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Insurers rely on doctors whose judgments have been criticized by courts

propublica.org

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Re: Insurers rely on doctors whose judgments have been criticized by courts

#21

Post by afthonos »

azalemeth wrote: post #15

I'm not American and grew up (and work) in Western Europe. Everyone is born, and, at some point, will get sick and die. Why does each of these cost tens or hundreds of thousands of dollars? I've heard American doctors at conferences describing their system as "the worst imaginable". Every American I know hates their system. It costs a lot more, has worse outcomes and shovels money and privilege towards the rich. Why…

Everyone hates “the system”, including the people in it. But every party of the system is perfectly fair and reasonable for the people benefitting from it, even if they hate every other part. So every part of the system will have people fighting for it—and if you try to change the whole system, the entire system will fight you. It’s an equilibrium, even if it’s obviously far from optimal.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#22

Post by londons_explore »

azalemeth wrote: post #15

I'm not American and grew up (and work) in Western Europe. Everyone is born, and, at some point, will get sick and die. Why does each of these cost tens or hundreds of thousands of dollars? I've heard American doctors at conferences describing their system as "the worst imaginable". Every American I know hates their system. It costs a lot more, has worse outcomes and shovels money and privilege towards the rich. Why…

> Why don't you change it?

I suspect because nobody can agree on what the new replacement system should look like.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#23

Post by bgnn »

azalemeth wrote: post #15

I'm not American and grew up (and work) in Western Europe. Everyone is born, and, at some point, will get sick and die. Why does each of these cost tens or hundreds of thousands of dollars? I've heard American doctors at conferences describing their system as "the worst imaginable". Every American I know hates their system. It costs a lot more, has worse outcomes and shovels money and privilege towards the rich. Why…

not an American, but it seems to me that the reason is purely ideological. They like a small state, especially the federal government. This would give too much power to the government. The idea of federal government providing care for citizens is not acceptable to people.

Now, weird thing is this doesn't work for the military somehow.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#24

Post by clcaev »

Aunche wrote: post #12

Ironically, I think that the increased attention to the denial of claims plays straight into insurer's hands. Healthcare isn't expensive because insurers don't pay enough to healthcare providers. In fact, it's the opposite. The ACA mandates that at least 80% of premiums must go towards medical expenses. This means that insurers are actually incentivized to overpay for care to maximize the size of their 20% slice. If…

> The ACA mandates that at least 80% of premiums must go towards medical expenses.

This is not precisely accurate. The medical loss ratio (80% for individual plans) can also be spent on quality improvement. There is a blurry line between administrative costs and QI initiatives. For example, a plan-provided coordinator could be QI rather than administrative.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#25

Post by School-Cotton »

azalemeth wrote: post #15

I'm not American and grew up (and work) in Western Europe. Everyone is born, and, at some point, will get sick and die. Why does each of these cost tens or hundreds of thousands of dollars? I've heard American doctors at conferences describing their system as "the worst imaginable". Every American I know hates their system. It costs a lot more, has worse outcomes and shovels money and privilege towards the rich. Why…

> Why don’t you change it?

Who do you think should change it, exactly?

You’re making the classic mistake of assuming the US works like the average European country: a functioning democracy where if something makes sense, politicians will promise it in their manifestos, and then implement it once they get elected.

In reality the US works completely differently and is not a functioning democracy. Making any major reform in any area is, to a first approximation, impossible.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#26

Post by SoftTalker »

franktankbank wrote: post #10
ceejayoz wrote: post #5

Earlier quoted context omitted.

Oddly, it's not currently considered to be. > Having the weight of an MD behind a decision can be powerful, but lawyers and judges who’ve handled these sorts of cases say it can be misleading. Although doctors ultimately determine whether to cut off insurance coverage for a particular treatment, those decisions are generally not considered the practice of medicine and therefore cannot be challenged in a malpractice l…

> Oddly, it's not currently considered to be. Odd indeed. Is it some semantic thing? Denying care is the purest form of not practicing medicine?

Denying care is the default state. It's the basis of the Hippocratic Oath, "First, do no harm." I.e. the determination of whether a treatment is beneficial is made by comparing it to doing nothing.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#27

Post by derektank »

Aunche wrote: post #12

Ironically, I think that the increased attention to the denial of claims plays straight into insurer's hands. Healthcare isn't expensive because insurers don't pay enough to healthcare providers. In fact, it's the opposite. The ACA mandates that at least 80% of premiums must go towards medical expenses. This means that insurers are actually incentivized to overpay for care to maximize the size of their 20% slice. If…

You can negotiate all you want but ultimately the productivity improvements have to come from providers (hospitals, pharmaceutical companies) if you want to lower costs. There are ways to make insurers better agents (one simple step would be to make their customers the actual patients, rather than the employers of patients) but I'm not sure how much power they actually have to keep costs low

Re: Insurers rely on doctors whose judgments have been criticized by courts

#28

Post by cjbgkagh »

bgnn wrote: post #23
azalemeth wrote: post #15

I'm not American and grew up (and work) in Western Europe. Everyone is born, and, at some point, will get sick and die. Why does each of these cost tens or hundreds of thousands of dollars? I've heard American doctors at conferences describing their system as "the worst imaginable". Every American I know hates their system. It costs a lot more, has worse outcomes and shovels money and privilege towards the rich. Why…

not an American, but it seems to me that the reason is purely ideological. They like a small state, especially the federal government. This would give too much power to the government. The idea of federal government providing care for citizens is not acceptable to people. Now, weird thing is this doesn't work for the military somehow.

The US should not be used as an example of a small government. Some people in the US may profess to wanting a small government, but they definitely don’t have one.

Haven’t run the numbers but I would suspect the US government is the largest government in human history.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#29

Post by derektank »

Spivak wrote: post #18
Aunche wrote: post #12

Ironically, I think that the increased attention to the denial of claims plays straight into insurer's hands. Healthcare isn't expensive because insurers don't pay enough to healthcare providers. In fact, it's the opposite. The ACA mandates that at least 80% of premiums must go towards medical expenses. This means that insurers are actually incentivized to overpay for care to maximize the size of their 20% slice. If…

I mean I guess but it would still be a huge improvement in real people's lives if the burden was flipped and insurance companies had to prove fraud to deny a claim. I think we want the opposite when it comes to negotiations and want instance companies to all have to pay out the cash price. The first step to making it possible to not need insurance for most care is making everyone pay the same.

It would be an improvement until premiums increased and/or there was a shortage of services, likely in the form of longer wait times. That would be a net benefit for some patients and a net loss for others.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#30

Post by asdf6969 »

azalemeth wrote: post #15

I'm not American and grew up (and work) in Western Europe. Everyone is born, and, at some point, will get sick and die. Why does each of these cost tens or hundreds of thousands of dollars? I've heard American doctors at conferences describing their system as "the worst imaginable". Every American I know hates their system. It costs a lot more, has worse outcomes and shovels money and privilege towards the rich. Why…

> Why don't you change it?

There is no general “you” with agency. The few people who have the ability to change it have no incentive to do that.

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