10 ms·

This sort of thing gets to two critical problems of the American system: 1. It is largely designed to make money, not actually help patients. So every step in t

This sort of thing gets to two critical problems of the American system: 1. It is largely designed to make money, not actually help patients. So every step in the healthcare chain that can extract a bit of value will do so, largely to boost profits. 2. Insane complexity with limited transparency. How much will something cost? Hard to tell. Will it be covered? Who knows? On the opacity, I have one informative anecdote. I had a single blood test done awhile back and no one knew if insurance would cover it, or which of the dozen or so billing codes it involved (taking the sample, delivering the sample, testing the sample, etc.) might be covered. It was an expensive test so I spent days bouncing between the doctor's billing team and the insurance company until the settled answer was: No one knows, do the test and insurance will decide. So I did it and insurance denied covering the doctor-recommended test. The salaries involved for all the billing people (and my time) would have covered the cost of the test. </rant>

hypeatei 1y ago
> No one knows, do the test and insurance will decide Oh, someone knew but the doctors office wanted to do the expensive thing and get paid (either by you or the insurance) Not saying the blood test was unnecessary but we have no idea what communication happened between the doctor and insurance company. Did they possibly recommend a less expensive test and the doctor decided that'd make him less money so he went forward anyway?
- danaris 1y ago
  No, I assure you, it is very common for doctors' offices not to know whether a particular procedure will be covered. This is not just because of the capriciousness of insurance adjusters, but because they have to deal with all the 273 different variations of insurance plans that people who come through their offices might have. In general, a doctor's primary goal will be to get you good care. An insurance company's only goal nowadays is to make as much money as possible for as little effort as possible.
  - hypeatei 1y ago
    > An insurance company's only goal nowadays is to make as much money as possible How can that be true when their profits are capped on collected premiums? Look up the Medical Loss Ratio (MLR) rule to see what I'm referring to. If you wanted to squeeze money out of people, health insurance would be the least appealing industry to do that in since you're required to spend 80-85% of premiums on medical care.
    - lozenge 1y ago
      So increase the health care spending, then you can raise premiums. An issue the ACA drafters already knew about, and tried (and failed) to deal with.
      - lotsofpulp 1y ago
        The linked article is about insurers trying to reduce spending by downcoding. So which is it? Insurers unfairly denying reimbursement for what should be valid claims, or insurers unfairly increasing spending on claims so they can increase their profits. Also, go look at 5, 10, and 15 year returns for the big insurers (UNH/Elevance/CVS/Cigna/Humana/Molina/Centene) if you think health insurance is a good business for earning money. Spoiler alert: they’re less than desirable, stick with SP500.
    - wat10000 1y ago
      A 25% margin is pretty good, and companies aren't hitting the limit currently.
      - lotsofpulp 1y ago
        The 7 publicly listed health insurers have ~2% profit margins, with the exception of UNH at 6%, but that is due to its healthcare provider business earning higher margins. The other insurers are almost all non profit (various BCBS affiliated insurers, Kaiser, Providence, etc).
        1y ago
- lotsofpulp 1y ago
  Health insurance companies have told me, on the phone, that they will not tell me the codes the doctor needs to charge for preventative visits in order to for my visit to be covered as preventative care (meaning I don’t have to pay anything). However, I could tell the insurance customer service person a code, then they could tell me if it was classified as a covered preventative service. So I, the insurance company’s customer, Googled medical procedure codes and found some on random PDFs, and checked which ones were covered, and then I asked the doctor to provide me the services for that code. That is American healthcare. On the flip side, I also had a doctor’s office try to bill my insurance $25 for towels used to wipe the ultrasound jelly off my wife’s belly. My insurance didn’t pay, so the doctor’s office sent me the bill for what insurance didn’t cover, so I called the doctor’s office and asked why I am being charged $25 for the few pieces of paper towel (not even linen towel), and the receptionist said they would waive the charge. So, moral of the story is bring your own paper towel roll when you expect to get messy at the doctor’s office.
  - testing22321 1y ago
    > However, I could tell the insurance customer service person a code, then they could tell me if it was classified as a covered preventative service. Malicious compliance engaged. Start with code “1” and go to “99999999999999999” until they tell you it’s covered.
    - dotancohen 1y ago
      Or ask your favorite LLM.
supportengineer 1y ago
Here are the magic words in US Health Care: "What is the cash price?" It's usually less than you think and often worth avoiding the insurance company hassle. Then you can just get reimbursed with your FSA or HSA anyway.
- i80and 1y ago
  FSAs are insane, conceptually. "Guess how much money you're spending in a year on healthcare! But beee caaareful: if you guess too high, YOU LOSE IT" I still used mine while I still had access to one, but it was grumpy-making and was usually almost more trouble than it was worth.
  - lotsofpulp 1y ago
    I don’t understand why any decision maker in any business in the USA chooses to offer their employees (and hence themselves) health FSAs at all, especially when the much superior in every way Fidelity HSA is available.
    - supportengineer 1y ago
      HSA requires a high deductible health plan, not everyone could afford that deductible. "To contribute to an HSA, you'll need to be enrolled in an HSA-eligible health plan, also called a high-deductible health plan (HDHP)."
      - xhrpost 1y ago
        Yup, I agree HSA is superior but depending on your situation (and plans offered), the HDHP can be much more expensive out of pocket[1], even if you're paying with after tax dollars. Sweet spot I think is using a good low deductible plan when it makes sense but having a spouse with an HSA which both spouses can use for expenses. [1]: or so it seems, I tried to figure this out earlier in the year and the data is just lacking in order to make a perfect decision.
    - delecti 1y ago
aduffy 1y ago
I've had numerous encounters where doctors (and dentists) attempt to charge me for services they've already been reimbursed for from the insurance company. It's only after hours of scouring my EOBs and being on the phone with my insurance that I then come back to the practice's office with evidence in hand, and they dismiss the charges. I'm pretty sure this is just a racket because they expect most people not to put up a fight and just pay, or get sent to collections hell. The amount of work you need to do as a patient in our health system is so dumb.
- empressplay 1y ago
  Where do you live, so people know not to move there? Jesus.
  - adastra22 1y ago
    Sunnyvale, California.
  - throwaway173738 1y ago
    I’m pretty sure this is the US.
- M95D 1y ago
  1) Report fraud to insurer? 2) Get a lawyer? Would any of that work?
alphazard 1y ago
The biggest problem with the American system is that it's just illegal for me to sell you good, simple insurance. Let's say I draft an insurance contract that says for any treatment if >5 of 10 randomly selected doctors agree that the procedure was warranted, then I have to pay out the cost of the procedure, no questions asked. This contract is less hassle, clear, and doesn't require arguing with an insurance company since it specifies how disputes are resolved. But I'm not going to give it to you for free. I need to know the expected payout in order to come up with a price and sell it to you. You know, like how all other insurance works. There is a price that is positive EV for me, but better aligns with your risk tolerance, and is therefore positive utility for you as well. In America, pricing it is illegal. I cannot, by my own methods, determine a fair price and sell it to you. That's why we can't have nice things, because it's illegal for two people to agree on a price and terms and create a good deal for themselves.
wisty 1y ago
I disagree with the language you use. It was not designed to make money. It was designed to cost less, in the same way the USSR was designed to make workers rich - it simply failed spectacularly. Neoliberals dislike both regulation and public ownership, but made a Faustian bargain where they replaced public ownership with more regulation, thinking that regulation was the lessor of the two evils. In reality, it's not - like in the USSR where they had corporatised but heavily regulated "companies". A heavily regulated company doesn't make money by offering better value to customers, it makes money by finding loopholes in regulations, and regulators will always lose the cat and mouse game of closing these loopholes. Neoliberals end up creating a system that's actually a lot like the USSR (if the famous "Well intentioned Commissaire" essay is representative of the USSR) - heavy regulations, with corporate entities outsmarting the regulators to enrich their owners (or managers) while minimising the value they create. Neoliberals deny the need for pubic management, but are forced to badly reinvent it (via heavy regulation). Communists deny the need for incentives, and are forced to badly reinvent it (once again via regulation), ending up not a million miles away from where neoliberals end up - with endless regulation and lost efficiency. It's worth noting that the US spends far more tax dollars (per capita) than Australia on health (Australia has a hybrid public / private model). Medicare, Medicaid and the VA costs about as much as Canada's expensive public system (per capita) since the US is so insanely inefficient. (edit: The essay I mentioned - https://highered.blogspot.com/2009/01/well-intentioned-commissar.html https://highered.blogspot.com/2009/01/well-intentioned-commi...)
- int_19h 1y ago
  I'm sorry, but this is bullshit. The American system is nothing like the Soviet one. I've seen both first hand. Both are kinda crappy but in very different ways. If I had to choose one though it'd be Soviet for sure because it's still guaranteed healthcare no matter what your financial situation is.
  - wisty 1y ago
    So you deny that both the US healthcare system and USSR economy are / were bogged down in red tape and regulation, which is clearly my main point? Or you're just mad that I'm using Communism as a punchline when criticising neoliberalism?
potatoicecoffee 1y ago
In Australia I just take my blood test form to any pathology place and they do it for free (for me) and bill the government a set price from the medicare benefits schedule.
- hintklb 1y ago
  Hmm sure, but there must similarly be things that are denied right? I lived in both systems. In a single payer system, the state essentially decide what is allowed and what is not. And with the state as a single payer, they also go back and forth on price with the hospitals. It still is a better system overall but there is no places where you can just spend as much as you want on healthcare without some type of centralized supervision.
  - empressplay 1y ago
    Yes, in Australia what and how much of it a doctor can prescribe is tightly regulated. Many medications require a specialist referral and approval. Any medical procedure requires a specialist to sign off on it. That and there is often a 'gap' that needs to be covered for GP and specialist services, although that tends to be balanced out by much cheaper prescription costs. (Prescriptions in Canada for example easily cost 2X as much). However, Australia has a two-tier system where you can buy private insurance cover that can cover the costs of gaps and allow you access to private hospitals. This insurance is much cheaper than the equivalent US versions.
  - codedokode 1y ago
    > In a single payer system, the state essentially decide what is allowed and what is not. Usually if the state decides you are not eligible for something (for example, some examination), you can just pay and get it anyway.
  - adastra22 1y ago
    In sensible countries that decision isn’t made after the fact. You know going in if it is covered or not.
  - ikr678 1y ago
xtajv 1y ago
Fire insurance protects against the rare disaster where there's a fire. Flood insurance protects against the rare disaster where there's a flood. Health insurance protects against the rare disaster where somebody's actually able to get healthcare.

hypeatei 1y ago

> No one knows, do the test and insurance will decide Oh, someone knew but the doctors office wanted to do the expensive thing and get paid (either by you or the insurance) Not saying the blood test was unnecessary but we have no idea what communication happened between the doctor and insurance company. Did they possibly recommend a less expensive test and the doctor decided that'd make him less money so he went forward anyway?

danaris 1y ago
No, I assure you, it is very common for doctors' offices not to know whether a particular procedure will be covered. This is not just because of the capriciousness of insurance adjusters, but because they have to deal with all the 273 different variations of insurance plans that people who come through their offices might have. In general, a doctor's primary goal will be to get you good care. An insurance company's only goal nowadays is to make as much money as possible for as little effort as possible.
- hypeatei 1y ago
  > An insurance company's only goal nowadays is to make as much money as possible How can that be true when their profits are capped on collected premiums? Look up the Medical Loss Ratio (MLR) rule to see what I'm referring to. If you wanted to squeeze money out of people, health insurance would be the least appealing industry to do that in since you're required to spend 80-85% of premiums on medical care.
  - lozenge 1y ago
    So increase the health care spending, then you can raise premiums. An issue the ACA drafters already knew about, and tried (and failed) to deal with.
    - lotsofpulp 1y ago
      The linked article is about insurers trying to reduce spending by downcoding. So which is it? Insurers unfairly denying reimbursement for what should be valid claims, or insurers unfairly increasing spending on claims so they can increase their profits. Also, go look at 5, 10, and 15 year returns for the big insurers (UNH/Elevance/CVS/Cigna/Humana/Molina/Centene) if you think health insurance is a good business for earning money. Spoiler alert: they’re less than desirable, stick with SP500.
  - wat10000 1y ago
    A 25% margin is pretty good, and companies aren't hitting the limit currently.
    - lotsofpulp 1y ago
      The 7 publicly listed health insurers have ~2% profit margins, with the exception of UNH at 6%, but that is due to its healthcare provider business earning higher margins. The other insurers are almost all non profit (various BCBS affiliated insurers, Kaiser, Providence, etc).
      - 1y ago
lotsofpulp 1y ago
Health insurance companies have told me, on the phone, that they will not tell me the codes the doctor needs to charge for preventative visits in order to for my visit to be covered as preventative care (meaning I don’t have to pay anything). However, I could tell the insurance customer service person a code, then they could tell me if it was classified as a covered preventative service. So I, the insurance company’s customer, Googled medical procedure codes and found some on random PDFs, and checked which ones were covered, and then I asked the doctor to provide me the services for that code. That is American healthcare. On the flip side, I also had a doctor’s office try to bill my insurance $25 for towels used to wipe the ultrasound jelly off my wife’s belly. My insurance didn’t pay, so the doctor’s office sent me the bill for what insurance didn’t cover, so I called the doctor’s office and asked why I am being charged $25 for the few pieces of paper towel (not even linen towel), and the receptionist said they would waive the charge. So, moral of the story is bring your own paper towel roll when you expect to get messy at the doctor’s office.
- testing22321 1y ago
  > However, I could tell the insurance customer service person a code, then they could tell me if it was classified as a covered preventative service. Malicious compliance engaged. Start with code “1” and go to “99999999999999999” until they tell you it’s covered.
  - dotancohen 1y ago
    Or ask your favorite LLM.

supportengineer 1y ago

Here are the magic words in US Health Care: "What is the cash price?" It's usually less than you think and often worth avoiding the insurance company hassle. Then you can just get reimbursed with your FSA or HSA anyway.

i80and 1y ago
FSAs are insane, conceptually. "Guess how much money you're spending in a year on healthcare! But beee caaareful: if you guess too high, YOU LOSE IT" I still used mine while I still had access to one, but it was grumpy-making and was usually almost more trouble than it was worth.
- lotsofpulp 1y ago
  I don’t understand why any decision maker in any business in the USA chooses to offer their employees (and hence themselves) health FSAs at all, especially when the much superior in every way Fidelity HSA is available.
  - supportengineer 1y ago
    HSA requires a high deductible health plan, not everyone could afford that deductible. "To contribute to an HSA, you'll need to be enrolled in an HSA-eligible health plan, also called a high-deductible health plan (HDHP)."
    - xhrpost 1y ago
      Yup, I agree HSA is superior but depending on your situation (and plans offered), the HDHP can be much more expensive out of pocket[1], even if you're paying with after tax dollars. Sweet spot I think is using a good low deductible plan when it makes sense but having a spouse with an HSA which both spouses can use for expenses. [1]: or so it seems, I tried to figure this out earlier in the year and the data is just lacking in order to make a perfect decision.
  - delecti 1y ago

aduffy 1y ago

I've had numerous encounters where doctors (and dentists) attempt to charge me for services they've already been reimbursed for from the insurance company. It's only after hours of scouring my EOBs and being on the phone with my insurance that I then come back to the practice's office with evidence in hand, and they dismiss the charges. I'm pretty sure this is just a racket because they expect most people not to put up a fight and just pay, or get sent to collections hell. The amount of work you need to do as a patient in our health system is so dumb.

empressplay 1y ago
Where do you live, so people know not to move there? Jesus.
- adastra22 1y ago
  Sunnyvale, California.
- throwaway173738 1y ago
  I’m pretty sure this is the US.
M95D 1y ago
1) Report fraud to insurer? 2) Get a lawyer? Would any of that work?

alphazard 1y ago

The biggest problem with the American system is that it's just illegal for me to sell you good, simple insurance. Let's say I draft an insurance contract that says for any treatment if >5 of 10 randomly selected doctors agree that the procedure was warranted, then I have to pay out the cost of the procedure, no questions asked. This contract is less hassle, clear, and doesn't require arguing with an insurance company since it specifies how disputes are resolved. But I'm not going to give it to you for free. I need to know the expected payout in order to come up with a price and sell it to you. You know, like how all other insurance works. There is a price that is positive EV for me, but better aligns with your risk tolerance, and is therefore positive utility for you as well. In America, pricing it is illegal. I cannot, by my own methods, determine a fair price and sell it to you. That's why we can't have nice things, because it's illegal for two people to agree on a price and terms and create a good deal for themselves.

wisty 1y ago

I disagree with the language you use. It was not designed to make money. It was designed to cost less, in the same way the USSR was designed to make workers rich - it simply failed spectacularly. Neoliberals dislike both regulation and public ownership, but made a Faustian bargain where they replaced public ownership with more regulation, thinking that regulation was the lessor of the two evils. In reality, it's not - like in the USSR where they had corporatised but heavily regulated "companies". A heavily regulated company doesn't make money by offering better value to customers, it makes money by finding loopholes in regulations, and regulators will always lose the cat and mouse game of closing these loopholes. Neoliberals end up creating a system that's actually a lot like the USSR (if the famous "Well intentioned Commissaire" essay is representative of the USSR) - heavy regulations, with corporate entities outsmarting the regulators to enrich their owners (or managers) while minimising the value they create. Neoliberals deny the need for pubic management, but are forced to badly reinvent it (via heavy regulation). Communists deny the need for incentives, and are forced to badly reinvent it (once again via regulation), ending up not a million miles away from where neoliberals end up - with endless regulation and lost efficiency. It's worth noting that the US spends far more tax dollars (per capita) than Australia on health (Australia has a hybrid public / private model). Medicare, Medicaid and the VA costs about as much as Canada's expensive public system (per capita) since the US is so insanely inefficient. (edit: The essay I mentioned - https://highered.blogspot.com/2009/01/well-intentioned-commissar.html https://highered.blogspot.com/2009/01/well-intentioned-commi...)

int_19h 1y ago
I'm sorry, but this is bullshit. The American system is nothing like the Soviet one. I've seen both first hand. Both are kinda crappy but in very different ways. If I had to choose one though it'd be Soviet for sure because it's still guaranteed healthcare no matter what your financial situation is.
- wisty 1y ago
  So you deny that both the US healthcare system and USSR economy are / were bogged down in red tape and regulation, which is clearly my main point? Or you're just mad that I'm using Communism as a punchline when criticising neoliberalism?

potatoicecoffee 1y ago

In Australia I just take my blood test form to any pathology place and they do it for free (for me) and bill the government a set price from the medicare benefits schedule.

hintklb 1y ago
Hmm sure, but there must similarly be things that are denied right? I lived in both systems. In a single payer system, the state essentially decide what is allowed and what is not. And with the state as a single payer, they also go back and forth on price with the hospitals. It still is a better system overall but there is no places where you can just spend as much as you want on healthcare without some type of centralized supervision.
- empressplay 1y ago
  Yes, in Australia what and how much of it a doctor can prescribe is tightly regulated. Many medications require a specialist referral and approval. Any medical procedure requires a specialist to sign off on it. That and there is often a 'gap' that needs to be covered for GP and specialist services, although that tends to be balanced out by much cheaper prescription costs. (Prescriptions in Canada for example easily cost 2X as much). However, Australia has a two-tier system where you can buy private insurance cover that can cover the costs of gaps and allow you access to private hospitals. This insurance is much cheaper than the equivalent US versions.
- codedokode 1y ago
  > In a single payer system, the state essentially decide what is allowed and what is not. Usually if the state decides you are not eligible for something (for example, some examination), you can just pay and get it anyway.
- adastra22 1y ago
  In sensible countries that decision isn’t made after the fact. You know going in if it is covered or not.
- ikr678 1y ago

xtajv 1y ago

Fire insurance protects against the rare disaster where there's a fire. Flood insurance protects against the rare disaster where there's a flood. Health insurance protects against the rare disaster where somebody's actually able to get healthcare.