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UnitedHealth's Effort to Deny Coverage for a Patient's Care (2023)

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Re: UnitedHealth's Effort to Deny Coverage for a Patient's Care (2023)

#351

Post by alp1n3_eth »

mgraczyk wrote: post #204
maxerickson wrote: post #170

Earlier quoted context omitted.

It seems the insurance company was happy to pay for treatment that wouldn't work though (the approved treatment had already been tried), they denied a treatment that was working.

One costs $60/year, the other is over $2M/year and not tested and not widely used outside the US

Remicade and Entyvio have both been heavily tested.

Remicade is available in (at least) these countries: - US - Japan - Europe - Turkey - Russia

Entyvio: - US - Europe - Canada - Japan - Australia

Biologics are the first line of defense for anything over mild IBD. The only effective treatment for above moderate that isn't a combination of other meds is Rinvoq. The small dose items like Azith and Pred are just for flare management, and aren't maintenance medications.

Re: UnitedHealth's Effort to Deny Coverage for a Patient's Care (2023)

#352

Post by alp1n3_eth »

mgraczyk wrote: post #223
maronato wrote: post #219

Earlier quoted context omitted.

If the doctor prescribed it, it shouldn’t be the insurance company’s decision to deny it. That’s how it works in most countries. Too bad it’s expensive, but that’s why people pay a lot more than $60/yr for insurance.

No, that's not how it works. Which countries work that way? Where can a doctor prescribe untested drugs and have it paid for?

The US, Canada, England, and most of Europe are beginning to embrace the use of dual biologics in Crohns disease. The FDA approved levels of a singular biological may have issues reigning in out-of-control cases of severe Crohns, and there have been tons of trials run in multiple university hospitals over the last 10 years showing that the dual biological combo can help in those instances.

That's exactly why his doctor wanted to do it, because it had worked in the past. This wasn't some insane lab experiment done by a fresh grad gastro doctor.

Re: UnitedHealth's Effort to Deny Coverage for a Patient's Care (2023)

#353

Post by alp1n3_eth »

mgraczyk wrote: post #211
ineptech wrote: post #208

Earlier quoted context omitted.

The point of single payer is to tell doctors and patients unambiguously how much they can spend. The free market puts the insurer(s), the provider(s), and the patient in a competition to see who can stick whom with the bill. The savings come more from not doing that than from the insurer's profit margin.

NHS currently does not recommend the treatment that this guy was receiving (as far as I could find): https://eastkentformulary.nhs.uk/media/1868/pr-2022-25-dual-...

The report you linked was from a single healthcare organization in the UK, not the entire NHS. Also, it mainly only covers their own cases and requests, they only treated 7,000 IBD patients in the specified year.

It does state that there was a request received, and it would fund it. Dual biologics usually isn't considered until all the regular biologics have been tried by themselves. You don't seem to understand that biologics and surgery are literally the only things to combat this disease, and surgery can end up just being a bandaid:

"The only formulary identified with a policy on dual biological therapy for IBD was South-East London which fund dual biologic therapy for severe, refractory CD in certain circumstances."

Re: UnitedHealth's Effort to Deny Coverage for a Patient's Care (2023)

#354

Post by alp1n3_eth »

mgraczyk wrote: post #248
uhtred wrote: post #245

Earlier quoted context omitted.

Did you read the article? The drugs did work, but only at the high doses prescribed. In fact I am certain you did not read it, as no decent person could read it and say "but it's crazy to me that people can read this and come away thinking the insurance companies are the bad guys."

I read it, the drugs may have worked but it's possible that one or both were not necessary, or that some other change caused it. The relevant question is bigger than "did it work", it's "was the likely causal improvement enough to justify the cost" These drug combinations are mostly not approved outside the US because of a lack of data

It literally says in the article: "McNaughton had tried individual biologics".

This means he most likely had already tried them alone. Remicade especially, as it's essentially been the most popular biologic (aside from humira) for the last 15 years. Do you need to see his full medical history before you have a little empathy? As a person who isn't a gastro doctor I'm sure you'll fully understand it.

Re: UnitedHealth's Effort to Deny Coverage for a Patient's Care (2023)

#355

Post by xracy »

breadwinner wrote: post #138

Insurance companies are hardly the only ones at fault here. Hospitals and Pharma companies are guilty of price gouging [1]. When insurance pays hospitals hike up the prices. When the patient pays (such as for cosmetic or plastic surgery) the prices charged by hospitals and doctors are more reasonable. [1] https://www.dolthub.com/blog/2022-05-31-hospital-price-gougi...

The Health Industry has this lovely 3-part structural defense they run behind every time that someone questions why the health industry costs so much.

Step 1: "The other 2 entities in the health industry are to blame!" Step 2: Profit, because no one is going to succeed a battle here that knocks down only one of these.

Every time, this is the response. In practice they are all to blame, and they could all be working to make this better. But none of them are incentivized to act in anything but their own self-interest. Insurance is definitely to blame, as are hospitals and pharmaceutical manufacturers. There's a reason the companies that ostensibly "save people's lives" are some of the most hated in the US.

I hope that Insurance companies have an epiphany from the public sentiment about this, that they're messing this up spectacularly. But honestly, they seem more likely to wait for this to blow over.

Re: UnitedHealth's Effort to Deny Coverage for a Patient's Care (2023)

#356

Post by Dalewyn »

cogman10 wrote: post #126
Dalewyn wrote: post #11

Earlier quoted context omitted.

>But also horrifying that treatment costs so much. My mother underwent chemotherapy for her cancer. According to the statements from her insurance company, each round of chemotherapy cost as much as a new luxury car before hospital vs. insurance negotiations. Yeah. The value of health insurance isn't just the offloading of expenses, it's also their power to tell hospitals to get fucking bent with ludicrous bills.

The health industry is what's wrong with a captured market and few players. Every party is trying to extract maximum value for minimum input. That leads hospitals to 1000x every treatment price so when insurance companies come to negotiate they can negotiate down to 100x. It causes hospitals to understaff because is cheaper to pay for legal staff to handle malpractice claims than it is to not work your nurses and doc…

>An even better idea is simply nationalizing medicine, top to bottom. That's unlikely to happen, but would result in the biggest drop in healthcare costs.

In the immortal words of President Ronald Reagan: "I'm from the government and I'm here to help."

Which is to say, no. Obviously this is a long-brewing problem in need of a solution, but more government is not it.

Re: UnitedHealth's Effort to Deny Coverage for a Patient's Care (2023)

#357

Post by cogman10 »

Dalewyn wrote: post #356
cogman10 wrote: post #126

Earlier quoted context omitted.

The health industry is what's wrong with a captured market and few players. Every party is trying to extract maximum value for minimum input. That leads hospitals to 1000x every treatment price so when insurance companies come to negotiate they can negotiate down to 100x. It causes hospitals to understaff because is cheaper to pay for legal staff to handle malpractice claims than it is to not work your nurses and doc…

>An even better idea is simply nationalizing medicine, top to bottom. That's unlikely to happen, but would result in the biggest drop in healthcare costs. In the immortal words of President Ronald Reagan: "I'm from the government and I'm here to help." Which is to say, no. Obviously this is a long-brewing problem in need of a solution, but more government is not it.

Destruction of government is exactly what got us into this mess in the first place. Reagan, Clinton, and Obama are each to blame for the current state of American healthcare.

Every semi functioning healthcare system has more government involvement than what the US does.

Reagan was wrong.

Re: UnitedHealth's Effort to Deny Coverage for a Patient's Care (2023)

#358

Post by lambda »

samatman wrote: post #96
77pt77 wrote: post #32

Earlier quoted context omitted.

And all it takes is one juror being inflexible.

That's all it takes for a hung jury, yes. In which case the prosecution will have plenty of grounds to screen for that in the next trial, that next trial will happen, and then the guy gets convicted of first degree murder. Presuming he's found in the first place. There's no world in which all twelve jurors vote not guilty if the defendant is demonstrated to be the assassin beyond reasonable doubt. That simply won't h…

Kyle Rittenhouse and Daniel Perry are both walking free after unambiguously murdering people in broad daylight.

You're right, I do find it less likely that the murderer of a CEO would get the same kind of treatment as murderers of civil rights protesters, but there are examples in recent history of people walking free despite unambiguously murdering people in broad daylight for political reasons.

Re: UnitedHealth's Effort to Deny Coverage for a Patient's Care (2023)

#359

Post by breadwinner »

toastercat wrote: post #346
breadwinner wrote: post #305

Earlier quoted context omitted.

> Suggesting that the average person should be able to make medical decisions and override their health care provider’s recommendation is ridiculous. The situation is similar to taking your out-of-warranty car to a dealer for repairs. Sometimes, you may suspect they’re not being completely honest with you. What do you do in that case? You get a second opinion before agreeing to a costly repair.

I'm willing to take a risk there because if my car craps out, I'll buy another. Wish I can say the same about health. If the doctor who has my entire medical history recommends x procedure, yes I'm not going to risk potentially having irreversible damage to my body.

> If the doctor who has my entire medical history

You think your primary care physician is the one that recommends surgery, and not a specialist?

Re: UnitedHealth's Effort to Deny Coverage for a Patient's Care (2023)

#360

Post by breadwinner »

voisin wrote: post #326
breadwinner wrote: post #305

Earlier quoted context omitted.

> Suggesting that the average person should be able to make medical decisions and override their health care provider’s recommendation is ridiculous. The situation is similar to taking your out-of-warranty car to a dealer for repairs. Sometimes, you may suspect they’re not being completely honest with you. What do you do in that case? You get a second opinion before agreeing to a costly repair.

Sure, and that’s possible (at significant added cost) in a portion of cases. But not all - you might be on an operating table or in the middle of a psychiatric event, etc etc, where time does not permit second opinions, and if the system is set up to “gotcha” as a baseline, then only the most minor, time insensitive, situations will receive fair pricing.

> if the system is set up to “gotcha” as a baseline

This is what we have to change. When physicians and hospitals know that patients are scrutinizing care plans they will find a new fairer baseline. That cultural change will subsume older practices.

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