> At one point, court records show, United inaccurately reported to Penn State and the family that McNaughton’s doctor had agreed to lower the doses of his medication. Another time, a doctor paid by United concluded that denying payments for McNaughton’s treatment could put his health at risk, but the company buried his report and did not consider its findings. The insurer did, however, consider a report submitted by a company doctor who rubber-stamped the recommendation of a United nurse to reject paying for the treatment.
> But the records reviewed by ProPublica show that United had another, equally urgent goal in dealing with McNaughton. In emails, officials calculated what McNaughton was costing them to keep his crippling disease at bay and how much they would save if they forced him to undergo a cheaper treatment that had already failed him. As the family pressed the company to back down, first through Penn State and then through a lawsuit, the United officials handling the case bristled.
It’s complicated. On the other hand are fraudsters and private-equity owned hospitals maxing the bill button. If the insurer is lax with payouts, it depletes its capital and could be left insolvent. It’s a scummy system more than a system of scumbags. (To be clear, there are scumbag insurers. But it’s reductive to cite that generally, or designate it as the source of the system’s troubles.)
> Taking 1.2 seconds to review claims means they are without any question "doing something wrong"
Nobody said they aren’t. The point is, given the volume of claims, to do a proper analysis, we’d need a material fraction of doctors doing insurance reviews (instead of seeing patients). So we get a reliance on heuristics.
If you’re lenient, you get targeted by fraudsters. So we get a bias towards denial. (Nobody is getting a material quarterly bonus for denying a few more claims. That nonsense occurs at the level of PBMs and other scale operations.)
If a business can't handle its own scale without negatively affecting its customers, it should probably stop growing. It's the same issue we see with Google accounts being seemingly randomly terminated.
Since that probably won't happen, heuristic usage should at least come with penalties attached, otherwise the incentives are lopsided. If an airline's overbooking heuristics fail and get you bumped, you either get put on another flight and/or receive financial compensation. If an insurance company's "heuristics" fail and deny a legitimate claim, there should be a penalty. If Google terminates your account because of a mistake, they should pay a fine. They shouldn't be allowed to have their cake and eat it too.
> If a business can't handle its own scale without negatively affecting its customers
The scale probably helps. The point is if every billable decision is medically reviewed for more than a few seconds, a material fraction of the healthcare workforce needs to be diverted from patients to review.
There is simply no solution, given the current industrial structure, to avoid some combination of non-expert, high-speed review without making even stupider trade-offs.
> Sounds like we need to replace the structure, given that it's not fit for purpose
We soundly agree. Health insurance, where risk is pooled, makes sense. Health "insurance," where payments are pooled with a bunch of needless intermediation, is unnecessary.
We have a system where doctors and nurses review medications and treatment options for patients. It's called _the medical system_. You know, the one where I can go see my doctor, talk to them about what's going on, and work with them to create a treatment plan that suits my problems and my goals.
Why do we need to bolt on a secondary system that sucks up an untold wealth of time and money?
> Overpayments to insurers administering Medicare Advantage plans now exceed $75 billion a year due to aggressive coding of patients' health conditions and easily-achieved bonus payments tied to quality, researchers with the USC Schaeffer Center for Health Policy & Economics found.
Insurers are not the ones coding, it is the healthcare providers. And the government is the one deciding to pay.
If anything, that would mean more claims should be denied.
Looking at the study, it seems like the government made some erroneous assumptions about who would be taking advantage of the policies the government created, resulting in the extra costs. (Third paragraph of “policy context” section).
> Anthem, a large insurer now called Elevance Health, paid more to doctors who said their patients were sicker. And executives at UnitedHealth Group, the country’s largest insurer, told their workers to mine old medical records for more illnesses — and when they couldn’t find enough, sent them back to try again.
> Each of the strategies — which were described by the Justice Department in lawsuits against the companies — led to diagnoses of serious diseases that might have never existed. But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.
> Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.
As another commenter pointed out, average review time is likely a misleading figure, since the overwhelming majority of decisions are made automatically, using predetermined rules engines.
So nearly all decisions take zero seconds, and a small minority take much longer, leading to an average of 1.2 seconds, when in reality, those claims that are reviewed manually take far more than 1.2 seconds to review.
As the other commenter put it: “(most cases take 0 time) + (a low number of cases take non-zero time) = 1.2 seconds on average.”
United healthcare in 2022 had $324 billion revenue (up from $75 billion in 2007) and profits of $20 billion (both up >15% year on year). There is absolutely no risk that they become insolvent.
Remember, the insurance companies are HAPPY to pay higher prices (in fact they have forced many small ObGyn into more expensive hospital practice) as long as their competitors do too!
Health Insurance companies grow their bottom line by growing the topline cost of healthcare since they're margins are limited.
I think you could make fundamentally the same argument for a great number of the issues in the world today. It's a huge web of banal evils. That doesn't mean that it excuses the behavior of any given cog in that machine though. If we allow blame to be passed on indefinitely because everything is broken then nothing will ever be fixed.
> If we allow blame to be passed on indefinitely because everything is broken then nothing will ever be fixed
Or we can skip scapegoating and fix the system. This is a fundamental lesson from aviation crash analysis: the goal should be a better system, not assigning blame.
I suspect the Germanwings Flight 9525 crash investigation assigns some blame to someone. There's a difference between accidents and deliberate action by motivated actors.
> suspect the Germanwings Flight 9525 crash investigation assigns some blame to someone
Read the synopsis [1].
Blaming the co-pilot would be fruitless. He's dead. There's no chance for retributive justice. And if he's the problem, the problem's solved: he's dead. Nothing more to do. Except, of course, there is. Blaming him is simply an unproductive emotional comfort.
Instead, the report examines the crash's root causes. The "co-pilot’s probable fear of losing his right to fly as a professional pilot if he had reported his decrease in medical fitness to an AME." The
"financial consequences generated by the lack of specific insurance covering the risks of loss of income in case of unfitness to fly." The "lack of clear guidelines" on when conditions need to be reported.
Addressing these factors helps prevent the next problem. Blaming the co-pilot actually does the opposite.
3.2 Causes blames the copilot in its first sentence. They absolutely tackle other failings of the systems and processes for it to get to this point, but there’s blame here, for a deliberate malicious act.
Of course the co-pilot is to blame. But that isn’t where the report starts nor ends. It’s incidental to fixing the problem. Those who choose to focus on blame are indeed propagating the root problems that led to the crash. Same in most other circumstances.
I'm assuming that the drs who end up as insruance claim evaluation drs are the Dr. Murphy's of the world who everyone decided it would be better if they weren't actually practicing medicine.
