How Medicare Advantage Plans Use Algorithms To Cut Off Care For Seniors In Need (statnews.com) 92
An anonymous reader quotes a report from STAT News: Health insurance companies have rejected medical claims for as long as they've been around. But a STAT investigation found artificial intelligence is now driving their denials to new heights in Medicare Advantage, the taxpayer-funded alternative to traditional Medicare that covers more than 31 million people. Behind the scenes, insurers are using unregulated predictive algorithms, under the guise of scientific rigor, to pinpoint the precise moment when they can plausibly cut off payment for an older patient's treatment. The denials that follow are setting off heated disputes between doctors and insurers, often delaying treatment of seriously ill patients who are neither aware of the algorithms, nor able to question their calculations. Older people who spent their lives paying into Medicare, and are now facing amputation, fast-spreading cancers, and other devastating diagnoses, are left to either pay for their care themselves or get by without it. If they disagree, they can file an appeal, and spend months trying to recover their costs, even if they don't recover from their illnesses.
The algorithms sit at the beginning of the process, promising to deliver personalized care and better outcomes. But patient advocates said in many cases they do the exact opposite -- spitting out recommendations that fail to adjust for a patient's individual circumstances and conflict with basic rules on what Medicare plans must cover. "While the firms say [the algorithm] is suggestive, it ends up being a hard-and-fast rule that the plan or the care management firms really try to follow," said David Lipschutz, associate director of the Center for Medicare Advocacy, a nonprofit group that has reviewed such denials for more than two years in its work with Medicare patients. "There's no deviation from it, no accounting for changes in condition, no accounting for situations in which a person could use more care."
STAT's investigation revealed these tools are becoming increasingly influential in decisions about patient care and coverage. The investigation is based on a review of hundreds of pages of federal records, court filings, and confidential corporate documents, as well as interviews with physicians, insurance executives, policy experts, lawyers, patient advocates, and family members of Medicare Advantage beneficiaries. It found that, for all of AI's power to crunch data, insurers with huge financial interests are leveraging it to help make life-altering decisions with little independent oversight. AI models used by physicians to detect diseases such as cancer, or suggest the most effective treatment, are evaluated by the Food and Drug Administration. But tools used by insurers in deciding whether those treatments should be paid for are not subjected to the same scrutiny, even though they also influence the care of the nation's sickest patients.
The algorithms sit at the beginning of the process, promising to deliver personalized care and better outcomes. But patient advocates said in many cases they do the exact opposite -- spitting out recommendations that fail to adjust for a patient's individual circumstances and conflict with basic rules on what Medicare plans must cover. "While the firms say [the algorithm] is suggestive, it ends up being a hard-and-fast rule that the plan or the care management firms really try to follow," said David Lipschutz, associate director of the Center for Medicare Advocacy, a nonprofit group that has reviewed such denials for more than two years in its work with Medicare patients. "There's no deviation from it, no accounting for changes in condition, no accounting for situations in which a person could use more care."
STAT's investigation revealed these tools are becoming increasingly influential in decisions about patient care and coverage. The investigation is based on a review of hundreds of pages of federal records, court filings, and confidential corporate documents, as well as interviews with physicians, insurance executives, policy experts, lawyers, patient advocates, and family members of Medicare Advantage beneficiaries. It found that, for all of AI's power to crunch data, insurers with huge financial interests are leveraging it to help make life-altering decisions with little independent oversight. AI models used by physicians to detect diseases such as cancer, or suggest the most effective treatment, are evaluated by the Food and Drug Administration. But tools used by insurers in deciding whether those treatments should be paid for are not subjected to the same scrutiny, even though they also influence the care of the nation's sickest patients.
Advantage for whom? (Score:5, Insightful)
As someone who cares for stage 4 cancer patients, it is pretty obvious that the advantage goes to the insurance companies, not the patients.
Re:Advantage for whom? (Score:5, Informative)
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You don't get death panels with government insurance but you do get it with *private* insurance
You can have the so-called "death panels" with or without government insurance, if anyone is denied care for cost reasons. But we certainly do have them with the private insurance schemes, despite conservatives only being worried about them if they're run by the government.
Re:Advantage for whom? (Score:4, Insightful)
Private companies have a stronger incentive to refuse treatment, if they can get away with it. Insurance companies are about as trustworthy as the guy managing a crypto-exchange, but they've got a *BIT* more government oversight. (Not enough.)
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Yes. Assuming the country is democratic, politicians usually want to be re-elected. If they screw around too much, somebody else gets elected.
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Everybody says they want change, but we nearly always reelect the incumbent
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At least in my country, the government changes after almost every election. The incumbents usually do enough to piss the voters off, then the new guys piss the voters off even more and now the previous party has a chance.
Mayors and Presidents are different though.If a Mayor is good enough he/she can stay for a long time (there are no term limits for Mayors). Presidents usually get to serve their two terms as well, but there is a new Prime Minister after every election.
Re:Advantage for whom? (Score:4, Insightful)
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Before these plans existed it should have been obvious that HMOs make money by NOT treating patients. Medicare Advantage plans just have lower premiums than the equivalent plans for younger people.
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This sounds a lot like those death panels they told us would never be a part of gov't sourced insurance. Just sayin'...
Literally every insurance plan ever has coverage limitations and those limitations change over time. The better, more responsible, ones use some sort of science/outcome-based criteria. Calling those, and the people reviewing them, "death panels" simply exposes a (conservative) partisan slant. Just sayin'.
Re:Advantage for whom? (Score:4, Insightful)
Which kinda backfires since Medicare Advantage is a George Bush initiative, not an Obamacare thing. In fact Obamacare was originally designed to *kill* medicare advantage as the lousy deal that it is. Unfortunately with all the crap tacked on during the ridiculous fight over the affordable care act during its journey through the houses, it ended up just making the whole cursed scheme more powerful.
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It only backfires logically, not emotionally. If you aren't paying much attention the first word "Medicare" signals that it's a government program, so being mad at it is being mad at the government.
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You are making a logical argument, which I stated in my post was successful. But that doesn't necessarily affect the emotional signaling, which is how decisions are often made.
If the plan had been named "Private Replacement" or some such this argument wouldn't apply.
Re:Advantage for whom? (Score:4, Insightful)
Well, other than the fact its private enterprise doing this.
Also woah, we're letting AI kill people now..... That feels like something as a society we ought be discussing....
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Of course we're not letting AI kill people. We're just letting AI withhold aid from people who need it. They die all on their own just like nature intended.
Kidding aside, we're not letting AI do anything. Certain unscrupulous people are using AI to justify the decisions they wanted to make anyway. This way they can deflect blame. "Oh, it's not me who decided that Granny isn't worth treating.
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Death panels have been a part of the insurance industry ever since we decided in the States that EVERYTHING must be about profit. There are entire floors full of people (or were before algorithm mania set in) dedicated to finding loopholes to excuse paying for services people need to survive to save profits for the C-Suite team. Why people freaked out about the government deciding who lives and dies instead of letting corporate vultures decide is still pissing me off. I guess death panels are just fine so l
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It is the US, what do you expect. That whole society is geared to make the rich richer and everybody else poorer. And if a lot of sick old people die (obviously after having been separated from their money), that is exactly as intended.
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OK this might be an unpopular post, but I was thinking about this a lot.
Historically, we were constrained ultimately by our capabilities but not really wealth. In say, the 19th century, if you had a heart attack or even a fairly low-stage cancer, you were fucked, it didn't matter if you had the wealth of Crassus, the treatments simply didn't exist to mitigate lots of stuff.
Fast forward to today, and we have a different situation; medtech is so advanced now that we are capable of a broad spectrum of treatme
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> Capitalism - as flawed as it may be - is the only system we know
What that is is very vague. Capitalism. It isn't mentioning other parts, other things that make up the system as you say. And of all those other things, it's not clear, and it doesn't follow, that if we have to pick one term for the **system we know**, that capitalism is the best or most representative term to use.
> the US medical system for the costs and inequalities but rarely have answers for such questions. (It also conveniently ten
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Completely agree; I'd say it's practically impossible to tease out what is exactly 'capitalism'* in the US from the context of the culture, etc. My reference there was only in the vaguest sense.
*and to be clear, the US system is only somewhat capitalist; the US health/medical market is one of the most heavily regulated, scrutinized, and gov't-controlled segment of the US economy. It's laughable whenever one sees a critique of the US medical system that leans on the 'capitalism failed' aspect since it's po
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> "western" systems-of and approaches-to medicine IRL have provided better outcomes generally for public health over those of alternatives (eg China, Russia, India)
Yeah, but it's a vague argument because the categories western and alternatives aren't well defined, and it's not like we would have to pick one side or the other and everything that comes with it.
> part of this benefit is the leveraging value of technology, in which again, for whatever reason, the west seems to have an advance on. This the
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> As someone who cares for stage 4 cancer patients, it is pretty obvious that the advantage goes to the insurance companies, not the patients.
Well, yeah - the program is designed to take money from Middle America and give it to corporations that donate money to politicians.
"Caring for Seniors" is just the sales pitch and cost-of-doing-business that they use to fool voters.
It's the most expensive possible way to provide poor care - everybody who cares about healthcare statistics knows this.
That's why Repu
The value of a life (Score:3, Interesting)
Don't get me wrong, the current medical system in the US is a travesty, siphoning money to the wealthy, who pay off politicians with the result of outcomes massively worse than they should be given what is spent. In my own opinion we need single payer and we need it now. BUT! Whoever is paying the decision needs to be made for each or all people. How much should we spend on each year of life?
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How much should we spend on each year of life?
I generally agree with you, however this final question is too simple (in my opinion). If a per-year payout value is determined by some means, in a privatized health care system it will be natural behavior for service providers to reduce their level of care to increase margin as much as possible with the $ limit bounds.
How much service-reduction/margin-increase is possible? That metaphorical branch keeps bending and bending, it's hard to say when it will break.
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More to the point, how much is a single human life worth altogether? And what are the modifiers that increase or decrease that value?
I think you're absolutely on the right track: these are questions that need addressed at a societal level. The west has developed a culture of life, which religious implications aside, effectively regards human life as invaluable. This is, typically, a wonderfully humanist mindset, as it pushes (and pulls) people towards helping on
Re:The value of a life (Score:5, Interesting)
Those decisions will have to be made. In general, medicine uses the qaly (Quality-adjusted life year) to gauge a medical treatment. As the name might suggest, it considers the quality of life as well as the likely lengthening of life from a treatment.
The idea is that a treatment that helps you live healthy for 6 months might score better than one that helps you live a few years bedridden and delirious.
There are some VERY expensive drugs that don't score well there and some fairly cheap treatments that hit it out of the park.
Of course, if we go single-payer and don't allow certain boneheads in congress to remove it's ability to play hardball in price negotiations, that 10 million treatment for grandma might be only a few thousand.
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Those decisions will have to be made. In general, medicine uses the qaly (Quality-adjusted life year) to gauge a medical treatment. As the name might suggest, it considers the quality of life as well as the likely lengthening of life from a treatment.
The idea is that a treatment that helps you live healthy for 6 months might score better than one that helps you live a few years bedridden and delirious.
It's interesting reading all this as someone who works in the industry. In health economics, QALYs are a standard measure. But, when decisions are made in the insurance industry as to whether to authorize treatment or not (at the clinician level), those decisions are often centered around guidelines such Milliman Care Guidelines (MCG) or InterQual. There are actually regulations forbidding utilization review staff from considering financials when adjudicating. One is to simply consider "medical necessity".
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That is a strong limitation. Quality is not strictly objective except perhaps in broad strokes. For example, it's not unreasonable to say unconscious without a chance to recover is a very low quality, but other things like wheelchair vs severely impaired walking will be up to the patient.
Re:The value of a life (Score:4, Interesting)
How much should we spend on each year of life?
We should take the profit motive out of medicine generally, beyond making a good (far better than average!) living. In fact physicians could make more money if we just shifted the money around. For example, virtually all of the money that Big Pharma spends on advertising, which is more than 50% of their collective overall spend, could be redirected to other purposes simply by outlawing advertising medications to the general public. Patients interested enough to learn something other than just enough to be dangerous to themselves can still learn about medical technologies including new medications through all of the other usual channels.
As you make medicine generally cheaper, you shift the discussion from money towards how much physician (&c) time we should spend on each "year" of life. And then you hire more physicians, and/or do whatever other things are most effective in increasing access to health care for all people.
Frankly though it's not just one thing, poor health in America is an interlocking web of greed-driven causes. We eat bad food designed to maximize profit, we use polluting transport and electrical generation equipment designed for the same, the medical system, the national defense system, I could go on all day until I listed pretty much everything we do. None of it is designed to maximize health, or to minimize waste. It's all engineered to permit some people who already have a lot of money and influence to get more money and influence.
Remember death panels? (Score:5, Insightful)
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What you are referring to " was warned about by those evil republicans " is called projecting - and even foreshadowing of their actions. More in the tone of " if you do this we will do that ".
I'm not saying that republicans are actively setting up the "panels" as referred to them - but they are the #1 reason why we STILL have the only for profit healthcare system in the modern world.
And as someone a few comments above mentioned - there has to be some point of reality applied (how much is it worth to extend
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This was warned about by those evil republicans because of the cost requirements in that prized democrat bill of ACA.
the warning about death panels was because in the bill it requires that once spending gets to high the panels would decide who gets any type of treatment or is just told to wait until a future year and more funding is available or as is the hope of the bill passers that you would just die.
It always was, things were just gonna get bad enough if we treated the poor that it would get noticed and it has.
Maybe that notice will push the scales back to patients being dumped in the streets because they are poor.
Maybe that notice will push us to join the rest of the civilized world when it comes to healthcare.
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Re:Remember death panels? (Score:4, Interesting)
Talk about flamebait. Medicare has never had death panels. "Medicare Advantage" is misleadingly named private insurance that *does* have death panels. Do you believe your own post or are you intentionally trolling?
Of course, the term "death panels" is itself a troll -- usually pushed by wealthier conservatives that can afford any treatment at any cost, while happy to deny benefits to others less fortunate. Every insurance plan ever has had coverage limitations, which change over time. Having that change driven by science/outcome-based criteria seems like a good thing, especially when enormous public funds are being used -- paying for and/or encouraging treatments that work better over treatments that don't and, perhaps, favoring better quality of life over simply living longer. No one lives forever, people should come to grips with that -- I have.
My wife died of a brain tumor (GBM next to her brain stem) in 2006, just 7 weeks after diagnosis. More aggressive treatment could have extended her life maybe a few months, but with a debilitating quality of life. The surgery alone would have left her completely paralyzed on one side of her body, followed by radiation and chemotherapy. She didn't want to go through that and/or be remembered like that and opted to skip the surgery.
I'll note that her chemotherapy medication was Temodar, with a list price of $11,000 for a one-month bottle of pills (several rounds would have been required). My BC/BS co-pay would have been 10%, her HMO co-pay was $40 -- yes Fourty Dollars. She didn't even finish the first bottle...
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Did you miss the part where this is part of Medicare? The best argument against socialized healthcare in the US is the one the Republicans don't want to directly come out and make: that they will do everything in their power to make sure it fails.
It's like getting into an Uber full of gremlins intent on tearing the car apart during your ride.
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obvious flamebait rant snipped
Don't shoot the messenger. It's clearly offered as part of Medicare [medicare.gov].
My city's garbage pick-up is performed by a private contractor, too. Are you going to make the argument that somehow disqualifies it as being considered a taxpayer-funded service provided by the government?
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Don't shoot the messenger. It's clearly offered as part of Medicare [medicare.gov].
You are deliberately missing the point that has already been made to you that it's private insurance companies making these decisions. It's not government employees.
If you opt for a Medicare advantage plan, you forgo any coverage under traditional Medicare.
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My original point was that if we had a hypothetical "Medicare for all" system, this is exactly the situation everyone would have to deal with. We'd have government-funded healthcare provided by private insurers, who act as middlemen and extract their pound of flesh for their trouble. The alternate reality where the government somehow manages to miraculously manage the healthcare needs of approximately 331.9 million Americans, in-house, is nothing more than some extremely wishful thinking that isn't reflec
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So it is your belief that Americans are uniquely incompetent? Because many other nations manage their socialized medicine without hiring private companies to do it.
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So it is your belief that Americans are uniquely incompetent? Because many other nations manage their socialized medicine without hiring private companies to do it.
I'm not sure I'd call it "uniquely incompetent", but we do have a substantial portion of the electorate who won't be able to restrain themselves from voting for the party that will actively sabotage any attempts at maintaining a functional single-payer healthcare system. Just the present partisan make up of the SCOTUS alone has pretty much damned any chance at progress for at least a generation.
Call it being a realist or a defeatist if you must, but it's where this country collectively decided it wants to
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It's less about incompetence than about corrupted from within. Obviously the health care (and I use the term loosely) companies do not want single payer, but the other companies don't either. As long as health insurance is tied to you employer then the employees are also tied to the employer more firmly than would otherwise be the case.
Case in point; my former employer ranted every year that they spent $14,000 per employee on health care costs. Private health insurance for me would have been maybe $6000 a y
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Probably the scum. Maybe you. Medicare Advantage may be run by private insurance companies, but because they're being PAID by medicare, the whole "medicare advantage" thing, they are indeed part of medicare.
As such, I'd be more careful about people lying. They may have merely misstated, or have a different interpretation.
Calm down there, cowboy... (Score:2)
Name calling and expletives are no substitute for a rational dialog, and only highlight your lack of a good argument.
You conveniently dodge one vital fact: WE ARE ALL LIVING UNDER OBAMACARE.
Yeah, the feckless Republicans promised their voters that they'd repeal it, and when Trump was in office (and in the first 2 years of his term they had the House and Senate) they got a repeal bill through the House and over to the Senate, Senator John McCain (R-AZ) famously strolled into the Senate and cast the decidin
Re: Calm down there, cowboy... (Score:2)
You do know obamacare is government set standards of minimum care run by private insurance right?
Literally all Obamacare is upping the standards of care from third world to second world. Because In the USA we don't believe in first world healthcare.
You're leaving out something important (Score:4, Informative)
Bottom line the problem with Private health insurance is that it's not compatible with capitalism. Capitalism requires informed consumers and you can't possibly have enough information without a medical degree to make the kind of informed decisions you need to. Also insurance is at its best with the largest pool of the insured and there's no larger pool than the entire country
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You pretty much have to assume government subsidized privatization is the inevitable conclusion. Look at the low income connectivity program. The government didn't start running their own MVNO, they just gave money to (what was at the time) Carlos Slim's América Móvil (or "SafeLink Wireless by TracFone", the name most people are more familiar with). Today it's owned by Verizon, which are evil in their own way.
We can't have socialized healthcare in this country because the government will never
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By the government, you mean the GOP, right? Because everyone else is sensible enough to understand that private corporations are not typically ethical enough to be allowed to make life and death decisions without a LOT of oversight. So much that it is cheaper to just do it in-house rather than contract and watch.
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It's also worth mentioning that the UK is right now going through a great example of how socialized healthcare can successfully be sabotaged. Centrism is an unenviable position to be in, because you get shit on by both sides, but the reality is solutions have to be found that work within the existing political framework of this country. That means finding a solution which accounts for the fact that the balance of political power is naturally going to swing between left and right.
Re:You're leaving out something important (Score:4, Insightful)
It's also worth mentioning that the UK is right now going through a great example of how socialized healthcare can successfully be sabotaged
Wait... your argument AGAINST socialized healthcare and FOR privatized healthcare, is that socialized healthcare can be broken by hostile actors who are pushing for privatized healthcare?
Therefore, because it can be broken, let's preemptively burn it to the ground?
Have you tried doing the same with your skull? Or your house? Both satisfy your argument perfectly.
Why don't you go and try that argument out?
I suggest covering yourself in some accelerant, such as gasoline, while standing in your living room, setting yourself on fire... and the rest will take care of itself.
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No, an accurate analogy would be a choice between private vehicle ownership (which, yes, some people can't afford), or taxpayer-funded Uber rides for all, but your driver might not reliably show up when the Republicans are in power.
Since you'll be paying for the "Uber for all" on your taxes whether you use it or not, there is an incentive to oppose the change if you prefer the status quo. It has nothing to do with your craziness about self immolation, calm down.
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Capitalism also requires competition, and in most of the country by area the local hospital is the only hospital. You are going there. In my case if they fix me I'll get sent to the nearest larger hospital 65 miles away. If they can't fix me the next stop is 120 miles east or 160 miles west, depending on what the problem is.
The city 120 miles to the east also only has one hospital. There used to be two, but they merged.
Re:Remember death panels? (Score:5, Interesting)
It is not a part of Medicare. It is a plan that people on Medicare can opt in to. It is a medical insurance plan in which a private insurance company takes over from Medicare all of the decision-making, and is funded by your Medicare dollars (and sometimes a small consumer--paid premium).
The result is still 80% coverage for medical needs, but the companies are using AI algorithms (i.e., algorithms) to make decisions, sometimes against the legally required Medicare minimums, about how much medical care a person can receive.
In other words, the insurance companies running the Medicare Advantage plans are using computer programs to make life-and-death decisions over who gets coverage and who doesn't, without taking into account case-specific factors. That's pretty heinous.
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The only thing they're missing is an implanted lifeclock in your palm and a computer saying in a dispassionate female voice that you must report to carousel. (or a sleep shop if you prefer the book)
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Specifically, this is the Republican wet dream of privatizing medicare.
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Did you miss the part where this is part of Medicare?
Medicare Advantage is (basically) a private insurance alternative to Traditional Medicare. The companies get a fixed sum from the government for each subscriber and how they spend those funds is up to them as long as they follow certain rules. Medicare Advantage usually includes the various parts of Traditional Medicare (parts A/B/D), but can cover things differently -- this is where the problems usually are. Medicare Advantage providers have a financial incentive to spend as little as possible on patient
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Death Panels Always Were a Thing (Score:2)
Despite the desire of some folks in politics to milk some "immediate" version of death panels in order to scare the beejezus out of their constituents, death panels (as a concept) have always been part and parcel of medical care. Health care is an economy - a situation of constrained resources. Decisions around the deployment of these resources must be made. Not everybody can be treated for everything.
Ethics, morality, appropriateness, and legality aside, somebody always has to make the hard call. Call them
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and medicare advantage is a private company so it is a private company death panel. I'd take my chances with a government one over them any day.
So, you're saying that you trust the same government that created this situation in the first place to make the correct decisions regarding your healthcare? If they can't even pay attention to the policies of the private insurers they're passing the buck off to, what makes you think they'd do any better for you?
That's like saying a manager who hires nothing but incompetent employees, is doing a fine job running his business.
Working as intended... (Score:2)
The only way insurers make money is by denying care. Therefore, they will find ever possible way to do it. And that people think this system provides them choice and freedom is baffling. The opposite is true.
Single payer works better. Period. We can have more than enough economic resources to provide effective care for everybody. It just requires us to have a more realistic defense budget, to raise some revenue and still get rid of the parasitic insurance companies.
Don't get me wrong, getting rid of a secto
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The only way insurers make money is by denying care. Therefore, they will find ever possible way to do it. And that people think this system provides them choice and freedom is baffling. The opposite is true.
What a shockingly bad understanding of how insurance underwriting works.
No, they make money by charging far more in premiums than they pay in claims. If your customer base is large enough (ie, Medicare, single-payer, or a Really Big Insurance Company), this is done by spreading the risk. Essentially, healthy people are paying for the unhealthy people's health care-- which sounds unfair, until you become one of the unhealthy people either through accident, neglect, or external factor.
Of course, if the insu
Medicare Advantage Plans Aren't Impressive (Score:5, Interesting)
While evaluating the Medicare choices for a relative two years ago I looked at Medicare Advantage plans. In my relative's area in Northern California, standard Medicare lists around 2,800 doctors in a 25 mile radius while not stating their specialities..
Most advantage plans offered less than 200 hundred local doctors, while not stating their speciality either. Looking at the physicians most of them appeared to be young (read inexperienced) and I didn't come across any who were board certified in family medicine. My relative's current primary care doctor - who is board certified - was not on any of the numerous plans that I checked.
Needless to say, I recommended staying far away from Advantage plans. There are many TV adverts for these plans around December (usually around two minutes long and in the middle of the day) and a huge number of mail offers, so they must be very profitable for the health insurance industry. That, by itself, is a bit worrying as they are less expensive and generally offer additional services (such as dental, routine vision care and free transportation to doctor visits.)
My relative chose standard Medicare and has been happy with the care she has received. She hasn't had to change any of her doctors (family medicine, rheumatologist, neurologist, podiatrist and probably others I'm unaware of.)
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But they *do* have to play by the Medicare rule book, and they get the Medicare negotiated prices. They do cover the so-called donut hole, as a rule. I believe my mother had to pay $49/mo. for her Medicare Advantage, and given the massive amount of her medical bills the last year of her life, it was a bargain.
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I disagree. There are fly-by-night organizations, but the larger organizations are actually pretty good. They do demand oversight of the patient's healthcare (which OG Medicare doesn't), but they also cover significantly more than OG Medicare.
And many of them, as I discovered with my mother's healthcare, have an annual out-of-pocket limit-- which when your healthcare claims break $1 million for that year, and your OOP is $6,500, you realize Medicare Advantage ain't that bad.
But be aware that many faciliti
Dante was wrong about the ninth circle of hell (Score:2)
The people he saw frozen head-down in the ice were actually insurance company executives. And when Satan gets tired of chewing on Brutus and Cassius, for an occasional change of pace he grabs some of the insurers and chews on them for a while... but even he can't stand their taste for long.
Duh! Not using ChatGPT are you? (Score:2)
Who uses still algorithms these days while you can use ChatGPT for everything.
With ChatGPT everyone would get enough dope to bring world peace.
Penalties for wrong initial rejections? (Score:2)
If an initial rejection is later reviewed and shown to be wrong, there should be severe penalties both civil and criminal (jail) for failure to abide by contract and health fraud. It is fraud to deny valid covered treatment or services.
Re: Penalties for wrong initial rejections? (Score:2)
Do you think that would make it easier or harder to get an initial rejection reversed?
The thing with private health insurance... (Score:3)
Need to create a penalty for bad-faith denial (Score:2)
Older people who spent their lives paying into Medicare, and are now facing amputation, fast-spreading cancers, and other devastating diagnoses, are left to either pay for their care themselves or get by without it...
This is really sad TBH. What should happen is there should be a penalty of 15-times the claim amount or $1Million, whichever amount is greater, plus interest and lawyer/legal costs/court fees created for bad-faith or improper denial of insurance claims that is allowed to exceed treatment cos
Is there anything more sinister (Score:2)
than what corporations do to protect their interests?
No surprises there (Score:2)
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Re: (Score:2)
Go to this website: https://qioprogram.org/locate-... [qioprogram.org]
And look up the QIO for your state. Call them.
What's the recovery rate on fast spreading cancers (Score:2)
I understand the complaint here.... but in a real general sense? I also see how these systems don't have unlimited budgets to throw around to cover every single thing a person would like them to pay for. Remember, all of us who work for a living help fund these programs - and we'd like them to remain solvent so they can provide at least a good standard of care for everyone who ages out of the workforce.
When you've got an aggressive cancer, I'm not sure it makes a lot of sense to keep burning through hundred
Re: (Score:2)
If you're diagnosed in stage 2, and the insurance company dicks you around until you're in stage 4 before approving treatment, has any money really been saved?
There's plenty of money for Medicare, and insurance in general, for all of us. For damned near any condition. We start by getting billionaires to pay something resembling 10-20% of their annual income like the rest of us. Then we get corporations to actually pay their share of taxes. Then we open up Medicare to people who can pay premiums, and gro
When guidelines become rules. (Score:1)
Little known fact (Score:2)
There are oversight organizations that you can appeal decisions by your Medicare provider, even for Medicare Advantage, that will trigger a review by a human.
They're called "Quality Improvement Organizations", or QIO's, and if you have a problem with a patient healthcare decision, a discharge order, or an insurance decision regarding payment, you can file an appeal with them almost instantly. While caring for my mother over an 18 month period, I had to file three appeals-- one on a discharge order, one on