Go after all the healthcare giants. If people knew even half of how consolidated their treatment was, they would riot.
For those who don't know about the significant conflict of interest present here:
1. United is a health insurer that has to make payments for people's
2. United owns several physician networks (totaling 90,000 physicians), who then determine what your care should be—no conflict with the fact that they pay the bills...
3. United owns Optum, which determines how much your drugs are going to cost, and of course, who makes them—brand vs. generic, etc.
4. Optum runs its own mail order and specialty pharmacies. Optum also writes your care plans for many chronic diseases and ships medications all over the country.
5. Optum could require their own customers to use their care plans and software in order to receive medications at all, or mark up the price for anyone who doesn't.
Let's step through a workflow.
You, a patient on United, go to a physician for treatment. Later on, you get referred to a specialist, then get diagnosed with a chronic disease and need medication that you receive delivered monthly.
That pans out to:
United pays United, who refers you to United, that forwards you to Optum (owned by United), who gets paid by United. Each and every month.
Let's say you find a better deal for your medication at another pharmacy. Too bad, its not going to be in your network and Optum will no longer cover it.
How is a health system or an independent supposed to compete with that level of integration?
This, of course, does not result in any savings or quality of life improvement for the patient or the physician. United and Optum charge the same prices as everyone else, or more.
If people knew half of how consolidated their treatment was they would riot.
Most Americans experience first hand how horrible health care here is. No one can get upset at whatever little details are involved, however 'cause it's beyond them. Especially, you won't get people excited about more competition in a field where markets and competition seem neither logical nor have shown any benefit.
The complex referral system you describe basically results in turning regulated monopoly behavior into unregulated monopoly behavior. And this is the upshot of breaking up the original, regulated monopoly Blue Cross/Blue Shield, which provided adequate insurance in America's "Golden Era". Which to say that, imo, "restoring the free market" isn't a useful action in this mess. State controlled medicine is essentially the only solution to the already partly collapsed US health care system.
Oh I don't disagree that the system is fundamentally broken, but we clearly need to attack from all angles.
quicker to start from scratch
That's lie rewriting a code base from scratch because the current is deemed unmaintainable. Most of the time you end up with the same number, but different problems or it's even worse.
In my view Medicare for all would be a viable path but even the Democrats are not interested in tackling healthcare.
Let's refactor it then:
The government simply takes ownership of UHC and they get a new charter to run it like the Postal Service.
My mailman refuses to take my stamped envelopes out of my mailbox. Can't be bothered.
I’ve lived at my current address for about five years. The first year, zero issues. Starting at around the 2020 election, service dropped off precipitously, to the point where I’ve had a piece of outgoing mail in my box since Friday. I can’t trust the mail with anything time sensitive any longer.
I blame this on Louis DeJoy, who was appointed Postmaster General in May 2020, and has numerous conflicts of interest.
It’s hard to make government services efficient when you have people in power who want to prove that government services are always bad.
Count your self lucky he is not stealing your packages.
Curious, how at this point could BigGov make UHC worse?
At this point I’m open to new and exciting problems, whatever they may be.
Hell, I’d be ok with leeches making a comeback if it meant I didn’t have to pay a copay on top of a premium.
Honesty at this point I'm planning to move to a country with sane healthcare sooner rather than later.
A code base doesn’t have tons of middlemen taking their cut. The current system is unsalvageable. Massive disruption is needed.
How would you even do that? You need nurses and doctors and buildings and training.
The lead time is decades and the cost incredible.
Best start now guess.
Imagine a time before health insurance existed
More doctors, less work per day per doctor, more attention to each patient?
What evidence do you have that this would be a good thing?
And to the larger question, which I hear all the time, what does “starting from scratch” even mean when it comes to ongoing health care?
You can’t seriously argue that we should risk medication interruptions so your friend loses her dad to his heart condition so we can somehow “start over?”
We need a smooth transition to a more sustainable system with incentives aligned to customers and not investors in one scenario, single payer in another, or some other working idea to continue to provide care while reducing the insane profits and aligning health and well being of patients, as well as the health and well being of the people providing it, with the actual service delivery again.
Burning everything down could kill a lot of people. I think this position is actually not particularly compassionate.
Ban all health insurance. And Medicare. And Medicaid. Require all healthcare services be transparently and consistently priced in cash. Transform the IRS into an insurer of last resort by providing 100% tax credits for all medical care in excess of 8% of income. Fixed.
Would you keep or get rid of EMTALA in this scenario? What would happen with medical debt? I'd hate my healthcare options to be tied to my credit score.
Obligatory Gall's law
I mean, no, most Americans are just upset about cost-sharing, most providers in the United States are pretty good and have pretty good facilities and equipments.
You can have systems that are mostly privatized (cough, France) that are better regulated than the United States, but that'd mean doctors would get paid less money & upper class folks would likely get worse care
Maybe in large urban areas, and if you can afford insurance at all. In rural areas, even smaller urban areas, there are few physicians, long waits and not enough facilities. [https://www.krqe.com/health/new-mexico-needs-hundreds-of-hea...]
It's the same in San Francisco, where we support returns to investors in residential real estate by banning new development since the 1960s and therefore doctor salaries don't afford a luxury lifestyle [https://www.nytimes.com/2017/06/03/business/economy/high-end...] and therefore we have a shortage of physicians.
San Francisco is also overwhelmingly young and healthy.
Between COVID and the millennial cohort in SF, that's not going to be true very much longer, if it is at all today.
This is because congress wont expand residencies so there arent enough doctors. Doctors make a bunch of money and can live anywhere they want, almost none of them want to live in bumfuck.
Remove the residency cap, allow foreign doctors to immigrate and quickly certify their skills, allow nurses to attend night school to become doctors, etc.
I agree this is the solution rural medicine needs.
[upper class folks would likely get worse care]
I agree that upper-class folks' experience would change in ways that would generate loud protests. But the biggest anger points likely wouldn't involve quality of care. Instead, we'd hear shouting about:
providers' increased emphasis on cost-effective care. (You don't need an MRI because there's nothing in your symptoms that warrants it.) Right now, there's a lot of overtreatment in the U.S. medical system, catering to patients' desire to get big workups.
scaling back of today's concierge-level ambiance, with fancy chairs, skyline views, etc.
I think has more to do with a combination of overtreating results in higher income and fear of malpractice suits if you undertreat.
Partly. Let's also talk about the ugly world of Certificates of Need and diagnostic imaging and how they collide.
CoNs are something lobbied for by hospitals. If you want to open a new hospital or healthcare facility in an area, you need to apply for a certificate of need, which allows/asks existing hospitals if they think there is a need for your facility, to avoid "overservice" (lol, okay) of an area.
Diagnostic imaging companies - each of the big ones (Siemens, GE, Philips) offer in house financing for MRI, CT, etc., that they advertise to physicians. They also all offer specialist consulting help to facilitate you getting a CoN for your facility. Hell, they all also well help you find other physicians in your area who'd like to go in on setting up a DI facility (and will assist with spinning up the practice).
And then we find that physicians who own a DI practice (or a share in one) refer their patients to diagnostic imaging at rates several standard deviations above other physicians, and at rates that are "statistically improbable" when correlated to underlying ICD-10 diagnostic codes.
Upton Sinclair comes to mind ("It is difficult to get a man to understand something, when his salary depends on his not understanding it").
unneeded surgery is also a recurrent theme; prescriptions for just about anything is now the norm
It’s not just happening in the US. What goes on in the US is very influential elsewhere, and both patients and staff get pulled into the vortex of over-testing. And then to top it off, sometimes they are correct and they did need the test.
the healthcare complex employs millions. all these people would lose jobs.
so there's really zero political will to crack the monolith, and why things like Obama care go forward, because they're bandaids.
then there's the who employer leverage that businesses live having to immobilize a significant portion of their work force.
it's absolutely not complicated to understand why nothing has moved the needle.
Not everyone in the healthcare industry would lose their jobs, that's absurd. It would mostly be the redundant insurance staff (and redundant sets of highly-paid insurance execs).
This!
Execs would lose their jobs. Billing specialists (who do a 4 year degree in medical billing, which is in and of itself fucking absurd) would lose their jobs.
You know who wouldn't lose their jobs? Doctors and nurses. The actual people who the system's outcome is dependent on.
The managed care apparatus in the United States is about allocating insufficient supply of healthcare to excess demand based on the political value of the healthcare recipient.
That is why Medicare pays doctors more than Medicaid for the same work (old people are worth more since they vote more than poorer and younger people).
You can endlessly bucket people into infinite changing tiers based on their political power using reimbursement, deductible, out of pocket maximum, in and out of network providers, formularies, and prior authorization protocols.
For example, you can give members of the military a different quality/quantity of healthcare than US federal Senators, who have a different set of policies, who in turn have a different set of policies from a highly profitable white collar firm’s employees, and yet again different from a less profitable business with lower paid employees, and so on and so forth.
You can adjust reimbursements so that some people can immediately see doctors whereas others have to go to Physician Assistants or Nurse Practitioners.
The system is a thing of beauty from a political point of view, and I bet countries with nationalized healthcare like UK and Canada move closer and closer to the US system as the population pyramids go upside down and cuts have to be made.
And the whole time, people will waste their time being mad at managed care organizations, when the government leaders are the ones hiring them to be the “bad guy”.
What? I have never heard of such a thing, and I worked in the claims benefit management industry for nearly a decade.
So I searched this, "bachelor medical billing" and while I got plenty of results, all of them were for certificate courses, which I'd expect. "Top rated medical billing courses" were all at community colleges.
I am yet to find a Bachelor degree in medical billing.
Indeed, on ... Indeed:
A certificate/diploma is going to be 9 months to 1 year. An associate diploma? 2 years. I also can't find any four year courses in medical billing.
Right. If these huge insurance companies had to "compete" with a real universal system, there's no way they could even exist. All they do is scrape profit off the top of every healthcare procedure in the US.
The most useless middleman to ever exist, in my opinion.
I agree with your broader point, but it’s worth noting that insurance middlemen exist in many European countries with universal health insurance, so surely some form of this can exist in a more regulated health insurance/provider market.
I had private insurance in Germany. The big difference is that they have to compete there instead of having a captive audience they have in the US with employer based health insurance. Your employer picks the insurance options that are convenient for them, they don't care much about what's good for you. So you are basically trapped unless you are willing to not take insurance from your employer but go on the open market which will be very expensive.
A while ago I asked my employer to just give me the money they give to Optum so I can buy insurance via ACA but they wouldn't do it.
The problem is the US has for-profit medical insurance as well as mutual insurance (collectively owned by their members). The laws were altered in the 90s to permit mutuals to convert to for-profit. This was generally a bad move as it takes out any real incentive to manage costs when jacking them up is the only way to boost profits so the C-levels can get 8-figure bonuses.
More competition increases the number of jobs
Optum has billions of dollars in profit annually, none of that is going into the employees pockets or patient savings.
They're also firing people for fun. I know of a guy who is deep in the weeds upgrading their scala libraries that just got laid off within the week. (You have to do that to stay on top of all of the cves)
I don't trust the US government is competent enough to run healthcare. If it can do better than the existing system, let it create a new voluntary, unsubsidized insurer, free of the BS rules it has created. Competition is the source of quality and low prices. Any monopoly is an invitation for poor quality and high prices.
The great thing about the "50 states" model is states can try random experiments. For example, Texas has done a lot to try to bring more competition but none of them have done a thing for the high cost of healthcare.
That would be great if we had real federalism. The states cannot try anything really unique, because they are hamstrung by federal law and federal subsidies with strings attached.
Yup. The big one to me being capping malpractice payouts. "Healthcare costs a lot because physicians have to carry very expensive malpractice insurance because of astronomical judgments".
Texas caps malpractice payments and everything stays exactly the same.
Also, malpractice insurance in itself isn't typically as onerous as people believe it to be. What is onerous, and what that industry does differently to most other insurance segments is "tail insurance".
Tail insurance is the concept that major malpractice suits may appear well after your claims-made liability policy has ended. In most cases it's actually DOUBLE the premium you're paying for malpractice insurance, implying the insurer believes that your coverage is less than one-third of the claims they expect to pay. What -should- happen is that you carry "claims-made and prior acts" coverage. The challenge there is that in many cases your employer will cover claims-made as part of your compensation or part of their insurance, but don't elect prior acts coverage (and because of the way they do it, I suspect it's not as simple as "let me pay the difference").
But in general capping malpractice payouts has done nothing to offset malpractice coverage costs, let alone flow-through to end consumer costs.
But wouldn't government control and subsidy lead to the same malinvestment and cost explosions as college tuitions?
Wouldn't fierce competition at all levels be a good thing?
Why not force insurers to cover everything up to a set cost on a per-disease basis? That is, let patients spend a set allowance before forcing them to use in-network?
Why not adapt upfront cost estimates? Allow overages, but if a hospital goes consistently over estimate, then they get penalized?
Allow patients to access cheaper doctors and services if they waive their rights to medical malpractice lawsuits.
Give patients cheaper healthcare for demonstrable good health practices (taking into account diseases and existing conditions).
It could do. It is hard to see how it could be worse. The USA health care system, "industry", is a case study in failure at all levels except some pointy headed technology
Definitely not. Competition is good in some areas, very bad in others. All sides must be able to enter and leave the market, and there must be even distribution of information. Most health care does not fit well
Many countries have socialised systems that use waiting lists rather than wealth to ration access to health care. The private health industry work very hard, at all levels I have seen, to undermine those systems, but in many cases they offer very good care.
Some of the best health care in the Americas is in Cuba
The little people and not so little people experience how horrible it is. All the big people get the platinum plated VIP treatment. And it's a great source of nomenklatura make work jobs for them.
Anecdote: Friend worked for a billionaire. Had a seizure at the office and ended up in the ER and the head of neurology department came down to check on him.
Yep. I have UHC through work. I'm on an expensive medication and UHC requires that I order it through Optum, so they keep more of the money. At least neither of the doctors I usually see work for them, so I don't have that conflict.
And has Optum conveniently forgotten to ship refills, but only for the expensive drugs? That happened to my wife on multiple occasions.
Or maybe they've rejected refill requests until right before your supply runs out, such that you have to go days without your meds while the new supply is shipped?
Optum is the shadiest shitshow I've ever dealt with.
They make it extra painful sometimes when it's time to refill, requiring re-authorization every year. My doctor has a woman working for his practice who spends almost full time battling insurance companies so that patients can get their meds, and she's been my ally at managing these fights.
Yep, and this is the sort of make work that the health care system is full of that drives up costs for everyone.
A lot of the doctors I've seen recently just don't take insurance. Basically they just tell me what something costs and then I pay it. Obviously if you are poor this is a problem, but then again so is everything else and you probably can't afford health insurance anyway.
Every doctor has one of these people, and they are probably the most valuable member of the practice, after the doctor, themselves.
Most of them (in my experience) have been middle-aged women, hard-nosed, cynical, and no-nonsense. They can easily be abrupt and cranky.
It's a real good idea to ignore that, and make them your friend. They can do miracles.
Getting new prior auths every year is annoying but not exclusive to Optum, thats been the case with all the specialty pharmacies I've gotten prescriptions from.
Wait until people catch on to the behemoth that is CVS Health…
Oh, and I love where my insurance would cover my prescriptions from CVS in Washington, but when I was down in California needing steroids and anti-inflammatories urgently for my gout, they would not cover them there (and I'd made the apparently idiot assumption of having the urgent care physician send the scripts to a nearby CVS because I thought they'd be covered. Nope. Not even "out of network" - I ended up paying out of pocket and arguing for reimbursement.
For non-Americans: US health insurance is often bound to a state or even a region of a state, paying only for emergency care (and that, only because they are required to) outside that area.
We basically need travel insurance to safely travel in our own damn country.
Add it to the list of crazy features of our system, any one of which would cause riots in another OECD state if not fixed promptly. And we’ve got several.
Isn't this basically how an HMO works? I've heard those have lower costs and patients seem to like them.
What's different with United?
I've been with Kaiser in Northern and Southern California. But not really with other HMOs.
I think the difference is Kaiser (in most places) is really a closed system; if you're with Kaiser, you go to Kaiser facilities for everything, as long as you're in the service area. If you're not with Kaiser, you don't go to Kaiser facilities, other than the emergency room maybe. Everyone you interact with is a Kaiser employee or contractor. You don't get recommended care that won't be covered, you don't get treated by someone who isn't in network, you show up, you pay your copay, and that's it, you're done.
For HMO plans with other providers, it seems like the doctors are often independent; you have to stay in network, but you still have to deal with network BS like this office is in network, but only some of the doctors. There's not a Blue Shield medical center with doctors, specialists, and a pharmacy at one location.
Because Blue Cross Blue Shield is neither a healthcare provider nor a managed care (health insurance) seller.
BCBS is kind of like a franchising business, where the franchisors get access to other members’ negotiated pricing and administrative services to create a larger (nationwide) network. For example, your employer could purchase managed care from Horizon BCBSNJ, and if you get into trouble on vacation on the west coast, then they coordinate with Elevance or BlueShield California or Regence in Washington/Oregon to figure out how much they are paying providers.
And this way Horizon BCBSNJ does not have to do all the legwork of negotiating with every healthcare provider in the country. I’m sure it is quite a bit more complicated in practice though.
Kaiser also sells PPO plans where you do not have to see a Kaiser employee for covered healthcare.
My partner deals with claims denials for care providers and if someone wrote a book on the stuff she's seen happen, I genuinely think it would be akin _The Jungle_ for modern audiences in terms of cultural impact.
I’ve been getting exposure to this space and the backend systems that drive it. It is mind-bogglingly dysfunctional.
Aphyr recently provided a limited window[1] into the level of dysfunction that happens with one of these behemoths that are the result of 100+ mergers, acquisitions, spinoffs, and joint ventures.
I feel terrible for the providers who have to try to navigate these antics.
In my opinion, all of this contributes to two primary “bad” things: 1) increased rates of retirement from older physicians who don’t want to deal with this anymore (despite wanting to continue practicing for 5-10 more years), and 2) consolidation of physician practices into larger entities as a way of coping which inevitably leads to the entity being acquired by a hospital and absorbed into another behemoth of an organization.
Both make it hard for individuals to receive consistent, quality care.
1: https://aphyr.com/posts/368-how-to-replace-your-cpap-in-only...
On paper this seems similar to how Kaiser operates. AFAIK Kaiser is generally well-liked by its members, why is UHC so terrible?
I guess UHC doesn't own the hospitals?
Kaiser is non-profit, that might change the incentives?
You didn't even mention Optum Bank, which they use to also sponge up that sweet HSA cash lest any drop of healthcare spend somehow escape UHG's toll.
Isn’t this just how HMO’s work? It’s not a PPO, you’re supposed to have the majority of your care managed within the large organization. Kaiser Permanente is another one.
In theory it makes sense - by keeping everything in network there’s no constant negotiation over reimbursement rates.
But the problem is there aren’t many competitive HMOs, and we have a healthcare system driven by employment, so you can’t switch to a new HMO if you’re unsatisfied by your current one.
Edit: My point is that it’s not a conflict of interest to be routed through the UH network - that’s the entire point of an HMO vs a PPO. The idealized goal is that you have a coordinated team of providers across the organization.
Imagine if the useless governments actually broke up these behemoth megacorporations that control the entire vertical and horizontal slice of industry they operate in. What a crazy concept, right?
That kind of extractive, anti-consumer business model would be worth going after in any industry, but it feels especially bad in health care. Most health care isn't optional for the patient, and of course the more non-optional the care is the more expensive it tends to be. And serious health problems are both rare and incredibly stressful for the patient. Someone with cancer is going to have no experience shopping around for oncologists and will be willing to pay almost anything not to die.
It's almost the worst possible scenario for consumer driven free market dynamics. My personal opinion is that giant health-care conglomerates probably shouldn't exist at all. But if they do, they should be subject to much higher standards when it comes to things like antitrust than regular companies.
Basically, most forms (including ours) of capitalism turn into a oligopoly where each oligo-member is highly vertical and controls the whole narrative.
Another word for this would be corporation-states.
Amazon is another example of this. So is Google. So is Apple.
It's high time that government steps in and breaks these 'too big to fail' corpo-states up into actual competing interests that, in the end, do better for the citizenry. Cause each corporation is a dictatorial 'state' acting in opposition to our elected government, and much of our monopoly laws, either in spirit or in application.
It's important to understand the factors driving consolidation in the healthcare industry as this goes beyond UnitedHealth Group. Everyone is sort of gradually converging on a "payvider" model like Kaiser Permanente with everything under one parent corporation. Payers and providers have been merging for years in order to gain more negotiating power over claim reimbursement rates. Regulatory compliance issues and IT costs are also killing off small, independent medical practices. In many regions a few large health systems now dominate the market. So, the only way for payers to hold down costs is to build up captive provider organizations where they can drive some operational efficiencies and economies of scale.
Thanks for breaking it down, especially for people outside America.
Rioting isn’t covered under the insurance terms and conditions so no one can afford to do so.
Feel like you also explained the Apple walled garden. You pay 30% tax or no entry. Regulation need to be passed to change adapter port. Things won't work if you aren't in the ecosystem. And they cost a buck for Mediocre service.
Feel like you also explained the Apple walled garden. You pay 30% tax or no entry. Regulation need to be passed to change adapter port. Things won't work if you aren't in the ecosystem. And they cost a buck for Mediocre service
I’m sick of paying 5k a year myself and close to 20k counting my employer for a doctor to see me for 20 minutes, ignore everything i say, and then prescribe some shit without explaining anything.
Additionally seeing how my wife is treated by doctors makes me feel physically sick. I have no respect for the medical field
This is like Luxottica owning optometrists offices, eyewear providers like Lenscrafters, and Eyemed vision insurance.