Seniors write in about how they’re eating dog food to pay for their medicine, I forward the letter to insurance doctors, who deny it because they “have to try these 3 drugs before you can get what works”.
Made me realize this whole country is broken and those at the top are morally bankrupt.
I get denied health insurance policy itself due to my physical disabilities against the local laws and regulations in my country[1]. That includes major International brands.
How can I put this gently, capitalism thinks I'm not worth living or saving.
[1] https://abishekmuthian.com/insurers-are-putting-the-lives-of...
Why use a $1000 per month branded drug unless you know the $5 per month generic drug doesn’t work?
The only sane response to that is “okay, I won’t give my kid either of those; we’ll just stick with OTC lotions”. Which is exactly what they intended.
These seniors should vote for and advocate for a more expansive social safety net then.
Why don't I throw you in a cage, and then you can try voting for someone to advocate for your release.
The point is the seniors need help now, not being told to go organize. The healthcare system is broken, and until you get sucked into it, you don't understand the extent of it.
It's different for people less fortunate than ourselves. We all mostly work tech jobs with great pay and decent insurance. These people don't have that. A lot of them can't pay for food.
So yeah, I'm doubling down. Downvote away.
- What did the insurer expect to happen, in order for this person to keep getting their medicine?
- Why did those things not happen?
- Whose job was it to make sure those things happened?
- Did that person know it was their job?
- ...etc.
I get that it was about prior authorization, but whose job was it to make sure the prior authorization happened? Why didn't that person do it in a timely fashion? Why isn't there an understanding within the insurer's system that Type 1 Diabetes is a life-long condition and not something that will just go away when the insulin runs out?
Was there a "happy path" here or does a scenario like this invariably degenerate into a scramble involving dozens of calls and day-destroying last-minute errands?
This statement about what a prior authorization is is also incorrect:
> They’re essentially requirements that a physician get approval from an insurance company before prescribing a treatment.
Doctors need no approval from anyone to prescribe. A prior authorization is approval from the insurance company that they agree with the treatment option and will pay for it (subject to deductible/copay/oop max).
The theory here is that the end user has no idea what they are getting since they are not knowledgeable about medicine. Doctors could be prescribing unnecessarily expensive medicine or treatment, so the managed care organization (MCO, or insurance company) “manages” the healthcare for the uninformed buyer by having the healthcare professionals employed by the MCO double check things.
In this specific person’s case, it looks like the biggest delay was in getting a doctor’s appointment when he needed both a new MCO and a new doctor. Technically, you can pin this on undersupply of doctors, MCOs tied to employer, MCOs not hiring good people and causing unnecessary delays, incompatible electronic documentation systems that do not talk to each other, and I could go on and on.
Ideally the doctor should be able to see what medications the MCO will cover on their computer while the doctor is seeing the patient so before they even leave the doctor’s office.
Another concern in the long list of concerns is the MCO is not necessarily the one deciding the rules for what treatment/medications to pay for or not. Many, many times it is state government (e.g. Medicaid), federal government (e.g. Medicare/Tricare), or other entity that is actually paying for the healthcare who will hire the MCO and give them the rubric on how much to pay for people’s healthcare/what treatment courses or brands of medications will be covered. This is how poor people (Medicaid) can be restricted access to healthcare by limiting the reimbursement for their healthcare so fewer doctors accept it while older people or members of military get access to better healthcare because their healthcare gets reimbursed at higher prices (Medicare/Tricare).
The system allows for a lot of opacity to allow for a lot of price segmentation while also providing political cover for such decisions due to the complexity of understanding it.
1. Wait for prior authorization and allow our appointment to be canceled and rescheduled (for the fourth time, having already wasted several weeks)
2. Pay out of pocket
We decided to pay out of pocket, since we knew that the prior authorization could delay us by an arbitrary amount of additional time and had recently read that the insurance might not even help us anyway.
The twisted thing is that you can't just get the operation done and let the prior authorization work itself out later. It truly has to be prior or you get stuck paying out of pocket, even if the operation is obviously medically necessary.
This structure seems expressly designed to screw the patient over. Maybe it doesn't prevent the doctor from prescribing, but it has a similar impact in the end.
And regardless of my anecdote about prior authorization, there is the question of why someone with Type 1 Diabetes is being denied their medicine. I feel like the only potentially valid excuse would be if the insurer literally didn't know the person had Type 1 Diabetes.
To the consumer, the experience is the same - they can’t get a necessary drug before spending hours or days playing telephone tag with their doctors office and insurance company. Often, this happens for a drug they’ve taken their whole life. Insulin, thyroid hormone, etc.
Well said overall, but the supply of doctors isn't the issue here (regardless of if it's a separate, bigger problem).
1) This case is what mid-levels are ideally suited for. Routine and can be seen within a day or two. Would have moved the whole timetable forward.
2) It's the supply of doctors participating in any given insurance plan or govt reimbursement scheme, not overall supply.
It's pretty easy to find a doctor to see same-day if you pay cash (either straight cash or front cash and submit your own reimbursement).
Which is itself more an issue about regulation being so burdensome and costly that doctors can't afford it without joining a large group or hospital owned practice. Especially the cost of required electronic records.
Which is why it seems like all the small private practices are being bought out by hospitals. Because they either are, or their docs are retiring, or they are opting out of all insurance and govt plans and going concierge/prepaid/membership/cash-only.
What I'm curious about is #1: why couldn't this person get in to see a mid-level sooner? They rarely book more than a few days out.
It's exactly the type of issue that they are meant to help with to reduce demand on the doctors and get patients seen quicker. A routine refill without any nontypical complexities or changes to report.
Did approval specifically require a physician? That would be more of a system problem that needs resolving.
The whole thing is performance politics to distract from the "insurance" companies running everything from medicine regulations to your kids playgrounds (so they don't hurt themselves and need care).
This is also a consequence of our legal/tort system. At one of my business, a person claims to have stepped on a landscaping rock and damaged their ankle or knee or something. They took pictures of this roughly 2in x 2in x 2in rock in the parking lot, maybe a foot away from the curb that separated the landscaping rocks and the parking lot surface.
This lawsuit has been going on for 3 years now, and I can only assume $10k+ in lawyer time has been spent asking the employees if they saw a rock there and when they last checked the parking lot to see if it was clear of rocks, etc.
With the courts accepting cases like these, and businesses needing to protect themselves from cases like these, it is no wonder as a society, we end up wrapping ourselves in insurance. Specifically in this case, the person or family suing has been found to have a history of these types of lawsuits. And yet still, the case drags on.
https://www.healthcare.gov/glossary/out-of-pocket-maximum-li...
With the recent laws regarding mandatory coverage of emergencies while out of network, it seems to qualify for the definition of “insurance”, as you are protected from expenses above $17.4k per calendar year per family.
The fact that most Americans probably cannot afford this is a separate matter, but it is more insurance than it has ever been in the US.
Given that this applies to in-network costs only, as you noted above, it seems very inaccurate to describe it as genuine protection. Any random provider in your current care situation can be out of network, it is very hard to know or have any control over especially in a crisis situation, and it is these providers that usually end up billing you through the nose.
It would be irresponsibly misleading to call your life insurance "protection" if the insurer just rolls a dice or consults the day of the month to determine if they'll pay your claim.
Your example is leagues of laws and regulation on top of a scam, a pyramid model that affords top care for those who can afford modest premiums and really do get expensive care for $5 copay, at the cost of everybody else who has to fight their employer via federal politics for the right to go bankrupt.
Indeed, I would say that using insurance to pay your insulin bill is coming out on top of the scam, because some books are getting cooked (+/- paper costs) at the expense of mutual indemnity (taxes, social security). An insulin user is a health insurance voter, but that is a weak expediency for actually fixing the price of insulin and ending the tyranny of insurance companies over healthcare, and it turns whole populations into do-or-die partisans.
Thanks, Obama!
As an analogy in the case above the car owner is having their insurance company pay for their gasoline - where you are referring to an insurer paying for a car accident.
Wife was on some serious (and expensive) medical treatment. After many months, the medical provider was at the final stages of the treatment. As usual, the provider needs insurance approval for arcane codes that constitute that segment of the treatment.
Get this, the medical provider applies for approval using a FAX. There is no acknowledgement or online tracking. And the authorization is received back using FAX. What a joke!
My wife didn't hear about the treatment for 3 weeks. Under pressure, she called her insurance. Insurance says, they didn't receive any request for authorization.
Why the fuck didn't the medical provider follow up? Exact question asked by my wife. Medical provider's explanation was that they faxed and were just waiting on insurance. They just sat on their fat bums while the time was running out.
So, wife patiently asked medical provider to apply for authorization again. The provider said they sent another request right away.
Another week later, wife had to call insurance again to find out that they STILL DID NOT receive any request.
Distraught wife asked insurance rep to call the medical provider immediately. Of course the call went to voice mail.
Wife then called the medical provider and left a scathing voicemail, threatening to sue. Only then this system worked miraculously. It still took a day for the medical provider to figure out what was wrong with their fax system. It still required my wife to follow up with insurance asking if they received the authorization request. Then 3 days later, the insurance provider approved the authorization and my wife had to call the medical provider again to confirm that the authorization was received.
All good now? Ohhh Noooo. Now the medical provider placed an order for medication that needs to be shipped from a pharmacy in another state. And they do place it. Now my wife gets a call from the shipping pharmacy to schedule a delivery. The delivery happens after 3 days.
Wife checks the delivery. Oops, it is missing a few items required for treatment. Guess what she needs to do to get the missing items delivered? You guessed it. Have the medical provider do the authorization process ALL OVER AGAIN.
Oh, and every call to the medical provider goes to a voicemail to which they take a minimum of 8 hours to reply and every call to insurance has a 30 min elevator music. Imagine all this 10 times in 3 weeks and that was just one round of shipping and nervousness.
Fuck American Healthcare.
France is starting.
Someone in the US should get funding for this. It's a 300M people's "market".
American healthcare is what I would wish on my enemies.
I'm sorry but this erodes my sympathy significantly. Learn about the options that exist if your first choice treatment isnt available. Learn about mitigation when no treatment is available. This is your life, act like its your responsibility already.
I have no love for pharma price gouging, but if insulin was free, everybody would be stuck on the 1921 formulation.
Science can help, alloxan destroys the islets of Langerhans, it is used to create diabetic mice. Go ahead, take a dose, lead by example. The Walmart insulin comes up here on this website from time to time, and the overall conclusion is that long-acting insulins prevent blood sugar excursions.
I am. I expect to be dead before the decade is out, the doctors offer ways to make that more comfortable but shorter. I disagree with their priorities and am thus on my own for other treatment options.
"I do not need to know about other options" seems inexcusable to me, and seems to be what the author assumes is the correct attitude towards their treatment.
In most countries insulin price is around $30. I remember it was cheap in US too.
Seems like another problem created by US kleptocracy. Make something prohibitively expensive, and "solve" problem by providing handouts to cover costs.
Edit: I just remembered that diabetes is recognised as a long term condition, so you would be 100% reimbursed by the public insurance scheme.
On top of the national mandatory health insurance, there's also optional private health insurance and private hospitals and such, but even for those the prices are nowhere near the insane numbers I see whenever US healthcare is discussed, and I frankly can't understand how people aren't revolting over there.
In short we haven’t come to a consensus as to derivation of the engineering axiom, you can have 1) broader access 2) quantity/quality 3) affordability —-pick two
That's seriously f'ed up.
If you don't believe that's the purpose of the new regulation you are insufficiently cynical. Where's the revolution?
Here's a page going through the story.
An Arm and A Leg is a really interesting podcast partially funded by Kaiser Health News that does similar stories to this one, going through the ridiculousness of the whole US Healthcare system and how people have successfully navigated it.
https://armandalegshow.com/about-x/partners-and-supporters/k...
