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Insurers rely on doctors whose judgments have been criticized by courts

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

#221

Post by JusticeJuice »

giantg2 wrote: post #155
JusticeJuice wrote: post #146

Earlier quoted context omitted.

I can't speak for Denmark, but I can speak for New Zealand, which has similar spend, and similar results (compared to the US). I wrote a thesis about healthcare software in uni, but as part of that I interviewed a bunch of people across the NZ healthcare industry, and learnt a lot about it. A big efficency for NZ is 'pharmac', which is essentially a country-wide medicine subsidizer, and supplier. It's a government en…

Thanks for the detailed response! In the US, Medicare is doing negotiation for meds for those in the program. There is talk about expanding that bargaining. The ACA was trying to get people into primary care early. I'm not sure how big of an impact that made. At least in my experience, the primary care is hard to get on short notice in my area - takes 1-4 weeks depending on different things. One big seems to be that…

The funding for primary care comes from a bunch of places in NZ, but most of it comes from the government. Most people in NZ don't have private healthcare insurance, it's just not needed.

The way it works is patients 'enroll' with a doctors office, and then the clinic gets funding based on that patient population (how many patients, what sort of patients, etc). GPs still set their own fees ontop of that, but it's usually not much (like $20 USD), as they're competitive.

There isn't really an incentive to maximize the number of visits, the goal is to maintain a good patient population, who's satisfied with your services.

The average book size for an individual doctor is about 1000 people (might have gone up a bit by now). But I found that number quite interesting, as it lets you frame the job of a doctor quite differently - their job isn't just to take appointments as they come, their job is to keep about 1k people healthy. It lets you think about how else that problem could be solved.

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

#222

Post by staticman2 »

DangitBobby wrote: post #179
SoftTalker wrote: post #125

Earlier quoted context omitted.

These insurance doctors are not really evaluating case particulars. They are not second-guessing the diagnosis, they are looking at whether the proposed treatment is the "standard of care" for the diagnosis, and that customary less expensive/invasive treatments have been exhausted. Medicare and any other potential "single payer" government plan would do this also because sadly fraud by clinicians does exist. For exam…

This is all just semantics. Arguably, the arbiter of what is "medically necessary" is practicing medicine. They have chosen to intercede in your care, and they should be liable for the decisions that they make leading to your health outcomes. The legal system could just as easily have seen that the determination of which procedures are "medically necessary" is indeed part of medicine itself. It's a miracle of delusio…

If you were designing a legal system you probably wouldn't want for profit insurance companies to decide who gets to determine if a patient needs treatment, due to the obvious conflict of interest.

But that doesn't mean applying the same "malpractice" framework to the people deciding what's covered under the program is necessarily the right approach either.

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

#223

Post by nozzlegear »

lostlogin wrote: post #187
kstrauser wrote: post #91

Earlier quoted context omitted.

As an American watching Brexit and other self-owns pouring out of the UK, I’m not completely sold on this. If our system is insane — and it is — I’d say it’s a family disorder we inherited.

> I’d say it’s a family disorder we inherited. A pre-existing condition? You’re not covered.

Funny, but pre-existing conditions are covered by default under the ACA.

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

#224

Post by [deleted] »

School-Cotton wrote: post #25
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 refor…

[deleted]

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

#225

Post by HDThoreaun »

rqtwteye wrote: post #108

Question for the techies here: Due to lack of political will and deep-seated corruption I believe a lot of issues in the US system are almost unfixable but I always wonder why it has to be so convoluted (besides being hyper-expensive). Why can't the insurers have an app where the patient (or the provider) can type in the procedure codes they are planning to use and then the insurer returns the co-pay, co-insurance an…

Trump actually forced hospitals to release their prices during his first admin. There are a few problems. First, quite a few hospitals refused and just took the fine instead. More importantly though, theres no standardization of codes. Your procedure might sound routine but there are usually quite a few different things being billed and there usually isnt a one to on relations hip between codes at different providers. Even if there was standardization a lot of the time unforeseen stuff comes up so you cant just get an out the door price before the procedure.

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

#226

Post by grumpy_coder »

cool_dude85 wrote: post #57
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…

Nobody, not this article or any other reasonable person, thinks that claim denial is the reason healthcare is expensive. Rather, they think it is fundamentally fraudulent that someone can pay their premiums, etc. and then when they need treatment, be arbitrarily denied by an in-house doctor employed by their insurer to deny treatment. This is a story of the fraud in the health insurance industry, not the racket part…

It's also important to realize claim denial isn't the same for all customers. When I was classed as an executive at a large blue chip company, my claims were approved quickly and easily at the company specific hotline. With the same provider, making the same claims, they are now partially denied initially and it requires long phone calls to get them to admit they should be covered and often it just isn't worth the hassle.

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

#227

Post by SoftTalker »

DangitBobby wrote: post #179
SoftTalker wrote: post #125

Earlier quoted context omitted.

These insurance doctors are not really evaluating case particulars. They are not second-guessing the diagnosis, they are looking at whether the proposed treatment is the "standard of care" for the diagnosis, and that customary less expensive/invasive treatments have been exhausted. Medicare and any other potential "single payer" government plan would do this also because sadly fraud by clinicians does exist. For exam…

This is all just semantics. Arguably, the arbiter of what is "medically necessary" is practicing medicine. They have chosen to intercede in your care, and they should be liable for the decisions that they make leading to your health outcomes. The legal system could just as easily have seen that the determination of which procedures are "medically necessary" is indeed part of medicine itself. It's a miracle of delusio…

Unfortunately there are many examples of fraud on the part of practicing doctors. The insurance companies (whether private or government) can't just pay for whatever the doctors say they want to do.

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

#228

Post by ClumsyPilot »

jack_h wrote: post #219
ClumsyPilot wrote: post #144

Earlier quoted context omitted.

> if demand is greater than supply you must ration the supply somehow. This is logic of post-2008 fail-capitalism instead of 1970’s and China’s aspirational, problem solving capitalism. You don’t address shortages of healthcare, housing or food with an elegant and fair system to decide who starves and dies. You expand supply to make sure no one has to. You examine supply chain and figure out the bottlenecks. For exam…

> This is logic of post-2008 fail-capitalism instead of 1970’s and China’s aspirational, problem solving capitalism. No, this is reality. It does not matter if you're working under capitalism, socialism, communism, mercantilism, or some as yet unknown system since economics is the “study of the allocation of scarce resources which have alternative uses.” You cannot deny resource scarcity anymore than you can deny nat…

> expanding supply of healthcare you are taking resources away from somewhere else

This is totally wrong. It takes 5 years to get planning approval in UK, it takes 1 year in France. Tunnelling costs are 3x higher in Uk than in europe. Building a tram takes 3 times less. Lower Thames crossing has been in planning for 15 years and we have spent 300 million on lawyers, more than Norway has spent on building an actual tonnel of comparable size.

If UK has economy of France but infrastructure worse than Poland, maybe we are doing something dumb.

If USA has expensive insulin and poor Bulgaria has cheap insulin and it works just as well, maybe you are doing something dumb.

You can expand supply of housing in UK without damaging other sectors of economy: introduce statutory right to add an extra story on your op if your house. Remove green belt protections, introduce 1 month limit on review of any planning application, after which it is automatically granted if valid objection is not found.

Introduce a single planning portal and standardise software for planning applications across the whole country instead of every Shropshire and Wolverhampton having their own practices. Purchase perpetual license for such software as a country and make it freely available to every citizen.

Introduce favourable mortgages for self-building.

Produce detailed, pre-approved designs for standardised homes and bulk purchase materials or modular components for them.

Organise mass production of high-speed trams and make them available to local government with favourable, pre approved finance terms, so that larger areas of housing are accessible by high speed transport.

All of the above is implemented in different countries around the world, whether it’s France, China or someone else.

References:

https://www.britainremade.co.uk/building_transport_in_britai...

https://www.samdumitriu.com/p/britains-infrastructure-is-too...

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

#229

Post by charrondev »

lostlogin wrote: post #187
kstrauser wrote: post #91

Earlier quoted context omitted.

As an American watching Brexit and other self-owns pouring out of the UK, I’m not completely sold on this. If our system is insane — and it is — I’d say it’s a family disorder we inherited.

> I’d say it’s a family disorder we inherited. A pre-existing condition? You’re not covered.

In the US you are.

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

#230

Post by ClumsyPilot »

liontwist wrote: post #169
ClumsyPilot wrote: post #144

Earlier quoted context omitted.

> if demand is greater than supply you must ration the supply somehow. This is logic of post-2008 fail-capitalism instead of 1970’s and China’s aspirational, problem solving capitalism. You don’t address shortages of healthcare, housing or food with an elegant and fair system to decide who starves and dies. You expand supply to make sure no one has to. You examine supply chain and figure out the bottlenecks. For exam…

> who starves and dies. It’s not a binary decision. Healthcare is a gradient of treatment options and outcomes. The concept you are missing is called economizing which includes substituting services, adjusting time preferences, sharing, expanding network of providers, etc. > post-2008 fail-capitalism You mean the one where government agencies were taking the risk of bad mortgages from sellers? We don’t have anything…

Well we did have TrueCapitalism in the FreeBanking era where all banks could issue their own currency and they would go bust every Tuesday.

https://en.wikipedia.org/wiki/Free_banking

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