I absolutely believe this story. From a hospital administration perspective, I can tell you with certainty, healthcare is one place where the invisible hand of everyone acting in their own best interests will magically work out. The interests of the for-profit insurance company and the insured (and even the provider) are adversarial. Unfortunately the individual patient has the least amount of leverage of anyone.mathjak107 wrote: ↑Thu Feb 11, 2021 6:06 pmFor those who want to know the difference between having a for profit insurer as your gate keeper vs not for profit govt Medicare I will give you an example.
A friend had an advantage plan ..she bragged all the time about how little she was paying .
Well she got pituitary gland cancer ....one side was cancerous,the other side not great shape ..her doctors wanted both haves removed ...her insurer denied both halves ...they only approved one side and she had to wait for the other side to possibly turn cancerous and spread .
Her doctors appealed and argued Medicare always pays to remove the entire gland ..
The insurer told them they can’t say what Medicare would have done in this cases, their patient does not have Medicare ....
So the insurer administering your plan has total say because you can’t say what govt Medicare would have done , you don’t have government Medicare..with an advantage plan you have a for profit insurer deciding your course of treatment...
The model for Medicare Advantage plans is pretty simple. Collect 92% of what Medicare would have otherwise paid on average per insured per month. Then ration/deny benefits as much as possible, and the best trick, compose a network of only the very cheapest providers in the market and penalize the insured for going out of network. There are also some claims adjudication and slow payment tricks, and these directly affect the providers more than the patients. In a nutshell, that's about it.
There is a mechanism for a third party Quality Improvement Organization (QIO) in every market who handles appeals and tries to keep the MA plan honest, but they play the averages that only a small % of patients will exercise those rights.
The only parties that do well with the for-profit health insurers, both commercial and MA, are the hospital systems that basically have a monopoly in their market where the insurer simply cannot have a complete network without that particular hospital system. If their network is not complete, they cannot compete with the commercial insurance in the large employer market. So they have to pay the piper, and in turn raise insurance rates on the commercial side on the smaller employers (this is why you hear about insurance rates going up 20, 30, 50% at renewal), and cram down other providers to try and make up the margin on the MA side. The crammed down providers try to make it up in volume (doctors who see 50+ patients/day, inpatient providers who shorten length of stay and run a revolving door model).
Most of healthcare in the US works off monopolistic practice and market leverage, whether we're talking pharmaceutical companies, hospitals, insurers, dialysis providers, large lab providers. I know the government sucks in every respect, but the alternative, which in the US is the private for-profit healthcare system, is a complete blood sport.