funded employers obviously haven't done the actuarial work, so they'll by and large follow an insurer plan because that's had a lot of effort put into balance, optimization and such. Otherwise it's like "I don't know, how much -should- we pay for X?"
  - nradov 1y ago
    Sure, I understand that. Health insurers and TPAs all have standard offerings that they'll sell off the shelf to any customer that wants one. But the point is that they're happy to build a custom product with better benefits for any large customer that asks. When consumers aren't happy with their coverage it's pointless and counterproductive to complain about "greedy" insurance companies: any major improvements will have to come from employers or government. (I suspect that some large employers are secretly happy to take advantage of public ignorance and let insurers take the blame for everything.) Of course if we take a step back it's crazy that the current system of tax incentives and penalties essentially forces most large employers to do some level of healthcare actuarial work. There's a whole niche industry of consultants who assist self-funded employers with this. But we'd all be better off if access to affordable health coverage wasn't tied to employment.