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0 pointsforgetfreeman1y ago0 comments

This sounds pretty good but there's still some friction between what you're describing and observed reality. If all if this is accurate what incentives exist for insurance providers to even consider policies like this: https://www.cnn.com/2024/12/05/health/anthem-blue-cross-blue...

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nradov1y ago· 2 in thread

So I'm obviously not privy to internal Anthem discussions but I'll speculate on what happened there based on industry trends. There has been a huge increase in anesthesia costs over the past several years and I suspect that Anthem's self-funded employer customers are pushing Anthem to find ways to cut those expenses. Most anesthesiologists work in private practices rather than as employees of hospitals or surgery centers. Private equity firms have been buying up those practices and establishing effective monopolies in some regions, then jacking their rates up. Anthem handled the messaging around this issue horribly but I kind of understand why they tried to impose some limits. It's not like patients would be denied necessary care or anesthesiologists wouldn't be paid, the insurance would just cap the maximum charges for certain procedures.

https://www.beckersasc.com/anesthesia/private-equity-has-a-g...

Ultimately only a small percentage of the total money in the healthcare system goes to payer (insurance company) profits. Much larger portions flow to providers, pharmaceutical companies, and device manufacturers. So as far as reforming the system we can maybe get a little savings by squeezing insurers but it's not going to solve any of the fundamental problems.

forgetfreemanOP1y ago

Your point about insurance industry profits is well-made, but I feel it slides rather smoothly past the gargantuan overhead the industry's mere existence demands. Given the industry does not provide healthcare services it seems straightforward to me that every penny spent either on insurance premiums or maintaining headcount to manage claims is money wasted.

nradov1y ago

Managing claims is a waste in the sense that it contributes nothing to patient care. But every modern healthcare system needs some mechanism for allocating resources and preventing waste / fraud / abuse by providers. There's a lot of room to improve efficiency around claims but even fully socialized healthcare systems incur a lot of administrative cost on those functions.

One alternative approach is to shift away from the current fee-for-service payment model towards a value-based care model. Financial risk is shifted from employers and consumers to provider organizations who receive a fixed capitated payment per member per month from the insurance company. Then the provider org has to do whatever is necessary to care for those patients. The participating providers no longer need to submit claims for payment, just report on what they did for each covered patient that month. It's not clear yet whether this model will work at scale but pilot programs have been encouraging.

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