True, but I have seen several projects recently that are focused on using Agents for Prior Auth Denial and though some are obviously biased e.g.: forus.com and simply trying to get more customers others are really just focused on resolving the denial.
I always wondered if this was as simple as reforming the insurance companies, or if the entire healthcare industry needed to be reworked.
>> Medicare for All would prevent an estimated 68,000 unnecessary deaths a year.
Are there doctors and specialists with the necessary equipment just twiddling their thumbs, wanting to help people but the insurance companies refuse to pay so they just sit idle? Or is our healthcare limited by supply?
We might have to revisit a bunch of things like how doctors get trained/residency, what insurance should cover, public health around prevention, etc. rather than just saying "Give everyone everything".
Recent estimates for the number of lives saved annually is actually around 114,000[0]. The number keeps going up because healthcare in the US just keeps getting worse and worse over time.
Aggressive spam filtering. It produces the most shareholder value. Operating against pute monetary gain distorts and acts against the market which is the aggregate revealed preference of participants.
> Why did we consent to live in a system where the worth of our bodies and lives were so negligible as to be exchangeable for dollars?
> polling showed that a third of Americans who had faced claim denials said they viewed Mangione positively. Some saw this reaction as sociopathic, but its extremity was the very point. How far must someone go in order to be taken seriously by those who adjudicate access to life itself?
> there is no justification, ever, for denying a sick person care
Everyone above is justified in their outrage, but they have picked the wrong target.
For-profit companies exist for the purpose of making profits. They will never offer services that produce sustained losses. It's weird to blame the CEO for this - he's just doing what the shareholders hired him to do. Blaming the CEO for denying you healthcare is a bit like blaming a real estate agent for not giving away an empty house to a homeless man.
You're better off blaming the shareholders for being selfish... but that too is a bit like blaming every single person you meet who chooses to buy an iPhone instead of putting that money into a GoFundMe for a sick patient.
The real blame lies with the government. It is the government's job to give everyone a baseline level of healthcare. Taxes exist for the express reason of overcoming collective-action problems like the above. And yet, our government refuses to provide better healthcare, because a large fraction of voters prefer lower taxes over better healthcare access. if you're looking for someone to blame, blame them
They can, however, be regulated. At it's core an insurance company should just be a risk pool that gives premiums for that risk, and covers its cost + profit on getting to hold your premium for the period.
IMO what's really missing in America is a collectively incentivized set of activities to deeply reduce risk, for example one of two should be true -- smokers pay way way higher premiums, or perhaps baking in incentives by taxing cigarettes heavily like they do in Canada, for example. I see so many opportunities for healthcare to be much much cheaper just unused -- Smoking, Alcohol, THC products, risky driving, lack of exercise, high body fat, Standard American Diet (SAD) all could save a lot. Just a WAG but probably on the order of many billions in the USA.
I think one thing that makes it a mess is that healthcare comes from your employer, and your employer isnt going to diagnose each employee's lifestyle factors and pass on the risk pool savings of good choices. If the individual paid and could somehow capture that incentive profit then they'd at least have the financial incentive to be healthy.
Edit: An example I see frequently of shirking the risk/incentives structure is how Auto insurance seems to have shifted from investigating to just 50/50 outcomes unless you have a dash cam to prove your innocence. Those with risky patterns are not paying their share of insurance premiums. So until everyone dashcams it's now under penalized to do risky behavior.
The cancer turned out to be more aggressive than was first surmised. Obviously, the insurance carrier was right to demand the aggressive, rather than "mild", chemotherapy.
Perhaps the insurer should defer to the doctor, who is not only generally an expert at treating cancer but also much more familiar with the details of the patient.
It baffles me why people are OK with insurers dictating care to doctors rather than the other way around.
> why people are OK with insurers dictating care to doctors
Because it's my money and I don't want it spent on low-success-rate snake-oil cures. I want that money to be available to me when I need it. Insurers have to diligently manage the pool of premiums to ensure the maximum number of people live, not just those who can write the best articles for magazines.
The problem is the doctors have a big financial incentive to do something. Whether it's useful or not is secondary. Likewise, the patients want to do something, it's a source of hope.
Remember the big flap about bone marrow transplants for advanced breast cancer? End result: a successful transplant meant you lived longer, but the risks of the transplant offset that, there was no survival advantage.
This is not to say that there are no improper denials. It's pretty obvious some companies use red tape, and I suspect some reviewers are either being held to unreasonable standards or being overworked, resulting in deliberately lost paperwork. (Remember the scandal with the VA dropping patient visits to make the numbers look better?)
And reading the article a few things stand out to me:
1) I can't find the name of the drug being denied.
2) She gives the stat that 49 million claims are denied but 0.2% were appealed--is that truly evidence of wrongdoing, or is it evidence of the insurance companies providing the no that doctors are afraid to give patients? And how many are entirely legitimate (my wife had a denial--right drug, right digits, wrong form, wrong dose. Clearly a human selected the wrong thing from a list)?
3) She talks about lives that would supposedly be saved by Medicare for All--never mind that that would collapse our system as there is considerable cost shifting from Medicare to those with commercial insurance.
You don't update standard of care by not trying new treatments, and insurance companies also have financial incentives. It turns out they are the opposite of the incentives of their customers and the doctors.
I returned to an email from the company’s chief scientific officer. Will approve tomorrow per oncologist request, his email said. The next day, I received multiple emails from company executives, authorizing milder chemo and apologizing.
Milder chemo came and went. My body felt like it was filled with cement after infusions; my eyes could not stay open; but the hairs on my head grew longer, and there were no more boils in my throat making it impossible to swallow or speak.
I went into remission that fall, and set myself to moving beyond cancer while also beginning to process the changes it had wrought on my body, and the nearness of my brush with death.
I'm sure the doctor arrived at that treatment plan magically without and without any clinical evidence whatsoever. If insurers want to practice medicine they can go work in a hospital.
It does help to be a journalist at a major magazine. Plebeians such as myself would be very lucky to get such a response.
100%. There's an implicit threat as a journalist -- I'll write this story up if I don't get my way.
True, but I have seen several projects recently that are focused on using Agents for Prior Auth Denial and though some are obviously biased e.g.: forus.com and simply trying to get more customers others are really just focused on resolving the denial.
https://archive.is/AIVji
I always wondered if this was as simple as reforming the insurance companies, or if the entire healthcare industry needed to be reworked.
>> Medicare for All would prevent an estimated 68,000 unnecessary deaths a year.
Are there doctors and specialists with the necessary equipment just twiddling their thumbs, wanting to help people but the insurance companies refuse to pay so they just sit idle? Or is our healthcare limited by supply?
We might have to revisit a bunch of things like how doctors get trained/residency, what insurance should cover, public health around prevention, etc. rather than just saying "Give everyone everything".
Recent estimates for the number of lives saved annually is actually around 114,000[0]. The number keeps going up because healthcare in the US just keeps getting worse and worse over time.
[0]: https://www.medrxiv.org/content/10.64898/2026.07.22.26358689...
All healthcare systems are limited. You have to triage.
In America this is done according to wealth and status. In my country this is done according to medical status.
- if the solution was to email the CEO for every denial
- how should the CEO handle this?
By actually solving the problem that leaves contacting the CEO as the only solution available to the customer.
Aggressive spam filtering. It produces the most shareholder value. Operating against pute monetary gain distorts and acts against the market which is the aggregate revealed preference of participants.
[dead]
> Why did we consent to live in a system where the worth of our bodies and lives were so negligible as to be exchangeable for dollars?
> polling showed that a third of Americans who had faced claim denials said they viewed Mangione positively. Some saw this reaction as sociopathic, but its extremity was the very point. How far must someone go in order to be taken seriously by those who adjudicate access to life itself?
> there is no justification, ever, for denying a sick person care
Everyone above is justified in their outrage, but they have picked the wrong target.
For-profit companies exist for the purpose of making profits. They will never offer services that produce sustained losses. It's weird to blame the CEO for this - he's just doing what the shareholders hired him to do. Blaming the CEO for denying you healthcare is a bit like blaming a real estate agent for not giving away an empty house to a homeless man.
You're better off blaming the shareholders for being selfish... but that too is a bit like blaming every single person you meet who chooses to buy an iPhone instead of putting that money into a GoFundMe for a sick patient.
The real blame lies with the government. It is the government's job to give everyone a baseline level of healthcare. Taxes exist for the express reason of overcoming collective-action problems like the above. And yet, our government refuses to provide better healthcare, because a large fraction of voters prefer lower taxes over better healthcare access. if you're looking for someone to blame, blame them
> For-profit companies ...
They can, however, be regulated. At it's core an insurance company should just be a risk pool that gives premiums for that risk, and covers its cost + profit on getting to hold your premium for the period.
IMO what's really missing in America is a collectively incentivized set of activities to deeply reduce risk, for example one of two should be true -- smokers pay way way higher premiums, or perhaps baking in incentives by taxing cigarettes heavily like they do in Canada, for example. I see so many opportunities for healthcare to be much much cheaper just unused -- Smoking, Alcohol, THC products, risky driving, lack of exercise, high body fat, Standard American Diet (SAD) all could save a lot. Just a WAG but probably on the order of many billions in the USA.
I think one thing that makes it a mess is that healthcare comes from your employer, and your employer isnt going to diagnose each employee's lifestyle factors and pass on the risk pool savings of good choices. If the individual paid and could somehow capture that incentive profit then they'd at least have the financial incentive to be healthy.
Edit: An example I see frequently of shirking the risk/incentives structure is how Auto insurance seems to have shifted from investigating to just 50/50 outcomes unless you have a dash cam to prove your innocence. Those with risky patterns are not paying their share of insurance premiums. So until everyone dashcams it's now under penalized to do risky behavior.
Not to mention the uninsured motorist issue.
The cancer turned out to be more aggressive than was first surmised. Obviously, the insurance carrier was right to demand the aggressive, rather than "mild", chemotherapy.
Perhaps the insurer should defer to the doctor, who is not only generally an expert at treating cancer but also much more familiar with the details of the patient.
It baffles me why people are OK with insurers dictating care to doctors rather than the other way around.
> why people are OK with insurers dictating care to doctors
Because it's my money and I don't want it spent on low-success-rate snake-oil cures. I want that money to be available to me when I need it. Insurers have to diligently manage the pool of premiums to ensure the maximum number of people live, not just those who can write the best articles for magazines.
It's not baffling because insurers are not dictating care. They only decide if they want to pay for it.
Doctors are free to give any care they want.
Yes of course, the doctor is “free” to choose between the treatment that the patient will be able to afford and the one the patient will not.
Sorry guys but you are really living in a shithole country.
The problem is the doctors have a big financial incentive to do something. Whether it's useful or not is secondary. Likewise, the patients want to do something, it's a source of hope.
Remember the big flap about bone marrow transplants for advanced breast cancer? End result: a successful transplant meant you lived longer, but the risks of the transplant offset that, there was no survival advantage.
This is not to say that there are no improper denials. It's pretty obvious some companies use red tape, and I suspect some reviewers are either being held to unreasonable standards or being overworked, resulting in deliberately lost paperwork. (Remember the scandal with the VA dropping patient visits to make the numbers look better?)
And reading the article a few things stand out to me:
1) I can't find the name of the drug being denied.
2) She gives the stat that 49 million claims are denied but 0.2% were appealed--is that truly evidence of wrongdoing, or is it evidence of the insurance companies providing the no that doctors are afraid to give patients? And how many are entirely legitimate (my wife had a denial--right drug, right digits, wrong form, wrong dose. Clearly a human selected the wrong thing from a list)?
3) She talks about lives that would supposedly be saved by Medicare for All--never mind that that would collapse our system as there is considerable cost shifting from Medicare to those with commercial insurance.
You don't update standard of care by not trying new treatments, and insurance companies also have financial incentives. It turns out they are the opposite of the incentives of their customers and the doctors.
I returned to an email from the company’s chief scientific officer. Will approve tomorrow per oncologist request, his email said. The next day, I received multiple emails from company executives, authorizing milder chemo and apologizing.
Milder chemo came and went. My body felt like it was filled with cement after infusions; my eyes could not stay open; but the hairs on my head grew longer, and there were no more boils in my throat making it impossible to swallow or speak.
I went into remission that fall, and set myself to moving beyond cancer while also beginning to process the changes it had wrought on my body, and the nearness of my brush with death.
n=1
I'm sure the doctor arrived at that treatment plan magically without and without any clinical evidence whatsoever. If insurers want to practice medicine they can go work in a hospital.
Doctors should do the treatment for free, and only bill if the outcome is positive. If they're so confident, put their money where their mouth is.
Hell of a ragebait title.
Insurance would pay for standard care of an aggressive cancer, not for something that was much worse at prognosis.
> Typically brisk, my oncologist was tender. “There’s good news,” she said. “We can use a much milder chemo this time.”
It's really weird to go to bat for the health insurance industry.