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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. The

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.
    - robocat 1y ago
      > "greedy" insurance companies: any major improvements will have to come from employers or government Pointless blaming employers or governments - their pockets aren't unlimited. The problem is the greedy insured. The insured only want the best when it comes to medicine and procedures. Infinite want for important needs is hard to deal with (our economics cannot match our morals). Part of the reason for our roundabout ways of managing healthcare is so that budgets exist at all (nobody wants their healthcare options restricted). For public healthcare in New Zealand waiting lists are used to ration procedures, and expensive drugs don't get funded.
      - FireBeyond 1y ago
        We're not the greedy insured in the US. Your point about unlimited resources is valid. But we spend far more, multiple times more for exactly the same medical goods andservices available in other countries, for that fraction of the price. It'd be a great start if there was equality, before we start talking about "greedy insured".
- antisthenes 1y ago
  Even more reasons for insurance companies to not exist. Not only does what you describe introduce additional middle-man costs that aren't being spent on actual care, but it also obscures the overall health of the public, by creating a number of private health pools that are administered separately. If we had a single payer system, we'd have much better data on spend vs outcomes and would be able to direct the flow of care much better.

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.
  - robocat 1y ago
    > "greedy" insurance companies: any major improvements will have to come from employers or government Pointless blaming employers or governments - their pockets aren't unlimited. The problem is the greedy insured. The insured only want the best when it comes to medicine and procedures. Infinite want for important needs is hard to deal with (our economics cannot match our morals). Part of the reason for our roundabout ways of managing healthcare is so that budgets exist at all (nobody wants their healthcare options restricted). For public healthcare in New Zealand waiting lists are used to ration procedures, and expensive drugs don't get funded.
    - FireBeyond 1y ago
      We're not the greedy insured in the US. Your point about unlimited resources is valid. But we spend far more, multiple times more for exactly the same medical goods andservices available in other countries, for that fraction of the price. It'd be a great start if there was equality, before we start talking about "greedy insured".
antisthenes 1y ago
Even more reasons for insurance companies to not exist. Not only does what you describe introduce additional middle-man costs that aren't being spent on actual care, but it also obscures the overall health of the public, by creating a number of private health pools that are administered separately. If we had a single payer system, we'd have much better data on spend vs outcomes and would be able to direct the flow of care much better.