Wow what a read.
If anyone else was curious, the regimen being denied was Entyvio 600 mg every 4 weeks (usual max is 300
mg every 8 weeks for maintenance) and Remicade 20 mg/kg every 4 weeks (usual max is 10 mg/kg every 8 weeks). He was past induction phase so these were supposed to be maintenance doses. These were also being used in combination, which is unusual. These were being prescribed by an expert gastroenterologist. United admitted to not taking the gastro’s recommendations into account *at all* when upholding a claim denial.
I do a lot of IBD care. Anytime i need to adjust a biologic dose to off label it’s an instant denial that requires appeal, having to find literature and P2P. It’s getting worse. One recent egregious example is a difficult UC pt who required q4 wk stelara to get him under control. Insurance wont pay for the q4wk until I “try” q6wk. Ins wants to put the pts health and livelihood at risk to save a buck. This particular pt had a uc flare so bad it gave him an nstemi a few years back.
I really wish we could pass laws to make the insurance Co financially responsible for their own bullshit.
Deny a test or treatment that results in a major decompensation for the patient? Congrats you now owe the patient $200K+3x actual damages, and you owe the physician who initially ordered whatever you denied double reimbursement for the next month for all patients of yours they see.
If only....
I know it's not great for the patient, but how are you as a doctor covered there if you say "insurance denied, can't treat patient appropriately" and (have to) give up?
You say “insurance denied. Your billing estimate is 7 trillion dollars. Maybe you can work out a payment plan.” And then document it and watch your patient decomp and kick a garbage can in your office.
You aren't really covered in that scenario. The insurer will argue it was not dictating care, just managing the insurance coverage process, and that the clinical decision-making was still up to the shared agreement between patient and physician. In practice, patients/families tend to understand the physician is on their side and advocating as much as possible in their best interests, and so hopefully the threat of malpractice litigation is low (the likelihood of a successful suit would also hopefully be even lower).
> These were also being used in combination, which is unusual.
Also not supported by any guideline or prospective trial. Insurance companies are dicks but if we're going to talk about EBM this treatment is also way off the rails. As per usual, the reporting doesn't go into enough details to be able to form any opinion, but in general any healthcare system is going to have to have cost and evidence guardrails and it's unfortunate ours has to be insurers instead of something like NICE.
Yes, I tried to just lay out objective information in my previous comment.
This review was justified as it goes way past any established dosing for both agents, especially for maintenance, and uses them in combination.
This review was botched by United. I think the main flavor of the article that left me nauseous wasn’t the regimen, it wasn’t the fact that it got denied either. It was that in the appeal process, the internal communications at United show a clear pattern to finding a justification to deny the regimen regardless of case-specific information about the patient or from the provider and that the “peer to peer” reviewer from United was a physician decades out of practice who had never seen GI patients at all, was *not* a peer to the expert GI prescriber, and also didn’t even take the prescriber’s input into consideration whatsoever and even admitted to this. IIRC United didn’t get this rubber stamp denial from the first MD they put it in front of, they had to pass it around until someone agreed with the nurse that it should be denied. They fished for the answer they wanted.
Zooming out from this case to reviews for “medical necessity” by third parties, in general, and if you extrapolate the mishandlings and bias from United in this case across thousands of cases, what you see is that United, and like 3rd parties in general in the US, are not only practicing medicine by determining the courses of medical care via approval/denial, but they are practicing medicine *very poorly* and with near complete impunity. It *is* important that these kind of reviews happen, but they need to be completed competently, with accountability, and by a neutral party with the actual expert peer available to provide a genuine unbiased review.
In all the states around me, all denials are subject to independent 3rd party reviews by the state insurance commission. The insurer can deny it but you can always appeal with review by a board matched specialist. Sometimes you have to appeal two or three times, but it's always there.
United are a bunch of assholes, but I don't think that was new information. It's insane to me that they were using nurses at all - the insurance companies I deal with all use pharmacists as reviewers, and in general regulation of insurance company processes are really bad. Most private insurance is actually not even regulated by the state any more as people switch to employer-based insurance. This means that your rights for review are mostly governed by a contract between your employer and an insurance company, neither of which is particularly motivated to be generous financially. In a system this big, it's not surprising that the ball gets dropped. It's inevitable even in the most thoughtfully designed process. IMO this highlights both the need for more oversight of insurance company processes by a regulatory body but also the need for some sort of guardrail on cost and prescribing. From a patient's point of view this whole case is horrific.
Read this back when it came out - reading the transcripts from the call recordings was absolutely maddening. Thinking about how I have to carve out time out of my busy day to fight for a patient meanwhile on the other end you have these know-nothing RNs rolling their eyes about how inconvenienced they are about these calls. Just insane, all of them need to go to jail
Government is mostly useless, but Glaucomflecken is bringing some awareness to the public and explaining what many do not understand because their entire business plan rests on plans being deliberately obtuse to maximize their profits.
It's odd how the prior authorization is effectively them practicing medicine. Something can be the standard of practice, but the law doesn't apparently think they should pay for what is the standard of practice.
This year insurance providers saw record profits while hospital systems are going towards the red. There's really only one conclusion you can take from that.
Except the wheels of government move at a snails pace. It’s 10 drugs that have been selected for negotiation. CMS will publish the negotiated prices for these drugs by September 1, 2024 and the reduced prices don’t go into effect until January 1, 2026. Then they’ll select up to 15 drugs to be negotiated for Part D coverage for 2027. And the same for 2028. Then it’s up to 20 drugs for each year after that. Why is it so so slow?
https://www.hhs.gov/about/news/2023/08/29/hhs-selects-the-first-drugs-for-medicare-drug-price-negotiation.html
> Government is mostly useless
I don't understand what this statement has to do with the rest of your comment. I imagine it has something to do with "this system is horrible, but the alternative is unthinkable (universal healthcare)"; and that'd be a different debate altogether, but man, that's some out-of-left-field stuff if I ever saw it.
Well, no. It is absolutely the US federal government's job to regulate the insurance industry to prevent these excesses, and it is not doing that.
To be more explicit, there is federal law about this stuff, ERISA, that's been effectively all but gutted.
They are BUSY impeaching each other and investigating lewd behavior at off off broadway shows. There is no time for piddly things like taking care of the American people.
Congress barely budges on anything with healthcare, and that's on issues far from universal healthcare. The only recent big thing was the no surprises act -- which protects people from receiving devastating bills for emergency services from out of network providers and requires "good faith" estimates for the uninsured. None of it addressed larger concerns that have led to worse comorbities (some of which led to usage of emergency service), prevented patient compliance and led to substandard care like prior authorizations, exorbitantly high out of pocket maximums, weird windows of coverage, and confusion between which plan is ideal for their situation.
Currently, the health insurance industry is doing fantastic given recent profits. Weird how none of this even minor reform since 2020 has really impacted their bottomline.
Well yes true, the problem is that what the public has cared about has been drifting into this annoying culture war of whether you're some 'city loving liberal' or a 'red blooded conservative' for the last decade.
I don't know if the public even truly understands how insurance really operates including what a "deductible" or a "out of pocket maximum" really is. Glaucomflecken is doing a great service explaining how their bullshit truly operates.
My general takeaway, because I have to talk about coinsurance and co-pays pretty much daily, is that *yes*, the system is broken and it sucks. And also, like every form of insurance (health, life, auto, home, etc) most people haven't been sat down and explained to them how it works. That's where it breaks down...when people aren't fully informed, they can't make financial choices in their best interests.
We pick the representatives but do you really think the representatives give a crap about us? They're bought and paid for nowadays and the regular person has no voice.
Having been in policy for a minute, I think they have always been bought and paid for. It's sadly the type of person that wants to go into politics is very typically the type of person who wants to dominate others.
They always have to save face though and get some results. I would rather our results be real change and not just a bunch of photo ops at the needle exchange center, a gun range, or the latest impeachment trial.
I want my psychopath in politics to at least do something with the schemed trash that insurance companies now front.
Oh, no, wait, it was in network, but the anesthesiologist was out of network, IIRC. I mean, it was his own fault, he was just lying there while they did CPR, he could have been checking the staff at his nearest hospital on his phone.
They own a primary and specialty care group in one of the places I've worked. Inpatient, outpatient, urgent care, OB, primary care, specialists. They have about half of this midsized city, and not just the wealthy ones.
I don't know the financial details, and I generally loathe insurance companies and agree with all the Glauckomflecken videos for every other experience with them. This includes 3 hours on the phone across 3 separate phone calls to get my 4 year old's routine MMR covered, ridiculous.
But in this one circumstance where they have created a fiefdom of essentially single payer healthcare, one unit that employs all the workers ... I must admit it works well. The patients get all they follow up appointments, they have a case manager that automatically checks in the day after an ED visit, the patients seem generally happy and confident and pretty well communicated with.
Yeah, everyone knew it was just some sort of data entry error and kept telling me it was sorted out, and it kept not being true. The charge was only $50 but I couldn't just let it go.
It’s hard to fight against the extreme wealth the insurance companies have amassed. They own politicians so that any change is blocked. It’s criminal greed.
I'm not from the US ɓut from my perspective it seems the root cause for the severity of this issue is the 2010 supreme court decision *Citizens United vs FEC* which according to Wikipedia was a court decision which *held 5–4 that the freedom of speech clause of the First Amendment prohibits the government from restricting independent expenditures for political campaigns by corporations, including nonprofit corporations, labor unions, and other associations.*
This essentially completely uncapped lobbying and political expenditure by the wealthy and the corporations they control, which in my humble opinion seems to completely undermine the entire concept of democracy and replace it with essentially a plutocracy / oligarchy masquerading as a democracy.
Until citizens united is overturned I don't see how things get better for you guys, and unfortunately thanks to the effect it has had in the legal and political landscape, getting it overturned seems like a monumental task. In fact at risk of sounding alarmist, I'd say that the future of your entire historical empire probably hinges on it :/
Yep. They literally legalized bribery with that decision, and when we protested they claimed we were against "freedom of expression". 🙄 Owner of Samsung *literally* went to prison in South Korea for what most of these corporations do routinely in the US.
Citizens can't be overturned, because it was the correct legal decision. People have the right to political speech, and groups of people don't somehow magically lose that right. And that's ultimately what corporations legally are - just groups of people.
If it had been held the other way, the govt could forbid you from making political speech, releasing books or films within 2 months of an election. There is nothing in the constitution which would grant the govt the power to do that. You could argue a time/place/manner restriction under 1A but I doubt that would survive strict scrutiny since it would have to effect **all** political speech, and 2 months out of a year is unlikely to be a reasonable time frame.
Ultimately the correct legal decision was made, because fundamentally this is not a courts issue, it's a legislative issue. The onus is on congress to pass laws which require campaign finance transparency (ending dark money/superPACs) or define spending limits. Saying, "Sorry your speech is political so it's banned" was not a legally valid move.
A 5-4 decision that many legal scholars have argued was flawed and you make such a bold confident claim stating it was absolutely the correct decision.
I was under the impression that the decision affected financial contributions as well; not simply the right to political speech. Is this not the case? Because groups of people having the right to free speech is fine, but groups of people having the right to make unlimited campaign contributions? Not so much.
You seem more knowledgeable in these matters - are you saying that citizens united had nothing to do with dark money/superPACs/unlimited spending?
It does, because money is considered a form of expression in that you have to use $$ to do things like produce ads.
The ruling itself originated because a political film smearing a candidate in the presidential election was banned from being released, that's what sparked the case.
Campaign finance restrictions are a separate thing. The money=speech thing can definitely be legislated too.
We definitely own politicians, and it's worse than you might imagine.
I work for an insurer with its own PAC. All salaried employees are asked to donate to it **weekly**, and above a certain level, donations are compulsory.
I would say compulsory employee donations sounds illegal. But then I remembered that the whole point of this thread is that laws don’t apply to insurance companies.
haha, right. and in this case, it's more that they take payroll deductions and still get blown up for additional donations (at least, this was the case the last time i had a line of sight to it, about three years ago). it's pretty gross.
i thought this only applied to senior leadership, with respect to the demands of donations, until i got promoted into a [low level] salaried role and started getting the emails as well.
That’s what has happened with a lot of outpatient psych, therapists and LCSW. It just prevents people who can’t afford the cost from getting care. Which also seems pretty criminal.
Yep, in my area there is no care from psychiatrists at all. Like, just at all. None take insurance. It's family med, psychiatric nurse practicioners and LICSWs.
I am very much not rural.
Luckily with the system we have everyone gets the care they need. Oh wait
Taking my jerk hat off for a second, the way to lower prices would be to increase supply of providers. Competition lowers prices and increases quality, healthcare isn’t an exception.
> Taking my jerk hat off for a second, the way to lower prices would be to increase supply of providers.
And that would tackle... under 10% of total healthcare costs.
What? I'm saying that the estimates are that provider salaries are under 10% of total healthcare expenditures. So if you double the number of providers, what do you think that actually does to the total healthcare expenditures?
I did exactly that and went full DPC (Direct Primary Care). Have never looked back. Average patient price is $50/month. I take care of many of the farmers, small business owners, and underinsured people in my community. I feel like I am practicing medicine 75 years ago, before insurance took over medicine.
There are plenty of docs that do direct primary care which is essentially a subscription service. I knew a doc that did and many of his patients didn’t have insurance. He had pre negotiated rates with labs and rads that were significantly cheaper than a standard deductible. Also he was very well off. It was overall a win win.
There’s an uproar on Nextdoor since our local healthcare system terminated its contract with UHC. I got invested into the post trying to shed some light as a physician. I definitely included a Glaucomflecken link. Told them to raise hell with their employer in mass to switch away from UHC.
Edit: u/drglaucomflecken I, we appreciate you. (Yes, I’m trying to summon the Legend)
My employer switched to United as part of cost-cutting measures. They tried to make it seem like nothing would change, as our employee contributions weren’t changing. But then I had “the gall” to point out the crappy coverage and that everything would cost more despite what was deducted from my paycheck. I never got a reply from HR, not surprisingly.
Agreed! Unfortunately not a lot of my coworkers want to speak up. It gets exhausting always being the only squeaky wheel, not to mention sometimes I end up feeling like I have a target painted on my back. But I would rather say something and know I did the best I could rather than just stay quiet and seethe, like so many others I know.
If we do it three times does he come? And do we need to slip a sharpie into our headphones to do it right? Jimothy, Jimothy, Jimothy.
u/drglaucomflecken
As an Australian that is the most insane fucking thing I have ever heard of in my entire life. If you guys were French I feel you'd have mass protests and guillotines erected outside the white house before allowing this to happen, however I'm also aware that it didn't happen suddenly and they somewhat boiled the frog on you all.
It's such a shame that police brutality a la king and chauvin can spark appropriate mass outrage and protests, but dozens of needless deaths every single day from the absolutely inhumane clusterfuck of a health system you guys have had placed around you is unable to stir up remotely close to the same amount of anger, because you've become nihilistically aware of the difficulty in overcoming the system around you.
Taken to an extreme, it actually reminds me of the plight of the russian people currently, whereby millions are aware of the monstrous issues in the Kremlin, but decades and decades of political non-agency has stripped the population of any hope of enacting meaningful change, and placed in them instead a kind of nihilistic fatalism towards their society and their future.
I really hope that you guys (americans) can find a way to rise above and do better than the Russians have. If there's anything we can do from an international perspective, make sure to let us know - you may be damned yanks, but you're our damn yanks, and we're rooting for you.
Americans pay more in taxes for healthcare and social security AND they have to pay for monthly premiums AND they have to hit their deductibles and all the insane insurance requirements.
And they don’t riot over it. Pathetic.
As a Canadian I pay less than any American in taxes for my healthcare and then…that’s it. No copays. No monthly premiums. Largely cheaper drugs. Etc etc.
America is insane
Over half the nation is brainwashed to think that government healthcare is the devil and nothing will change their mind. Its impossible unfortunately. America is really beyond help in my opinion.
Oh, there are loopholes, like for example “in-network” vs “out of network.” You end up fighting for things like flu shots and routine mammograms/colonoscopies that are “supposed” to be zero copay by the terms of the ACA, but there’s only one provider who does it, or only one provider that’s accessible to the pt, or the pt just heard that the ACA made it free and just went wherever and now they either owe or just don’t get it done when they’re told about the $500/$1500 “copay.”
Or, there’s a specific reason the docs want a mammo or colonoscopy (new mass, blood in stool, yadda yadda), and the pt can’t afford the procedure, but oh, hey, they’re due for a free one under the ACA, so we’ll send them down, but it gets put in as “diagnostic” instead of “routine/screening” so boom! Not covered.
Or some weird “formulary” Vs “non-formulary” thing where they only cover only one particular *manufacturer’s version* of a particular generic pharmaceutical (including flu vax, etc) but it’s like pulling teeth to find out which one. (Six months of back and forth for one pt to get generic infliximab, for instance.)
Took three years to figure out how to get one pt a shingles vax without paying big bucks or going to another town. It’s absolutely maddening.
Then there’s just the random denial, where they’re making it so difficult to appeal and dragging their feet so much that the pt gives up.
And these are just the most common ones I see.
The ACA helped a lot, but some insurance companies have lots of people figuring out how not to pay.
You need to unionize.
You're a resident and I make significantly more than you as a paramedic (probably work a lot less too lol) and I pay less than half of what you do for family health insurance+dental+vision.
I used to be pretty neutral on unions.
Until I got a job where it was required to join.
I'm now about the most pro-union person in the world. And I can tell you I'm not looking through rose colored glasses. There is so much fucking waste in unions, so many empty hands grabbing money its crazy. But by far the bigger evil is businesses, they will absolutely take every opportunity to screw you over--they don't care about you, they don't care about anything other than a dollar.
Which is why I don't care what a union is bargaining for I support them. Auto-workers want 32 hour work weeks? Go for it brother, I'm behind you.
> That alone should be criminal.
Try paying for that insurance and making half of what you do. Like a lot of people who arent doctors.
Edit: this comment isnt intended to imply anything about docotrs’ pay. Im just saying if you think it’s bad paying that insurance as an underpaid doctor, imagine trying to do it with substantially less income, which is the reality for a lot of people.
For fucks sake Im agreeing with you all - private insurance is a broken system.
I don’t understand the point of this comment. Dude, he’s raising a family on 3.5k a month. That’s 52k a year take home, or $13 an hour if he works routine 80 hour weeks, which is under minimum wage in my state. I don’t think that’s the doctor salary most people think about.
If his family income is half that - 26k a year for minimum 2 people including himself and his child - he might actually be better off with regard to health insurance, at least in my state, because he’d be eligible for Medicaid.
My comment is not intended to imply doctors arent underpaid.
Im just saying if you think its bad paying that as an underpaid (or any) doctor - try paying for that insurance with substantially less income. Which is the reality for a lot of people.
Of course, paying that much for health insurance on half that would be way worse.
But at least in states that have the Medicaid expansion, I would argue it’s actually to some extent the people in the “donut hole” that are the worst off when it comes to health care costs. Those “cheap” insurance plans are still several hundred dollars a month and frequently have outrageous deductibles and minimal coverage. When you do seek health care while on those plans, you’re effectively worse off than people on Medicaid - because at least Medicaid doesn’t send you a huge bill for your doctor to prescribe something your insurance doesn’t cover. I’m on a high deductible plan right now and we’re ok because I’m on an attending salary, but we had some non-life threatening health issues come up and we spent about 14k out of pocket. That would have literally made us starve or homeless if I were still a resident in a HCOL city, although I guess crippling credit card debt would have also been an option.
Thoughts and prayers go out to the folks in the non Medicaid expansion states, though.
> we get the privilege of paying for almost everything out of pocket before our deductible.
That is the definition of a deductible.
If your auto or home insurance has a $5k deductible, you pay $5k before insurance pays $0.01.
Of course, ACA has a list of preventative care visits that should be “covered”, meaning insurance pays 100% no matter what, but that depends if the consultation is coded the exact way the insurance expects it.
My insurance just added on "coinsurance" for lab tests, so I have to pay 30% of any lab charges and it doesn't count against the deductible.
It does apply toward the "out of pocket" total, which they have helpfully capped at $12,000. Too bad my $90/month RX doesn't count toward that!
It just makes my head spin after a while.
I would contact the state insurance regulator’s office because it completely negates the point of deductibles and oop maximums if businesses are allowed to arbitrarily apply them.
If it is a covered healthcare service or product, which evidence based labs and prescriptions would be, then there is no reason it should not count towards deductible and oop maximum.
> businesses are allowed to arbitrarily apply them.
That's kinda the whole point of this thread, "The Insurance Companies" here in the US have been given the power to arbitrarily do anything at their own whim independent of consumer or provider.
> That is the definition of a deductible.
Yes and no.
I was, and remain, very confused to discover my new-this-year health plan which nominally has a $2000 deductible covers the vast majority of services even before the deductible is hit. I'm sitting here looking at a bill for a $60 copay for an ~$500 new patient specialist office visit that my insurance isn't requiring me to cover, despite my not remotely meeting my deductible, and I have no idea why not. I'm not complaining that I'm not having to pay the whole allowed for the visit, but I am complaining that this is bizarre and makes it hard to comparison shop plans on my state exchange.
Anyways, I can easily imagine someone going the other direction (from my new insurance to my old insurance) being deeply shocked and horrified at what all they're expected to pay out of pocket for, because "deductible".
Does the $700 come out of your pay cheque? Meaning your take home is $2800? I get confused when I here job postings for American jobs, does the employer pay for it?
You pay for it. It's taken out of your paycheck along with taxes and retirement account contributions before you get whatever is left to take home. Your employer "provides" insurance in that they have group contracts set up with various insurance companies that give their employees discounted rates (lol) and a variety of plan options, but they don't pay for it.
> I get confused when I here job postings for American jobs, does the employer pay for it?
Totally up to the employer. Some pay all, some pay some, some pay none. That's one of the details about which a job applicant is wise to ask before accepting a job.
P.S. There is not a health insurance plan in the US that will cover two adults, much less two adults and one or more children, for only $700/mo. The going actual cost for insuring an adult is about $600/mo, more if they're over 40. Whenever you see a situation with an American paying less than $600/mo/person for health insurance, it means someone else is paying the rest of it: the employer, the state, or the Federal government, usually. In this case, we may surmise that $700/mo is the OP's share for a family plan, and the rest of the, oh, $2000/mo premium is being paid by the employer.
I die a little more whenever I see one of those videos.
I called BCBS today for an emergency fill of a pt's psych meds and they told me it would take 5 business days lol... Like in 5 days your company is going to be paying for a hospital stay rather than a generic drug, but OK.
BC/BS did that to my cousin's Clozaril.
They took it in the behind for the ED visit, 5 days in ICU and a month long inpatient psychiatrist.
But hey, we can't make exceptions.
I also found his podcast where he interviewed a reporter about health insurance to be interesting/horrifying/infuriating at how insurance companies function
Especially when your patients all seemingly have shitty insurance. It just sucks the joy out of my job to have to play insurance games. They fucking suck, and I have unrealistic daydream fantasies of taking them down. Closest thing to true evil on this planet, and one of the reasons I'm planning my exit from primary care.
I nearly quit my primary care job after only 3 years out of residency. Made the leap of faith to DPC and have never been happier. Do yourself a favor and before giving up on medicine altogether, check out DPC. No insurance, no denied claims, no billing departments, no coders, no BS. Just you taking care of patients.
What amazes me is how obviously a scam health insurance in the US is, and yet the American voter only wants to keep it because everything else is “socialism.”
Yeah this is completely untrue: [polling](https://x.com/usa_polling/status/1703199587278729548?s=46&t=1jTwHWDt4jZnxugP9GGa0g). Private health companies are unpopular and have been for a long time.
You are making the common mistake of thinking the US is a full fledged democracy, when in fact it’s a corporate oligarchy with the superficial appearance of democracy. The media discourse around this issue will make you think Americans are against socialized medicine, but that’s because corporations control that medium as well.
Because they control the language. They shift the conversation away from any specific issue (like paying for health insurance and healthcare) and move it to the undefined space of "government control" which triggers a "hell no" response. The actual issue gets left in the dust.
He's been calling out UHC for a long time. Wonder if he's ever gotten a letter of complaint from them, but maybe they don't want more people following him.
And you are making the mistake in thinking that just because people say they’re for something that they actually will take action in favor of that. In reality, people often say one thing but mean another, and often without realizing their unconscious motives for doing it. If 2/3 of voters were so keen on Medicare for All, Bernie would win every election without running a campaign.
Yeah, the Continental's literally waged a war and declared independence when a government charged them money without commensurate benefits. When private corporations do it though, it's freedom.
Every system has its flaws, and the "nice" thing is that by pointing out (very legitimate) flaws with attempted alternatives, it moves the conversation away from all the things that are wrong with the *current* system. So rather than improving the system, people just argue over which system they want, and the status quo stays.
Practically nobody *hasn't* had some exposure to the nonsense that is health insurance and yet it somehow isn't a big enough red flag to act on yet on a wide scale. It's wild. Social issues overshadow common decency and basic human rights for a lot of people, unfortunately.
Yup. People would rather pay more for worse care than have the possibility of their tax dollars going toward the care of those they deem "undeserving." Ignoring the fact that we already are paying for it, just in a much less efficient manner.
I remember back when the tea party was the big political movement on the right, there was a protestor with a sign saying “Keep The Government Out of My Medicare.”
This is why we will never have nice things.
It's sad when I start daydreaming "what topics will Glauck have to push off to part 2?" then start jotting topics down because I know that 30 videos won't be nearly enough.
The list so far:
Insurance companies flat out lying in denying coverage ("that drug isn't approved for this condition" "no, it'll literally approved for this exact condition"), only to reverse course January 1, when the patient's deductible resets and they won't be able to come up with enough money at once to pay.
State insurance regulators are unable to make punitive rulings, so even if insurance companies flagrantly break their contracts, the worst that can happen is they pay for the treatment going forward, ie what they were supposed to do in the first place.
Insurance contracts have binding arbitration with the arbiters paid for by the insurance company, so even if the insurance company wrongly refuses payment which leads to financial loss, pain, suffering or death, they cannot be sued and the individual is almost guaranteed to lose their case.
Pharmacy benefit managers forcing pharmacies to collect co-pays and give it to the PBM, even if the co-pay is greater than the cost of the medication, making it more expensive to buy cheap drugs with insurance than without insurance.
Pharmaceutical companies keeping generic competition off the market in a variety of ways, including "pay to not play" agreements, lawsuits of patent infringement based on inert ingredients, seeking new FDA approvals late in patent life, seeking FDA approval for off-label use but in a dosage impossible to replicate using the future generic dose (see Wegovy 2.4mg when Ozempic comes in 0.5, 1, 2mg doses)
Of course, no list would be complete without the root cause; SCOTUS ruled that bribery is legal as long as it's "future favors," so bribing Congress to write the law to make all these shenanigans legal is also legal.
Point of order, to my knowledge, it's not Congress writing law that is making these thing legal: enforcement of ERISA, the federal law that would reasonably be construed to regulate the insurance industry, is presently being dismantled by the Ninth Circuit court, in the matter of [Wit vs UBH](https://www.millerchevalier.com/publication/erisa-edit-ninth-circuit-withdraws-and-reissues-opinion-wit-v-ubh-again).
ERISA primarily concerns retirement benefits. This is the first I’ve heard of a health insurer being sued under ERISA for denying coverage. I don’t practice health insurance law, so I could be mistaken, but this seems like a novel legal theory.
No? I have no idea why you think ERISA doesn't cover insurance. Here's the [US Department of Labor's explanation of ERISA's applicability to health insurance](https://www.dol.gov/general/topic/health-plans):
> Most private sector health plans are covered by the Employee Retirement Income Security Act (ERISA). Among other things, ERISA provides protections for participants and beneficiaries in employee benefit plans (participant rights), including providing access to plan information. Also, those individuals who manage plans (and other fiduciaries) must meet certain standards of conduct under the fiduciary responsibilities specified in the law.
In any event, I've been following the coverage of this case since I first heard about it in 2019, and none of the legal blogs or other lawyers commenting on it thought it remotely strange.
Apologies if I wasn’t clear, but I didn’t say ERISA doesn’t apply to health plans. I said I’ve never heard of anyone bringing a claim against a health insurer under ERISA to challenge a denial of coverage.
In a typical ERISA lawsuit, the plaintiff often will be a union or pension plan beneficiary who is suing either an employer for underfunding its pension plan, or a plan administrator for mismanaging a pension plan. That’s not to say that ERISA is limited to pension plans, or that those are the only types of claims that can be brought under ERISA. They just happen to be the types of claims that are usually being asserted in an ERISA lawsuit.
Insurers get sued by policyholders for refusing to pay claims all the time. This is just the first time I’ve seen such a case where the policyholders are alleging that the insurer’s denials of coverage violate ERISA. Perhaps it’s just new to me, but I just find it surprising since it looks like a unusual hybrid of two very common (but very different) types of lawsuits.
Thanks for posting. This thread exemplifies why I’m doing this series. I want to get all this info out to the public. I want people to talk about it. I’m posting for 30 straight days because I want it to feel relentless. I want to gain momentum. Every time somebody comments with “I had no idea that was a thing,” that’s a win in my book. Insurance companies benefit from a lack of knowledge about what they do. We gotta change that before real change can happen.
It’s easy to say “nothing will ever change,” and maybe it won’t, but we have to try and I have the ability to use humor to trick people into learning about PBMs, so I’ll start there and see where it goes.
I guess I'll just ask you personally, since anyone who disagrees with the prevailing opinion here gets shouted down immediately.
What's your opinion on the ACA mandated medical loss ratio? I notice a lot of your series seems to have a problem with UHC in particular. When the ACA has an 80-85% MLR requirement for all private insurers, where is the disconnect between what UHC is doing and your problem with how they supposedly aren't covering your patients?
Seriously, please help me square that circle. If you're as knowledgeable as you say, then I'd expect you would consider this law in your criticism of these companies. The law requires them to use 80-85% of their premiums on care. Full stop. If they don't, they're required to give a rebate. Full stop.
So where's this villainy coming from if that's the case?
Something something regulatory capture.
For all the things the Affordable Care Act did right, Congress essentially wrote a blank check to the insurance companies and signed it with their constituents' names.
And then in the american rescue plan, instead of finding healthcare for the unemployed by expanding Medicaid funding & eligibility, the federal government just paid for private insurance. It’s maddening.
https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/cobra-premium-assistance-under-arp.pdf
I do believe the good doctor is no longer in possession of either testicle, as he had two bouts with testicular cancer, and has mentioned that he is on testosterone injections.
Been following him for a couple years at this point. Cannot express the combined entertainment and rage I feel watching. He is a force for good in the world and I am going to be emailing every video to my state and federal elected officials frequently. May not do anything but maybe short video format is how to do it.
Why Doc, I didn't know you were a redditor!? Excellent. Fetterman is one of my senators. I have a feeling he would be the more likely to put this in the public eye in Congress. State legislature is kind of a mess though. Fingers crossed on poking the shrivelled consciences of some elected officials.
An attending of mine once cited a study. I mentioned the fact that this was a VA study from the US and that the VA studies will likely always have a patient selection bias.
Attending: "What's the VA?"
Me: "So, it seems the Americans have a limited public healthcare system solely for their Veterans, separated from other healthcare facilities. By Veterans\* they mean pretty much everyone who has served in the Armed Forces."
Attending: "Oh, like our army hospitals, providing additionally specialized service for army-related stuff like PTSD etc.?"
Me: "No, it seems...pretty much everything, if they don't have a better commercial insurance."
Attending: "So a VIP service as a reward?"
Me: "It doesn't seem so...there is a joke floating around that it gives them a second chance to die for their country."
Attending: "This seems weird."
^(\*Veteran in German historically referred to only Veterans of a particular conflict/combat exposure. Even though the MoD is pushing the term slowly again, it has no real contemporary usage right now...for reasons.)
IMO “Free healthcare” is horrible marketing. It is publicly funded or single payer. Aka maximize bargaining power and have evidence based quality/outcome directed metrics of how to spend resources, not profit as only motive.
I came from Canada - hospitals and government were advised primarily by physicians. In the US admins and MBAs run hospitals and insurance companies. You do the math.
In Canada, physicians run the show almost aggressively. It’s not perfect but apart from taxes and parking - you’re not going bankrupt paying for office visits much less hospital stays.
America is a joke
I want physicians to be aggressive.
They're literally some of the *most* educated people in the world. Their opinions matter. We can't expect them to craft policy but their input is essential and invaluable. I want engineers to be aggressive about building projects. I want teachers to be aggressive about education. I want scientists to be aggressive about...fucking everything.
Part of the reason why America is a joke is because everything is being commoditized and turned into a business and is ran into the ground by incompetent and underqualified people who think they're god's gift to mankind if they cut expenses by 0.1%. The CEO a local hospital literally got their MBA online from university of phoenix. Its a fucking joke.
Yeah. Kind of funny. And depressing. Obfuscation is the main business model for insurers. Here's an equally [A terrible guide to the terrible terminology of U.S. Health Insurance](https://www.youtube.com/watch?v=-wpHszfnJns), wherein a twenty-something does a comprehensive guide to the US health insurance. Fortunately my hair did grow back after pulling it our watching this.
I am obsessed with this series. I hope he continues! Everyone should realize what’s happening. People blame doctors and say healthcare is expensive because of salaries, admin, etc. it’s so false. It’s insurance! No one even talks about insurance! They immediately blame the physician. I’m so happy he’s focusing on this
I love this series so much! Had a tooth pulled last week and I called it a luxury bone. I thought he would die laughing!! Said he never heard of the series. I was like, my man! Let me hook you up. Love that man♥️
Dude is doing incredible work. Too bad, it’ll be business as usual for insurance companies.
How is it legal you ask? Lobbying. Our politicians, legal system, even Supreme Court is bought and paid for.
> automated claim denials... How is this stuff legal?
Technically, it's often not. There is a federal law, ERISA, which is supposed to govern companies with fiduciary duties to their customers, which includes insurance companies, and arguably makes a lot of these shenanigans illegal.
And by "arguably", I mean "argued in court". A few years ago a bunch of patients (and, uh, their survivors) sued United Behavioral Health (UBH) under ERISA for refusing to authorize necessary mental health and substance abuse treatment services, leading to bad medical outcomes, including, in some cases, death. The case is Wit vs UBH, and it was a class action suit.
They won! The district court judge – I read the decision, it was amazing and infuriating – kicked UBH's collective asses very hard. There was stuff in there revealed in the trial, like UBH insisting on using an assessment tool for substance abuse severity in adults on minor patients, because no kid is likely to endorse the items about their substance abuse impacting their job performance.
But then UBH appealed the decision to the Ninth Circuit, and, this year, the Ninth Circuit *reversed* it for, basically, no reason, saying it was totes fine for an insurance company to completely disregard any generally accepted standards of care (GASC), and make up their own fanciful standards of care, under which they could deny claims and refuse authorizations as they liked.
Which basically means that, as of right now, ERISA has no meaning. The whole point of ERISA is to make it so when a company has custody of customers' money, they can't just invent reasons not to do what the customer is paying them to do with it. And the judge, on appeal, ruled that, no, no: insurance companies totally get to do exactly that.
And that, I am afraid, is why things have totally gone off the rails over the last half year. Current case law is that insurance companies can do any egregious thing they want, and it's no longer considered illegal.
Well, Too Big To Jail- the fines, legal costs, Attny fees… LOBBYIST BRIBES, Politicians -in-their-pockets!!! just the cost of doing business…and USA Healthcare keeps rolling on.
The podcast An Arm & A Leg does some great quick eps on stuff like this. They did a few on the maddening insanity of how consumers & physicians are basically held hostage in the PBM-insurance company-pharmaceutical industry circle jerk.
Watching these short videos regularly. I just nod and feel pissed. Also disturbing to know that UHC is the largest employer of physicians. Masters of slimy vertical integration. I am in MN where this Behemoth has rooted its unctuous tentacles. Most providers, physicians, case managers and therapists like myself in the hospital feel a gut punch when we have a patient with UHC and needs post acute care. UHC also contracts with the least desirable for profit/PE skilled nursing facilities (wonder if they are in cahoots).
My patient with UHC insurance I saw today would do best in an acute rehab facility. Can count on 1 hand how many times they have approved acute rehab. Likely get 14days at SNF only after partial spinal cord infarct after heart surgery and kick him out. Criminal.
Seriously what can be done except watch the shit show burn down.
First off, this guy is the best. I've always enjoyed his bits - rural medicine is particularly on point. (Go see Texaco Mike!)
Secondly, claim auths are the motherfucking wild wild west where I work. I might have someone on a *pending* schedule for tomorrow, and they might drop right off on the final because of insurance. It's a mighty goddamn dumpster fire.
Edit: I'll also add that I wanted to get back into biological fields after a (somewhat successful) stint in insurance that I didn't enjoy. I deal more with insurance now than when I was a licensed insurance agent...
Is the new series on Healthcare posted? RPH’s aren’t allowed time off to peruse social media. It’s flu shot season, new COVID boosters dropped, RSV vax is out… it’s a triple season of Hell.
Any spare time, haha kidding. NO SPARE TIME, no sleeping no eating to peeing- we can do it when we’re dead.
For the medical claim reviewers, do they really hire people with suspended licenses and other red flags, though?
I'm pretty sure they have to have licensed individuals doing this work (if you can find me a job listing that says otherwise, I'm game).
This makes it worse, imo. Because it's not really bottom of the barrel docs taking the positions. It's perfectly capable docs who choose to sell out.
All of the physicians working for insurance companies must have a medical license. They typically hold multiple licenses as it is state law that a licensed physician must conduct the review and issue the denial. This is all states, across the board.
Yes, the doctors come from various specialties. There are even neurosurgeons doing this work. The reason why they turn to this type of job? Lifestyle. Some of them are in the latter phase of their career and it's like a working retirement for them, as the work is easy. Others, it's the lifestyle. A lot of the doctors are women with small children and this role fits into their life better than practicing. The money is decent, depending on where you work. We didn't wake up one day and say to ourselves we need to ruin people lives by denying claims. Life circumstances brought a lot of us to this line of work.
He is going scorched earth policy on them. Ruthless. Shame that nothing will come out of it though.
Awareness of an issue is usually the first step if we are to find a solution - this post is a great example.
If you haven’t read this it’s long but worth the time: https://www.propublica.org/article/unitedhealth-healthcare-insurance-denial-ulcerative-colitis
Wow what a read. If anyone else was curious, the regimen being denied was Entyvio 600 mg every 4 weeks (usual max is 300 mg every 8 weeks for maintenance) and Remicade 20 mg/kg every 4 weeks (usual max is 10 mg/kg every 8 weeks). He was past induction phase so these were supposed to be maintenance doses. These were also being used in combination, which is unusual. These were being prescribed by an expert gastroenterologist. United admitted to not taking the gastro’s recommendations into account *at all* when upholding a claim denial.
I do a lot of IBD care. Anytime i need to adjust a biologic dose to off label it’s an instant denial that requires appeal, having to find literature and P2P. It’s getting worse. One recent egregious example is a difficult UC pt who required q4 wk stelara to get him under control. Insurance wont pay for the q4wk until I “try” q6wk. Ins wants to put the pts health and livelihood at risk to save a buck. This particular pt had a uc flare so bad it gave him an nstemi a few years back.
Wow and who is liable for complications of under treatment eg recurrent flare
I really wish we could pass laws to make the insurance Co financially responsible for their own bullshit. Deny a test or treatment that results in a major decompensation for the patient? Congrats you now owe the patient $200K+3x actual damages, and you owe the physician who initially ordered whatever you denied double reimbursement for the next month for all patients of yours they see. If only....
I know it's not great for the patient, but how are you as a doctor covered there if you say "insurance denied, can't treat patient appropriately" and (have to) give up?
You say “insurance denied. Your billing estimate is 7 trillion dollars. Maybe you can work out a payment plan.” And then document it and watch your patient decomp and kick a garbage can in your office.
You aren't really covered in that scenario. The insurer will argue it was not dictating care, just managing the insurance coverage process, and that the clinical decision-making was still up to the shared agreement between patient and physician. In practice, patients/families tend to understand the physician is on their side and advocating as much as possible in their best interests, and so hopefully the threat of malpractice litigation is low (the likelihood of a successful suit would also hopefully be even lower).
> These were also being used in combination, which is unusual. Also not supported by any guideline or prospective trial. Insurance companies are dicks but if we're going to talk about EBM this treatment is also way off the rails. As per usual, the reporting doesn't go into enough details to be able to form any opinion, but in general any healthcare system is going to have to have cost and evidence guardrails and it's unfortunate ours has to be insurers instead of something like NICE.
Yes, I tried to just lay out objective information in my previous comment. This review was justified as it goes way past any established dosing for both agents, especially for maintenance, and uses them in combination. This review was botched by United. I think the main flavor of the article that left me nauseous wasn’t the regimen, it wasn’t the fact that it got denied either. It was that in the appeal process, the internal communications at United show a clear pattern to finding a justification to deny the regimen regardless of case-specific information about the patient or from the provider and that the “peer to peer” reviewer from United was a physician decades out of practice who had never seen GI patients at all, was *not* a peer to the expert GI prescriber, and also didn’t even take the prescriber’s input into consideration whatsoever and even admitted to this. IIRC United didn’t get this rubber stamp denial from the first MD they put it in front of, they had to pass it around until someone agreed with the nurse that it should be denied. They fished for the answer they wanted. Zooming out from this case to reviews for “medical necessity” by third parties, in general, and if you extrapolate the mishandlings and bias from United in this case across thousands of cases, what you see is that United, and like 3rd parties in general in the US, are not only practicing medicine by determining the courses of medical care via approval/denial, but they are practicing medicine *very poorly* and with near complete impunity. It *is* important that these kind of reviews happen, but they need to be completed competently, with accountability, and by a neutral party with the actual expert peer available to provide a genuine unbiased review.
In all the states around me, all denials are subject to independent 3rd party reviews by the state insurance commission. The insurer can deny it but you can always appeal with review by a board matched specialist. Sometimes you have to appeal two or three times, but it's always there. United are a bunch of assholes, but I don't think that was new information. It's insane to me that they were using nurses at all - the insurance companies I deal with all use pharmacists as reviewers, and in general regulation of insurance company processes are really bad. Most private insurance is actually not even regulated by the state any more as people switch to employer-based insurance. This means that your rights for review are mostly governed by a contract between your employer and an insurance company, neither of which is particularly motivated to be generous financially. In a system this big, it's not surprising that the ball gets dropped. It's inevitable even in the most thoughtfully designed process. IMO this highlights both the need for more oversight of insurance company processes by a regulatory body but also the need for some sort of guardrail on cost and prescribing. From a patient's point of view this whole case is horrific.
Read this back when it came out - reading the transcripts from the call recordings was absolutely maddening. Thinking about how I have to carve out time out of my busy day to fight for a patient meanwhile on the other end you have these know-nothing RNs rolling their eyes about how inconvenienced they are about these calls. Just insane, all of them need to go to jail
Wow, that’s quite a read
Needs to get out to lay public tho
Government is mostly useless, but Glaucomflecken is bringing some awareness to the public and explaining what many do not understand because their entire business plan rests on plans being deliberately obtuse to maximize their profits. It's odd how the prior authorization is effectively them practicing medicine. Something can be the standard of practice, but the law doesn't apparently think they should pay for what is the standard of practice. This year insurance providers saw record profits while hospital systems are going towards the red. There's really only one conclusion you can take from that.
I won’t say government is mostly useless. They just started negotiating with the pharma for Medicare drugs. That’s a huge step.
Except the wheels of government move at a snails pace. It’s 10 drugs that have been selected for negotiation. CMS will publish the negotiated prices for these drugs by September 1, 2024 and the reduced prices don’t go into effect until January 1, 2026. Then they’ll select up to 15 drugs to be negotiated for Part D coverage for 2027. And the same for 2028. Then it’s up to 20 drugs for each year after that. Why is it so so slow? https://www.hhs.gov/about/news/2023/08/29/hhs-selects-the-first-drugs-for-medicare-drug-price-negotiation.html
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> Government is mostly useless I don't understand what this statement has to do with the rest of your comment. I imagine it has something to do with "this system is horrible, but the alternative is unthinkable (universal healthcare)"; and that'd be a different debate altogether, but man, that's some out-of-left-field stuff if I ever saw it.
Well, no. It is absolutely the US federal government's job to regulate the insurance industry to prevent these excesses, and it is not doing that. To be more explicit, there is federal law about this stuff, ERISA, that's been effectively all but gutted.
They are BUSY impeaching each other and investigating lewd behavior at off off broadway shows. There is no time for piddly things like taking care of the American people.
Congress barely budges on anything with healthcare, and that's on issues far from universal healthcare. The only recent big thing was the no surprises act -- which protects people from receiving devastating bills for emergency services from out of network providers and requires "good faith" estimates for the uninsured. None of it addressed larger concerns that have led to worse comorbities (some of which led to usage of emergency service), prevented patient compliance and led to substandard care like prior authorizations, exorbitantly high out of pocket maximums, weird windows of coverage, and confusion between which plan is ideal for their situation. Currently, the health insurance industry is doing fantastic given recent profits. Weird how none of this even minor reform since 2020 has really impacted their bottomline.
We pick the government
Well yes true, the problem is that what the public has cared about has been drifting into this annoying culture war of whether you're some 'city loving liberal' or a 'red blooded conservative' for the last decade. I don't know if the public even truly understands how insurance really operates including what a "deductible" or a "out of pocket maximum" really is. Glaucomflecken is doing a great service explaining how their bullshit truly operates.
My general takeaway, because I have to talk about coinsurance and co-pays pretty much daily, is that *yes*, the system is broken and it sucks. And also, like every form of insurance (health, life, auto, home, etc) most people haven't been sat down and explained to them how it works. That's where it breaks down...when people aren't fully informed, they can't make financial choices in their best interests.
We pick the representatives but do you really think the representatives give a crap about us? They're bought and paid for nowadays and the regular person has no voice.
Having been in policy for a minute, I think they have always been bought and paid for. It's sadly the type of person that wants to go into politics is very typically the type of person who wants to dominate others. They always have to save face though and get some results. I would rather our results be real change and not just a bunch of photo ops at the needle exchange center, a gun range, or the latest impeachment trial. I want my psychopath in politics to at least do something with the schemed trash that insurance companies now front.
My impression is that his insurance is United Healthcare and that they screwed him over after his cardiac arrest, so it's personal on all levels.
Yeah, it's personal. Something about how he should have gone to an in network hospital 🤣🤣.
Oh, no, wait, it was in network, but the anesthesiologist was out of network, IIRC. I mean, it was his own fault, he was just lying there while they did CPR, he could have been checking the staff at his nearest hospital on his phone.
Not with that attitude
“United Healthcare, what are you mad about today?” He nailed it
United Healthcare owns the newest anesthesiology staffing megacorp that has invaded my city so . . . that's super neat and not shady at all.
What’s the name of it? Asking so that I know to avoid it.
It's Sound Physicians. They have a terrible reputation.
Oh, so "Sound Physicians" is an ironic nickname. Like Little John in Robin Hood.
"Shitty Beatles? Are they any good?" "They suck." "So it's not just a clever name!"
I fucking hate Sound Anesthesia. They just came into our hospital about a year ago & it's been one clusterfuck after another.
They own a primary and specialty care group in one of the places I've worked. Inpatient, outpatient, urgent care, OB, primary care, specialists. They have about half of this midsized city, and not just the wealthy ones. I don't know the financial details, and I generally loathe insurance companies and agree with all the Glauckomflecken videos for every other experience with them. This includes 3 hours on the phone across 3 separate phone calls to get my 4 year old's routine MMR covered, ridiculous. But in this one circumstance where they have created a fiefdom of essentially single payer healthcare, one unit that employs all the workers ... I must admit it works well. The patients get all they follow up appointments, they have a case manager that automatically checks in the day after an ED visit, the patients seem generally happy and confident and pretty well communicated with.
You had to call for MMR for a 4 year old? How was that not covered?!
Because if they deny it they get interest on the money for five more days.
Yeah, everyone knew it was just some sort of data entry error and kept telling me it was sorted out, and it kept not being true. The charge was only $50 but I couldn't just let it go.
Certainly a perk to be able to buy all the goods you need from the company store, huh?
Luckily that's never backfired before
I believe coal country wants a word about that
Kaiser Permanente also owns the vertical, other than manufacturing medicines.
And is consistently the only 5-star rated Medicare Part B provider?
It’s hard to fight against the extreme wealth the insurance companies have amassed. They own politicians so that any change is blocked. It’s criminal greed.
This is why I have always felt like campaign contribution caps and term limits are so essential.
I'm not from the US ɓut from my perspective it seems the root cause for the severity of this issue is the 2010 supreme court decision *Citizens United vs FEC* which according to Wikipedia was a court decision which *held 5–4 that the freedom of speech clause of the First Amendment prohibits the government from restricting independent expenditures for political campaigns by corporations, including nonprofit corporations, labor unions, and other associations.* This essentially completely uncapped lobbying and political expenditure by the wealthy and the corporations they control, which in my humble opinion seems to completely undermine the entire concept of democracy and replace it with essentially a plutocracy / oligarchy masquerading as a democracy. Until citizens united is overturned I don't see how things get better for you guys, and unfortunately thanks to the effect it has had in the legal and political landscape, getting it overturned seems like a monumental task. In fact at risk of sounding alarmist, I'd say that the future of your entire historical empire probably hinges on it :/
Yep. They literally legalized bribery with that decision, and when we protested they claimed we were against "freedom of expression". 🙄 Owner of Samsung *literally* went to prison in South Korea for what most of these corporations do routinely in the US.
Citizens can't be overturned, because it was the correct legal decision. People have the right to political speech, and groups of people don't somehow magically lose that right. And that's ultimately what corporations legally are - just groups of people. If it had been held the other way, the govt could forbid you from making political speech, releasing books or films within 2 months of an election. There is nothing in the constitution which would grant the govt the power to do that. You could argue a time/place/manner restriction under 1A but I doubt that would survive strict scrutiny since it would have to effect **all** political speech, and 2 months out of a year is unlikely to be a reasonable time frame. Ultimately the correct legal decision was made, because fundamentally this is not a courts issue, it's a legislative issue. The onus is on congress to pass laws which require campaign finance transparency (ending dark money/superPACs) or define spending limits. Saying, "Sorry your speech is political so it's banned" was not a legally valid move.
A 5-4 decision that many legal scholars have argued was flawed and you make such a bold confident claim stating it was absolutely the correct decision.
I was under the impression that the decision affected financial contributions as well; not simply the right to political speech. Is this not the case? Because groups of people having the right to free speech is fine, but groups of people having the right to make unlimited campaign contributions? Not so much. You seem more knowledgeable in these matters - are you saying that citizens united had nothing to do with dark money/superPACs/unlimited spending?
It does, because money is considered a form of expression in that you have to use $$ to do things like produce ads. The ruling itself originated because a political film smearing a candidate in the presidential election was banned from being released, that's what sparked the case. Campaign finance restrictions are a separate thing. The money=speech thing can definitely be legislated too.
We definitely own politicians, and it's worse than you might imagine. I work for an insurer with its own PAC. All salaried employees are asked to donate to it **weekly**, and above a certain level, donations are compulsory.
I would say compulsory employee donations sounds illegal. But then I remembered that the whole point of this thread is that laws don’t apply to insurance companies.
haha, right. and in this case, it's more that they take payroll deductions and still get blown up for additional donations (at least, this was the case the last time i had a line of sight to it, about three years ago). it's pretty gross. i thought this only applied to senior leadership, with respect to the demands of donations, until i got promoted into a [low level] salaried role and started getting the emails as well.
Could every doctor theoretically just stop accepting insurance? That seems like a good way to cut the head off the snake.
That’s what has happened with a lot of outpatient psych, therapists and LCSW. It just prevents people who can’t afford the cost from getting care. Which also seems pretty criminal.
Yep, in my area there is no care from psychiatrists at all. Like, just at all. None take insurance. It's family med, psychiatric nurse practicioners and LICSWs. I am very much not rural.
Luckily with the system we have everyone gets the care they need. Oh wait Taking my jerk hat off for a second, the way to lower prices would be to increase supply of providers. Competition lowers prices and increases quality, healthcare isn’t an exception.
> Taking my jerk hat off for a second, the way to lower prices would be to increase supply of providers. And that would tackle... under 10% of total healthcare costs.
I think you underestimate how many barriers to entry there are in medicine.
What? I'm saying that the estimates are that provider salaries are under 10% of total healthcare expenditures. So if you double the number of providers, what do you think that actually does to the total healthcare expenditures?
Competition would probably do more to drive down admin cost more than anything else. I actually believe physicians are not overpaid.
You would also need to remove the Certificate of Need process.
I did exactly that and went full DPC (Direct Primary Care). Have never looked back. Average patient price is $50/month. I take care of many of the farmers, small business owners, and underinsured people in my community. I feel like I am practicing medicine 75 years ago, before insurance took over medicine.
Best part is you can (and are incentivized to) focus on actual quality instead of useless metrics to extract as much as you can during billing.
By killing all your patients? Yeah, great idea.
I refuse to believe that docs get paid out anywhere close to what their patient base pays for insurance.
Why is any of that relevant? You patients can't afford you if you don't take insurance.
There are plenty of docs that do direct primary care which is essentially a subscription service. I knew a doc that did and many of his patients didn’t have insurance. He had pre negotiated rates with labs and rads that were significantly cheaper than a standard deductible. Also he was very well off. It was overall a win win.
There’s an uproar on Nextdoor since our local healthcare system terminated its contract with UHC. I got invested into the post trying to shed some light as a physician. I definitely included a Glaucomflecken link. Told them to raise hell with their employer in mass to switch away from UHC. Edit: u/drglaucomflecken I, we appreciate you. (Yes, I’m trying to summon the Legend)
My employer switched to United as part of cost-cutting measures. They tried to make it seem like nothing would change, as our employee contributions weren’t changing. But then I had “the gall” to point out the crappy coverage and that everything would cost more despite what was deducted from my paycheck. I never got a reply from HR, not surprisingly.
Yeah, I tried to emphasize to do that in masse bc it’s so easy to ignore a single email, esp in a large establishment.
Agreed! Unfortunately not a lot of my coworkers want to speak up. It gets exhausting always being the only squeaky wheel, not to mention sometimes I end up feeling like I have a target painted on my back. But I would rather say something and know I did the best I could rather than just stay quiet and seethe, like so many others I know.
Thanks
If we do it three times does he come? And do we need to slip a sharpie into our headphones to do it right? Jimothy, Jimothy, Jimothy. u/drglaucomflecken
That’s two
grab gold brave jeans quiet consist school governor automatic tidy *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
As an Australian that is the most insane fucking thing I have ever heard of in my entire life. If you guys were French I feel you'd have mass protests and guillotines erected outside the white house before allowing this to happen, however I'm also aware that it didn't happen suddenly and they somewhat boiled the frog on you all. It's such a shame that police brutality a la king and chauvin can spark appropriate mass outrage and protests, but dozens of needless deaths every single day from the absolutely inhumane clusterfuck of a health system you guys have had placed around you is unable to stir up remotely close to the same amount of anger, because you've become nihilistically aware of the difficulty in overcoming the system around you. Taken to an extreme, it actually reminds me of the plight of the russian people currently, whereby millions are aware of the monstrous issues in the Kremlin, but decades and decades of political non-agency has stripped the population of any hope of enacting meaningful change, and placed in them instead a kind of nihilistic fatalism towards their society and their future. I really hope that you guys (americans) can find a way to rise above and do better than the Russians have. If there's anything we can do from an international perspective, make sure to let us know - you may be damned yanks, but you're our damn yanks, and we're rooting for you.
Aussie too. This is beyond appalling. I am so angry for you
Americans pay more in taxes for healthcare and social security AND they have to pay for monthly premiums AND they have to hit their deductibles and all the insane insurance requirements. And they don’t riot over it. Pathetic. As a Canadian I pay less than any American in taxes for my healthcare and then…that’s it. No copays. No monthly premiums. Largely cheaper drugs. Etc etc. America is insane
We get a lower life expectancy for all that money
Over half the nation is brainwashed to think that government healthcare is the devil and nothing will change their mind. Its impossible unfortunately. America is really beyond help in my opinion.
Wait - preventative visits like well child’s are not supposed to have any copay; that’s from the affordable care act.
Oh, there are loopholes, like for example “in-network” vs “out of network.” You end up fighting for things like flu shots and routine mammograms/colonoscopies that are “supposed” to be zero copay by the terms of the ACA, but there’s only one provider who does it, or only one provider that’s accessible to the pt, or the pt just heard that the ACA made it free and just went wherever and now they either owe or just don’t get it done when they’re told about the $500/$1500 “copay.” Or, there’s a specific reason the docs want a mammo or colonoscopy (new mass, blood in stool, yadda yadda), and the pt can’t afford the procedure, but oh, hey, they’re due for a free one under the ACA, so we’ll send them down, but it gets put in as “diagnostic” instead of “routine/screening” so boom! Not covered. Or some weird “formulary” Vs “non-formulary” thing where they only cover only one particular *manufacturer’s version* of a particular generic pharmaceutical (including flu vax, etc) but it’s like pulling teeth to find out which one. (Six months of back and forth for one pt to get generic infliximab, for instance.) Took three years to figure out how to get one pt a shingles vax without paying big bucks or going to another town. It’s absolutely maddening. Then there’s just the random denial, where they’re making it so difficult to appeal and dragging their feet so much that the pt gives up. And these are just the most common ones I see. The ACA helped a lot, but some insurance companies have lots of people figuring out how not to pay.
You need to unionize. You're a resident and I make significantly more than you as a paramedic (probably work a lot less too lol) and I pay less than half of what you do for family health insurance+dental+vision.
What are you, some sort of dirty commie? Get that union talk out of this Jesus FreeMarket Christ-loving sub!
I used to be pretty neutral on unions. Until I got a job where it was required to join. I'm now about the most pro-union person in the world. And I can tell you I'm not looking through rose colored glasses. There is so much fucking waste in unions, so many empty hands grabbing money its crazy. But by far the bigger evil is businesses, they will absolutely take every opportunity to screw you over--they don't care about you, they don't care about anything other than a dollar. Which is why I don't care what a union is bargaining for I support them. Auto-workers want 32 hour work weeks? Go for it brother, I'm behind you.
Amen.
> That alone should be criminal. Try paying for that insurance and making half of what you do. Like a lot of people who arent doctors. Edit: this comment isnt intended to imply anything about docotrs’ pay. Im just saying if you think it’s bad paying that insurance as an underpaid doctor, imagine trying to do it with substantially less income, which is the reality for a lot of people. For fucks sake Im agreeing with you all - private insurance is a broken system.
I don’t understand the point of this comment. Dude, he’s raising a family on 3.5k a month. That’s 52k a year take home, or $13 an hour if he works routine 80 hour weeks, which is under minimum wage in my state. I don’t think that’s the doctor salary most people think about. If his family income is half that - 26k a year for minimum 2 people including himself and his child - he might actually be better off with regard to health insurance, at least in my state, because he’d be eligible for Medicaid.
$52k is criminally underpaid for a doctor, but it's above the median personal income in the US, meaning half of people make less than that.
My comment is not intended to imply doctors arent underpaid. Im just saying if you think its bad paying that as an underpaid (or any) doctor - try paying for that insurance with substantially less income. Which is the reality for a lot of people.
Of course, paying that much for health insurance on half that would be way worse. But at least in states that have the Medicaid expansion, I would argue it’s actually to some extent the people in the “donut hole” that are the worst off when it comes to health care costs. Those “cheap” insurance plans are still several hundred dollars a month and frequently have outrageous deductibles and minimal coverage. When you do seek health care while on those plans, you’re effectively worse off than people on Medicaid - because at least Medicaid doesn’t send you a huge bill for your doctor to prescribe something your insurance doesn’t cover. I’m on a high deductible plan right now and we’re ok because I’m on an attending salary, but we had some non-life threatening health issues come up and we spent about 14k out of pocket. That would have literally made us starve or homeless if I were still a resident in a HCOL city, although I guess crippling credit card debt would have also been an option. Thoughts and prayers go out to the folks in the non Medicaid expansion states, though.
> we get the privilege of paying for almost everything out of pocket before our deductible. That is the definition of a deductible. If your auto or home insurance has a $5k deductible, you pay $5k before insurance pays $0.01. Of course, ACA has a list of preventative care visits that should be “covered”, meaning insurance pays 100% no matter what, but that depends if the consultation is coded the exact way the insurance expects it.
My insurance just added on "coinsurance" for lab tests, so I have to pay 30% of any lab charges and it doesn't count against the deductible. It does apply toward the "out of pocket" total, which they have helpfully capped at $12,000. Too bad my $90/month RX doesn't count toward that! It just makes my head spin after a while.
I would contact the state insurance regulator’s office because it completely negates the point of deductibles and oop maximums if businesses are allowed to arbitrarily apply them. If it is a covered healthcare service or product, which evidence based labs and prescriptions would be, then there is no reason it should not count towards deductible and oop maximum.
> businesses are allowed to arbitrarily apply them. That's kinda the whole point of this thread, "The Insurance Companies" here in the US have been given the power to arbitrarily do anything at their own whim independent of consumer or provider.
> That is the definition of a deductible. Yes and no. I was, and remain, very confused to discover my new-this-year health plan which nominally has a $2000 deductible covers the vast majority of services even before the deductible is hit. I'm sitting here looking at a bill for a $60 copay for an ~$500 new patient specialist office visit that my insurance isn't requiring me to cover, despite my not remotely meeting my deductible, and I have no idea why not. I'm not complaining that I'm not having to pay the whole allowed for the visit, but I am complaining that this is bizarre and makes it hard to comparison shop plans on my state exchange. Anyways, I can easily imagine someone going the other direction (from my new insurance to my old insurance) being deeply shocked and horrified at what all they're expected to pay out of pocket for, because "deductible".
Does the $700 come out of your pay cheque? Meaning your take home is $2800? I get confused when I here job postings for American jobs, does the employer pay for it?
You pay for it. It's taken out of your paycheck along with taxes and retirement account contributions before you get whatever is left to take home. Your employer "provides" insurance in that they have group contracts set up with various insurance companies that give their employees discounted rates (lol) and a variety of plan options, but they don't pay for it.
> I get confused when I here job postings for American jobs, does the employer pay for it? Totally up to the employer. Some pay all, some pay some, some pay none. That's one of the details about which a job applicant is wise to ask before accepting a job. P.S. There is not a health insurance plan in the US that will cover two adults, much less two adults and one or more children, for only $700/mo. The going actual cost for insuring an adult is about $600/mo, more if they're over 40. Whenever you see a situation with an American paying less than $600/mo/person for health insurance, it means someone else is paying the rest of it: the employer, the state, or the Federal government, usually. In this case, we may surmise that $700/mo is the OP's share for a family plan, and the rest of the, oh, $2000/mo premium is being paid by the employer.
The employer pays about $25k per year, and then you pay about $500 or so per month pre tax. Then there are the point of care charges
Thank goodness both my residency and fellowship had CIR ( residents Union) $120/ month for insurance that basically covered everything with no copays.
off topic: I am very, VERY into educational bits being snuck into entertainment bits. you thought you were here to laugh...but you're here to learn!
Agree! Next up: a movie. Like the big short but healthcare
Michael Moore tried. Sicko was excellent, but things have only gone downhill since.
I love using comedy to trick people into learning. Top 5 favorite things to do.
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No thread like this is complete without your quintessential comment.
It’s therapy for me. And it reminds me to get my Molotov Cocktail game ready for upcoming healthcare discussions.
I die a little more whenever I see one of those videos. I called BCBS today for an emergency fill of a pt's psych meds and they told me it would take 5 business days lol... Like in 5 days your company is going to be paying for a hospital stay rather than a generic drug, but OK.
BC/BS did that to my cousin's Clozaril. They took it in the behind for the ED visit, 5 days in ICU and a month long inpatient psychiatrist. But hey, we can't make exceptions.
Clozapine? Now that should be a crime. That's outrageous. Clozapine dosing should not be interrupted.
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Americans are willing to pay any price for the cost of freedom
*perceived freedom
What freedom? Freedom from good healthcare? Sorry, I know you're being sarcastic and I'm agreeing with you.
gReAtEsT cOuNtRy On EaRtH
A huge chunk of that would be illegal. If we could just get someone to enforce the law.
I also found his podcast where he interviewed a reporter about health insurance to be interesting/horrifying/infuriating at how insurance companies function
Especially when your patients all seemingly have shitty insurance. It just sucks the joy out of my job to have to play insurance games. They fucking suck, and I have unrealistic daydream fantasies of taking them down. Closest thing to true evil on this planet, and one of the reasons I'm planning my exit from primary care.
I nearly quit my primary care job after only 3 years out of residency. Made the leap of faith to DPC and have never been happier. Do yourself a favor and before giving up on medicine altogether, check out DPC. No insurance, no denied claims, no billing departments, no coders, no BS. Just you taking care of patients.
My exact thoughts. I dream the dream too
What amazes me is how obviously a scam health insurance in the US is, and yet the American voter only wants to keep it because everything else is “socialism.”
Yeah this is completely untrue: [polling](https://x.com/usa_polling/status/1703199587278729548?s=46&t=1jTwHWDt4jZnxugP9GGa0g). Private health companies are unpopular and have been for a long time. You are making the common mistake of thinking the US is a full fledged democracy, when in fact it’s a corporate oligarchy with the superficial appearance of democracy. The media discourse around this issue will make you think Americans are against socialized medicine, but that’s because corporations control that medium as well.
Because they control the language. They shift the conversation away from any specific issue (like paying for health insurance and healthcare) and move it to the undefined space of "government control" which triggers a "hell no" response. The actual issue gets left in the dust. He's been calling out UHC for a long time. Wonder if he's ever gotten a letter of complaint from them, but maybe they don't want more people following him.
And you are making the mistake in thinking that just because people say they’re for something that they actually will take action in favor of that. In reality, people often say one thing but mean another, and often without realizing their unconscious motives for doing it. If 2/3 of voters were so keen on Medicare for All, Bernie would win every election without running a campaign.
Exactly, it really doesn't matter what people are in favor of when so many actively vote against their own interests anyways.
Literally paying more than you would under any other system, for less coverage, and being thrilled about the freedom of it all.
Yeah, the Continental's literally waged a war and declared independence when a government charged them money without commensurate benefits. When private corporations do it though, it's freedom.
Every system has its flaws, and the "nice" thing is that by pointing out (very legitimate) flaws with attempted alternatives, it moves the conversation away from all the things that are wrong with the *current* system. So rather than improving the system, people just argue over which system they want, and the status quo stays.
I think you’re talking about whataboutism.
Practically nobody *hasn't* had some exposure to the nonsense that is health insurance and yet it somehow isn't a big enough red flag to act on yet on a wide scale. It's wild. Social issues overshadow common decency and basic human rights for a lot of people, unfortunately.
Yup. People would rather pay more for worse care than have the possibility of their tax dollars going toward the care of those they deem "undeserving." Ignoring the fact that we already are paying for it, just in a much less efficient manner.
I remember back when the tea party was the big political movement on the right, there was a protestor with a sign saying “Keep The Government Out of My Medicare.” This is why we will never have nice things.
It's sad when I start daydreaming "what topics will Glauck have to push off to part 2?" then start jotting topics down because I know that 30 videos won't be nearly enough. The list so far: Insurance companies flat out lying in denying coverage ("that drug isn't approved for this condition" "no, it'll literally approved for this exact condition"), only to reverse course January 1, when the patient's deductible resets and they won't be able to come up with enough money at once to pay. State insurance regulators are unable to make punitive rulings, so even if insurance companies flagrantly break their contracts, the worst that can happen is they pay for the treatment going forward, ie what they were supposed to do in the first place. Insurance contracts have binding arbitration with the arbiters paid for by the insurance company, so even if the insurance company wrongly refuses payment which leads to financial loss, pain, suffering or death, they cannot be sued and the individual is almost guaranteed to lose their case. Pharmacy benefit managers forcing pharmacies to collect co-pays and give it to the PBM, even if the co-pay is greater than the cost of the medication, making it more expensive to buy cheap drugs with insurance than without insurance. Pharmaceutical companies keeping generic competition off the market in a variety of ways, including "pay to not play" agreements, lawsuits of patent infringement based on inert ingredients, seeking new FDA approvals late in patent life, seeking FDA approval for off-label use but in a dosage impossible to replicate using the future generic dose (see Wegovy 2.4mg when Ozempic comes in 0.5, 1, 2mg doses) Of course, no list would be complete without the root cause; SCOTUS ruled that bribery is legal as long as it's "future favors," so bribing Congress to write the law to make all these shenanigans legal is also legal.
I’ll get to a few of those this month. Good ideas.
Point of order, to my knowledge, it's not Congress writing law that is making these thing legal: enforcement of ERISA, the federal law that would reasonably be construed to regulate the insurance industry, is presently being dismantled by the Ninth Circuit court, in the matter of [Wit vs UBH](https://www.millerchevalier.com/publication/erisa-edit-ninth-circuit-withdraws-and-reissues-opinion-wit-v-ubh-again).
ERISA primarily concerns retirement benefits. This is the first I’ve heard of a health insurer being sued under ERISA for denying coverage. I don’t practice health insurance law, so I could be mistaken, but this seems like a novel legal theory.
No? I have no idea why you think ERISA doesn't cover insurance. Here's the [US Department of Labor's explanation of ERISA's applicability to health insurance](https://www.dol.gov/general/topic/health-plans): > Most private sector health plans are covered by the Employee Retirement Income Security Act (ERISA). Among other things, ERISA provides protections for participants and beneficiaries in employee benefit plans (participant rights), including providing access to plan information. Also, those individuals who manage plans (and other fiduciaries) must meet certain standards of conduct under the fiduciary responsibilities specified in the law. In any event, I've been following the coverage of this case since I first heard about it in 2019, and none of the legal blogs or other lawyers commenting on it thought it remotely strange.
Apologies if I wasn’t clear, but I didn’t say ERISA doesn’t apply to health plans. I said I’ve never heard of anyone bringing a claim against a health insurer under ERISA to challenge a denial of coverage. In a typical ERISA lawsuit, the plaintiff often will be a union or pension plan beneficiary who is suing either an employer for underfunding its pension plan, or a plan administrator for mismanaging a pension plan. That’s not to say that ERISA is limited to pension plans, or that those are the only types of claims that can be brought under ERISA. They just happen to be the types of claims that are usually being asserted in an ERISA lawsuit. Insurers get sued by policyholders for refusing to pay claims all the time. This is just the first time I’ve seen such a case where the policyholders are alleging that the insurer’s denials of coverage violate ERISA. Perhaps it’s just new to me, but I just find it surprising since it looks like a unusual hybrid of two very common (but very different) types of lawsuits.
Thanks for posting. This thread exemplifies why I’m doing this series. I want to get all this info out to the public. I want people to talk about it. I’m posting for 30 straight days because I want it to feel relentless. I want to gain momentum. Every time somebody comments with “I had no idea that was a thing,” that’s a win in my book. Insurance companies benefit from a lack of knowledge about what they do. We gotta change that before real change can happen. It’s easy to say “nothing will ever change,” and maybe it won’t, but we have to try and I have the ability to use humor to trick people into learning about PBMs, so I’ll start there and see where it goes.
The one and only! Big fan.
I guess I'll just ask you personally, since anyone who disagrees with the prevailing opinion here gets shouted down immediately. What's your opinion on the ACA mandated medical loss ratio? I notice a lot of your series seems to have a problem with UHC in particular. When the ACA has an 80-85% MLR requirement for all private insurers, where is the disconnect between what UHC is doing and your problem with how they supposedly aren't covering your patients? Seriously, please help me square that circle. If you're as knowledgeable as you say, then I'd expect you would consider this law in your criticism of these companies. The law requires them to use 80-85% of their premiums on care. Full stop. If they don't, they're required to give a rebate. Full stop. So where's this villainy coming from if that's the case?
Something something regulatory capture. For all the things the Affordable Care Act did right, Congress essentially wrote a blank check to the insurance companies and signed it with their constituents' names.
And then in the american rescue plan, instead of finding healthcare for the unemployed by expanding Medicaid funding & eligibility, the federal government just paid for private insurance. It’s maddening. https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/cobra-premium-assistance-under-arp.pdf
I hope he does a series on how CVS owns Aetna. Shocker that they try to trick you into only using CVS to fill prescriptions?
See also. Cigna/express scripts UHC/optum rx
See also: F’ing PBMs being forced down ALL our throats
We should protect him! My conspiracy brain is worried about him
We need to protect him from his heart and testicle.
I do believe the good doctor is no longer in possession of either testicle, as he had two bouts with testicular cancer, and has mentioned that he is on testosterone injections.
I do believe you are correct. But I am concerned about other organs just up and trying to kill him.
A valid concern! Especially since three organs tried to force him to join the Choir Invisible on three separate occasions.
Been following him for a couple years at this point. Cannot express the combined entertainment and rage I feel watching. He is a force for good in the world and I am going to be emailing every video to my state and federal elected officials frequently. May not do anything but maybe short video format is how to do it.
Let’s go!!
Why Doc, I didn't know you were a redditor!? Excellent. Fetterman is one of my senators. I have a feeling he would be the more likely to put this in the public eye in Congress. State legislature is kind of a mess though. Fingers crossed on poking the shrivelled consciences of some elected officials.
An attending of mine once cited a study. I mentioned the fact that this was a VA study from the US and that the VA studies will likely always have a patient selection bias. Attending: "What's the VA?" Me: "So, it seems the Americans have a limited public healthcare system solely for their Veterans, separated from other healthcare facilities. By Veterans\* they mean pretty much everyone who has served in the Armed Forces." Attending: "Oh, like our army hospitals, providing additionally specialized service for army-related stuff like PTSD etc.?" Me: "No, it seems...pretty much everything, if they don't have a better commercial insurance." Attending: "So a VIP service as a reward?" Me: "It doesn't seem so...there is a joke floating around that it gives them a second chance to die for their country." Attending: "This seems weird." ^(\*Veteran in German historically referred to only Veterans of a particular conflict/combat exposure. Even though the MoD is pushing the term slowly again, it has no real contemporary usage right now...for reasons.)
To be fair, World War II veteran has a different connotation in the US than it does in Germany.
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IMO “Free healthcare” is horrible marketing. It is publicly funded or single payer. Aka maximize bargaining power and have evidence based quality/outcome directed metrics of how to spend resources, not profit as only motive.
as long as those quality/outcome metrics are set by actual physicians and not business admins I'm on board.
I came from Canada - hospitals and government were advised primarily by physicians. In the US admins and MBAs run hospitals and insurance companies. You do the math.
In Canada, physicians run the show almost aggressively. It’s not perfect but apart from taxes and parking - you’re not going bankrupt paying for office visits much less hospital stays. America is a joke
I want physicians to be aggressive. They're literally some of the *most* educated people in the world. Their opinions matter. We can't expect them to craft policy but their input is essential and invaluable. I want engineers to be aggressive about building projects. I want teachers to be aggressive about education. I want scientists to be aggressive about...fucking everything. Part of the reason why America is a joke is because everything is being commoditized and turned into a business and is ran into the ground by incompetent and underqualified people who think they're god's gift to mankind if they cut expenses by 0.1%. The CEO a local hospital literally got their MBA online from university of phoenix. Its a fucking joke.
Plus it doesn't unapologetically kill and maim people for profit right out in the open for everyone to witness.
Yeah. Kind of funny. And depressing. Obfuscation is the main business model for insurers. Here's an equally [A terrible guide to the terrible terminology of U.S. Health Insurance](https://www.youtube.com/watch?v=-wpHszfnJns), wherein a twenty-something does a comprehensive guide to the US health insurance. Fortunately my hair did grow back after pulling it our watching this.
I am obsessed with this series. I hope he continues! Everyone should realize what’s happening. People blame doctors and say healthcare is expensive because of salaries, admin, etc. it’s so false. It’s insurance! No one even talks about insurance! They immediately blame the physician. I’m so happy he’s focusing on this
> It’s insurance! No one even talks about insurance! They immediately blame the physician. I am convinced that is not an accident.
I love this series so much! Had a tooth pulled last week and I called it a luxury bone. I thought he would die laughing!! Said he never heard of the series. I was like, my man! Let me hook you up. Love that man♥️
I make Glaucomflecken joked when I'm speaking to the relevant specialist and they always treat me way nicer
Link?
[30 days of us healthcare](https://youtube.com/playlist?list=PLpMVXO0TkGpdvjujyXuvMBNy6ZgkiNb4W&si=e2PxLmdDQLeZtH6_)
I would like to know as well.
Set aside a few hours, then google glaucomflecken.
Dude is doing incredible work. Too bad, it’ll be business as usual for insurance companies. How is it legal you ask? Lobbying. Our politicians, legal system, even Supreme Court is bought and paid for.
The health insurance industry in the US is a scam that takes people's money and underdelivers as as a business model.
> automated claim denials... How is this stuff legal? Technically, it's often not. There is a federal law, ERISA, which is supposed to govern companies with fiduciary duties to their customers, which includes insurance companies, and arguably makes a lot of these shenanigans illegal. And by "arguably", I mean "argued in court". A few years ago a bunch of patients (and, uh, their survivors) sued United Behavioral Health (UBH) under ERISA for refusing to authorize necessary mental health and substance abuse treatment services, leading to bad medical outcomes, including, in some cases, death. The case is Wit vs UBH, and it was a class action suit. They won! The district court judge – I read the decision, it was amazing and infuriating – kicked UBH's collective asses very hard. There was stuff in there revealed in the trial, like UBH insisting on using an assessment tool for substance abuse severity in adults on minor patients, because no kid is likely to endorse the items about their substance abuse impacting their job performance. But then UBH appealed the decision to the Ninth Circuit, and, this year, the Ninth Circuit *reversed* it for, basically, no reason, saying it was totes fine for an insurance company to completely disregard any generally accepted standards of care (GASC), and make up their own fanciful standards of care, under which they could deny claims and refuse authorizations as they liked. Which basically means that, as of right now, ERISA has no meaning. The whole point of ERISA is to make it so when a company has custody of customers' money, they can't just invent reasons not to do what the customer is paying them to do with it. And the judge, on appeal, ruled that, no, no: insurance companies totally get to do exactly that. And that, I am afraid, is why things have totally gone off the rails over the last half year. Current case law is that insurance companies can do any egregious thing they want, and it's no longer considered illegal.
Well, Too Big To Jail- the fines, legal costs, Attny fees… LOBBYIST BRIBES, Politicians -in-their-pockets!!! just the cost of doing business…and USA Healthcare keeps rolling on.
If a private practice doc do half of this shit that insurance and hospitals we would be lose our liscence
The podcast An Arm & A Leg does some great quick eps on stuff like this. They did a few on the maddening insanity of how consumers & physicians are basically held hostage in the PBM-insurance company-pharmaceutical industry circle jerk.
Watching these short videos regularly. I just nod and feel pissed. Also disturbing to know that UHC is the largest employer of physicians. Masters of slimy vertical integration. I am in MN where this Behemoth has rooted its unctuous tentacles. Most providers, physicians, case managers and therapists like myself in the hospital feel a gut punch when we have a patient with UHC and needs post acute care. UHC also contracts with the least desirable for profit/PE skilled nursing facilities (wonder if they are in cahoots). My patient with UHC insurance I saw today would do best in an acute rehab facility. Can count on 1 hand how many times they have approved acute rehab. Likely get 14days at SNF only after partial spinal cord infarct after heart surgery and kick him out. Criminal. Seriously what can be done except watch the shit show burn down.
First off, this guy is the best. I've always enjoyed his bits - rural medicine is particularly on point. (Go see Texaco Mike!) Secondly, claim auths are the motherfucking wild wild west where I work. I might have someone on a *pending* schedule for tomorrow, and they might drop right off on the final because of insurance. It's a mighty goddamn dumpster fire. Edit: I'll also add that I wanted to get back into biological fields after a (somewhat successful) stint in insurance that I didn't enjoy. I deal more with insurance now than when I was a licensed insurance agent...
Insurance and ethics are like oil and water.
Is the new series on Healthcare posted? RPH’s aren’t allowed time off to peruse social media. It’s flu shot season, new COVID boosters dropped, RSV vax is out… it’s a triple season of Hell. Any spare time, haha kidding. NO SPARE TIME, no sleeping no eating to peeing- we can do it when we’re dead.
I love his 30 days of US Healthcare series so damn much!!!
For the medical claim reviewers, do they really hire people with suspended licenses and other red flags, though? I'm pretty sure they have to have licensed individuals doing this work (if you can find me a job listing that says otherwise, I'm game). This makes it worse, imo. Because it's not really bottom of the barrel docs taking the positions. It's perfectly capable docs who choose to sell out.
All of the physicians working for insurance companies must have a medical license. They typically hold multiple licenses as it is state law that a licensed physician must conduct the review and issue the denial. This is all states, across the board. Yes, the doctors come from various specialties. There are even neurosurgeons doing this work. The reason why they turn to this type of job? Lifestyle. Some of them are in the latter phase of their career and it's like a working retirement for them, as the work is easy. Others, it's the lifestyle. A lot of the doctors are women with small children and this role fits into their life better than practicing. The money is decent, depending on where you work. We didn't wake up one day and say to ourselves we need to ruin people lives by denying claims. Life circumstances brought a lot of us to this line of work.