Cigna denied my claim for an ER stay for a broken leg because it "wasn't medically necessary". This whole "click and close" thing is so obviously happening that I find it hard to believe that the company is even bothering to deny that they do that.
One of the worst parts about this for me was that while I was dealing with trying to get my life back together from that kind of injury, I thought I was also going to go bankrupt as well.
In my case, everything did turn out fine because apparently the hospital has an entire department dedicated to dealing with insurance claim denials. This whole system is an absolute joke.
There's so much ancillary work around medical care. Like 20% of US workers are in some supporting industry. Insurance companies pay a bunch of people to find reasons to deny claims, hospitals pay a bunch of people to fight the insurance companies. They all ultimately get paid by my medical bills and premiums.
In my mind's eye is a political-style poster depicting the patriotic duty it is to pay your medical bill. Insurance company takes a cut, people who fight insurance companies take a cut, CEOs take a cut, everyone takes a cut, my medical bill is keeping half the nation afloat it seems, until at the end there's even a few dollars left over for the doctor. All because I spent 5 minutes talking to a doctor about an ear ache.
Fixing this will require eliminating a lot of these ancillary jobs and it won't be popular among those groups.
This is one reason I hate it when productive jobs are destroyed. Economists say we'll find new things things for people to do, but those often seem extremely low value, like insurers/providers paying people to fight with each other over billing questions. And a lot of the time it seems like the replacement is either that sort of bullshit-esq job, or else some minimum-wage thing which is not acceptable to a lot of people - especially those carrying tens of thousands of debt in student loans from college.
Not just healthcare, the US outspends everyone at everything: infrastructure, education, defense, research, police, housing, prisons, etc. both in relative(by % GDP) and in absolute numbers.
It does so because it can. It's the wealthiest country on Earth so such high inefficiencies where a lot of the money is squandered to the benefit of few wealthy and unscrupulous parties, can be financially absorbed while still delivering a system that's functional enough for its citizens to not revolt over and want to hang someone. After all, it's still better than scary communism.
If Country A is spending 10% of it's GDP on 10 things, Country B cannot possibly outspend it in every category as a percentage of their respective GDPs, because "percentage of GDP" is always a 100-point scale.
If you go up one percent in one category, you have to go down one percent somewhere in the other categories.
I think as the industry moves from a post-pay model, to a pre-pay/real-time model, this antagonistic relationship between providers and payers should slowly improve. Definately not a silver bullet though.
In terms of aligning incentives, there is a lot of potential in shifting from a fee-for-service model to a capitated value-based care model. But this will force further consolidation by provider organizations. Only the largest, most sophisticated multi-specialty health systems have the scale to take on and manage those risks. Small, independent practices will essentially be forced to either sell their businesses or switch to something like concierge medicine.
Sorry, i used some jargon most people don't know. Prepay the way I meant it is not referring to prior auths, but rather pre-adjudication. Not everything can go through a pre-pay process, but I believe most claims can.
Look, the denial created at least one extra job! Cigna is out there creating jobs, and it only cost you the very real fear that you could have your life ruined from a broken leg!
“One of the worst parts about this for me was that while I was dealing with trying to get my life back together from that kind of injury, I thought I was also going to go bankrupt as well.”
I have seen the same with people I knew who had cancer. They are already super sick but are then in addition expected to navigate this insane system or accept to pay tens and hundreds thousands of dollars. All this while they can barely function at all.
There is a whole niche industry in cancer care navigation. Perhaps that shouldn't be necessary in the sense of working around defects in a broken system but those care navigators can help a lot.
A co-worker here had a neighbor who broke his leg falling out the back of a pickup truck (doing a job unsafely which seems to be SOP in rural Texas). He never worried about a bill since he didn't have money to pay anyway and I assume the hospital just ate the cost. The system is indeed a joke.
Quote from Obama on single payer. The system is set up quite specifically so certain parties can profit from it.
“Everybody who supports single-payer health care says, ‘Look at all this money we would be saving from insurance and paperwork,’ ” the former President noted. “That represents one million, two million, three million jobs.”
https://www.newyorker.com/books/under-review/the-bullshit-jo...
It's a reasonable statement, though. There's a LOT of people that think a single payer healthcare system is the right goal. And a LOT of those people also realize that getting from where we are right not to a single payer system is HARD. One reason it's hard is that there are millions of jobs that will go poof when that happens. Those people could be put to work doing something that's actually beneficial to society. But the transition from <working in bullshit job> to <working in useful job> for millions of people is not trivial.
The change isn't something where you just pass a law / flip a switch, and everything is better. It's HARD.
Maybe this is an upside to the looming AI-taking-jobs issue.
I bet a ton of these bureaucratic approve/deny/request-more-information workflows in current EMR systems will be replaced by AI in a few years, putting the people out of work.
Once AI eats their jobs, less resistance to changing the system.
Hopefully these jobs go away sooner than later, they are not exactally fufilling work & there are much better jobs out there.
I am now buidling an aprove deny API, going to call it dPANEL for deterministicPanel. Also chatGPT seems ungodly enthusiastic to help me build it...
Pricing Strategy for Health Insurance Approve || Deny API
Pricing Structure
Base Subscription Fee:
Annual Subscription: $120,000 per year, covering up to 50,000 API calls.
Volume-Based Pricing:
Beyond the initial 50,000 calls:
Tier 1: 50,001 to 100,000 calls at $1.50 per call.
Tier 2: 100,001 to 200,000 calls at $1.25 per call.
Tier 3: Over 200,001 calls at $1.00 per call.
Multi-Year Discounts:
2-Year Contract: 10% discount on the annual subscription fee.
3-Year Contract or more: 15% discount on the annual subscription fee.
Additional Services:
Custom Integration: $30,000 one-time fee.
Premium Support Package: $25,000 per year for dedicated support and quarterly performance reviews.
Early Termination Benefits:
Early termination within the first year incurs a 50% fee of the remaining contract value.
Termination in the second year or later incurs a 25% fee of the remaining contract value.
Cost-Saving Benefits
Labor Cost Reduction: Automation of approval and denial processes reduces the need for manual labor.
Increased Efficiency: Faster processing times improve operational efficiency and customer satisfaction.
Error Reduction: Minimized human errors reduce costs related to claim reprocessing and disputes.
Scalability: Efficiently manages varying loads without significant staffing changes.
Regulatory Compliance: Helps ensure decisions are consistent and compliant, reducing potential fines.
Data Insights: Offers valuable analytics that can lead to better risk management and operational adjustments.
Most of it doesn't even require AI. The majority of those jobs can be eliminated just by implementing existing interoperability standards between payer and provider organizers, and then writing some simple deterministic rules. I previously worked on projects to do just that. There is a tremendous amount of waste (and associated jobs) that can be eliminated without buying a single GPU.
Ha ha, but even single payer or socialized systems have similar mechanisms for preventing payments for treatments that don't meet medical necessity criteria. Blindly approving all claims would only serve to make the system more expensive and overloaded than it already is.
>I bet a ton of these bureaucratic approve/deny/request-more-information workflows in current EMR systems will be replaced by AI in a few years, putting the people out of work.
It is, but that doesn’t change the political calculus at all. If you’re the president who does something which cuts millions of jobs, that’s a LOT of people who are now voting for the other guy. Obama won reelection by 5 million votes, so that could be all of his margin when you think about friends and family.
I am not saying we shouldn’t try, but you really do need to think carefully about how to phase things in so people have time to adjust.
> “I don’t think in ideological terms. I never have,” Obama said, continuing on the healthcare theme. “Everybody who supports single-payer healthcare says, ‘Look at all this money we would be saving from insurance and paperwork.’ That represents 1 million, 2 million, 3 million jobs of people who are working at Blue Cross Blue Shield or Kaiser or other places. What are we doing with them? Where are we employing them?”
If Kaiser could figure out how to cut those jobs themselves, it’d be done by next week. When it’s for the good of society, we have a conscience; when it’s for the bottom line, there’s no conscience and that’s celebrated. I have no solutions, only a pervasive anxiety.
Would they? Internal corporate politics says a team's manager, who's going to best know the value the team provides, is not going to declare their team is redundant and fire them and then quit themselves because what they're doing isn't necessary.
I sustained significant injuries last year in New York which requires $50,000 PIP coverage for every driver. The driver's insurance, Geico, illegally refused to cover me because I "wasn't related to the driver". Fortunately the insurance company of the car owner was willing to comply with the law.
Basically every single US healthcare provider needs someone whose job involves insurance claim disputes, just because there's just too much money in it. The person denying claims, and the person maximizing billing on the other side are ultimately getting paid by the rest of us.
Can you imagine how much worse it would be if we had 'socialism'? /s
We've not hit this point overnight - it's been decades in the making. But I'm not sure we'll ever 'fix' this by small incremental reforms around the edges. We need some moonshot revolution, but I'm not sure we have enough collective appetite for that.
As do the European healthcare systems that have so many advocates here. In any system, there is a finite amount of money that can be paid out. Some level of review and denial of some claims or authorizations is unavoidable.
I'm not saying that the current system in the US is great, but moving to a 100% "single-payer" model will not get rid of claim review.
Pretty much. I'm insured in the public system of my relatively wealthy EU country but I still pay for a lot of stuff out of my own pocket. Not life threating stuff, that would usually be free, but still, things I need to make my conditions more bearable or for prevention, or physiotherapy for back pain, or getting appointments sooner than 3 months for a checkup.
With the ever increasing ageing population, and stagnating economy, the pressure on the healthcare system balloons while the money pot is finite, so the existing resources keep getting split more and more aggressively creating a system of winners and losers. It's inevitable when the resources are finite but the demand virtually infinite.
Nine times out of ten it’s because the provider did not document or code it correctly when they billed your insurance.
Of course the insurance companies always get the heat but it’s probably the minimum wage biller at the office that justified the bone set with an incorrect urinary tract infection diagnosis code that will obviously get denied.
In the future it’s useful to call the provider and ask for a copy of what they submitted to your insurance.
My wife runs a small medical clinic. In the past, she worked as a physical medical biller contracting for large hospital systems, which gives her an unusually good understanding of how to submit a good claim to an insurance company. Despite this, for every hour of patient care, there's an addition 90-120 minutes of staff time to deal with insurance companies, plus additional time spent by a third party (who bills on a percentage, so we don't know exactly how much time they spend). That third party consistently complements her billing staff at being unusually good.
Sometimes a claim is denied because the insurer says they need additional documentation when that documentation was already provided. Sometimes this happens more than once. Sometimes prior authorization requests get "lost".
I think the problem is that if an insurer wrongly denies claims some of the time, nothing bad happens to them but they might save some money. The only fix I see is to change the rules of the system so that it the insurer gets no financial advantage for wrongly denying claims.
If the visit is in-network or an emergency the insurance company will prevent the practice from billing you anything until the denial is fixed. You don’t have to do anything other than throw the letter away and just wait for them to fix it.
If the practice tries to bill you anyway that’s called balance billing, is illegal, and violates their contract with your insurance company and you can call your insurance’s hotline to report them.
Medical establishments are stupid everywhere. If your employer doesn’t choose an insurer or self-funded benefit administrator like Cigna, you don’t have these issues.
I have had a generous United Healthcare plan for 15 years. That time period included a high risk pregnancy, a spinal fusion, and a high risk cancer treatment program.
I’ve had zero billing issues. Zero. We did have some prescription formulary issues that were a result of some drugs being specialty drugs with a different process.
My sibling has Cigna, and literally has a problem of some sort with 80% of claims. The latest is an 8-year olds ear infection was determined by Cigna’s subrogation process to be related to a car accident.
That is because you likely went to a provider with a competent billing department. If you go to one with a bad one you will get results like OP. It does not matter if your employer was self funded or if you got the plan over the marketplace. The claim simply will not adjudicate correctly.
It is purposeful obfuscation. The number of people that can't get the paper work correct, is profit for the insurance company.
I knew someone whos wife got cancer. But good luck, she actually worked in the insurance industry and knew everything. Yet, it still turned into a Full Time job for her to get all the paper work corrected. How is the common person going to fight the system if insiders have difficulty.
I didn't realize that was mandated by law? Surely not down to individual codes?
If that is what you are talking about, it kind of makes sense. Part of how the industry obfuscates is by using a lot of different terminology for the same thing, thus nobody can do price comparison across vendors. But of course, trying to impose order onto something purposefully confusing, is going to be difficult.
Something I wrote about the ICD10 coding system many years ago. These are real billing codes:
It is possible to arraigned the codes in rather amusing orders such as:
I required a Face Transplant, from a Cadaver; “0WY20Z0 Transplantation of Face, Allogeneic, Open Approach Transplantation of Face, Allogeneic, Open Approach” after my many spacecraft crashes into the ocean; “V9541XD Spacecraft crash injuring occupant, subsequent encounter”.
Sadly the first Face Transplant failed so one was grown in a lab for the second Face Transplant; “0WY20Z1 Transplantation of Face, Syngeneic, Open Approach Transplantation of Face, Syngeneic, Open Approach”.
Alas all of this made my “F52 Sexual dysfunction not due to a substance or known physiological condition” became so bad that I tried to harm myself with a jellyfish; “T63622A Toxic effect of contact with other jellyfish, intentional self-harm, initial encounter”. -- Amusement with the Medicare ICD10 Billing Codes –
ICD-10 is only one of several code systems (terminologies) used in HIPAA mandated transactions. The actual billable procedures for outpatient care are typically coded using CPT / HCPCS. The ICD codes are usually supplementary, to indicate a patient's condition as part of establishing medical necessity. The industry will move to the new ICD-11 version in a few years.
The HIPAA final rule mandates ASC X12 as the standard format for certain interactions such as eligibility and claims. It's old and somewhat clunky, but it's not terribly hard to implement. Libraries are available for most popular languages. Even if we replaced X12 with a modern format like HL7 FHIR (which is now legally allowed for some interactions such as prior authorization) that wouldn't solve the fundamental business, legal, and clinical problems.
It’s terrible to implement at the business and industry level - the required details enclosed with the messages are wholly insufficient to properly communicate claims as well as claim payments between payers and providers. Yet nothing can be done as the law requires its usage.
Could you clarify which specific details are missing from the messages? Additional clinical documentation can be sent in 275 attachments.
The law does not specifically require X12. The law gives CMS the authority to set technical standards and they chose X12 for those transactions because there was no other practical option. But recently they have granted at least one exception to use FHIR instead.
I hate to suggest adding yet another layer to the US healthcare system, but you are right and it seems there is a huge space for some kind of private (third party) health advocate/Sherpa - not the free ones that many health plans are offering now to find in-network doctors for you - that you PAY and in return they maximize the healthcare system for you the way that a good tax accountant/lawyer will minimize your taxes
The problem is that what is profitable is marking the case as reviewed. What is needed is skin in the game. Misdiagnosis should have financial penalties like speeding tickets otherwise the optimal most capital-effective solution is a rubber stamp.
I think you're on the right track but not quite there.
The incentivized behavior for insurance companiese right now isn't fast review, it's fast denial (which saves money on both review time and insurance payout). We need to make a coverage denial take an order of magnitude more time and effort than an approval, so insurance companies are forced to think real hard about denying access to care, and are incentivized to only deny care in relatively extreme cases.
Raise the bar for denial reasons, and forbid generic denial templates.
> need to make a coverage denial take an order of magnitude more time and effort than an approval
More difficult or more expensive. A random sample of denials being sent to a public board might do the trick, with a mandatory per-review fee charged to the insurer, and the sample size increasing as a function of reversed denials.
CMS does do random inspections, but they are far too infrequent (on the order of years between inspections) and the penalties far too low to correctly align incentives.
It should be a continuous stream of cases being randomly selected and reviewed.
That doesn't make sense to me. Why wouldn't maximizing denials always be the priority for an insurance company? If you make denials slower, it will just slow down all cases.
Insurance is fundamentally incentivized to scam its own customers. We need to add more regulation/oversight to reduce situations where management can play tricks to tip the balance in their favor. It's an arms race.
The article was mostly about optimizing medical director "productivity levels", but it also mentioned that they outsourced to nurses in the Philippines who were doing a really bad job. Is there any oversight there? Are the nurses being incentivized to maximize denials? It'd be interesting to see how their productivity measurements are calculated too.
Of course nothing is going to change (because of something to do with "socialism" I bet), but at least now I know to avoid Cigna.
> Is there any oversight there? Are the nurses being incentivized to maximize denials? It'd be interesting to see how their productivity measurements are calculated too.
I'm sure there's a degree of thinly-veiled abstraction there. "Oh, we never specified such incentives for the outsourced nurses" ("... and while we did specify those incentives for their contract agency, we had NO idea that they'd put such incentives on their employees, none at all!")
> Why wouldn't maximizing denials always be the priority for an insurance company?
I mean it shouldn't be.
Imagine this; you have the choice between 2 insurance companies. One has a reputation of denying all claims and the other doesn't. Which do you pick for your insurance?
> Imagine this; you have the choice between 2 insurance companies. One has a reputation of denying all claims and the other doesn't. Which do you pick for your insurance?
And as some of the pre-ACA "catastrophic" plans often showed, those who do often go with "whichever is cheaper", and only find out when they get sick how dismal they are.
You are hinting at the edges of the issue: mis-aligned incentives. A big problem is that your health care is tied to your employer for most people (WW2 is over, we need to stop this practice). It makes sense for an insurer to deny everything because it is low chance that the repercussions will come back to their bottom line, some other company or Medicare will get the bill. If once signed up, your healthcare came from one company forever, the math would change. We could finally move to value based healthcare where is makes more money to prevent health problems in the first place.
It would also enable unhappy customers to move to a different insurance. I'm currently taking a prolonged time off and there was so much more flexibility on the market than what I've ever gotten from an employer.
I mean, I think that is the problem with "insurance" vs "coverage". "Insurance" is about pooling unlikely but costly risk, like getting hit by a meteorite. Unlikely, it happens, but there will be head trauma, CAT scans, x-rays, and hospital stays. That is what insurance is perfectly aimed at.
People with known medical issues aren't really looking for insurance, they aren't pooling risk, they are sick. They need coverage. Businesses can easily handle insurance, but coverage is another matter. You are talking about people you know will cost more than they payout. That's charity, and better left to the state than the private sector.
Medicare only comes in if the recipient is over 65 (or some edge cases of disability).
Paying for health insurance premiums with pre tax dollars is tied to employers, or you can do it if you are self employed.
By and large, you can purchase the same health insurance that an employer offers on healthcare.gov, that meets the minimum ACA coverage standards.
However, there is no reason for employers to be able to compensate employees with pre tax dollars via subsidizing health insurance, but an individual cannot buy health insurance with pre tax dollars. That is just a handout to big businesses to give them an advantage over smaller businesses.
Also, employers compensating employees only in straight pay only also makes it easier for employees to compare compensation offers.
>Misdiagnosis should have financial penalties like speeding tickets
Bad analogy. Speeding tickets carry no penalties to those who issue them wrongly. You can sue and if you win the local government will eventually pay for the damages, meaning the taxpayers, meaning also you. They have no skin in the game.
Speeding tickets aren't the worst because they are in principle disputable, but they are present and real. SEC fines are so rare and late they aren't a real deterrent. Speeding tickets are regular and actually paid and a deterrent. Some systems are better than other (photo radar), but these are quibbles.
The point is that these companies should get hit several times a month with a bill till middle management sees it is a cost center and actually worries about "how do we bring down this number?" and it becomes a bigger problem than "how do we reduce our coffee budget?".
They mean the financial penalties should be like the financial penalties of getting a speeding ticket, not that they should have financial penalties for misdiagnosis "like governments have for misissuing speeding tickets".
I have never heard anyone getting paid damages for a traffic ticket. The biggest you can hope for is a case dismissed which still requires direct and indirect costs.
> What is needed is skin in the game. Misdiagnosis should have financial penalties like speeding tickets
By this logic, would you say that software engineers should be financially liable for any bugs they cause along with people who misdiagnose those bugs in the process of root cause?
> By this logic, would you say that software engineers should be financially liable for any bugs they cause
Yes. Professional engineers are held ethically, professionally, and in some cases financially responsible for the work they sign off on. Personally, I agree with Dijkstra who pointed out in a speech in 1993 that the term "software engineer" is a hollow sham:
> And also the programming manager has found the euphemism with which to lend an air of respectability to what he does: “software engineering”...
> In the mean time, software engineering has become an almost empty term, as was nicely demonstrated by Data General who overnight promoted all its programmers to the exalted rank of “software engineer”! But for the managing community it was a godsend which now covers a brew of management, budgeting, sales, advertising and other forms of applied psychology.
> Ours is the task to remember (and to remind) that, in what is now called “software engineering”, not a single sound engineering principle is involved. (On the contrary: its spokesmen take the trouble of arguing the irrelevance of the engineering principles known.) Software Engineering as it is today is just humbug; from an academic —i.e. scientific and educational— point of view it is a sham, a fraud.
I don't think we have a market failure around that. If I introduce bugs that matter the company loses money. If that happens the company will penalize me by not getting promoted or a raise our even getting fired. Both the company and the individual are already held accountable.
In contrast, how do I even know my medical diagnosis was wrong? How do I know it could have been better given the facts at hand at the time? There also seems to be no market function at all that gives market feedback to the medical institution
Edit: procedures going wrong is of course already highly penalized and insurance for this is a significant cost of our health care.
I don't know how US works, but anywhere in Europe doctors making any sort of mistake can and are sued to hell, my wife is one of them (luckily only once and error was done by her senior doctor not herself).
Now depends what happened, how much you sue for, but losing license and ending in jail are not impossible results. Its up to judge to decide. If that's not skin in the game then I don't know what is. Compared to 99.9% of IT folks who at worst can lose their jobs and move on (not ideal situation of course, but incomparable pressure for relatively similar compensation).
This definitely is the case for medical procedures and surgeonts carry high insurance for this. Not sure how this would work for diagnosis though. It's harder to know you were misdiagnosed and even harder to proof they could have done better with the information available at the time.
I'd be happy to subscribe to a $10 a month service that acts on my behalf for any denied insurance claims. Their job would be to become the "squeaky wheel".
The insurance companies are banking on most people not having the time, energy, or knowledge on how to push back on them. Having a service provider that can do this will cause those insurance companies untold amount of pain.
This is a great idea. Having been on the "automatic denial" side of the fence one too many times, I'd subscribe. But I'd want the service to act as an ombudsman for all insurance -- auto, home, health, etc.
I suspect the real trick would be to keep insurance company lobbyists from finding a way to shut that down.
I was thinking the same. Insurance companies should get punished if the ratio of denied claims vs accepted claims after appeal. If that ration is high, it’s pretty much clear that insurance denies claims by default although they know the claim is valid.
I agree, but this will be a horrific example of Goodhart’s law unless the appeals are third-party and there’s a SEC whistleblower-level retribution against anyone who tries to bribe or intimidate anyone involved. You need every executive knowing that the penalties will be denominated in percentage points of their annual revenue.
To me, the most surprising thing—and that it isn’t garnering more attention—is that the initial determination is that the relevant medical records and billing are reviewed by nurses in the Phillipines.
I’m sure they’re competent, but that sending these records to a foreign location where HIPAA does not exist is a matter of course should have people up in arms.
I figured it did and should have been clearer that I believe it to be an ethical problem, because groups like Cigna are masters of finding just the level of unethical that they can perpetrate without crossing the line to illegal, most of the time.
None, no, and no. The Clinton administration sought to overhaul the healthcare system and there was lots of testimony by employees of insurance companies whose job was to improperly deny claims. Americans have an irrational fear of socialism and if you can convince them that something is socialist they will be against it.
What is interesting today is that Republicans campaigned for years on getting rid of Obamacare. When they finally got control of Congress and the Presidency they did not kill it. Eventually there will be another overhaul because these companies just can’t help but be shitty.
> What is interesting today is that Republicans campaigned for years on getting rid of Obamacare.
What is perennially interesting is that Republicans (Baby Boomers specifically, in this case) claim to hate "socialized medicine" but every time cuts to Medicare are floated under the guise of "fiscal responsibility" or whatever they're DOA. It's a trite observation at this point they are truly the fuck-you-got-mine generation.
Sadly, one of the only things that _has_ trickled down from their generation is the belief that "socialized medicine" is evil. A maddeningly large percentage of Gen-Xers, Millennials and beyond have fallen for this line of reasoning. The ironic part, in my direct experience, is that a lot of those folks are the ones getting health insurance from the federal/local governments through the military, emergency response positions, sanitation, etc. So, again, got-mine-fuck-yours.
As a counterpoint, I know a number of people in Europe who have been able to take entrepreneurial risks that either aren't realistic or responsible for people in the U.S. who are tied to their jobs for the sake of healthcare, medical/maternity/paternity/etc. leave, etc. One of them recently had a major health crisis that would have devastated an upstart entrepreneur in the U.S. and was actually able to focus on recovering instead of hustling side gigs or taking out predatory loans to ensure he didn't lose his house or his ability to send his kids to daycare. It's been very enlightening to watch play out in real-time.
> What is perennially interesting is that Republicans (Baby Boomers specifically, in this case) claim to hate "socialized medicine" but every time cuts to Medicare are floated under the guise of "fiscal responsibility" or whatever they're DOA.
Existing socialized medicine, that helps them, is OK. New socialized medicine, which might help other people, is not OK. The politics involved here are not complex.
Because the real role of managed care organizations (MCOs, health insurance companies) is to take the heat for government leaders for having a tiered healthcare system where individuals get access to healthcare based on their socioeconomic position.
If you are a government leader and you offer healthcare to everyone, you are now clearly responsible for any failures. But with an MCO in the middle, fingers can be pointed all over the place.
Different formularies and prior authorization rules can be set for different populations. For example, reimbursement can be lower for Medicaid patients (poorer/younger people), so they end up with less access to doctors, and higher for Medicare (older, likelier to vote), so more doctors are available there. Senators can get their own plan, and the military another, and the tech company employees yet another, and fast food employees, and so on and so forth.
This system benefits all the leaders, so it is not going anywhere. In fact, I would bet UK and Canada move towards this.
I imagine those are dependent on population pyramids not turning upside down. But they seem to be at least flattening, if not turning upside down in all developed countries, hence my prediction of why there would be a change.
I keep reading about NHS in the UK having issues holding it together.
>>I keep reading about NHS in the UK having issues holding it together
I'm in the UK and yep, the system is on the verge of collapse, but it feels like it's entirely by design so it can be finally privatised and killed off once and for all - it feels inevitable at this point.
Basically right now it works for:
- maternity
- anything child related
- emergency services(to an extent, unless you are literally dying you will still wait hours for an ambulance).
Everything else is so massively underfunded it's a miracle it exists at all.
A friend was referred to see a psychiatrist on the NHS recently - you know what the wait time is to see a psychiatrist on the NHS in our region? 210 weeks. About 4 years.
There's a PA at my general practitioner's office who's got to be about 80; it seems like a lot of healthcare jobs can be done into old age. I think about going the PA route after my next layoff actually because it seems like a job that could be a better fit for me.
The NHS (and many other UK institutions) has been starved of cash for fifteen years by the Tories led by increasingly incompetent PMs (I mean, seriously, if the best PM in the last fifteen years is David Cameron; frankly, a head of lettuce would have done better than most of the Tory caucus).
The population pyramid is in better shape than many other countries with universal healthcare. Instead of imagining or searching for plausible sounding excuses study the issue a bit. A government run healthcare system can do much better than our current system and in a much more moral way.
> yet many countries have successful universal healthcare
Few which provide the level of care the upper middle class and above have come to expect in America. If you make more than $100 yo 167k (85th and 95th percentiles [1]), a good fraction of HN readers, you should be able to virtually walk into any medical establishment and get not only seen within a few days, but also tested and imaged by the latest technology, and consulted on by some of the best doctors in the world. You will do this without worrying about costs, because your employer has chosen an insurer who pitched on experience in addition to cost, because you have the market power to change jobs (or be heard by management) if your healthcare sucks.
Universal healthcare means everyone on a PPO falls to the middle class’s HMO-esque standards. For us privileged few, that’s a tough pill to swallow. That is the fundamental injustice and tradeoff that locks us into the status quo, not some paranoia about socialism.
> Few which provide the level of care the upper middle class and above have come to expect in America
This opinion is the opposite of what I’ve heard from people from peer countries who’ve experienced both, not to mention even countries we tend to look down on (there’s an entire industry around even pretty affluent Americans going to Mexico to save money for equivalent treatment). I’d believe it for the 98+th percentile crowd, but I’ve also known people considering going back to Europe because the lower salary is better than all of the out of pocket costs, stress, and risk.
Take the money being extracted out of the system in the form of executive pay, umpteen layers of administration and terrible software -> put it towards increasing the actual work of care.
This is entirely wrong. My household income exceeds $300,000. My wife is a physician. It takes months to get an appointment with an ENT or dermatologist. In Germany, despite not being a citizen or having travel insurance I got an appointment with a dermatologist in 1 day. The cost was around 40 euros. These are anecdotes but they are just as valid as, “you should be able to virtually walk into..” statements.
It was fear of socialism that caused the outrage at Clinton’s healthcare proposals. The fear and outrage was so great that for the first time in decades Republicans took control of the House of Representatives in 1994. Look up the number of times things being labeled communism and socialism has been used to try to halt legislation.
> It takes months to get an appointment with an ENT or dermatologist
Out of curiosity, where are you? (I should have geographically qualified my statement.) In New York, the Bay Area and even western Wyoming (in a wealthy enclave), I have never waited more than a week for an appointment.
> fear and outrage was so great that for the first time in decades Republicans took control of the House of Representatives in 1992
Fair enough, will further qualify by last decades.
The bracket I’m speaking of knows European healthcare. They understand it is generally high quality and much cheaper. But being able to demand an MRI or the surgeon of your choice when something goes wrong is a real perk, and the one politicians are talking about when they reference public medicine.
What you said in the previous comment might be why those in power wish to keep the status quo in terms of healthcare but I don’t think it’s why middle and lower class voters vote against universal healthcare. I believe regulatory capture is why we haven’t done away with health insurance companies in their current incarnation. I believe but don’t know that upper class Europeans can pay for private care. I think Canada was the only country to banned privately paying for healthcare but they have relaxed this in recent years.
Not the parent, but in Seattle-Tacoma area, I have waited 10 weeks for an ENT, and 12 weeks for PT availability following a car accident (in which case I ended up doing my own PT and bought bands and tools to do so until then).
I wonder if there is a resource that tabulates wait times somewhere.
Anecdotally those wait times seem crazy. The PT one especially. I have 5 different pt choices in walking distance to me that can typically get you in next day or worst case a week lead time if you want a time block that is contended (right before/after normal business hours).
When I managed a call center, we had employees that were amazing and accurate at repetitive and rapid tasks (1-2 min calls) and others that were comparatively better at slower-paced more deep-dive calls (30-40 min). We had elaborate routing rules that were matched to skill set and training. My job as a manager was to mix all of the data available to me into a plan that worked best for the collective team.
Nevertheless, we still had to sometimes let people go that didn't have an effective place in the team.
I did not find sufficient information in the article to determine if this was a management problem or a personnel issue.
Without quantitative expectations of performance and safety trade-offs, the actual argument being made here is that a doctor can spend infinite time on a single case and never be reprimanded.
> Without quantitative expectations of performance and safety trade-offs, the actual argument being made here is that a doctor can spend infinite time on a single case and never be reprimanded.
Woah, hold on there, false dichotomy.
It's NOT a matter of "Infinite amount of time" vs "quantified expectations with reasonable trade-offs".
It's a matter of "a doctor putting in the time to be careful" vs "being pressured to take 2-5 minutes of to make LIFE-CHANGING medical decisions".
At the end of the day Cigna cares about hitting their numbers to squeeze every last drop of profit while the doctors are being forced to live with the possibility of making a grave mistake being rushed at "burger-flipper" (or "call-center") time scales.
I didn't create a false dichotomy, you are doing the same thing as the article. You are setting absolutely no threshold for speed, except to "side with the docs" That implies your upper limit has no bounds either.
I am not on either side, but this God worship of doctors in America is sickening.
> did not find sufficient information in the article to determine if this was a management problem or a personnel issue
Dr. Day having put together the framework for IVIG “based on the scientific evidence available at the time” that “saved millions of dollars” such “that Cigna rewarded her with bonuses and stock options” seems to imply she can balance medical efficacy and speed.
Given ProPublica “reproduced the [productivity] scores of 87% of the Cigna doctors listed; the scores of all but one of the rest fell within 1 to 2 percentage points” simply by “multipl[ying] the number of cases…handled by the time Cigna allotted for each type of case, then divid[ing] that total by the hours…worked that month,” and that the productivity score was used to threaten Day with termination, it would seem there is no safety factor being considered.
The risk in a call center is generally that someone won't have their issue fixed and will have to call again tomorrow. I would say the risk in denying treatment to a cancer patient is a bit higher than that, so every patient should be entitled to a review of their case that is not skewed to increase the insurer's profits or rushed to meet some "productivity" metrics. Of course doctors shouldn't spend infinite time on a case, but if the only way to not fall behind is to quickly deny cases, then something is wrong...
I did not explicitly state that call center and cancer treatment were the same. I was under the impression that management practices can provide insight across industries.
There is an obsession that doctors are special and that no rules can apply to them excpet the ones they write themselves. As someone that has had two relatives die due to medical errors, I stopped drinking the cool-aid of God-complex doctors awhile ago.
If a doctor takes too long they shouldn't be reprimanded, the claim should be automatically approved since it's muddy enough to not be a clear and obvious denial.
Health insurance companies can set the maximum time of review to whatever they want, and if the doctor doesn't decide by then, it gets approved. Doctors should also not be evaluated on % approved vs disapproved, since that provides a perverse incentive.
>>I did not find sufficient information in the article to determine if this was a management problem or a personnel issue.
She had been working at Cigna 15 years. If she was a bad employee, either she changed personality mid-life or Cigna never noticed in the previous decade plus.
I have terminated employees with over a decade tenure. Skill decline, complacency, quiet quitting, etc. are all real. This is entirely hypothetical, but "I've worked here for 15 years" is irrelevant in a discussion of how effective you are at your job today.
> I did not find sufficient information in the article to determine if this was a management problem or a personnel issue.
It’s a management problem: she was there for 15 years and had a non-entry level position. Whatever she reported was deliberately created by Cigna’s policies – if not, they would have corrected those policies the first time she reported the problem.
You can see the same pattern with the claim about being unaware of “click to close” or the refusal to clarify when their excuse about the dashboards being misunderstood was challenged. If this wasn’t intentional, someone would correct it the first time they saw patients being denied treatment and they’d easily be able to show, for example, employee training & review policies showing the opposite. We’re not talking about McDonald’s here, it would be very uncontroversial to have a policy that their medical doctors need time to get the best outcome for the patient – if that was actually their goal.
The doctor in the article makes this point a couple of times as well: if the only metrics are "time to close" the particular file or case, that's the only metric they are being judged upon. Cigna clearly decided that they did not want to measure quality, only time-to-close.
Not exactly the same thing, but I recently used a service of telemedecine provided by my employer to get a prescription (not pain medication but still not that casual) and my mic didn't work but instead of waiting ~30 seconds for me to plug in my microphone, they literally took the name of the medication from the chat, closed the call and sent me my prescription with no words being exchanged.
I'm happy I got what I wanted, but at this point what's their service, rubberstamping requests for money?
In most companies, "operations" staff is among their lowest-paid: customer service, cashiers, bank tellers, factory workers, etc. They are used to constant adherence to strict metrics.
Medical care is strange in that the operational staff includes doctors, who will bristle at their expertise and years of schooling culminating into being judged on how many reviews (or appointments) they can churn through.
It's an interesting issue that I sense naturally causes this kind of conflict.
The reason this is so incredibly bad, is that there is no competition in Medical.
Each special interest group carved out a chunk of taxes and Power, and now they seek to expand through taxation or higher prices/lower quality.
I own a clinic and our most maligned incentives are that medicaid patients have basically free care, so they will somehow find themselves getting more visits than someone who has private insurance is paying out of pocket until deductibles are met and is much more cost conscious.
Annecdotaly: I was recovering from hip surgery. Further PT denied even though I was still in pain and didn't recover 100%. I'm 35. Not 75. I expect to get back to hiking 10 miles.
But their denial lead to more pain, and an appeal takes at least 30 days.
There should be a law that says you are guaranteed continued treatment when your appeal is pending. That way they actually have the incentive to do it properly. Now whether that again is a close and deny... yea, not sure what the solution is there.
> The "click and close" practice was common at Cigna, where doctors would quickly deny coverage requests by simply copying and pasting denial language prepared by nurses, rather than thoroughly reviewing each case.
You get fifteen minutes. Per issue. One appointment is fifteen minutes. Can't talk about two issues at one appointment. My wife ran into that the other day.
This article is about “staff doctors” who are board certified doctors but typically do not practice medicine. Instead they are employed by an insurer, sit in a home office and review submissions for coverage to decide whether to approve or deny
One of the worst parts about this for me was that while I was dealing with trying to get my life back together from that kind of injury, I thought I was also going to go bankrupt as well.
In my case, everything did turn out fine because apparently the hospital has an entire department dedicated to dealing with insurance claim denials. This whole system is an absolute joke.