All it takes is being a human to sympathize-- for example, the pause in the recorded music for advertising to the captive audience thing.
I've dealt with Lab Corp as a impatient, and it's all the same, except for leaving out the number of times it took calling them when they had no record of having talked about the problem before.
But remember, all this is done for your convenience and safety, customer! It's certainly not so we can cut costs by removing real human operators to talk to people!
I wonder if upper management has ever tried calling their own service centre. Probably not, and they have their own direct access.
Or maybe when they call, they're such experts it doesn't seem like a burden. Just speed dial 2, hit 3, #, 2, enter 6969 to bypass the menu, say "speak to human" press # again, press 2. Takes 2 seconds. Why can't users figure that out?
You know, I don't think lack of humans is the problem. There are plenty of humans, they just aren't helpful. I think it's a design issue. It isn't trivially easy to make a great help service.
The companies that succeed in doing so are the ones whose bottom line is harmed by bad customer service. If Rocket Mortgage made it difficult to fill out a mortgage application, they would go out of business tomorrow. Good customer service is probably the most important feature of their business. On the other hand, almost no one selects their insurance carrier based on customer service (indeed, many people don't select their insurance carrier at all). So why on earth would they spend time and effort making their customer service better?
There's probably a startup in here somewhere, gluing together speech-to-text (Openai Whisper), a large language model, and text-to-speech (Amazon Polly or similar).
I'm (in Germany) privately insured with a health insurance that's basically a non-profit.
I.e. no owners/shareholders who expect profit (they still can have internal incentive structures to encourage good management).
(Disclaimer: private health insurance "cooperatives" like this are not the norm & generally speaking more expensive than the public option. I'm merely describing a different model for health insurance.)
Any money they have above certain reserves at the end of a year, they have to distribute to its customers/members; also, if you don't make any claims for reimbursement of treatments within a given year, you get a non-insignificant part of your premium back.
Iirc, towards the end of the year, if you haven't claimed any reimbursement yet, they sent you a friendly letter
telling you what the amount of premium refund for you would be this year. Then they suggest it could be a good idea to, if you have any medical bills you'd planned to get reimbursed that year, to compare their total amount to the refund, and if it's lower, do nothing and wait for your refund to arrive.
Like, this actually *saves* work.
These non-profit insurance companies aren't without their problems, but at least they don't have an obvious incentive to deny as much coverage as they can get away with without losing their customers or getting branded "impossible to work with" by too many doctors.
The only thing they can do with the money they save denying coverage for patient A's treatment X is paying for patient(s) B's treatment(s) Y, otherwise it gets thrown into the redistribution-bucket at the end of the year.
I guess in some ways, it's more similar to the system most Amish use, these sort of church-organized mutual aid collectives?
Except it's anonymized, and coverage is set out in regular insurance plan contracts.
They do have some disgressionary¹, but my experience (and that of others I know insured there) is that the insurance is, in most cases², quite forthcoming and easygoing in covering bills, both guaranteed and disgressionary.
A lot of other (non-health) insurances seem to work a lot more like in the US, though, trying their best to either deny coverage, or make it out like it's someone else's responsibility².
¹Relevant to this blog's interests: my plan covers a guaranteed amount of psychotherapy, no questions asked - basically half a year of weekly sessions per year - and only if I want/need more than that do I need any kind of prescription/psychotherapist's explanation why it's indicated. And (from what I heard) these are often mostly a formality.
I expect if I would lodge claims for, say, the no-questions-asked-amount plus four sessions, they would just pay, bc it's not worth the work.
Overall, it feels like there are actual human beings working there.
²The only category of cases that easily comes to mind, where my health insurance would try to divert responsibility, is if the medical issue might be due to an accident covered by relevant insurance (as a majority of Germans have - public - accident insurance), as then the responsibility to pay for necessary medical treatment lies with the accident insurance.
But it's very much a "if they won't pay, we will" scenario.
A fair number of insurance companies in the US are non-profits. Including Blue Cross/Blue Shield, which "Blue Helmet" in the OP is riffing on. My own plan--which I get from my job with the federal government--is through Kaiser Permanente which is also a non-profit. At least on the customer side, you still have exactly what you see in the OP.
This is one of those "not without problems" issues.
I think the most appropriate English term for what I'm talking about is "mutual insurance" (like what the original guy who took actuarial tables and calculated the projected financial requirements for a life insurance, and instigated the founding of the first
proper, "professional" life insurance), where the whole enterprise is owned by the insurees (that a word?).
I'm pretty sure they have some clauses in their charters or whatever intended to limit how much money executives can extract from the whole thing. And as the insured are legally the boss, if someone is discovered trying to sneakily/creatively extract excess money, there's likely some personell and/or rule changes on the horizon.
Huh. I feel like there must be something I'm missing about the incentive structure operating there?
Or legal constraints?
Or just standard "the larger the organization, the worse they are at things" and/or simplistic middle management-style decisions ignoring many possible/probable 2nd etc order effects?
Eg, someone thought "If we cut cost in the customer service (ie "people calling in with their problems") department, we can lower the insurance premiums, which is good for our customers!"
...only now they or (probably worse) their doctor is spending a lot more time doing this kind of silly BS, and as other doctors don't operate on a "subscription service" like Scott, they can then presumably bill patients/insurances for that work?
At the very least, more BS busywork = less time to actually interact with patients.
But even if customer service was made this way starting with benevolent intent, why would it still so frequently lead to these phone trees from hell?
(Literally - it's easy to imagine some sort of eternal punishment, where you're set some seemingly trivial thing to clear up, and then you're just navigating and endless maze of OP-like BS. Like Sisyphus, just without the open air, mountain views, exercise, and sense of progress at least between the bottom and the rolling-back-down point.)
Point is: I am slightly confused about this, would appreciate explanations by people who know more about the US healthcare thing.
Blue Cross/Blue Shield is an association made up of for-profit insurance companies, the largest of which Anthem/Elevance is publicly traded on the NYSE. Their non-profit status as an association is misleading in terms of understanding the commercial operations of their member insurance companies.
The other large health insurers in the US -- United Healthcare, Aetna, Cigna -- are all publicly-traded for-profit corporations.
All of these companies are optimized to maximize returns to shareholders, not to provide service to patient/members.
Actual non-profits were created in some states under ACA. We have one here in my state. As a provider, I've gotten consistently better service from the non-profit insurance company than any of the private insurance companies. No long wait times on the phone, prompt responses to specific questions via email, very quick escalation to higher ups where things could not be quickly resolved, etc.
Kaiser is a consortium similar to how Blue Cross/Blue Shield is a consortium. Kaiser has a mix of for-profit and not-for-profit entities in its consortium. I haven't looked closely at their corporate structure; it looks like they are criticized for retaining excessively large cash reserves rather than putting them back into the community.
Certainly non-profits can optimize for things other than their actual mission (executive compensation instead of patient care, for instance) and they often do. But it seems at least they may not be optimizing for short-term shareholder value. But I haven't looked to see which parts of Kaiser are actually for-profit.
The healthcare consortia are confusing because the outer shell can be a non-profit while all the businesses operating inside the shell are for-profit. The outer shell I assume is mainly for throwing political weight around.
Non-profit healthcare companies that act as both insurer and provider -- there are huge ones like Kaiser and small state-level ones -- tend to do what's called patient dumping in order to control costs and maximize profits. The profits in this case may return to the providers rather than the patient/members in the form of higher compensation.
I know the one here in our state engages in patient dumping because I have friends and family dumped by them. Patient dumping may mean discouraging people from getting medically necessary treatment, encouraging people to go to the emergency room of the hospital (not part of the non-profit's system) over non-urgent things, or referring on people to other practices when they are perfectly capable of treating them.
No that is basically illegal (seriously). The rules are so tight in the US to survive you basically need to stay on these tiny railroad tracks, because the medical system has so few options as regards its policies.
Hmm, well, Anthem makes about $4B a year in profit, so apparently they're surviving ok. Also, One Medical charges a small annual fee and provides better service. So it seems doable to me.
I'm very curious about how Scott's "model company" is gonna work out, that seems meaningfully different?
Although (particularly non-hospital) psychiatry is very cost-bounded compared to general coverage, as it's mostly "just" psychotherapy and prescribing drugs - it's not like some doctor within that model is suddenly gonna be called on to perform brain surgery within that subscription model!
In the US at least, the person having to make these calls is almost never the person who decides what insurance company to contract with, so there's not much way for that to translate into a market advantage.
Yeah, maybe not. It would be interesting to see if it could be turned into a provider network advantage (e.g., include all those doctors who don't take insurance because it's too much of a pain) and/or establish a premium brand that would be meaningful to employees/employers. I've seen companies switch providers because of perceptions of poor service, although I agree it's probably uncommon currently.
I think this just leads to an AI arms-race where 40% of the world's electricity output is dedicated to AIs trying to crack obscure customer service phone trees to get an actual resolution, and 40% of the world's electricity output is dedicated to AIs trying to create increasingly obscure customer service phone trees to avoid having to actually provide the services their company is contracted for.
Startup, hell. This is Microsoft Bot Framework with Microsoft Cognitive Services Speech Recognition and Microsoft Cognitive Services Speech Synthesis. Contact your Microsoft Sales Representative for a quote.
There really has to be a way to like a post more than once. This phenomenon is part of the shared human experience c.2022 and it really needs to die in a fire.
Experiences like this seem so common place, even in other industries, but it's extra tragic to see people suffer when it's medicine. A good friend of mine lost access to his psych meds and we basically had to take turns making sure he was ok for a month due to pharmacy bs. Finally his relative drove him a few hundred miles away to a pharmacy with someone manning the counter whose soul hadn't been double-mortgaged yet and he got the meds needed to function. It could have easily gone the other way with him jumping into traffic or something though during a bad spell. At least we know Hell is real because we're there.
I’ve always had this naive idea that sure they keep the ordinary consumers like me on hold in these terrible systems, but if only I could opt for the “physician” option it would zip me right through to a helpful representative. No way the VIPs have to deal with this.
This was very funny but also extremely depressing. I had a lesser version of this dealing with some medical bills, figuring out that a two of a hospital's different departments billed different claims separately and didn't communicate, that they sent things to the wrong address, etc. HOWEVER: I was pleasantly surprised that there were notes documenting my interactions on the hospital's call-center billing side, which meant that I didn't actually start from scratch every time. Confirming names and keeping a record of calls might not help you, but if the operation is at least somewhat legitimate, it can.
If this is reflective of your style.... again I'm just a rando who encounters this on a consumer side, in privileged circumstances. But perhaps there are ways to phrase your initial requests to get more traction with the representatives? I don't know. Also when you call you should probably have maximum info from the patient available, including any claims information and explanations of benefits. The patient should have access to those, possibly online these days, establishing more of a paper trail than a fax or a phone contact. In fact, it may be that the patient might get better traction if they do the calling? It's a start....
But then who's got time and energy for that, if you're working during their working hours and also need to be on a medication to be functional anyway, which you're not getting?
So it's a catch 22. This is really horrible and I don't expect the bureaucracy to improve anytime soon. So good luck.
It’s sad how realistic it is. I once had to go through 30+ phone calls, over several months, to get a surgery covered that my insurance specifically said ahead of time that they would cover, but which they claimed afterwards that they weren’t covering at all. Ultimately I also had to fill out some special exception form too. It was terrible.
If only you could resolve the problem by getting the patient’s prescription tattooed on your body over and over again for hours until it covers every bit of your skin.
I know this group tends to skew libertarian, but this really *really* seems like something that needs regulation. It's so widespread across every industry, to the point where bad customer service is an accepted standard and everyone is racing to minimize customer service expenses to the collective detriment of the entire society.
This is literally a tragedy of the commons situation that damages labour productivity across multiple sectors.
If I thought regulation could fix it I'd be all for that but how exactly do you propose to do that?
Pass a law saying it can't take more than X minutes on average on the phone to resolve an issue - incentive: don't fix simple issues so average stays low.
Pass a law preventing automated phone trees? The insurance companies have same incentives to make it difficult to get them to cover things and to minimize their risk of lawsuit in abuse so now they just pay humans in India to do it. Same effect but more pricey. And some amount of automated phone trees helps everyone.
Pass a law saying that all medications with a valid physician script must be covered?
The nation just demanded (and got) blood from Walmart etc from daring to believe that doctors not pharmacists are best places to decide who needs what meds. First time someone steals a physician pad or someone dies of an OD after their insurance let them fill multiple scripts and the insurance company says their hands are tied it will get repealed.
Also what about the effect of the physicians who just write scripts for crazy expensive brand name drugs and check don't substitute (bc they had a hot pharma rep or bc they once had a patient who responded better and why not bc neither they or the patient pay). Without national coverage the benefits might not be worth increase in price for those buying own insurance.
I agree something should be done but I fear there is a real chance that you try to regulate it and you add an extra layer of fuckery.
But come up with a well designed reg and I'm on board.
Definitely a tricky one to regulate well, but I think a starting point might look something like this:
-you get a live human with a max hold time of x minutes, or a callback within x hours of a request
-hold time limits include time on hold after getting a live human (no taking the call to reset the clock then throwing people in a different queue)
-if the type of call has been correctly pre-sorted by phone tree, some very high percent of calls (90ish) must be concluded by the initial human without transfer (reduce to some.much smaller percent if the call is not pre-sorted)
-information collected over the call must be available to all persons receiving the call, requiring customers to re-enter information is not oermitted
-disconnected calls must be contacted back within x minutes.
Failure in each of these cases should result in a small fine. 100 bucks or so. Customers can flag bad calls at the end of an interaction, or call a seperate number/web form to report an incident.
The key incentives.that companies.have is to make talking to a human hard (humans.cost money) and to waste as.much time as possible in hopes.customers will go away (or at least not pursue higher level support from LVL 2 agents who can actually make decisions ).
Once you force an actual human on the line, you are costing the company money for every minute they don't resolve the problem. Making it expensive (via fines) to transfer calls incentivizes empowering LVL 1 CSRs. I think once you disable the strategy of "don't let customers talk to a human" providing decent service is in their best interest.
I like the no requesting info again thing but . You'd have to make a more complex to handle security concerns rule but that seems good.
Limitations on xfers seem bad as you'll literally never get to the person who really knows you'll just do everything through your first contact who will text the info to higher levels.
On the charge for exceeding weight times I have some objections below. I like the general idea but im not sure how we can get the data to figure out what works and what makes behavior even worse. Maybe something along these lines will work but I don't see how we can figure out what given the difficulty of changing regs especially given lobbying. But if selected right it might help somewhat...but I feel there has to be a more elegant general solution.
---
Regarding the limits on hold I don't think you appreciate just how cheap call center workers overseas truly are..I fear the natural result of this is just literally having some guy in India sit on the line with the doctor while he holds saying "sorry I'm waiting to hear back from my manager"...indeed the social awkwardness might be a very effective deterrent to calls itself.
Also, I worry that this ensures that once you pass the threshold they move you to the back of the line and keep you on hold. I'm particularly worried what happens when some national pharmacy fucks up or there is a medication shortage and the system gets overloaded.
Also, does the insurer rack up huge fines when that happens because tons of ppl are calling repeatedly? If the fines are low enough that's not a huge deal then I fear they might be low enough just to eat. After all a bad experience on the phone deters future calls too.
I definitely saw that kind of gamesmanship in the call center I ran the doctor-relations side of. The supervisors/dispatchers on the call-taking end would manually prioritize calls that were under X rings and let others go long and hope for an abandon, since the targets were Y% under X rings and under Z% abandon. Obviously not every call was like this, and not every supervisor, but it happened a lot and the people who did it invariably had better stats even if they had a slightly higher (but still acceptable) abandon rate.
Sigh...yes its hard...i think we need to just let insurers incentivize with limited cash to docs (levelized per specialty/patient demo) in kind of nhs imitation. Sounds bad but no worse than now given time is money and a doc could lose several times duration of visir.
Not many people stick around for a post-call survey (or click the links at the bottom of the email saying that it was a good/bad job). Maybe because they assume it doesn't do anything while tipping would. I haven't eaten at restaurants in non-tipping countries / outside of tourist areas where they still expect US tips, is service genuinely better there than here? Taxis were tipped before Uber but the service there was pretty bad...
I tried one year to do a pay-for-performance scheme where we literally paid people a few pennies for every call that met target length (I know, not the same as customer satisfaction, but it was something we could monitor easily) but it never got traction... and honestly it would have been subject to the same gamesmanship (although I had a good strategy in mind to detect it... we had a hard time firing poor performers because hiring was so hard).
I guess my internal economist thinks that the fundamental problem is trying to use temporal investment to allocate limited supply.
My solution sketch would be twofold. First, pass a bill making the feds responsible for abuse monitoring and not the insurance companies. It doesnt make sense to have them do it anyway and let docs override flags online on the fed system.
Second, replace the implicit costs in time with explicit charges in some way with certain caps. I mean it feels wrong but the doctor's time is money and its wasted and now at least the time isnt wasted.
I think we are also looking at two different problems when we compare insurance service to Verizon. In Verizon's case the cost of actually good service is negligable to their bottom line EXCEPT the literal cost of providing good service (wages, giving up the occasional overage charge).
For the insurance companies, if you can get someone to kill themselves while on hold you might be saving a grand of medication.
The mechanic that enables this ehavior in both cases is a lack of accountability: libertarian economist types might describe it as a lack of competition, but only because they tend to think of competition as the only legitimate/functional form of accountability.
An interesting tension: by spending that grand on medication, the insurance company is allowed to make more profits. (Their profits are capped as a percent they spend on claims.)
I'm not sure if they are really trying to prevent the spend by making the call aggravating. But I'd go to trade shows or workshops with people that ran other call centers and... often they just weren't that bright, or maybe they were, but not in the logical sense. And the budgets were often very low (a dollar spent on a claim increases profitability, but one spent on overhead I don't believe does).
How about a simple per minute tax for time spent by customers on the phone without a human on the other end? You could have a threshold so that it would only hit businesses that are reasonably large and make heavy use of phone trees and wait times. Then we wouldn't have to decide what is reasonable and what isn't; we just charge for the use of other people's time.
This is also the technical solution to robocalls. Collect a tax of just a few cents per call or text. It can be applied evenhandedly to everyone and collected through the phone bill, but will only really affect high volume robocallers and scammers.
The hard part would be a regulation requiring that, when you get to a person, you get someone with enough sense, knowledge, and authority to solve your problem.
Requiring conference calls on request would be nice.
"I'm sorry sir, that's a pharmacy issue and you'll have to call the pharmacy."
"Well, let's call the pharmacy together, then."
"They have very long wait times!"
"I hope you weren't doing anything else today, because I sure wasn't."
Once you have three representatives actively sitting on the line, I'm pretty sure they would find a way to solve it besides waiting *another* twenty minutes for a fourth.
Regulation = even worse fuckery, because at that point there is no way out. No to mention there is no incentive for those designing the system to make it make sense. Obamacare roll out anyone? Do you people actually have to recreate the USSR before you realize bureaucrats don’t fix anything? They just make the fuckery mandatory. How come no one sees that this fuckery comes from an excess of corporate bureaucracy? No one understands that the corporate apparatchiks who design this shite for their corporate overlords will design the same sort of shite for their governmental overlords? Gah, I’m so sick of well meaning people who don’t think things through. Calls for regulation amount to the cry “let’s get someone else to fix this! I know, let’s go to the well of kind selfless people who staff our government bureaucracies to figure it out! Then if it still sucks, we can say oh well, we tried!”
I think it's important to distinguish between knee jerk regulation that sees something bad and tries to ban it (think rent control bc rent is too high) which often makes things worse and piles up red tape and systemic design to align incentives that can actually reduce the amount of red tape by ensuring incentives are aligned.
For instance, I'd count things like FDIC insurance and some mandatory standardization laws in the later category.
The world doesn't magically provide ideal conditions for markets (externalities not internalized, tragedy of commons, natural monopolies) and there is no reason why regulation can't simply better align incentives for action so ppl acting in their own interest result in more societal good.
Unfortunately getting those regs enacted in our system is virtually impossible. The left hates them because it feels too capitalistic and based on selfishness not virtue. The right (well old libertarian right) hates it because it's regulation and they think of it as no different than the patchwork kind. Established biz prefers complex regs to resist competition and it's virtually anathemic to passing via grand political compromise.
I think it may not be an accident that we don't have a simple national health insurance system and that we don't have a parliamentary system.
How about, if a prescription or procedure is denied, there's a government agency that reviews the contract and rules on whether the denial was proper or not, and if it was improper, the company has to cover it plus pay the insured $5,000,000 in damages.
I agree with you that the problem here is that the system incentivizes obfuscation to avoid covering things, and as long as that is true companies will find new ways to obfuscate. But it's not actually hard to remove that incentive. Removing incentives to do bad things are what fines, penalties, and jail time is *for*.
I think that will make things way worse. Ultimately the base rate of errors that insurers can't avoid gets added to our cost. At those figures rather than building a system that has 99.9% accuracy they'll go for 99.9999% accuracy/uptime (a global sys crash could deny millions) and it will look like NASA rockets in terms of cost.
Worse, the strong incentive is for patients and doctors to delibrately script things they think insurance company might deny wrongly in hopes of getting a pay day.
The inevitable uncertainty of subsequent review means insurance companies will have to approve a bunch of stuff that should have a small amount of friction. For instance, a doctor should have to do a bit more work to script an expensive name brand rather than a generic (if u pass the extra cost on to patient insurance isnt working for the small frac who really need the name brand bc of allergy etc) or they'll just script it bc the pharma rep flirts with them (or bc patient asks in hope of a big pay day).
You'd be better just mandating coverage for all meds on some list for any reason.
Ultimately, the problem isnt that there is some cost for doctors making some kinds of scripts. Its that insurers have to run abuse detection, the system is opaque random and that the cost comes in terms of time generating pure social loss.
They don't need 99.9999999% accuracy, they just need a policy of 'approved unless we say otherwise'. Also clearly-written, unambiguous contracts that avoid the possibility for confusion or error.
This is literally what the word 'failsafe' means, design the system so that its failure states are safe. If the penalty for false denials is too high, design the system so the fail state is approval. I doubt it's actually hard to do if the incentives are aligned that way.
>Worse, the strong incentive is for patients and doctors to deliberately script things they think insurance company might deny wrongly in hopes of getting a pay day.
What you're describing here is committing fraud by submitting your fraudulent documents directly to a government agency specialized in evaluating such cases. Doesn't seem smart.
> For instance, a doctor should have to do a bit more work to script an expensive name brand rather than a generic
The proposal isn't that they have to cover every prescription, it's that they have to cover every prescription that their contract says they will cover. As I said, I expect those contracts to become much less ambiguously-worded as a result, and that's a good thing.
>You'd be better just mandating coverage for all meds on some list for any reason.
I mean obviously I just want a nationalized healthcare system like a civilized nation, but I was sticking to the limited scope of the hypothetical.
>Ultimately, the problem is... that insurers have to run abuse detection,
That's *a* problem, but it's not the problem with the current system. The problem with the current system is that insurers directly profit from denying as much coverage as they can get away with, and I'm talking about how to solve *that* problem. Yes, that doesn't sole *every imaginable possible problem relating to the entire process all at once*, but solving the biggest problem *is* a big improvement.
The very fact of having to go through a physician, pharmacist, and health "insurer"* - typically coupled to your employer - to get medication is itself a product of regulation; my prior is that more regulation would make this worse, although path dependence does make it non-trivial to unwind the current state without causing unacceptable collateral damage.
*Insurance is fundamentally a financial product, but so many other things have been shoehorned into it that health insurance isn't.
I don't see how that is a product of regulation. In a perfect free market we'd expect specialization and there is almost no overlap between the skills needed for the three services so it's natural they'd be seperated.
Indeed, vertical integration here would be potentially quite dangerous. You want honest advice from your doctor and if they are part of same corp as insurance company you can't even figure out how to evaluate the quality of your insurance (are they covering the drugs best for you or inducing your doc to favor the drugs they do cover). Similar concerns with stocking and ordering meds at the pharmacy.
In that sense there is a natural antisynergy here so in a ideal market of rational agents we'd expect these to be handled by seperate companies.
--
If what you mean is that in a perfect market insurance would primarily be only catastrophic ...maybe but I think for creatures of limited mental capacity and akrasia we are willing to pay more to limit the variability of our health costs and ensure we are never caught short.
None of the three roles are required intermediaries when I go buy a bottle of ibuprofen; regulation puts them in the way for all but a privileged few medications.
I absolutely agree you should be able to show up and just purchase whatever med you want with cash (perhaps for the addictive ones once you've been informed in some way about risks) but I don't think it will stop ppl wanting insurance and once you have insurance they need cost controls so they don't pay out tons of money to cover someone who gets a crazy idea they need to take 60 brand name prozac a day and that brings in this whole problem again.
Unless you plan to let ppl die who don't have the money for meds at the bottom you need a program for the poor. And if those who aren't poor dont buy insurance at all the poverty program effectively insures everyone.
But wouldn't a perfect market result in everyone only buying catastrophic insurance? No, utility isn't linear in money so we rationally want to limit the downside more than improve the upside so it's rational to want to limit your exposure to medication cost by buying insurance even at non-catastrophic levels.
In a perfectly rational world without employer insurance and ACA limits on preexisting conditions everyone would pay a regular fee to option the ability to keep their medical bills relatively small and those insurers would need to both limit costs while meeting people's desired health needs.
We'd still want to consult experts and insurers would still use them to limit costs. Though we might eliminate the abuse holds.
Kaiser Permanente is trying vertical integration. Their HMO lets you see their doctors and use their pharmacies. I know some people that use it and like it (in spite of HMOs getting a really bad name in the '90s). Haven't used it myself (I prefer high-deductible plans and just paying cash for everything, but thankfully I don't have chronic diseases that require medication management, whenever I run the math on other plans than HDHPs are cheaper when costs are small, are cheaper when costs are large, and are usually only a little less expensive when costs are in a narrow range, and seems more complicated, not easier, than just taking the money I would have paid in premiums and putting it in an HSA automatically), but wanted to add the anecdata.
I have mixed feelings. I just moved to an area where vertically integrated HMO is only option (we picked ppo insurance but virtually all docs through IU health). It's great and efficient if you fit into their categories.
Unfortunately, I've been taking buprenorphone for last 20 years (some issues in grad school subsequent to depression and I found trying to go off brought depression back). Everywhere else I've lived either in states or Israel I could eventually just find a private doc to handle it (tho not always on insurance). Here in southern Indiana I've been shunted off to some horrible company that's literally entered multiple pleas to medicaid fraud that treats me like a criminal.
Here in a decent sized uni city in us I literally had a healthcare worker express surprise when I told her everywhere else I'd lived I could just look up a psychiatrist and pay them money to see me.
They are never going to be ok for that for controlled substances. Too likely ppl who stop needing it build up huge stockpiles and sell them. Even if you agree drugs shouldn't be illegal recreational use probably shouldn't be subsidized by insurance.
Based on anecdata I've heard about Kaiser, it sounds like they're well-optimized for people with what might be terms "Newtonian" health problems: i.e. it's a relatively common problem with clear-cut diagnostic criteria and a pretty good standard protocol for treating/managing it. For example, if you've got high cholesterol or type-II diabetes, they're set up to diagnose it, recommend appropriate lifestyle changes, and keep you supplied with appropriate doses statins or metformin or whatever.
They're also decent at administering PRATFOs (Patient Reassured and Told to [expletive deleted] Off) to patients with minor complaints and no underlying disorder.
Where they're not so good is if you've got legitimate health problems that are rare, tricky to diagnose, or hard to treat. They seem to try really hard to pattern match you to either a common, easily-treatable complaint, or if they can't shoehorn you into one of those, default to PRATFOs.
This failure mode is not unique to Kaiser by any means (particularly since hard-to-diagnose and hard-to-treat complaints are by definition difficult to deal with appropriately), but they seem to fall into it pretty consistently among people whose experiences with Kaiser I've heard about.
Do you know anything about the age profile of doctors at Kaiser. The docs I've seen at these massive integrated facilities (tho I haven't used kaiser) tend to be younger than the one's I've seen in private practice so I wonder how much of that is Kaiser employing docs that are relatively fresh out of residency who then migrate to private practices as they age.
I've actually had the opposite experience in terms of younger docs being more interested in playing Dr. House, while older docs tend to be more apt to expect the familiar patterns.
The biggest example in my own experience was several years ago when I went to the ER with what I feared to be a detached retina but instead turned out to be an ocular migraine. After a long wait, the ER nurse tried to diagnose me as a lying non-compliant diabetic until my wife vouched for my non-diabetic status. Then a resident came in, and I gave him a very detailed and precise history of my symptoms. He got very excited, told me it was the best history he'd ever gotten from a patient, did a full neuro workup, started asking questions that seemed intended to explore the possibility of brain cancer or other similarly exotic causes, and then left to talk to his attending.
The ER attending came in a bit later and basically diagnosed me with "probably not going to die or go blind tonight" [he phrased it more diplomatically, but that was the gist] and prescribed a course of "go home and rest, then call your regular eye doctor in the morning and ask for the first available appointment". My eye doctor was the one who diagnosed ocular migraines.
That was exactly my experience with Group Health, a WA-based HMO that Kaiser took over somehow. They were great for all the normal stuff, but once I developed something out of the ordinary, I bounced through years of misdiagnoses and medications that made my condition worse.
Regulations get Goodharted. That's how this mess came to exist. The fix is to align incentives. This usuallu means less regulation, but it's not the amount of regulation that's essential, but where each party's interests are.
Do you think that the environmental regulations which prevent dumping raw chemical efluent into rivers have been Goodgarted? Goodharts law is typically a problem of operationalizing a problem definition, which isn't always an impossible task.
Regulation: making it very expensive to act against the public interest. As long as you can properly define the prohibited acts, a realignment of interests will follow!
Goodhart's law states that when a measure becomes a target, it ceases to be a good measure. It says nothing about not setting targets if a target is what you want!
It is not less or more regulation. It is the *wrong* regulation.
The US system spends a huge amount of regulatory and bureaucratic window dressing taking what looks like a competitive market of private insurers, and making it in effect a near single payer system where they are all the same, the systme is basically resdistributive (and barely insurance at all really since the risk pooling isn't happening before the risk actualization).
So you cannot get together with a bunch of other healthy people and make a new insurace pool, literally illegal. You cannot cover this sort of thing and not that sort of thing, and so on and so forth.
In exchange for all this bureaucratic madness the legislation mostly insures everyone still gets their full cut. So costs stay high, all the efficiencies are lost, and it is a nightmare.
You need real competition and real market forces for the "private" nature of of our system to do any good, but there is none. When I look for insurance plans I have a choice of maybe 4-6 providers, all overing a few levels of plan which are more or less exactly the same product excpet a few minor details. There is no competition.
So the "insurers" make their giant pile of money, and so does pahrma, and doctors, and hospitals, and people mostly get care, but it is all a nightmarish hellscape becuas eyou are having the costs of both a public system and a private one, but almost none of the benefit sof a private one.
I agree our system is a mess. But I think really giving people what they want in a competitive private system is essentially impossible.
What people want insurance to provide is safety. They want to be sure that if things go bad it won't turn out they fucked up some detail in the plan they choose or forgot to pay the premium for a few months while abroad and now they are fucked.
Without these regs a competitive market forces insurers to deny converge to preexisting conditions. So the only way this market could possibly offer ppl the thing they want is if you contracted very early in life (arguably B4 your parents conceive you) to do something like exchange a percent of your lifetime income for permanent coverage. Any pay by the month/year system just isn't letting ppl insure against the risk they primarily want insured: the possibility they get unlucky and they get diagnosed while uncovered.
But if you have to commit at the start of your life the normal informed consumer choice can't really happen (even your parents would be limited by very imperfect info about the future). Moreover the notion of individual tailoring to preferences doesn't apply since the choices must be made before those exist.
So yah stop pretending it's a free market and just choose a national health insurance scheme (tho maybe more Germany style than UK).
I am not remotely convinced a system with a much freer market of actual insurance where pre-existing conditions are not covered and where the residstributive aspects are just done as straight handouts to the less well off wouldn't be a lot easier.
I would also pull almost all non-catatrophic care out of the insurance. So people can get insurance that will help them if they get cancer or a heart attack or whatever.
Already had a heart attack? Well that is too bad, the same way it is too bad if you try and get fire insurance after your house has burned down.
But but but you say, what about the 3 year old who develops cancer. Well frankly there are not many of them and that will work better handled as a line item in the federal budget instead of smugglign them in by breaking the whole insurance system but pretending it is still insurance.
Either that or just bare bones single-payer where everyone is force enrolled, which I don't think is too bad, but there would need to be A LOT more rationing than we do in the US currently to keep costs down. And people would hate that.
The system right now is like the worst of both worlds.
First, just as a matter of values I certainly don't want (and voters don't either) as system that lets the 21 year old die bc he let his insurance lapse for a month between college and his job who gets stabbed stopping a robbery and now needs dialysis plus kidney transplant.
Not only do I think the voters don't want that I think ppl would be so scared of that they would never let their insurance lapse. PROBLEM, once you've been diagnosed as being at greater risk how do you switch insurers?
And any insurer who doesn't get a lifetime contract faces adverse selection selection. Ppl learn about their level of health and those who are healthy switch plans to a cheaper one leaving only the sickest. Market solution is to pay for lifetime coverage upfront (eg debt) so literally no one gets to switch insurers and bc of the info asymmetry (as in sale of used car) even if existing insurance is for some reason (doubtful imo) willing to offer you a buyout they'll never offer you the full amount (ppl have private info about their health and healthier ones will preferentially take buyout) so everyone buys insurance once at 18. Bc of bankruptcy floor the market becomes a series of insurers who offer good service for a bit then profit take off their existing clients who can't leave funneling money to shareholders until bankruptcy.
So on your system say a doctor does a genetic test on a 3 year old and discovers they have 50x the usual risk of getting some very expensive disease at 35. How do they buy insurance at 18? Their risk adjusted insurance premiums might well be 50x or more then average.
If you try and have the government cover the difference you recreate the current system. Even if you give ppl a lump sum the government needs to define a standard level of care to infer NPV of the lifetime risk adjustment and then maybe even pass laws to ensure the insurers offer insurance at that rate (the insurers and purchaser have an incentive to uprate the expected cost to fund a more luxurious plan and the only way you avoid forcing those with higher risk into crap coverage is to somehow define minimum coverage and then how do you handle the case where the market seems to rate price higher than gov? There just isn't any workable price discovery here if you commit to not screwing over those with higher risk).
>If you try and have the government cover the difference you recreate the current system.
No you don't recreate the current system because the two systems are not mashed together into some unholy frankenstien whose main purpose is to hide what is going on and obscure all signals about who is paying for what.
You don't have "subsidy for kids who develop cerebral palsy at 6 months" just lumped into everyone's undifferentiated premiums and hidden, but instead as specific line items that are coming directly out of people's taxes and the government coffers. There is more price sensitivity and transparency.
Yes that might mean socety balks and stops covering $200,000/year cystic firbosis treatments that improve someone's quality of life from 62% to 89% instead of the 81% they would get on a much cheaper cours eof treatment, but that would happen outside the insurance system.
As it is now the insurance system is being asked to do about 197 differnet things simultaneously and so it does a ton fo them very poorly.
And sure there is price discovery, it is just the tapayers discovering price for the prexisting condition people isnetad of those individuals.
And yes some people will get screwed, that is life. Two people drive exactly the same, one person gets in an accident and ruins their future happiness, the other lives a carefree life. You aren't going to be able to mash all that out of life even if we doevoted 100% of the eocnomy to just that. We should stop trying to achieve it.
You could also have a separate system where people having kids (or taxpayers generally) simply are required to pay into a "future healthcare for children of X illnesses fund". Then have tehcnical experts decide what level of care the fund can actually afford.
You want to keep as much of the system working with fucnitonal price signals as possible and the current system does a HORRIBLE job of doing that.
My literal optiosn for insurance are something like:
Company A, Product 1: Pay $10k/year in premiums and be at risk for another ~$15k in costs max, at group of providers X
Company A, Product 2: Pay $12k/year in premiums and be at risk for another ~$13k in costs max, at group of providers X +.1(Y)
Company A, Product 3: Pay $15k/year in premiums and be at risk for another ~$10k in costs max, at group of providers X +.1(Z)
Company B, Product 1: Pay $11k/year in premiums and be at risk for another ~$14k in costs max, at group of providers Y
Company B, Product 2: Pay $13k/year in premiums and be at risk for another ~$12k in costs max, at group of providers Y+.1(X)
Company B, Product 3: Pay $14k/year in premiums and be at risk for another ~$11k in costs max, at group of providers Y +.1(Z)
That sounds like an exaggeration, but it is not. I have about 15 different choices and they are all more or less exactly the same product with EXTREMELY MINOR variations. Moreover the fact that I was at low risk of helath costs, have been low risk, never made a insurance claim against and house or car in my life, all things which should be extremely beneficial in terms of my risk profile. All meaningless.
So instead as an adult I have paid in maybe $200k into the medical system in premiums, more? The government has probably chipped in another $100k on my and my family's behalf in one way or another. And used maybe 1/6th of that. Less?
For my and the government's $250k I have gotten a product where half the time I can barely even fucking use when I need it it andrisk goign to jail if I try and not buy it. It is not a good system. Don't hide the cost of being old in premiums for people in their 20s and 30s.
I still don't understand how you allow switching insurers without sinking the system under adverse selection.
If I get a get a DNA test while insured and have way higher risk of some disease how can I ever switch insurers? If I discover I'm at low risk what stops me from switching to a special low risk plan and leaving the first company only with the high priced individuals.
Is it legal for me to start and insurer F who only charges 8k/year and max risk 10k but only for ppl whose genetic risk score is in bottom 40%? If so every customer at other insurers listed takes test and switches if in bottom 40% and stays put if not.
Now those other companies are jn the red bc say A1 still gets same revenue per person but all their customers are now in top 60% of expected healthcare costs.
Either you have to stop ppl from switching or you can only get insured after full dna analysis and if you are in top 10% (healthcare cost weighted to top tail) you are just screwed and need to pay 100k a year for that coverage out of the gate at 18.
To illustrate issue imagine there was a magic device you could use to determine exactly how much your total lifetime health cost would be that you can use secretly at home. Now suppose every year i can choose between your plans. What I do is secretly take the test check of I'll make or lose money on each insurance and only buy it if it's a net positive. Since everyone does this any insurance plan that charges less than the literal maximum medical bill in the country goes under because they pay out more than they get to all their customers. End result is that no one can buy insurance at all.
DNA tests arent perfect but they in combination with other tests are a noisy approximation. As tests get better and better we are able to insure against less and less.
My understanding (based on a moderate amount of research 5-6 years ago) is that the whole pre-existing conditions argument is based on a misunderstanding.
Insurance pre-ACA sure had pre-existing condition exclusions, but they were just a waiting period. If you had a pre-existing condition prior to signing up for an insurance, you would need to wait 3-6 months for that specific coverage. It was always intended to prevent you from calling up an insurer while they were doing open heart surgery on you (absurd mental image intended) and not stop you from ever changing jobs if you had diabetes.
It was also intended so that insurance companies could hand-pick lower cost members, refuse to take people based on their conditions, and charge higher premiums to individuals with pre-existing health conditions. A lot of people in that situation were effectively uninsurable -- they couldn't find an insurance company that would take them.
Hipaa regulates how patient information needs to be secured when stored and transmitted electronically. It doesn’t regulate what medical procedures insurers need to cover or how.
Having spent a lot of time trying to make call centers and other service operations better, I think regulation is a distant root cause here. The more proximate cause is people (sometimes consultants) trying to make their one piece of the operation better, e.g., triaging out live calls to lower cost. In a truly competitive market there's a feedback loop that can correct the excesses, but you need only a small constraint on competition, or a big bureaucracy with lots of inertia, to get the bad result here. I've had the same nightmare experience that Scott describes but with my home internet-TV-phone provider, which theoretically faces some competition. So I think there's overregulation in the mix, but to me it's more Goodhart and principal-agent problems and short-termism.
A competitive market in which those making the decisions pay the costs. That's not true in insurance.
The ultimate problem here seems to be that the insurer wants to discourage the doctor from certain kind of prescription (either bc it costs them money directly or they fear it will expose them to liability if patient is abusing). As long as we have a free market in insurance (and they have potential abuse liability) this is inevitable and arguably socially beneficial to some extent.
The problem is that the insurer isn't allowed to just directly charge the doc in a transparent way that creates optimal incentives. Instead we get a pure social loss in wasted time via a complex highly random system,
I agree with all that, just saying a more parsimonious explanation is "big-company customer service trends toward cheap and bad, absent strong leadership and a brand that depends on good CSAT." There are principal-agent problems in lots of industries, not just in health care. For what it's worth, I've had a few different payors recently and some opportunity to select among them (i.e., it's at least a little competitive), and customer experience is one of my buying factors, but it's a lumpy annual decision so the feedback loop is weak.
Fair. But I've found that in digital age when u have at least weekly aligned incentives u can at least discover the cheap mechanism that makes it easier for everyone. Even most utilities have online payment, outage reports etc...
It's still really bad as u say but this level of bad I only see with misaligned incentives (eg subscription cancellation). I agree but I don't think we are even at the just "tends toward bad and cheap" level here but the "let me make u call between 9-5 London timr the week it's going to renew" level (yes really what a magazine told me)
We might be able to develop a theory of Crap Customer Experience, like a predictive model for where the customer experience will be unbelievably bad, beyond where it would be economically rational to be bad. Feels like some parameters would be
1. Currently overregulated industry with many constraints
2. Vestiges of historical monopoly
3. Many layers between market discipline and decision making (you call this lack of competition, I call it size + principal-agent conflict, same thing)
4. The cancellation experience (dark-pattern save desks and other hurdles)
To play the rolê of stereotypical libertarian, most of this stuff is a result of regulation, not markets operating. Health care's bizarre third party payer model distorts prices and restricts the ability of medical service providers to act outside the narrow confines of what they know is legal and profitable and try new ways of serving customers.
Sounds good, but some of the problem is that the regulation (or more precisely, the misunderstanding of the regulation and fear of lawsuits) is what causes some of these problems.
You'd have to have an invested team of people able to push legislation that doesn't just end up causing more fear and paralysis and the will to follow up when it isn't working out like expected. Based on the history of other medical reform (such as HIPAA) I doubt that is going to happen in this sector.
I've had some insurance companies that were very easy to get ahold of a competent individual who could help you. But honestly when it came time to renew, I regularly opted for the one that was 2,000-4,000 dollars cheaper per year USD. It didn't make sense to pay that amount of money when I had no clue if the cheaper one was worse or better and I only had to call in every 1-3 years.
Agreed. I'd love a world where laws were enforced regularly and fairly, and it was the responsibility of law enforcement to actually do it. I would hope doing so would actually decrease the laws on the books instead of increasing them. In the US there doesn't seem to be much appetite for enforcement. See privacy concerns over speeding cameras, police unions protesting by enforcing all laws to create huge backlogs in the system and generally annoy people, etc.
I wonder how much of the insanity of pharmacies comes from the fact that they are expected to provide second-line service to keep people from being prescribed drugs with harmful interactions and to take them the correct way, instead of just a place to pick up things that the doctor already selected for you and told you how to use.
If everyone had only one doctor, that would work. Unfortunately, many people have more than one doctor; I myself routinely see 6. The pharmacist really is the "last line of defense" to prevent Doctor A from prescribing drug B, which has a lethal interaction with drug C prescribed by Doctor D.
Is it every industry? For instance, how is it in extremely competitive, customer oriented industries like, say, TV sales? Are Best Buy and Panasonic as bad as CVS and Blue Cross?
That depends on your point of view. In small practices, I expect that the physician is absolutely the one that's on the phone. At a moderately sized practice like mine, people like me are hired to perform these duties in tandem with everything else that is required.
A technician like myself has to do the work up, i.e. get the basics of the doctor's bookwork done (thankfully, we do this electronically). That means doing, more or less, anything that doesn't require a doctorate to assess. Which is most parts of the full visit in my field.
Several technicians work for a small number of doctors, so that each 30-60 minute appointment doesn't eat 30-60 minutes of the attending's time. Anything that we do or don't do is ultimately the physician's responsibility, and can be called into question in court. A chart note is a legal record of what happened during the visit, and has to treated as such and amended by strict protocols.
So, yes, the doctor is the one on the phone all day, if in a distributed sense. Any time that I spend sitting on my ass and hoping that either I die or this cockamamie hold music that someone dug out of the dumpsters outside of Hell's orchestra circa 1963 will just please end, whichever comes first, is time not spent tending to someone in the building or answering a question that takes all of 3 minutes to do. That is time that the doctor is losing to what could be charitably described as "smooth jazz as described to an alien that cannot perceive sound".
>A chart note is a legal record of what happened during the visit, and has to treated as such and amended by strict protocols.
Tangentially, this is a big part of why medical transcriptionists are a thing and continue to be a thing even though most doctors know how to type now and text-to-speech software is available for docs who prefer dictating notes. The actual transcribing is only part of what medical transcriptionists do, and the other big parts (cleaning up causal notes into a formal legal document, and recognizing and flagging possible mistakes for the doctor to double-check) remain important.
You can even outsource it, just call InsuriCall on a toll-free number and have your Medical Assessment Number ready and they'll call the insurer and pharmacist for you (for a fee).
Some hospitals have drug reimbursement specialists whose full time job is doing this sort of thing. Some physicians hire medical secretaries, but how good they are and how devoted they are to this aspect of their jobs vary a lot.
Finally, an ACX post to vindicate my absolute seething hatred of deliberately confusing phone trees. Any utilitarian argument for the joys and benefits of widespread automation that does not seem to acknowledge this unparalleled evil earns my immediate suspicion.
This works equally well for the interplay between Verizon and Asurion when attempting to get a replacement phone through the warranty process. Half a dozen calls, multiple transfers that mysteriously drop, call back numbers that don't work, shouting "SPEAK TO A CUSTOMER SERVICE REPRESENTATIVE" at every menu tree, tech support people all reading the same scripts, tech support people asking me for all the information I just entered, multiple "tech support" people trying to up-sell me new services instead of fixing my issue ("Maybe your phone would be able to get text messages if you just upgraded to a more expensive plan!"), Asurion telling me to call Verizon, Verizon telling me to call Asurion. I eventually made it through but it took hours.
I'm not saying that the first political candidate that promises to find the people who design systems like this and have them publicly executed will automatically get my vote, but I'm not NOT saying that either.
But at least that situation is responsive to market forces. Asurion is cheap bc they make it hard to make claims. If you want to avoid that you pay for apple care or similar.
This is particularly horrible because those who bear the costs arent the ones making the deciscions (at least not with any information about future costs).
This resonates deeply. The times I've had to navigate phone trees (usually verizon) always made me miserable for the rest of the day. I hope this particular post wasn't inspired by any recent events.
Bonus points for not offering any other way to contact that leaves a paper trail (and basically no way for people who have speech/hearing impairments to get in contact).
Ohh I'm sure they offer those tty enabled phone call things. I suspect they are far too smart and legally advised to fail to obviously violate the ADA. How realistic that accessibility is might be another story.
Someone (deaf person, government agency) is paying for another person to sit on hold so even more people can suffer at one time and interpret for them.
Sometimes those relay services are used by "drug-seekers" as a way to anonymize their calls, but mostly they are just people trying to get service.
Huh, always thought drug seekers avoided insurance (at least on extra/skeevy scripts). But I guess they've probably cracked down on that more recently. I never scammed scripts but back in a less pleasant period of my life in bay area I remember being surprised to learn there was a going rate for fronting the cash to let someone retrieve a script.
I really don't understand why the insurance companies need to be involved. Don't all pharmacies have to report to a PMID? Every doctor I've seen for past 8 years can look up my prescription history. Why not make that master check?
I remember when that law got passed in Illinois and my mom tried to opt out for privacy (she refused to trust ATMs until late 90s) and despite quoting the law which supposedly gave her that right and not having any scheduled prescriptions she couldn't get them to do it and I thought it was at least sorta mandatory for controlled substances.
I've been out of the industry for about 4 years and drug-seeking behavior had really died down towards the end of my tenure compared to the beginning, so some of those solutions may have been solving the problem, but I wouldn't be surprised if nobody went back to get rid of the older solutions that were made useless by the new ones.
And again: many company policies are put in place by people who do not have a firm understanding of the law, either because they haven't put in the work or because the law is purposefully vague and the fear is of lawsuit. There are a lot of horror stories out there of businesses and individuals in businesses being sued or going to prison for something that (as the story tells it) wasn't explicitly forbidden and seemed perfectly fine. Often when you got more details in the situation, it was a lot skeevier, but that isn't how the story goes.
You could always hire a consultant to tell you what to do, but I found that a lot of consultants either also didn't know the law or creatively interpreted the law to scare you as much as possibly and justify their services (immediate and ongoing).
1) Integrated healthcare systems where a giant sprawling complex of docs all under one roof (like IU health here in Indiana). I think they sometimes tend to work alot with one health insurance company (eg here in Bloomington IU is probably the largest employer)
Like does that kind of giant system either allow those costs to be amortized (someone has a full time job fussing with this and that cost is amortized over many many patients) or change incentives?
2) In single payer systems like the NHS? Or do these systems inevitably use cost in time to deter expenditure as well?
The NHS used to be good at this but chronic underfunding particularly of support staff means you don't get a phone tree, the phone just keeps ringing until it disconnects or you get an answerphone which is either a black hole or full; the way to get treatment is often just to show up in person and wait there.
If you're very lucky your GP will have implemented an e-consult form which means that you at least don't have to wait through ages of hold music and 'you are a valued person who is twenty third in the queue' to get hung up on, although generally the form will only be open briefly in the morning as they shut it once they have too much work for the day (to stop emergency patients filling in the form then dying waiting for a response, which may be accounted their fault).
It's not even the case that the phone lines don't try to upsell you any more because of the takeover of services by Virgin etc.
A good way to fix this is to somehow make medical support staff as valued as front line medical staff, and spend money on admins and phone answerers rather than expensive management consultants - but they are less likely to be the friends of people in government, so it seems unlikely to happen.
That doesn't really sound like fixing it to me. If you are paying ppl a lot in doctor offices to sit on the phone with insurance companies you are wasting a bunch of money no matter who is doing it.
And it seems pretty obvious that the insurance company could implement an easy to use electronic form to handle this kind of thing in a way that cost them less if they wanted to but they don't want to make it costless for doctors to inflict higher costs on them or expose them to lawsuits for ppl who get addicted.
I guess my fear is that insurance (national or private) need to limit costs and if you take out price as a way to do this directly they substitute inconvenience.
Most patients currently still can't easily use electronic forms easily because health care need is biased to the elderly - this is if course gradually changing, but people with high healthcare needs will always need a range of options because eyesight, hearing and money for reliable technology access is anticorrelated with healthcare need.
I meant forms for the doctor since that was what the post was about. The issue if personal interaction with the insurance company is a whole other concern, but also interesting. But for in network care it's usually been the doctor's office who works it out in my experience but dunno how universal that is.
I'm still talking about the NHS - so the doctor does have to submit all kinds of QoF paperwork to get the government payments but doesn't deal with insurance per se. Generally their automated GP computer system will spit out the reports on their end too. Computer says no is still a problem for referrals but the equivalent of this is them trying to phone the hospital / specialist clinic and having to do so repeatedly to catch someone actually able to take their call.
Sorry, I misunderstood. Thanks for explaining. What do docs do for the patient who needs the expensive brand name drugs (eg allergy)? And what discourages doc from just always picking those? Honor system? Threat of review of paperwork?
The previous method of cost control was mostly gatekeeping - stereotypically by GP receptionists. This is also not a perfect allocation method (in particular it tends to be biased in favour of articulate, middle class patients who can play the social game) but probably somewhat better than the current situation in most cases (really obviously serious cases could get through more easily).
But that's not gatekeeping for cost. Only gatekeeping for ppl asking for scripts. No skin off the doc's nose if you take an expensive script rather than a cheap one unless insurance company makes his life hard as a result.
I'm talking about the NHS, so gatekeeping for cost is done with NICE prescription guidelines, incentive payments to GP offices for prescribing generics etc
Ohh incentive payments. That's much better than my idea of disincentive fees. Same thing ultimately but far more psychologically palatable. Good system.
Tho I guess with private insurer you don't want them to offer huge bribes to give worse care and at least reducing visit coverage limits size of disincentive.
> 2) In single payer systems like the NHS? Or do these systems inevitably use cost in time to deter expenditure as well?
It's not as strictly single-payer as the NHS from my understanding, but the Australian system is a lot less time consuming. Medications that are covered on the PBS are either unrestricted (can be prescribed for any indication), restricted (e.g. prozac is covered for depression or OCD only, honour system), or authority (like restricted but with some hurdles that basically break down the restriction and make you promise you're following each part of them).
Getting an authority prescription approved used to need a phone call and a wait on hold, but these days it can be done online in <5mins. The disincentive to inappropriate prescribing? If you're audited and you've lied on the forms then you'd be open to fraud charges I guess. I don't know how much that actually happens, but it'd be pretty rare.
Ok so I'm guessing it becomes virtually impossible to demand the name brand? That's probably a reasonable tradeoff.
Like this seems mostly good but I'm curious how it works with drug approvals? I mean does this mean that if prozac did trials to show ocd effectiveness but another SSRI didn't you (theoretically) shouldn't be able to script that other SSRI for OCD?
I don't necessarily disagree... the whole requirement the you prove efficacy for one condition get prescribed for anything is kinda fucked up but I wonder how that would work for pharma incentives if every country did it this way? Do you just lower the burden to show efficacy? That could be good.
Also, if a patient is willing to pay out of pocket can you prescribe outside those indications?
Idk about Australia but UK private prescriptions are mostly handled by pharmacists (or private GPs if you need something that can't be directly pharmacist prescribed) rather than your regular GP.
An alternate ending - the block is lifted, but when Jane Smith goes to get the prescription, it can’t be filled because the medication is out of stock there. And then she gets the prescription transferred to another pharmacy but by the time she gets there, it’s closed because the pharmacist takes a lunch from 1:30 to 2 pm and techs can’t dispense meds unless the credential is on duty.
Or, in the version with the meaner doctor, Jane hasn’t kept up with the constant blood draws so the physician won’t write the refill until she gets a blood draw and makes an appointment (at which they say it’s fine to remain on the same dose). It’s not just the customer service misery. Maintenance medication by prescription somehow insults the universe and obstacles proliferate in front of it.
The other great version - the doctor no longer works there and if Jane wants her pill, she’ll have to reestablish care with a new “care provider.” Which will take three months. Better hit ACX for some advice on nootropics, Ms. Smith.
That's not even the half of it if you want to deal with a medication like buprenorphone that has special approvals needed.
Moving is almost impossible as most receptionists won't even know or be able to tell you if their doc handles the med (unless you go to a shady place that's basically built to rip off medicaid) but you need the meds within a month of moving.
> "Jane hasn’t kept up with the constant blood draws so the physician won’t write the refill until she gets a blood draw and makes an appointment (at which they say it’s fine to remain on the same dose)."
I have this problem with my rheumatologist. It synergizes excellently with the complete inability to get a human on the phone to *make* said appointment. More often than not I physically drive over there to do so. Also appointment waiting room times are 3-4 hours.
And there are no other rheumatology clinics within a 20-mile radius, as far as I can tell.
I spent an hour and two minutes on the phone with Cigna today *before I'd even reached the correct department*. It takes 3-5 minutes just to get through the automated phone system and get to sitting on hold.
I promise I'll read more than the opening paragraphs, in a moment. I opened this to do some light reading in bed and now I am wide awake.
If you work for Cigna, no offense to you at all, but *fuck* Cigna. I could have seen at least four people from start to finish in the time it took to start unraveling the knot that took me to them. Third call today, fifth since the start of the week, all for the same problem.
Aaaagh!
Edit: I hate how close this is to what I've been doing for the past two days. Dammit, Scott!
Argh! This should probably have a trigger warning. Very accurately observed, and left me almost shaking with anger.
I'm thankful that a) I don't have to deal with this in my day job and b) I don't have to deal with it for anything medical, thanks to the NHS. But it's still an unavoidable part of being an ordinary citizen in the modern world and dealing with banks, utilities companies (including phone and internet), mortgage providers, insurance (non-medical), companies you order things from and they don't send it or they send the wrong thing (except Amazon, who let you do it online, which is a fraction of the stress).
And you missed the bits where the company's phone line is so bad you can't make out what they're saying, or the person's accent is unintelligible (maybe Glaswegian, to avoid the appearance of racism). I once tried to make a trivial change to a life insurance policy, which I thought would be a 5-minute phone call, but they made me stay on the line for an hour so they could basically reassess eligibility from scratch. "Have you ever suffered from any of the following conditions: (long string of nonsense syllables in a very strong accent)?"
Maybe hire an assistant? (Although once the assistant gets through to a human, maybe they'd be told "sorry, I can only speak with Dr Alexander himself," as this is what happens when the wrong member of a married couple phones the bank or utility company to discuss their joint account.)
Maybe move to the UK, where at least you won't have to deal with this for medical stuff?
On the one hand, crazy that doctors whose time is ultra valuable have to spend a significant portion of their time on nonsense like this.
On the other hand, the phone maze described here, humorous exaggeration and all, is still pretty good compared to the experience of trying to get a large tech company on the line. Some common tropes:
* There is no phone number or other way to contact them given *at all*. You go to the customer support page, you just get a FAQ or some kind of keyword-matching textbox which attempts to guess what your problem is and gives you a cookie-cutter answer. In order to be allowed to contact the helpdesk, you have to find the one path through the FAQ maze which will give you the phone number plus a one-time passcode. If such a path exists at all.
* Variant: to get the passcode, you need to already have a customer account and a specific transaction (e.g. in the case of a hotel booking website, a specific booking ID) which your question is about. If your problem is that you can't login or can't create a booking, you're stuck.
* The only way to contact the helpdesk is via a little chatbox in a corner of the website. It always pops up automatically as soon as you linger on the site's main page for more than a few seconds, making you feel watched and pressured. It opens with an automated message like "hi, I am Dan, how may I help you" but then when you type something in there, you either get no response, or a "there is currently nobody available" message, or a chatbot that makes 1970-era ELIZA look like GPT-4 by comparison.
It's even better if you're an in-patient, as then all your frustration is evidence of emotional disregulation, and your attempts to communicate your previous medical service interactions is evidence of mania and psychosis. Here, have a lorazapam while we schedule you for E.C.T.
I realize this is probably exaggerated by about 15±5%, but why does every single aspect of the US medical system - aside from, idk, maybe getting the most super cutting edge surgery or treatment (not relying on any kind of mass-market drug) for something - seem, on average, to be slightly to very much worse/inefficient than what I know of the one in Germany?
I think I need to read more blogs/Twitter/etc of German doctors/healthcare people complaining about all the bullshit they encounter, I'm probably availability-biasing a bit here.
Though it seems pretty clear that Germamy's is more efficient at least in the sense that it gets similar outcomes with a lot less per capita healthcare spending.
As someone from elsewhere in Europe, my impression is that Germany makes up for any reduced inefficiency in dealing with its medical system by its other government/state bureaucracies being extra inefficient, requiring personal appointments, not having online forms (and requiring many, long forms for simple things) etc. My impression is *also* that Germans often don't see these things as issues because of your national psychology, to put it vaguely, i.e. the same reason why Germans are a decade behind the rest of Europe in terms of electronic banking services and uptake (and why they don't consider their difference in this as being "behind"), why the stupidest EU digital regulation proposals are usually pushed by some German politician or weird German NGO, etc.
Each country seems to have its own issues with difficult bureaucracy (and often don't consider them to be problems), but Germany has an especially poor reputation in this regard.
Students in Germany can now fill in their requests for financial aid digitally which promptly led to a paper shortage where the requests are processed. I wish I was joking.
"We've changed process X so it can be completed digitally!"
is actually German government language for
"The citizen-facing, initial phase of process X can now (maybe?) completed entirely digitally; we'll then print the received information and process them using paper & fax machines, to honour the spirits of our ancestors."
Oh, hard agree on German government, bureaucracy & politicians (who then push legislation) being, generally speaking, truly abysmal when it comes to anything digital/IT/internet-related.
Please accept my deepesr apologies for Axel Voss in particular :(
I think the electronic banking uptake & use has gone up a lot in recent decades, partly because offers got better, partly because banks implemented charges for many traditional paper-based/bank teller interactions.
I was wondering, though:
Were you thinking of any specific "weird German NGO" pushing any specific stupid digital legislation?
I'm sure there's generally organisations doing that, but they're often more like... disguised industry associations/lobby groups.
The pattern I'm seeing is usually that with these stupid proposals, any NGOs that can be described as both financially independent from/not associated with the supposed beneficiaries of the proposal, and as having some relevant expertise, are very publicly tellinf everyone who'll listen how bad an idea the stupid proposal is, only to be roundly ignored by the politicians.
If you want to laugh and/or cry, watch this video about the problems the German military getting its weapons. And possibly other supplies, I'm not sure about that.
Germany makes excellent weapons, and sells them to other countries because the bureaucratic process is so onerous for trying to get German weapons for the German military.
I gotta say, I saw the "drugs that belong to the Emperor" coming a mile (or, ahem, most of that paragraph) away - like I literally had it formulated in my head and was anticipating the sensory input
Scott has referenced this "classification system" multiple times in the past. Particularly, the list of other recommended blogs on SSC was organised according to the classification.
Odd thing was, it made sense somehow?
Eg, it listed SSC itself under the category "those included in this classification", and under "those that have just broken the vase" it had Zvi's "Don't worry about the vase".
I have a similar problem with Amazon and auto blocking. Which led to the phone tree hell.
1) Amazon deemed as suspicious an e-card I sent to myself.
2) I talked to Amazon.de on chat when the e-card was processing after about an hour (it should take 5 minutes) - this got through quickly but the guy said it was an issue with the bank. I knew it wasn’t as I had verified in the app but I ended the chat.
3) Amazon sent an email and disabled my Amazon.de account the next day.
4) text chatted to a guy on Amazon.co.uk. Said he would look into it.
5) Amazon.co.uk disabled my U.K. account that same day.
So I’m locked out which means i have to use the phone. Always worse.
On the first call the automatic voice said that they could send a link to the known registered mobile I was calling from to allow me to get called back. I agree to this, get the link, and it links to a login screen. I have to login to use it but I’m disabled so can’t.
Wait a day. No kindle books or prime TV available. I have about 15 years of kindle books.
Call next day. Can’t get past the initial human operator to security because I live in an apartment which is the street and the number is 11. The postal address is therefore:
11 Building Name, street, city
But the software knows it’s an apartment and expects:
Apt 11, street number, Building name, street, city
So they are taking 11 as the street number.
The building doesn’t have a street number. No apt number works. Even though I have a postal code which maps exactly to my address, and they can see that, this doesn’t work. He agrees it’s me, that the address is correct but typing 11, or 1, or anything into the apartment number doesn’t work. End call.
Wait a day. Call again. Same issue. The operator asks for another delivery address. I give my parent’s address. There’s no number on my parents rural house so I don’t expect that to work. I just in exasperation ask him to type in 1. That works.
I need to get to account security. The original
Operator trues to pass me over to the correct department, but that department says I have to wait longer as I just received an email. But I hit the email a day or two before?. The operator can see that. But checking my mail it turns out they’ve sent out another one saying I’m still blocked just before the call. The emails say to call in a 24 hours and not before. I take this as a glitch rather than being deliberate.
Wait a day.
Call again. Get eventually to accounts, after the initial operator went though the two addresses again.
Talk to a frazzled guy who has a strong Scottish accent. He asks me about my recent purchases and my basket. Well I can’t login so I fire up my email to find the most recent purchases. This was a pain since Amazon email me *a lot*. The basket I just remembered. That worked, I passed that test.
Then he wanted any credit card associated with the account, last 4 digits and expiry. I have more than one but gave two I was certain off. He kept telling me I was wrong and was actually getting annoyed to the extent of cursing, albeit softly, but it turns out that the cards I gave were disabled (as well as the account?). He agreed it was me and should have check those as well.
Then he told me he would call me back. I said ok, and he probably has the mobile number I was calling from. He did not. I said it was the mobile that Amazon uses to send an sms to verify me logging on when I use a new device, or from a new location. He said that he didn’t have that on record.
The phone number *has* to be associated with a delivery address. He reads out the last 4 digits of numbers he could call me back on. I recognise some of them as perhaps old delivery address land line numbers but I’ve been on Amazon for 15 years and have sent to multiple addresses.
The only last 4 digits I recognised were my parents. But I am not there until after Christmas. It looks like phone numbers are not obligatory as otherwise I would have given my mobile number for my present permanent address. Hard to tell as I can’t login.
He said he could create a whole new account and reset everything, but that deletes my kindle purchases. Didn’t do that. That’s what I’m trying to avoid. It’s probably a few hundred euro. And it’s my book collection
So that’s where i am. Possibly I can recover at Christmas or they might permanently delete my account. There’s no recourse if this fails again, no obvious higher authority on Amazon. All emails are no reply.
(All the operators can see that e-card was sent to the same address as the account but that’s not something they can do anything with).
That is one of the reasons why I refuse to "buy" DRM protected media. (Well, non-games. I have a Steam account with some games I "bought" on it. I could claim that the situation is different for Turing-complete media, especially if you want to play online. Or I am just lazy/inconsequential there. But paying as much as I would pay for a softcover for a file which I can only view on the devices of one particular vendor and until they decide that they cancel my account? While the 5th Amendment Online Bookstore offers the same without any DRM at a rather competitive price? Totally worth the hassle of converting file formats.)
Do you now own your books? I have a good toolchain for it but the setup is annoying. Download all the books locally with the Kindle desktop app, figure out where this version of the app stores its files, import them into Calibre, install the DeDRM plugin, convert all the books to epub, upload them to libgen.
If you need help with that, I'm happy to 1) help you set it up, 2) run your books through it if you send me the azw files, or 3) run your books through it if you let me log into your account to do so.
Jeff at amazon dot com (as in Bezos) is purportedly an escalation email address monitored by a real team of highly powered exec assistants. I'd try that in your situation, with the description you've given here prefaced by a one or two line "here is what I need".
Healthcare press/researchers/executives: “The NIH has mercifully allocated $1,000,000,000 towards understanding the root causes of “burnout,” a condition afflicting a growing number of healthcare professionals. While theories abound, nothing has been proven with science numbers and words aplenty. Until then, healthcare professionals will need to survive on, uh, passion and the clapping of children’s hands.”
Funded study- “Godspeed: A 10-year prospective study into the root causes of “burnoutre” in healthcare, a pilot study, proof of feasibility”
Researcher in 10 years: “I dont want to get ahead of the data, as the root causes of burnout are themselves multi-determined and with many intercorrelated socioeconomic sub-factors, BUUUUUT...we think burnout is caused by, well, bullshit.”
They say laughter is the best medicine, and fortunately, it isn't under the control of insurance companies.
There's a theory that humans behaving like machines is a fundamental source of humor, but machines behaving like machines while pretending to be human is also funny, especially when it happens to someone else.
I've gotten excellent customer service from calligraphy supply companies, but no doubt, if a lot of people tried calligraphy as a career, the companies would start using phone trees.
Earlier this year I got told, "You're going to have to pay out of pocket for this Rx refill. We can't bill your insurance because your PCP retired and their provider ID is no longer active. You'll need a new doctor and a new prescription." So I got a new PCP, booked the next available new patient appointment because they refused to reissue the Rx until I saw them, and had to pay out of pocket for the six months it took to see them.
My impression is that this is less of a problem in other countries, because there either the national government or some large quasi-governmental organization steps in and negotiates drug prices with the pharma companies. This lower price then applies to everyone in the country. This often makes medicines cheap enough to pay for out of pocket, with no complicated pricing bureaucracy on the consumer end.
The American approach is different in that the sticker price of medicines is high, but every major medical insurance provider separately negotiates a lower price for their cients. Unfortunately this tends to introduce rather a lot of bureaucracy, since each company is a bit different in what drugs they cover, under what conditions, and to what extent. You really don't want to be in the position of being prescribed a medication that your insurance provider doesn't cover, since you'd be stuck paying the (high) sticker price yourself.
I'm so sorry for your suffering, but so glad to know that my doctor's experience of trying to get my prescriptions refilled is precisely identical to my own.
How much of this is real? For example, does it actually happen that a patient is put on hold for some stupid, paranoid reason? What is actually a common reason for this?
Does it actually happen that they have some fake or obsolete entry in their system like Medical Assessment Number, and you need to answer that to get through?
Yes, it absolutely happens that a patient is put on hold for a stupid reason.
For example, just last month I had a prescription (for a maintenance medication that I've been on for a decade and that people with my diagnosis are expected to remain on for life) put on hold because I didn't refill it on time. Except I did request the refill on time. My pharmacy just didn't fill it because, ever since they were acquired by a national chain, they no longer actually process refills that patients request online or through the automated phone system.
The new procedure appears to be request refill 7 days in advance -> show up in person the day you run out -> be told it's not ready but you can come back in an hour -> go home and wait -> come back and pick it up. Which is what I've been doing.
The problem, apparently, is that the prescription in question was desynchronized from my other monthly refills, so I waited until I ran out of the others to do the "show up in person" step so I wouldn't have to do it twice in a week. Turns out it's that step that causes the refill request to actually be submitted to the insurance company, so I was "late" requesting my refill, so I had to wait another week for a preauthorization, because that makes sense.
Oh god, I once had a place (Walgreens) where they had screwed me on the "your perscription is ready" so many times where I came in and STILL had to wait an hour or two.
So I called in to double check, make sure it was actually really ready, and they assured me yes my perscription was ready and I could come in and pick it up immediately.
And of course it was like a 3 hour wait this time. Made worse by them the whole time making it sound like it would be ready any minute. It is a good thing I didn't have the home address of the CEO that day.
I'm a bit surprised to hear that *you* are the one who has to deal with this. Isn't "insurance wrangler" already a job, with every medical practice having one on staff?
Many patients understandably get the impression that "insurance wrangler" is their own job.
I know of workplaces who've had dedicated insurance wrangler for employees on the company plan. My most recent experience with a company wrangler suggests even wranglers are having a tougher time navigating their plans' latest innovations. Company plans are no longer of much interest to private-plan providers, anyhow. Medicare Advantage is the new hotness: the biggest players in the US "private" health-plan game are increasingly hired by the US government with taxpayer dollars to run quasi-privatized public plans:
At larger healthcare organizations, there definitely are. Maybe Scott's practice, being pretty new, is too small to add someone in this role, just yet?
And all this time, I've been jealous of the "if you're a provider, press 2" option, as I assumed they got special treatment compared to the mere mortal patients.
Anyone else read Vladimir Voĭnovich‘s The Ivankiad? It’s a Soviet-era tale of the bureaucracy involved in getting a new apartment. Scott’s piece strongly reminded me of it. Funny, but in a wanting-to-tear-my hair-out kind of way.
Moloch, who hides customer service in a forest of phone trees, FAQs and chatbots.
This seems to be the bane of big corporations. My trash is picked up by Waste Management, whose corporate office is somewhere in Texas. Customer service is frustrating and worthless. I dream of some local competition.
Giant Meteor 2024. Giant Meteor pledges to resolve all problems related to patients not getting reimbursed for care, and to more generally correct all issues with the medical system once and for all.
...
...
...
...
I recently had the pleasure of going to a hospital emergency room with someone having heart problems, made it clear we need to see a cardiologist. We have "excellent insurance" (not sure that is actually a real thing no matter how much you pay these days).
It took ~4 hours to see anyone, probably another 4-6 to see a doctor, who just got us admitted to a cardiology department, and then said it was time to sleep for the night (~12 hours), and then in the morning it took another good 6 hours to see a cardiologist. At which point googling the results of the various procedures/tests which had been previously done had already found me the Cleveland Clinic webpage the cardiologist then basically read to us when they saw us.
As a bonus we later found out the doctors we saw were covered, and the hospital we were in was covered, but not the cardiology department we were in..............................................................................
Made me want to start a new hospital called "there are actual fucking doctors at this hospital and if you have money you can pay them to provide services for you". But of course that would be illegal.
No, they have (had?) one of those in Oklahoma. Some people fly (flew?) to it from across the nation. because the prices were transparent and reasonable.
Doesn't really work the same for urgent situations, but....
But you point at my favorite regulation I would love to see: if you go to the hospital, only the hospital can bill you. Only the hospital needs to be covered. If they hire/contract/allow non-covered / non-network providers into their facility, that is their own problem.
We really need to move to a cash-based, market-based healthcare system. Here's what I think should happen:
1) The average American pays $456 per month in health insurance premiums. Instead, the government should make them pay $456 each month into a health savings account. The money would be automatically subtracted from their paychecks, just like Social Security funds.
2) The health savings account money could only be spent on medical services and items. The government would decide what things counted. Yes, there would be disagreement at the margins, but things like Prozac would definitely be counted.
3) The government would copy one of the online account portals used by a big bank, like Bank of America or Capital One, and use that for the health savings accounts. Each person would be able to easily log in through the internet and see what his account balance was, along with previous transactions. There would also be a smartphone app and a debit card.
4) All medical services providers and pharmacies would have to publicly post prices for their goods and services, and to honor them. Charging different prices for different people would be illegal.
5) People could transfer additional money into their health savings accounts from any outside sources (e.g. - personal checking account, GoFundMe account to pay for my heart surgery, anonymous gift to other person), but they could not do the reverse.
6) Every health industry bureaucrat who spends his time re-writing rules about what things health insurance covers and fighting with people over the phone about the rules would lose his job.
This is the structure of alternatives to Obamacare that sounded good to me. Insurance that specifically covers extreme events that you could not normally afford and a savings account to ensure people do have the money to pay for everyday things. They might even have an effective incentive to price shop!
So how does point 7, the rare, major problems work?
(of note, parts 1, 2, 5 and kind of 3 but it's private are how I do it currently, of course it isn't required, just optimal. And you'd need to tweak 4 so not just charging different prices is illegal, but providing any kind of rebates or kickbacks is also illegal even if they are "charging" the same amount)
I have an HSA with a high deductible insurance plan. Anything under 6000/yr I pay out of pocket (via the HSA). After that, insurance starts covering things. That seems pretty reasonable to me. Routine medical procedures are probably going to be well under that limit and anything major is likely to be _way_ over (a single bad injury/surgery is almost certainly going to cross that limit).
"So how does point 7, the rare, major problems work?"
I still want prices to be market-based, so all medical providers would still need to post their prices publicly and to honor them. The insurance company or government health agency would pick the cheapest treatment provider.
> 6) Every health industry bureaucrat who spends his time re-writing rules about what things health insurance covers and fighting with people over the phone about the rules would lose his job.
Congratulations, you've successfully identified the special interest group who will spend money to lobby to ensure that your bill dies in committee.
It's a bandaid for the problem, but I really hate it when companies don't have online chat for customer support. I can use that asynchronously much better than a phone call.
But it has to be real support rather than one of these places where the chat support agent has no ability to actually fix anything.
I'm surprised it doesn't wok to hire a secretary or other support staff to do this work, at least for larger practices with several doctors. Even if they couldn't handle the actual conversation with the person, they could do the phone tree navigation and waiting on hold, then transfer the call to the doctor.
Pharmacy phone trees are indeed terrible. I can't tell you how many hours I've spent going through them as I try to find a single pharmacy anywhere within 2 hr of me that has any stimulant medication of any dose in stock whenever there is a shortage (like the past 3 months). Even worse, the big boys generally refuse give stock check or backorder status over the phone without a prescription being sent to them.
Also, sometimes they refuse to even pick up if you select that you are a patient rather than a doctors office - for multiple days at a time.
I live on a state road, and a few years ago there was a tree down that was mostly blocking it. The company that contracted with the state DOT to clear trees refused to touch it, because it was sitting on wires. The power company refused to touch it because it was on data lines, not power lines. The cable company doesn't do tree work, have we considered contacting the DOT? This took several days and at least 30 phone calls to resolve. Top tip though, going directly to local officials can grease a lot of wheels. Desperate, we eventually called our state rep and explained things. I don't know whose heads they knocked together, but the DOT people were out clearing the tree the next day.
Having an alternative to phone-system bullshit is one of the few remaining advantages of patronizing companies with brick-and-mortar locations. If I have, say, a bank problem, I drive to the bank rather than even attempting to call them. Same for (some of) my doctors' offices.
I do wonder: suppose companies charged per-case to skip the bullshit and immediately get a human being for all calls related to that case. What would the price settle at?
I've had plenty of instances of going into a brick-and-mortar place and having them make me pick up a phone in their lobby that connects to their customer service and makes me go through the same annoyances as when you do it from home.
I used to work for a medical answering service. Basically a human phone tree / answering machine for patients calling their doctors (usually after hours) or hospitals paging doctors. I ran the department that met with doctors and tweaked their scripts to their liking.
It was not an easy job. I had some basic suggestions and framework for their script, but depending on their preferences and how they structured their on-call schedule it could get rather complex, and often the doctors (or their administrative staff) couldn't see the impact of their decisions. I made sure to pack our meetings with cautionary tales of logic loops and we would make sure to check everything ourselves before implementing. A common one was a doctor who would only take emergency calls, and his on-call partner would only take non-emergency calls. Even getting past the whole "what is an emergency, everybody interprets that differently" bit we'd have to explain that if him and his partner have different instructions, we'd have to follow each of them and it was best to get everyone on the same page.
And then there were the practices that had complex routing protocols based on specialty, who was calling, where the patient was located, what the call was about, whether it was a new or existing patient, etc etc etc. I'd do up their flowchart and get it printed on a giant posterboard, and show up at their office with sandwiches and sharpies. Every time I'd get the comment "This looks really complex" I'd just nod and say "yes, every one of those diamonds on that chart is a question we have to ask your caller, and I'd love to make it simpler for your callers and our operators (and your wallet, since we bill by the minute) but if we didn't ask those questions the call might end up going to the floor doctor instead of the wing doctor, or after 2 pm on days before weekends and holidays it might go to the attending admitting doctor instead of the primary admitting doctor. I mean, we could always ask the caller who they wanted to speak with, but last time we did that you got quite upset when you were paged instead of the doctor you were in the break room with, not every nurse is going to know the difference between the circle doctor and the rounder doctor."
And usually I'd walk out of those meetings without many changes to the flowchart, but with perhaps a bit more empathy from the doctors.
One thing I did spend a number of years fighting for, and only managed to get a bit of success towards the end, was to stop answering the phone "_______, how may I help you" and instead answer the phone "______, <insert the first question we need from the caller right here, usually something like "are you a patient?">" when HMIHY invariably generated a story that took up 15% of the target call length and the operator couldn't even write down until they got five more screens into the system.
I've been refusing to buy health insurance and instead paying the Obamacare penalty for the last 4 years because:
1. I don't want to deal with this insurance company bullshit
2. I'm rich enough to handle the fluctuations
3. goodRX gets me good prices on prescriptions and my GP takes $100 cash for office visits
4. It's a positive CE wager for me, even before considering the value of all the time I save by not dealing with insurance company bullshit.
In gambling, a bet where you can win but you can't lose is called a "freeroll".
Every time an insurance company denies a claim they're freerolling the patient. Some percentage of the time, the patient won't find it worthwhile to go through this red tape, and the insurance company saves the money. Otherwise the insurance company is no worse off than if they had paid the claim in the first place. Ignoring second order effects on reputation and attrition (individual attrition may not even be possible in employer sponsored plans), the optimal strategy for insurance companies is to deny valid claims and make it maximally inconvenient to dispute them. Other product-sellers can have perverse incentives to sell shoddy products, but customers are particularly vulnerable when the product is complex illegible promises about the future behavior of the seller, and the reputations of the sellers are unclear and undifferentiated. Recourse exists on paper, but in practice you're totally at the mercy of the insurance company's goodwill when the claim is worth less than the opportunity cost of disputing it (i.e., the vast majority of claims, especially for high earners).
Routine expenses like generic prescriptions that you take for 10 years straight probably shouldn't be a thing that people buy insurance for, and I'm going to argue this based on my experience as a professional gambler. In the outside view, insurance is a negative expectation wager, because the insurance companies have overhead expenses and profits. A negative expectation wager can have a positive CE (certainty equivalent) if it reduces variance enough relative to your bankroll. A wager is worth making if and only if it has a positive CE. CE is defined as the amount you would need to get paid to raise the expectation of the log of your bankroll by the same amount as placing the wager. In the case of routine expenses, the reduction in variance is negligible so buying insurance for that will have negative CE. Only catastrophic insurance is worth having. The log of 0 is negative infinity but this never actually occurs in real life because your future earnings have a discounted present value which is not taken away by bankruptcy. Your primary residence is also except from bankruptcy in most states. Your partner/friends/parents/children are not on the hook for your debts and can help support you when you are legally bankrupt -- this is essentially another asset you have which is immune from bankruptcy proceedings. For most people young enough to be reading this blog, the present value of their predictable future earnings far exceeds their net worth, so the relevant logarithms become approximately linear, so it wouldn't be very wrong to just maximize EV, except for life insurance if you have dependents and not much savings. If it gets to the point that your medical bills are seven figures, you're probably a goner anyway, and they're probably just wasting money torturing you with overpriced surgeries for the last week of life instead of sending you to a nice cheap hospice with lots of heroin.
(Personally I don't buy any insurance whatsoever, except the minimum required by the DMV and my landlord. The DMV makes me waste 1k/year on 25k/person of liability coverage, but the renter's insurance is only $85/yr through lemonade.)
This is the kind of situation where Scott could just leave the problem to the patient to solve. The problem doesn't affect him directly -- does not, for instance, affect his receiving payment -- and is not his fault. However, he's more likely than most patients to be able to solve it. Good for you for taking it on, Scott. The The situation's full of unfairness, but you're probably much more able than the patient to absorb a dose of unfairness, and if you don't take it on nobody else will.
How do you keep it down to 80%? Thank you for writing this up - the same holds for all calls to Bank of America. I used to spend 95% of my time on the phone attempting to talk to Bank of America, before I moved into this Faraday cage deep underground.
When I saw the title of the post, I thought this was going to be about dealing with an EMR system. I think that's what doctors at big hospitals spend 80% of their time doing, and what you described gets outsourced to nurses, secretaries, or patients.
I do most of these calls for our family of 4. Sometimes there's nobody in the system who can figure out what's going on, and it can take months for the process to reach someone who can override something that nobody can understand.
I have phlegm constantly collecting in my throat. This is, notably, the exact approach taken by doctors when I try to get my throat cured.
It's not a problem to speak to a human doctor. But they are completely unwilling to try to determine what might be happening to me, or to make any effort at all to improve my situation. The state of the art is:
General Practitioner: Let me refer you to Specialist A.
Specialist A: I can test you for condition A, which affects 2/3 of all Americans without causing any symptoms of any kind. But there is, technically, also a chance it's causing your problem.
Specialist A: Sure enough, you have the same condition that 2/3 of all Americans also have. Let's try doing something about that.
Specialist A: Well, I guess that wasn't related to your problem. You should see Specialist B.
Specialist B: Since you've been referred to me, I assume you need to be tested for condition B.
Specialist B: Good news! You don't have a medical problem!
General Practitioner: I have no advice for you other than to follow the advice of a specialist.
My mother is a practicing obstetrician, and her opinion is that I should stop complaining about the doctors because addressing my problem is not part of their job.
Random thought I had lately. Could local governments pass legislation against local pharmacies and insurance to ensure proper care? It could be a lot easier than agitating at the state or national level.
Sure! Given that the existing situation is due to state and national governments passing legislation against pharmacies, insurance, and health care providers to ensure proper care, I’m sure local governments doing the same thing will fix everything!
You'd probably have to spend more time filling out forms for HIPAA compliance than you spend on the phone.
It's hard enough for me to make these sorts of calls on behalf of other members of my family; insurance companies are set up to deal with providers and patients, and in extreme cases spouses or parents. Even trying to get help for my mother who physically can't call on her own behalf is a struggle above and beyond the issues described in the OP.
So yes, I'd expect that "you're not the doctor, go to hell!" is a very likely outcome. I think in order for a business like that to succeed, you'd need to get the insurance companies to alter their phone trees, which they have no incentive to do.
Of course, if you wanted to go through with it anyway and they do require speaking directly to the doctor or patient, you could try putting customer support on hold while you fetch them. I think they might be disallowed from hanging up on their end—I've sometimes been absent-minded about hanging up when I'm using my headset, and only realized the line was still open several seconds later. Even if you need to call the doctor/patient in order to connect the lines, "hang on, they're in the other room" isn't *technically* a lie.
Was just buying a small medical device under my plan. Insurer gives us a list of covered manufacturers.
Mfg insists I'm not covered, insurer insists I am. Each says the other is a filthy liar.
Insurer says mfg should just call the provider line. Mfg refuses, says insurer should fix it on its end. We try a conference call, mfg line is just a busy signal all day, no call handling or menus at all.
I ask the insurance if, after all this hassle, can I just buy my own?
Insurance says absolutely not! Though this mfg is staffed entirely by filthy liars, far better the devil we know...
This isn't complete without the regular breaks in the hold music to remind you to try to use their website to solve your problem, which of course you have tried endlessly before resorting to going to hell and using their phone tree.
I'm not in anything medically related at all, but this is most of my day even so
What field are you in?
Government finance
My apologies.
All it takes is being a human to sympathize-- for example, the pause in the recorded music for advertising to the captive audience thing.
I've dealt with Lab Corp as a impatient, and it's all the same, except for leaving out the number of times it took calling them when they had no record of having talked about the problem before.
I love that you wrote “impatient” instead of “inpatient.” Accidentally or not, it’s sublime
It was intentional. I'm glad you liked it.
But remember, all this is done for your convenience and safety, customer! It's certainly not so we can cut costs by removing real human operators to talk to people!
I wonder if upper management has ever tried calling their own service centre. Probably not, and they have their own direct access.
Or maybe when they call, they're such experts it doesn't seem like a burden. Just speed dial 2, hit 3, #, 2, enter 6969 to bypass the menu, say "speak to human" press # again, press 2. Takes 2 seconds. Why can't users figure that out?
You know, I don't think lack of humans is the problem. There are plenty of humans, they just aren't helpful. I think it's a design issue. It isn't trivially easy to make a great help service.
The companies that succeed in doing so are the ones whose bottom line is harmed by bad customer service. If Rocket Mortgage made it difficult to fill out a mortgage application, they would go out of business tomorrow. Good customer service is probably the most important feature of their business. On the other hand, almost no one selects their insurance carrier based on customer service (indeed, many people don't select their insurance carrier at all). So why on earth would they spend time and effort making their customer service better?
There's probably a startup in here somewhere, gluing together speech-to-text (Openai Whisper), a large language model, and text-to-speech (Amazon Polly or similar).
Google is already piloting various components, with their call screening and automated restaurant reservation systems.
There’s also another startup in here, a health insurance company that actually provides customer support.
I'm (in Germany) privately insured with a health insurance that's basically a non-profit.
I.e. no owners/shareholders who expect profit (they still can have internal incentive structures to encourage good management).
(Disclaimer: private health insurance "cooperatives" like this are not the norm & generally speaking more expensive than the public option. I'm merely describing a different model for health insurance.)
Any money they have above certain reserves at the end of a year, they have to distribute to its customers/members; also, if you don't make any claims for reimbursement of treatments within a given year, you get a non-insignificant part of your premium back.
Iirc, towards the end of the year, if you haven't claimed any reimbursement yet, they sent you a friendly letter
telling you what the amount of premium refund for you would be this year. Then they suggest it could be a good idea to, if you have any medical bills you'd planned to get reimbursed that year, to compare their total amount to the refund, and if it's lower, do nothing and wait for your refund to arrive.
Like, this actually *saves* work.
These non-profit insurance companies aren't without their problems, but at least they don't have an obvious incentive to deny as much coverage as they can get away with without losing their customers or getting branded "impossible to work with" by too many doctors.
The only thing they can do with the money they save denying coverage for patient A's treatment X is paying for patient(s) B's treatment(s) Y, otherwise it gets thrown into the redistribution-bucket at the end of the year.
I guess in some ways, it's more similar to the system most Amish use, these sort of church-organized mutual aid collectives?
Except it's anonymized, and coverage is set out in regular insurance plan contracts.
They do have some disgressionary¹, but my experience (and that of others I know insured there) is that the insurance is, in most cases², quite forthcoming and easygoing in covering bills, both guaranteed and disgressionary.
A lot of other (non-health) insurances seem to work a lot more like in the US, though, trying their best to either deny coverage, or make it out like it's someone else's responsibility².
¹Relevant to this blog's interests: my plan covers a guaranteed amount of psychotherapy, no questions asked - basically half a year of weekly sessions per year - and only if I want/need more than that do I need any kind of prescription/psychotherapist's explanation why it's indicated. And (from what I heard) these are often mostly a formality.
I expect if I would lodge claims for, say, the no-questions-asked-amount plus four sessions, they would just pay, bc it's not worth the work.
Overall, it feels like there are actual human beings working there.
²The only category of cases that easily comes to mind, where my health insurance would try to divert responsibility, is if the medical issue might be due to an accident covered by relevant insurance (as a majority of Germans have - public - accident insurance), as then the responsibility to pay for necessary medical treatment lies with the accident insurance.
But it's very much a "if they won't pay, we will" scenario.
A fair number of insurance companies in the US are non-profits. Including Blue Cross/Blue Shield, which "Blue Helmet" in the OP is riffing on. My own plan--which I get from my job with the federal government--is through Kaiser Permanente which is also a non-profit. At least on the customer side, you still have exactly what you see in the OP.
A non-profit can be just as greedy as any other organization.
It just means the top officials take the money as wages, not stock dividends.
This is one of those "not without problems" issues.
I think the most appropriate English term for what I'm talking about is "mutual insurance" (like what the original guy who took actuarial tables and calculated the projected financial requirements for a life insurance, and instigated the founding of the first
proper, "professional" life insurance), where the whole enterprise is owned by the insurees (that a word?).
I'm pretty sure they have some clauses in their charters or whatever intended to limit how much money executives can extract from the whole thing. And as the insured are legally the boss, if someone is discovered trying to sneakily/creatively extract excess money, there's likely some personell and/or rule changes on the horizon.
Huh. I feel like there must be something I'm missing about the incentive structure operating there?
Or legal constraints?
Or just standard "the larger the organization, the worse they are at things" and/or simplistic middle management-style decisions ignoring many possible/probable 2nd etc order effects?
Eg, someone thought "If we cut cost in the customer service (ie "people calling in with their problems") department, we can lower the insurance premiums, which is good for our customers!"
...only now they or (probably worse) their doctor is spending a lot more time doing this kind of silly BS, and as other doctors don't operate on a "subscription service" like Scott, they can then presumably bill patients/insurances for that work?
At the very least, more BS busywork = less time to actually interact with patients.
But even if customer service was made this way starting with benevolent intent, why would it still so frequently lead to these phone trees from hell?
(Literally - it's easy to imagine some sort of eternal punishment, where you're set some seemingly trivial thing to clear up, and then you're just navigating and endless maze of OP-like BS. Like Sisyphus, just without the open air, mountain views, exercise, and sense of progress at least between the bottom and the rolling-back-down point.)
Point is: I am slightly confused about this, would appreciate explanations by people who know more about the US healthcare thing.
Blue Cross/Blue Shield is an association made up of for-profit insurance companies, the largest of which Anthem/Elevance is publicly traded on the NYSE. Their non-profit status as an association is misleading in terms of understanding the commercial operations of their member insurance companies.
The other large health insurers in the US -- United Healthcare, Aetna, Cigna -- are all publicly-traded for-profit corporations.
All of these companies are optimized to maximize returns to shareholders, not to provide service to patient/members.
Actual non-profits were created in some states under ACA. We have one here in my state. As a provider, I've gotten consistently better service from the non-profit insurance company than any of the private insurance companies. No long wait times on the phone, prompt responses to specific questions via email, very quick escalation to higher ups where things could not be quickly resolved, etc.
Kaiser is a consortium similar to how Blue Cross/Blue Shield is a consortium. Kaiser has a mix of for-profit and not-for-profit entities in its consortium. I haven't looked closely at their corporate structure; it looks like they are criticized for retaining excessively large cash reserves rather than putting them back into the community.
Certainly non-profits can optimize for things other than their actual mission (executive compensation instead of patient care, for instance) and they often do. But it seems at least they may not be optimizing for short-term shareholder value. But I haven't looked to see which parts of Kaiser are actually for-profit.
The healthcare consortia are confusing because the outer shell can be a non-profit while all the businesses operating inside the shell are for-profit. The outer shell I assume is mainly for throwing political weight around.
Non-profit healthcare companies that act as both insurer and provider -- there are huge ones like Kaiser and small state-level ones -- tend to do what's called patient dumping in order to control costs and maximize profits. The profits in this case may return to the providers rather than the patient/members in the form of higher compensation.
I know the one here in our state engages in patient dumping because I have friends and family dumped by them. Patient dumping may mean discouraging people from getting medically necessary treatment, encouraging people to go to the emergency room of the hospital (not part of the non-profit's system) over non-urgent things, or referring on people to other practices when they are perfectly capable of treating them.
The ACA also has rebates if minimum loss ratios are not met.
No that is basically illegal (seriously). The rules are so tight in the US to survive you basically need to stay on these tiny railroad tracks, because the medical system has so few options as regards its policies.
Hmm, well, Anthem makes about $4B a year in profit, so apparently they're surviving ok. Also, One Medical charges a small annual fee and provides better service. So it seems doable to me.
On $150B in revenue. Thats not really nearly as much as it sounds like.
I'm very curious about how Scott's "model company" is gonna work out, that seems meaningfully different?
Although (particularly non-hospital) psychiatry is very cost-bounded compared to general coverage, as it's mostly "just" psychotherapy and prescribing drugs - it's not like some doctor within that model is suddenly gonna be called on to perform brain surgery within that subscription model!
In the US at least, the person having to make these calls is almost never the person who decides what insurance company to contract with, so there's not much way for that to translate into a market advantage.
Yeah, maybe not. It would be interesting to see if it could be turned into a provider network advantage (e.g., include all those doctors who don't take insurance because it's too much of a pain) and/or establish a premium brand that would be meaningful to employees/employers. I've seen companies switch providers because of perceptions of poor service, although I agree it's probably uncommon currently.
I think this just leads to an AI arms-race where 40% of the world's electricity output is dedicated to AIs trying to crack obscure customer service phone trees to get an actual resolution, and 40% of the world's electricity output is dedicated to AIs trying to create increasingly obscure customer service phone trees to avoid having to actually provide the services their company is contracted for.
The one thing cryptocurrency mining was missing - a direct connection to human suffering.
You win the Internet today.
Startup, hell. This is Microsoft Bot Framework with Microsoft Cognitive Services Speech Recognition and Microsoft Cognitive Services Speech Synthesis. Contact your Microsoft Sales Representative for a quote.
There really has to be a way to like a post more than once. This phenomenon is part of the shared human experience c.2022 and it really needs to die in a fire.
This is the funniest-ever ACX post (!).
Hopefully some suitable pharmaceutical use can be found for all of my tears of laughter.
Experiences like this seem so common place, even in other industries, but it's extra tragic to see people suffer when it's medicine. A good friend of mine lost access to his psych meds and we basically had to take turns making sure he was ok for a month due to pharmacy bs. Finally his relative drove him a few hundred miles away to a pharmacy with someone manning the counter whose soul hadn't been double-mortgaged yet and he got the meds needed to function. It could have easily gone the other way with him jumping into traffic or something though during a bad spell. At least we know Hell is real because we're there.
I’ve always had this naive idea that sure they keep the ordinary consumers like me on hold in these terrible systems, but if only I could opt for the “physician” option it would zip me right through to a helpful representative. No way the VIPs have to deal with this.
This was very funny but also extremely depressing. I had a lesser version of this dealing with some medical bills, figuring out that a two of a hospital's different departments billed different claims separately and didn't communicate, that they sent things to the wrong address, etc. HOWEVER: I was pleasantly surprised that there were notes documenting my interactions on the hospital's call-center billing side, which meant that I didn't actually start from scratch every time. Confirming names and keeping a record of calls might not help you, but if the operation is at least somewhat legitimate, it can.
If this is reflective of your style.... again I'm just a rando who encounters this on a consumer side, in privileged circumstances. But perhaps there are ways to phrase your initial requests to get more traction with the representatives? I don't know. Also when you call you should probably have maximum info from the patient available, including any claims information and explanations of benefits. The patient should have access to those, possibly online these days, establishing more of a paper trail than a fax or a phone contact. In fact, it may be that the patient might get better traction if they do the calling? It's a start....
But then who's got time and energy for that, if you're working during their working hours and also need to be on a medication to be functional anyway, which you're not getting?
So it's a catch 22. This is really horrible and I don't expect the bureaucracy to improve anytime soon. So good luck.
It’s sad how realistic it is. I once had to go through 30+ phone calls, over several months, to get a surgery covered that my insurance specifically said ahead of time that they would cover, but which they claimed afterwards that they weren’t covering at all. Ultimately I also had to fill out some special exception form too. It was terrible.
If only you could resolve the problem by getting the patient’s prescription tattooed on your body over and over again for hours until it covers every bit of your skin.
I know this group tends to skew libertarian, but this really *really* seems like something that needs regulation. It's so widespread across every industry, to the point where bad customer service is an accepted standard and everyone is racing to minimize customer service expenses to the collective detriment of the entire society.
This is literally a tragedy of the commons situation that damages labour productivity across multiple sectors.
I think you're right. It feels like this strongly resembles the situation that caused the Paperwork Reduction Act to be passed.
If I thought regulation could fix it I'd be all for that but how exactly do you propose to do that?
Pass a law saying it can't take more than X minutes on average on the phone to resolve an issue - incentive: don't fix simple issues so average stays low.
Pass a law preventing automated phone trees? The insurance companies have same incentives to make it difficult to get them to cover things and to minimize their risk of lawsuit in abuse so now they just pay humans in India to do it. Same effect but more pricey. And some amount of automated phone trees helps everyone.
Pass a law saying that all medications with a valid physician script must be covered?
The nation just demanded (and got) blood from Walmart etc from daring to believe that doctors not pharmacists are best places to decide who needs what meds. First time someone steals a physician pad or someone dies of an OD after their insurance let them fill multiple scripts and the insurance company says their hands are tied it will get repealed.
Also what about the effect of the physicians who just write scripts for crazy expensive brand name drugs and check don't substitute (bc they had a hot pharma rep or bc they once had a patient who responded better and why not bc neither they or the patient pay). Without national coverage the benefits might not be worth increase in price for those buying own insurance.
I agree something should be done but I fear there is a real chance that you try to regulate it and you add an extra layer of fuckery.
But come up with a well designed reg and I'm on board.
Definitely a tricky one to regulate well, but I think a starting point might look something like this:
-you get a live human with a max hold time of x minutes, or a callback within x hours of a request
-hold time limits include time on hold after getting a live human (no taking the call to reset the clock then throwing people in a different queue)
-if the type of call has been correctly pre-sorted by phone tree, some very high percent of calls (90ish) must be concluded by the initial human without transfer (reduce to some.much smaller percent if the call is not pre-sorted)
-information collected over the call must be available to all persons receiving the call, requiring customers to re-enter information is not oermitted
-disconnected calls must be contacted back within x minutes.
Failure in each of these cases should result in a small fine. 100 bucks or so. Customers can flag bad calls at the end of an interaction, or call a seperate number/web form to report an incident.
The key incentives.that companies.have is to make talking to a human hard (humans.cost money) and to waste as.much time as possible in hopes.customers will go away (or at least not pursue higher level support from LVL 2 agents who can actually make decisions ).
Once you force an actual human on the line, you are costing the company money for every minute they don't resolve the problem. Making it expensive (via fines) to transfer calls incentivizes empowering LVL 1 CSRs. I think once you disable the strategy of "don't let customers talk to a human" providing decent service is in their best interest.
I like the no requesting info again thing but . You'd have to make a more complex to handle security concerns rule but that seems good.
Limitations on xfers seem bad as you'll literally never get to the person who really knows you'll just do everything through your first contact who will text the info to higher levels.
On the charge for exceeding weight times I have some objections below. I like the general idea but im not sure how we can get the data to figure out what works and what makes behavior even worse. Maybe something along these lines will work but I don't see how we can figure out what given the difficulty of changing regs especially given lobbying. But if selected right it might help somewhat...but I feel there has to be a more elegant general solution.
---
Regarding the limits on hold I don't think you appreciate just how cheap call center workers overseas truly are..I fear the natural result of this is just literally having some guy in India sit on the line with the doctor while he holds saying "sorry I'm waiting to hear back from my manager"...indeed the social awkwardness might be a very effective deterrent to calls itself.
Also, I worry that this ensures that once you pass the threshold they move you to the back of the line and keep you on hold. I'm particularly worried what happens when some national pharmacy fucks up or there is a medication shortage and the system gets overloaded.
Also, does the insurer rack up huge fines when that happens because tons of ppl are calling repeatedly? If the fines are low enough that's not a huge deal then I fear they might be low enough just to eat. After all a bad experience on the phone deters future calls too.
I definitely saw that kind of gamesmanship in the call center I ran the doctor-relations side of. The supervisors/dispatchers on the call-taking end would manually prioritize calls that were under X rings and let others go long and hope for an abandon, since the targets were Y% under X rings and under Z% abandon. Obviously not every call was like this, and not every supervisor, but it happened a lot and the people who did it invariably had better stats even if they had a slightly higher (but still acceptable) abandon rate.
Sigh...yes its hard...i think we need to just let insurers incentivize with limited cash to docs (levelized per specialty/patient demo) in kind of nhs imitation. Sounds bad but no worse than now given time is money and a doc could lose several times duration of visir.
Is this actually a case where moving to tip-based compensation would be an improvement?
Not many people stick around for a post-call survey (or click the links at the bottom of the email saying that it was a good/bad job). Maybe because they assume it doesn't do anything while tipping would. I haven't eaten at restaurants in non-tipping countries / outside of tourist areas where they still expect US tips, is service genuinely better there than here? Taxis were tipped before Uber but the service there was pretty bad...
I tried one year to do a pay-for-performance scheme where we literally paid people a few pennies for every call that met target length (I know, not the same as customer satisfaction, but it was something we could monitor easily) but it never got traction... and honestly it would have been subject to the same gamesmanship (although I had a good strategy in mind to detect it... we had a hard time firing poor performers because hiring was so hard).
I guess my internal economist thinks that the fundamental problem is trying to use temporal investment to allocate limited supply.
My solution sketch would be twofold. First, pass a bill making the feds responsible for abuse monitoring and not the insurance companies. It doesnt make sense to have them do it anyway and let docs override flags online on the fed system.
Second, replace the implicit costs in time with explicit charges in some way with certain caps. I mean it feels wrong but the doctor's time is money and its wasted and now at least the time isnt wasted.
I think we are also looking at two different problems when we compare insurance service to Verizon. In Verizon's case the cost of actually good service is negligable to their bottom line EXCEPT the literal cost of providing good service (wages, giving up the occasional overage charge).
For the insurance companies, if you can get someone to kill themselves while on hold you might be saving a grand of medication.
The mechanic that enables this ehavior in both cases is a lack of accountability: libertarian economist types might describe it as a lack of competition, but only because they tend to think of competition as the only legitimate/functional form of accountability.
An interesting tension: by spending that grand on medication, the insurance company is allowed to make more profits. (Their profits are capped as a percent they spend on claims.)
I'm not sure if they are really trying to prevent the spend by making the call aggravating. But I'd go to trade shows or workshops with people that ran other call centers and... often they just weren't that bright, or maybe they were, but not in the logical sense. And the budgets were often very low (a dollar spent on a claim increases profitability, but one spent on overhead I don't believe does).
How about a simple per minute tax for time spent by customers on the phone without a human on the other end? You could have a threshold so that it would only hit businesses that are reasonably large and make heavy use of phone trees and wait times. Then we wouldn't have to decide what is reasonable and what isn't; we just charge for the use of other people's time.
This is also the technical solution to robocalls. Collect a tax of just a few cents per call or text. It can be applied evenhandedly to everyone and collected through the phone bill, but will only really affect high volume robocallers and scammers.
Require that insurance companies keep tickets for requests so that you don't have to keep starting over.
Forbid interrupting the wait music with anything but a person coming in.
The hard part would be a regulation requiring that, when you get to a person, you get someone with enough sense, knowledge, and authority to solve your problem.
Obligatory XKCD: https://xkcd.com/806/
Requiring conference calls on request would be nice.
"I'm sorry sir, that's a pharmacy issue and you'll have to call the pharmacy."
"Well, let's call the pharmacy together, then."
"They have very long wait times!"
"I hope you weren't doing anything else today, because I sure wasn't."
Once you have three representatives actively sitting on the line, I'm pretty sure they would find a way to solve it besides waiting *another* twenty minutes for a fourth.
Brilliant! It wouldn't solve everything, but it would solve the infuriating "he said, she said" where two parties try to blame each other.
Regulation = even worse fuckery, because at that point there is no way out. No to mention there is no incentive for those designing the system to make it make sense. Obamacare roll out anyone? Do you people actually have to recreate the USSR before you realize bureaucrats don’t fix anything? They just make the fuckery mandatory. How come no one sees that this fuckery comes from an excess of corporate bureaucracy? No one understands that the corporate apparatchiks who design this shite for their corporate overlords will design the same sort of shite for their governmental overlords? Gah, I’m so sick of well meaning people who don’t think things through. Calls for regulation amount to the cry “let’s get someone else to fix this! I know, let’s go to the well of kind selfless people who staff our government bureaucracies to figure it out! Then if it still sucks, we can say oh well, we tried!”
I think it's important to distinguish between knee jerk regulation that sees something bad and tries to ban it (think rent control bc rent is too high) which often makes things worse and piles up red tape and systemic design to align incentives that can actually reduce the amount of red tape by ensuring incentives are aligned.
For instance, I'd count things like FDIC insurance and some mandatory standardization laws in the later category.
The world doesn't magically provide ideal conditions for markets (externalities not internalized, tragedy of commons, natural monopolies) and there is no reason why regulation can't simply better align incentives for action so ppl acting in their own interest result in more societal good.
Unfortunately getting those regs enacted in our system is virtually impossible. The left hates them because it feels too capitalistic and based on selfishness not virtue. The right (well old libertarian right) hates it because it's regulation and they think of it as no different than the patchwork kind. Established biz prefers complex regs to resist competition and it's virtually anathemic to passing via grand political compromise.
I think it may not be an accident that we don't have a simple national health insurance system and that we don't have a parliamentary system.
How about, if a prescription or procedure is denied, there's a government agency that reviews the contract and rules on whether the denial was proper or not, and if it was improper, the company has to cover it plus pay the insured $5,000,000 in damages.
I agree with you that the problem here is that the system incentivizes obfuscation to avoid covering things, and as long as that is true companies will find new ways to obfuscate. But it's not actually hard to remove that incentive. Removing incentives to do bad things are what fines, penalties, and jail time is *for*.
I think that will make things way worse. Ultimately the base rate of errors that insurers can't avoid gets added to our cost. At those figures rather than building a system that has 99.9% accuracy they'll go for 99.9999% accuracy/uptime (a global sys crash could deny millions) and it will look like NASA rockets in terms of cost.
Worse, the strong incentive is for patients and doctors to delibrately script things they think insurance company might deny wrongly in hopes of getting a pay day.
The inevitable uncertainty of subsequent review means insurance companies will have to approve a bunch of stuff that should have a small amount of friction. For instance, a doctor should have to do a bit more work to script an expensive name brand rather than a generic (if u pass the extra cost on to patient insurance isnt working for the small frac who really need the name brand bc of allergy etc) or they'll just script it bc the pharma rep flirts with them (or bc patient asks in hope of a big pay day).
You'd be better just mandating coverage for all meds on some list for any reason.
Ultimately, the problem isnt that there is some cost for doctors making some kinds of scripts. Its that insurers have to run abuse detection, the system is opaque random and that the cost comes in terms of time generating pure social loss.
They don't need 99.9999999% accuracy, they just need a policy of 'approved unless we say otherwise'. Also clearly-written, unambiguous contracts that avoid the possibility for confusion or error.
This is literally what the word 'failsafe' means, design the system so that its failure states are safe. If the penalty for false denials is too high, design the system so the fail state is approval. I doubt it's actually hard to do if the incentives are aligned that way.
>Worse, the strong incentive is for patients and doctors to deliberately script things they think insurance company might deny wrongly in hopes of getting a pay day.
What you're describing here is committing fraud by submitting your fraudulent documents directly to a government agency specialized in evaluating such cases. Doesn't seem smart.
> For instance, a doctor should have to do a bit more work to script an expensive name brand rather than a generic
The proposal isn't that they have to cover every prescription, it's that they have to cover every prescription that their contract says they will cover. As I said, I expect those contracts to become much less ambiguously-worded as a result, and that's a good thing.
>You'd be better just mandating coverage for all meds on some list for any reason.
I mean obviously I just want a nationalized healthcare system like a civilized nation, but I was sticking to the limited scope of the hypothetical.
>Ultimately, the problem is... that insurers have to run abuse detection,
That's *a* problem, but it's not the problem with the current system. The problem with the current system is that insurers directly profit from denying as much coverage as they can get away with, and I'm talking about how to solve *that* problem. Yes, that doesn't sole *every imaginable possible problem relating to the entire process all at once*, but solving the biggest problem *is* a big improvement.
The very fact of having to go through a physician, pharmacist, and health "insurer"* - typically coupled to your employer - to get medication is itself a product of regulation; my prior is that more regulation would make this worse, although path dependence does make it non-trivial to unwind the current state without causing unacceptable collateral damage.
*Insurance is fundamentally a financial product, but so many other things have been shoehorned into it that health insurance isn't.
I don't see how that is a product of regulation. In a perfect free market we'd expect specialization and there is almost no overlap between the skills needed for the three services so it's natural they'd be seperated.
Indeed, vertical integration here would be potentially quite dangerous. You want honest advice from your doctor and if they are part of same corp as insurance company you can't even figure out how to evaluate the quality of your insurance (are they covering the drugs best for you or inducing your doc to favor the drugs they do cover). Similar concerns with stocking and ordering meds at the pharmacy.
In that sense there is a natural antisynergy here so in a ideal market of rational agents we'd expect these to be handled by seperate companies.
--
If what you mean is that in a perfect market insurance would primarily be only catastrophic ...maybe but I think for creatures of limited mental capacity and akrasia we are willing to pay more to limit the variability of our health costs and ensure we are never caught short.
None of the three roles are required intermediaries when I go buy a bottle of ibuprofen; regulation puts them in the way for all but a privileged few medications.
I absolutely agree you should be able to show up and just purchase whatever med you want with cash (perhaps for the addictive ones once you've been informed in some way about risks) but I don't think it will stop ppl wanting insurance and once you have insurance they need cost controls so they don't pay out tons of money to cover someone who gets a crazy idea they need to take 60 brand name prozac a day and that brings in this whole problem again.
Unless you plan to let ppl die who don't have the money for meds at the bottom you need a program for the poor. And if those who aren't poor dont buy insurance at all the poverty program effectively insures everyone.
But wouldn't a perfect market result in everyone only buying catastrophic insurance? No, utility isn't linear in money so we rationally want to limit the downside more than improve the upside so it's rational to want to limit your exposure to medication cost by buying insurance even at non-catastrophic levels.
In a perfectly rational world without employer insurance and ACA limits on preexisting conditions everyone would pay a regular fee to option the ability to keep their medical bills relatively small and those insurers would need to both limit costs while meeting people's desired health needs.
We'd still want to consult experts and insurers would still use them to limit costs. Though we might eliminate the abuse holds.
Kaiser Permanente is trying vertical integration. Their HMO lets you see their doctors and use their pharmacies. I know some people that use it and like it (in spite of HMOs getting a really bad name in the '90s). Haven't used it myself (I prefer high-deductible plans and just paying cash for everything, but thankfully I don't have chronic diseases that require medication management, whenever I run the math on other plans than HDHPs are cheaper when costs are small, are cheaper when costs are large, and are usually only a little less expensive when costs are in a narrow range, and seems more complicated, not easier, than just taking the money I would have paid in premiums and putting it in an HSA automatically), but wanted to add the anecdata.
I have mixed feelings. I just moved to an area where vertically integrated HMO is only option (we picked ppo insurance but virtually all docs through IU health). It's great and efficient if you fit into their categories.
Unfortunately, I've been taking buprenorphone for last 20 years (some issues in grad school subsequent to depression and I found trying to go off brought depression back). Everywhere else I've lived either in states or Israel I could eventually just find a private doc to handle it (tho not always on insurance). Here in southern Indiana I've been shunted off to some horrible company that's literally entered multiple pleas to medicaid fraud that treats me like a criminal.
Here in a decent sized uni city in us I literally had a healthcare worker express surprise when I told her everywhere else I'd lived I could just look up a psychiatrist and pay them money to see me.
There ought to be a way to get a permanent prescription for chronic conditions.
They are never going to be ok for that for controlled substances. Too likely ppl who stop needing it build up huge stockpiles and sell them. Even if you agree drugs shouldn't be illegal recreational use probably shouldn't be subsidized by insurance.
Based on anecdata I've heard about Kaiser, it sounds like they're well-optimized for people with what might be terms "Newtonian" health problems: i.e. it's a relatively common problem with clear-cut diagnostic criteria and a pretty good standard protocol for treating/managing it. For example, if you've got high cholesterol or type-II diabetes, they're set up to diagnose it, recommend appropriate lifestyle changes, and keep you supplied with appropriate doses statins or metformin or whatever.
They're also decent at administering PRATFOs (Patient Reassured and Told to [expletive deleted] Off) to patients with minor complaints and no underlying disorder.
Where they're not so good is if you've got legitimate health problems that are rare, tricky to diagnose, or hard to treat. They seem to try really hard to pattern match you to either a common, easily-treatable complaint, or if they can't shoehorn you into one of those, default to PRATFOs.
This failure mode is not unique to Kaiser by any means (particularly since hard-to-diagnose and hard-to-treat complaints are by definition difficult to deal with appropriately), but they seem to fall into it pretty consistently among people whose experiences with Kaiser I've heard about.
Do you know anything about the age profile of doctors at Kaiser. The docs I've seen at these massive integrated facilities (tho I haven't used kaiser) tend to be younger than the one's I've seen in private practice so I wonder how much of that is Kaiser employing docs that are relatively fresh out of residency who then migrate to private practices as they age.
I'm not sure.
I've actually had the opposite experience in terms of younger docs being more interested in playing Dr. House, while older docs tend to be more apt to expect the familiar patterns.
The biggest example in my own experience was several years ago when I went to the ER with what I feared to be a detached retina but instead turned out to be an ocular migraine. After a long wait, the ER nurse tried to diagnose me as a lying non-compliant diabetic until my wife vouched for my non-diabetic status. Then a resident came in, and I gave him a very detailed and precise history of my symptoms. He got very excited, told me it was the best history he'd ever gotten from a patient, did a full neuro workup, started asking questions that seemed intended to explore the possibility of brain cancer or other similarly exotic causes, and then left to talk to his attending.
The ER attending came in a bit later and basically diagnosed me with "probably not going to die or go blind tonight" [he phrased it more diplomatically, but that was the gist] and prescribed a course of "go home and rest, then call your regular eye doctor in the morning and ask for the first available appointment". My eye doctor was the one who diagnosed ocular migraines.
That was exactly my experience with Group Health, a WA-based HMO that Kaiser took over somehow. They were great for all the normal stuff, but once I developed something out of the ordinary, I bounced through years of misdiagnoses and medications that made my condition worse.
I first read that as "ignorance is a financial product". We'll make you an offer you can't understand.
Regulations get Goodharted. That's how this mess came to exist. The fix is to align incentives. This usuallu means less regulation, but it's not the amount of regulation that's essential, but where each party's interests are.
Do you think that the environmental regulations which prevent dumping raw chemical efluent into rivers have been Goodgarted? Goodharts law is typically a problem of operationalizing a problem definition, which isn't always an impossible task.
Regulation: making it very expensive to act against the public interest. As long as you can properly define the prohibited acts, a realignment of interests will follow!
Goodhart's law states that when a measure becomes a target, it ceases to be a good measure. It says nothing about not setting targets if a target is what you want!
It is not less or more regulation. It is the *wrong* regulation.
The US system spends a huge amount of regulatory and bureaucratic window dressing taking what looks like a competitive market of private insurers, and making it in effect a near single payer system where they are all the same, the systme is basically resdistributive (and barely insurance at all really since the risk pooling isn't happening before the risk actualization).
So you cannot get together with a bunch of other healthy people and make a new insurace pool, literally illegal. You cannot cover this sort of thing and not that sort of thing, and so on and so forth.
In exchange for all this bureaucratic madness the legislation mostly insures everyone still gets their full cut. So costs stay high, all the efficiencies are lost, and it is a nightmare.
You need real competition and real market forces for the "private" nature of of our system to do any good, but there is none. When I look for insurance plans I have a choice of maybe 4-6 providers, all overing a few levels of plan which are more or less exactly the same product excpet a few minor details. There is no competition.
So the "insurers" make their giant pile of money, and so does pahrma, and doctors, and hospitals, and people mostly get care, but it is all a nightmarish hellscape becuas eyou are having the costs of both a public system and a private one, but almost none of the benefit sof a private one.
I agree our system is a mess. But I think really giving people what they want in a competitive private system is essentially impossible.
What people want insurance to provide is safety. They want to be sure that if things go bad it won't turn out they fucked up some detail in the plan they choose or forgot to pay the premium for a few months while abroad and now they are fucked.
Without these regs a competitive market forces insurers to deny converge to preexisting conditions. So the only way this market could possibly offer ppl the thing they want is if you contracted very early in life (arguably B4 your parents conceive you) to do something like exchange a percent of your lifetime income for permanent coverage. Any pay by the month/year system just isn't letting ppl insure against the risk they primarily want insured: the possibility they get unlucky and they get diagnosed while uncovered.
But if you have to commit at the start of your life the normal informed consumer choice can't really happen (even your parents would be limited by very imperfect info about the future). Moreover the notion of individual tailoring to preferences doesn't apply since the choices must be made before those exist.
So yah stop pretending it's a free market and just choose a national health insurance scheme (tho maybe more Germany style than UK).
I am not remotely convinced a system with a much freer market of actual insurance where pre-existing conditions are not covered and where the residstributive aspects are just done as straight handouts to the less well off wouldn't be a lot easier.
I would also pull almost all non-catatrophic care out of the insurance. So people can get insurance that will help them if they get cancer or a heart attack or whatever.
Already had a heart attack? Well that is too bad, the same way it is too bad if you try and get fire insurance after your house has burned down.
But but but you say, what about the 3 year old who develops cancer. Well frankly there are not many of them and that will work better handled as a line item in the federal budget instead of smugglign them in by breaking the whole insurance system but pretending it is still insurance.
Either that or just bare bones single-payer where everyone is force enrolled, which I don't think is too bad, but there would need to be A LOT more rationing than we do in the US currently to keep costs down. And people would hate that.
The system right now is like the worst of both worlds.
First, just as a matter of values I certainly don't want (and voters don't either) as system that lets the 21 year old die bc he let his insurance lapse for a month between college and his job who gets stabbed stopping a robbery and now needs dialysis plus kidney transplant.
Not only do I think the voters don't want that I think ppl would be so scared of that they would never let their insurance lapse. PROBLEM, once you've been diagnosed as being at greater risk how do you switch insurers?
And any insurer who doesn't get a lifetime contract faces adverse selection selection. Ppl learn about their level of health and those who are healthy switch plans to a cheaper one leaving only the sickest. Market solution is to pay for lifetime coverage upfront (eg debt) so literally no one gets to switch insurers and bc of the info asymmetry (as in sale of used car) even if existing insurance is for some reason (doubtful imo) willing to offer you a buyout they'll never offer you the full amount (ppl have private info about their health and healthier ones will preferentially take buyout) so everyone buys insurance once at 18. Bc of bankruptcy floor the market becomes a series of insurers who offer good service for a bit then profit take off their existing clients who can't leave funneling money to shareholders until bankruptcy.
So on your system say a doctor does a genetic test on a 3 year old and discovers they have 50x the usual risk of getting some very expensive disease at 35. How do they buy insurance at 18? Their risk adjusted insurance premiums might well be 50x or more then average.
If you try and have the government cover the difference you recreate the current system. Even if you give ppl a lump sum the government needs to define a standard level of care to infer NPV of the lifetime risk adjustment and then maybe even pass laws to ensure the insurers offer insurance at that rate (the insurers and purchaser have an incentive to uprate the expected cost to fund a more luxurious plan and the only way you avoid forcing those with higher risk into crap coverage is to somehow define minimum coverage and then how do you handle the case where the market seems to rate price higher than gov? There just isn't any workable price discovery here if you commit to not screwing over those with higher risk).
>If you try and have the government cover the difference you recreate the current system.
No you don't recreate the current system because the two systems are not mashed together into some unholy frankenstien whose main purpose is to hide what is going on and obscure all signals about who is paying for what.
You don't have "subsidy for kids who develop cerebral palsy at 6 months" just lumped into everyone's undifferentiated premiums and hidden, but instead as specific line items that are coming directly out of people's taxes and the government coffers. There is more price sensitivity and transparency.
Yes that might mean socety balks and stops covering $200,000/year cystic firbosis treatments that improve someone's quality of life from 62% to 89% instead of the 81% they would get on a much cheaper cours eof treatment, but that would happen outside the insurance system.
As it is now the insurance system is being asked to do about 197 differnet things simultaneously and so it does a ton fo them very poorly.
And sure there is price discovery, it is just the tapayers discovering price for the prexisting condition people isnetad of those individuals.
And yes some people will get screwed, that is life. Two people drive exactly the same, one person gets in an accident and ruins their future happiness, the other lives a carefree life. You aren't going to be able to mash all that out of life even if we doevoted 100% of the eocnomy to just that. We should stop trying to achieve it.
You could also have a separate system where people having kids (or taxpayers generally) simply are required to pay into a "future healthcare for children of X illnesses fund". Then have tehcnical experts decide what level of care the fund can actually afford.
You want to keep as much of the system working with fucnitonal price signals as possible and the current system does a HORRIBLE job of doing that.
My literal optiosn for insurance are something like:
Company A, Product 1: Pay $10k/year in premiums and be at risk for another ~$15k in costs max, at group of providers X
Company A, Product 2: Pay $12k/year in premiums and be at risk for another ~$13k in costs max, at group of providers X +.1(Y)
Company A, Product 3: Pay $15k/year in premiums and be at risk for another ~$10k in costs max, at group of providers X +.1(Z)
Company B, Product 1: Pay $11k/year in premiums and be at risk for another ~$14k in costs max, at group of providers Y
Company B, Product 2: Pay $13k/year in premiums and be at risk for another ~$12k in costs max, at group of providers Y+.1(X)
Company B, Product 3: Pay $14k/year in premiums and be at risk for another ~$11k in costs max, at group of providers Y +.1(Z)
That sounds like an exaggeration, but it is not. I have about 15 different choices and they are all more or less exactly the same product with EXTREMELY MINOR variations. Moreover the fact that I was at low risk of helath costs, have been low risk, never made a insurance claim against and house or car in my life, all things which should be extremely beneficial in terms of my risk profile. All meaningless.
So instead as an adult I have paid in maybe $200k into the medical system in premiums, more? The government has probably chipped in another $100k on my and my family's behalf in one way or another. And used maybe 1/6th of that. Less?
For my and the government's $250k I have gotten a product where half the time I can barely even fucking use when I need it it andrisk goign to jail if I try and not buy it. It is not a good system. Don't hide the cost of being old in premiums for people in their 20s and 30s.
I still don't understand how you allow switching insurers without sinking the system under adverse selection.
If I get a get a DNA test while insured and have way higher risk of some disease how can I ever switch insurers? If I discover I'm at low risk what stops me from switching to a special low risk plan and leaving the first company only with the high priced individuals.
Is it legal for me to start and insurer F who only charges 8k/year and max risk 10k but only for ppl whose genetic risk score is in bottom 40%? If so every customer at other insurers listed takes test and switches if in bottom 40% and stays put if not.
Now those other companies are jn the red bc say A1 still gets same revenue per person but all their customers are now in top 60% of expected healthcare costs.
Either you have to stop ppl from switching or you can only get insured after full dna analysis and if you are in top 10% (healthcare cost weighted to top tail) you are just screwed and need to pay 100k a year for that coverage out of the gate at 18.
To illustrate issue imagine there was a magic device you could use to determine exactly how much your total lifetime health cost would be that you can use secretly at home. Now suppose every year i can choose between your plans. What I do is secretly take the test check of I'll make or lose money on each insurance and only buy it if it's a net positive. Since everyone does this any insurance plan that charges less than the literal maximum medical bill in the country goes under because they pay out more than they get to all their customers. End result is that no one can buy insurance at all.
DNA tests arent perfect but they in combination with other tests are a noisy approximation. As tests get better and better we are able to insure against less and less.
My understanding (based on a moderate amount of research 5-6 years ago) is that the whole pre-existing conditions argument is based on a misunderstanding.
Insurance pre-ACA sure had pre-existing condition exclusions, but they were just a waiting period. If you had a pre-existing condition prior to signing up for an insurance, you would need to wait 3-6 months for that specific coverage. It was always intended to prevent you from calling up an insurer while they were doing open heart surgery on you (absurd mental image intended) and not stop you from ever changing jobs if you had diabetes.
It was also intended so that insurance companies could hand-pick lower cost members, refuse to take people based on their conditions, and charge higher premiums to individuals with pre-existing health conditions. A lot of people in that situation were effectively uninsurable -- they couldn't find an insurance company that would take them.
Are you sure that was possible after HIPAA in 1996?
Hipaa regulates how patient information needs to be secured when stored and transmitted electronically. It doesn’t regulate what medical procedures insurers need to cover or how.
Having spent a lot of time trying to make call centers and other service operations better, I think regulation is a distant root cause here. The more proximate cause is people (sometimes consultants) trying to make their one piece of the operation better, e.g., triaging out live calls to lower cost. In a truly competitive market there's a feedback loop that can correct the excesses, but you need only a small constraint on competition, or a big bureaucracy with lots of inertia, to get the bad result here. I've had the same nightmare experience that Scott describes but with my home internet-TV-phone provider, which theoretically faces some competition. So I think there's overregulation in the mix, but to me it's more Goodhart and principal-agent problems and short-termism.
A competitive market in which those making the decisions pay the costs. That's not true in insurance.
The ultimate problem here seems to be that the insurer wants to discourage the doctor from certain kind of prescription (either bc it costs them money directly or they fear it will expose them to liability if patient is abusing). As long as we have a free market in insurance (and they have potential abuse liability) this is inevitable and arguably socially beneficial to some extent.
The problem is that the insurer isn't allowed to just directly charge the doc in a transparent way that creates optimal incentives. Instead we get a pure social loss in wasted time via a complex highly random system,
[oops, I replied to wrong thread at first]
I agree with all that, just saying a more parsimonious explanation is "big-company customer service trends toward cheap and bad, absent strong leadership and a brand that depends on good CSAT." There are principal-agent problems in lots of industries, not just in health care. For what it's worth, I've had a few different payors recently and some opportunity to select among them (i.e., it's at least a little competitive), and customer experience is one of my buying factors, but it's a lumpy annual decision so the feedback loop is weak.
Fair. But I've found that in digital age when u have at least weekly aligned incentives u can at least discover the cheap mechanism that makes it easier for everyone. Even most utilities have online payment, outage reports etc...
It's still really bad as u say but this level of bad I only see with misaligned incentives (eg subscription cancellation). I agree but I don't think we are even at the just "tends toward bad and cheap" level here but the "let me make u call between 9-5 London timr the week it's going to renew" level (yes really what a magazine told me)
We might be able to develop a theory of Crap Customer Experience, like a predictive model for where the customer experience will be unbelievably bad, beyond where it would be economically rational to be bad. Feels like some parameters would be
1. Currently overregulated industry with many constraints
2. Vestiges of historical monopoly
3. Many layers between market discipline and decision making (you call this lack of competition, I call it size + principal-agent conflict, same thing)
4. The cancellation experience (dark-pattern save desks and other hurdles)
What else?
To play the rolê of stereotypical libertarian, most of this stuff is a result of regulation, not markets operating. Health care's bizarre third party payer model distorts prices and restricts the ability of medical service providers to act outside the narrow confines of what they know is legal and profitable and try new ways of serving customers.
Insurance is as regulated an industry as there is on this planet.
Sounds good, but some of the problem is that the regulation (or more precisely, the misunderstanding of the regulation and fear of lawsuits) is what causes some of these problems.
You'd have to have an invested team of people able to push legislation that doesn't just end up causing more fear and paralysis and the will to follow up when it isn't working out like expected. Based on the history of other medical reform (such as HIPAA) I doubt that is going to happen in this sector.
I've had some insurance companies that were very easy to get ahold of a competent individual who could help you. But honestly when it came time to renew, I regularly opted for the one that was 2,000-4,000 dollars cheaper per year USD. It didn't make sense to pay that amount of money when I had no clue if the cheaper one was worse or better and I only had to call in every 1-3 years.
It's insane that insurers are responsible for flagging/stopping abuse. Almost as bad as making Walmart liable for that.
It should be only the doc and the feds doing that. Making insurer or pharmacy responsible is a certain recipe for racial and socioeconomic inequity.
Agreed. I'd love a world where laws were enforced regularly and fairly, and it was the responsibility of law enforcement to actually do it. I would hope doing so would actually decrease the laws on the books instead of increasing them. In the US there doesn't seem to be much appetite for enforcement. See privacy concerns over speeding cameras, police unions protesting by enforcing all laws to create huge backlogs in the system and generally annoy people, etc.
I wonder how much of the insanity of pharmacies comes from the fact that they are expected to provide second-line service to keep people from being prescribed drugs with harmful interactions and to take them the correct way, instead of just a place to pick up things that the doctor already selected for you and told you how to use.
If everyone had only one doctor, that would work. Unfortunately, many people have more than one doctor; I myself routinely see 6. The pharmacist really is the "last line of defense" to prevent Doctor A from prescribing drug B, which has a lethal interaction with drug C prescribed by Doctor D.
Is it every industry? For instance, how is it in extremely competitive, customer oriented industries like, say, TV sales? Are Best Buy and Panasonic as bad as CVS and Blue Cross?
Genuine question; I don’t know the answer.
Funny, but in real life physicians have someone in the office to do all this for them. Right? (Please tell me they don’t do this themselves.)
That depends on your point of view. In small practices, I expect that the physician is absolutely the one that's on the phone. At a moderately sized practice like mine, people like me are hired to perform these duties in tandem with everything else that is required.
A technician like myself has to do the work up, i.e. get the basics of the doctor's bookwork done (thankfully, we do this electronically). That means doing, more or less, anything that doesn't require a doctorate to assess. Which is most parts of the full visit in my field.
Several technicians work for a small number of doctors, so that each 30-60 minute appointment doesn't eat 30-60 minutes of the attending's time. Anything that we do or don't do is ultimately the physician's responsibility, and can be called into question in court. A chart note is a legal record of what happened during the visit, and has to treated as such and amended by strict protocols.
So, yes, the doctor is the one on the phone all day, if in a distributed sense. Any time that I spend sitting on my ass and hoping that either I die or this cockamamie hold music that someone dug out of the dumpsters outside of Hell's orchestra circa 1963 will just please end, whichever comes first, is time not spent tending to someone in the building or answering a question that takes all of 3 minutes to do. That is time that the doctor is losing to what could be charitably described as "smooth jazz as described to an alien that cannot perceive sound".
>A chart note is a legal record of what happened during the visit, and has to treated as such and amended by strict protocols.
Tangentially, this is a big part of why medical transcriptionists are a thing and continue to be a thing even though most doctors know how to type now and text-to-speech software is available for docs who prefer dictating notes. The actual transcribing is only part of what medical transcriptionists do, and the other big parts (cleaning up causal notes into a formal legal document, and recognizing and flagging possible mistakes for the doctor to double-check) remain important.
It's a pretty good job if you can get into it. A former coworker of mine loves it.
You can even outsource it, just call InsuriCall on a toll-free number and have your Medical Assessment Number ready and they'll call the insurer and pharmacist for you (for a fee).
Some hospitals have drug reimbursement specialists whose full time job is doing this sort of thing. Some physicians hire medical secretaries, but how good they are and how devoted they are to this aspect of their jobs vary a lot.
Finally, an ACX post to vindicate my absolute seething hatred of deliberately confusing phone trees. Any utilitarian argument for the joys and benefits of widespread automation that does not seem to acknowledge this unparalleled evil earns my immediate suspicion.
This works equally well for the interplay between Verizon and Asurion when attempting to get a replacement phone through the warranty process. Half a dozen calls, multiple transfers that mysteriously drop, call back numbers that don't work, shouting "SPEAK TO A CUSTOMER SERVICE REPRESENTATIVE" at every menu tree, tech support people all reading the same scripts, tech support people asking me for all the information I just entered, multiple "tech support" people trying to up-sell me new services instead of fixing my issue ("Maybe your phone would be able to get text messages if you just upgraded to a more expensive plan!"), Asurion telling me to call Verizon, Verizon telling me to call Asurion. I eventually made it through but it took hours.
I'm not saying that the first political candidate that promises to find the people who design systems like this and have them publicly executed will automatically get my vote, but I'm not NOT saying that either.
But at least that situation is responsive to market forces. Asurion is cheap bc they make it hard to make claims. If you want to avoid that you pay for apple care or similar.
This is particularly horrible because those who bear the costs arent the ones making the deciscions (at least not with any information about future costs).
This resonates deeply. The times I've had to navigate phone trees (usually verizon) always made me miserable for the rest of the day. I hope this particular post wasn't inspired by any recent events.
This is the kind of paywalled post I am happy to subscribe for!
Bonus points for not offering any other way to contact that leaves a paper trail (and basically no way for people who have speech/hearing impairments to get in contact).
Ohh I'm sure they offer those tty enabled phone call things. I suspect they are far too smart and legally advised to fail to obviously violate the ADA. How realistic that accessibility is might be another story.
Relay services, video or text.
Someone (deaf person, government agency) is paying for another person to sit on hold so even more people can suffer at one time and interpret for them.
Sometimes those relay services are used by "drug-seekers" as a way to anonymize their calls, but mostly they are just people trying to get service.
Huh, always thought drug seekers avoided insurance (at least on extra/skeevy scripts). But I guess they've probably cracked down on that more recently. I never scammed scripts but back in a less pleasant period of my life in bay area I remember being surprised to learn there was a going rate for fronting the cash to let someone retrieve a script.
I really don't understand why the insurance companies need to be involved. Don't all pharmacies have to report to a PMID? Every doctor I've seen for past 8 years can look up my prescription history. Why not make that master check?
I remember when that law got passed in Illinois and my mom tried to opt out for privacy (she refused to trust ATMs until late 90s) and despite quoting the law which supposedly gave her that right and not having any scheduled prescriptions she couldn't get them to do it and I thought it was at least sorta mandatory for controlled substances.
I've been out of the industry for about 4 years and drug-seeking behavior had really died down towards the end of my tenure compared to the beginning, so some of those solutions may have been solving the problem, but I wouldn't be surprised if nobody went back to get rid of the older solutions that were made useless by the new ones.
And again: many company policies are put in place by people who do not have a firm understanding of the law, either because they haven't put in the work or because the law is purposefully vague and the fear is of lawsuit. There are a lot of horror stories out there of businesses and individuals in businesses being sued or going to prison for something that (as the story tells it) wasn't explicitly forbidden and seemed perfectly fine. Often when you got more details in the situation, it was a lot skeevier, but that isn't how the story goes.
You could always hire a consultant to tell you what to do, but I found that a lot of consultants either also didn't know the law or creatively interpreted the law to scare you as much as possibly and justify their services (immediate and ongoing).
I didnt mean that as a practical Q just venting about the annoyingly wasteful state of the law.
Do you know if this is any better in either:
1) Integrated healthcare systems where a giant sprawling complex of docs all under one roof (like IU health here in Indiana). I think they sometimes tend to work alot with one health insurance company (eg here in Bloomington IU is probably the largest employer)
Like does that kind of giant system either allow those costs to be amortized (someone has a full time job fussing with this and that cost is amortized over many many patients) or change incentives?
2) In single payer systems like the NHS? Or do these systems inevitably use cost in time to deter expenditure as well?
I'd love to know what a good way to fix this is.
The NHS used to be good at this but chronic underfunding particularly of support staff means you don't get a phone tree, the phone just keeps ringing until it disconnects or you get an answerphone which is either a black hole or full; the way to get treatment is often just to show up in person and wait there.
If you're very lucky your GP will have implemented an e-consult form which means that you at least don't have to wait through ages of hold music and 'you are a valued person who is twenty third in the queue' to get hung up on, although generally the form will only be open briefly in the morning as they shut it once they have too much work for the day (to stop emergency patients filling in the form then dying waiting for a response, which may be accounted their fault).
It's not even the case that the phone lines don't try to upsell you any more because of the takeover of services by Virgin etc.
A good way to fix this is to somehow make medical support staff as valued as front line medical staff, and spend money on admins and phone answerers rather than expensive management consultants - but they are less likely to be the friends of people in government, so it seems unlikely to happen.
That doesn't really sound like fixing it to me. If you are paying ppl a lot in doctor offices to sit on the phone with insurance companies you are wasting a bunch of money no matter who is doing it.
And it seems pretty obvious that the insurance company could implement an easy to use electronic form to handle this kind of thing in a way that cost them less if they wanted to but they don't want to make it costless for doctors to inflict higher costs on them or expose them to lawsuits for ppl who get addicted.
I guess my fear is that insurance (national or private) need to limit costs and if you take out price as a way to do this directly they substitute inconvenience.
Most patients currently still can't easily use electronic forms easily because health care need is biased to the elderly - this is if course gradually changing, but people with high healthcare needs will always need a range of options because eyesight, hearing and money for reliable technology access is anticorrelated with healthcare need.
I meant forms for the doctor since that was what the post was about. The issue if personal interaction with the insurance company is a whole other concern, but also interesting. But for in network care it's usually been the doctor's office who works it out in my experience but dunno how universal that is.
I'm still talking about the NHS - so the doctor does have to submit all kinds of QoF paperwork to get the government payments but doesn't deal with insurance per se. Generally their automated GP computer system will spit out the reports on their end too. Computer says no is still a problem for referrals but the equivalent of this is them trying to phone the hospital / specialist clinic and having to do so repeatedly to catch someone actually able to take their call.
Sorry, I misunderstood. Thanks for explaining. What do docs do for the patient who needs the expensive brand name drugs (eg allergy)? And what discourages doc from just always picking those? Honor system? Threat of review of paperwork?
The previous method of cost control was mostly gatekeeping - stereotypically by GP receptionists. This is also not a perfect allocation method (in particular it tends to be biased in favour of articulate, middle class patients who can play the social game) but probably somewhat better than the current situation in most cases (really obviously serious cases could get through more easily).
But that's not gatekeeping for cost. Only gatekeeping for ppl asking for scripts. No skin off the doc's nose if you take an expensive script rather than a cheap one unless insurance company makes his life hard as a result.
I'm talking about the NHS, so gatekeeping for cost is done with NICE prescription guidelines, incentive payments to GP offices for prescribing generics etc
Ohh incentive payments. That's much better than my idea of disincentive fees. Same thing ultimately but far more psychologically palatable. Good system.
Tho I guess with private insurer you don't want them to offer huge bribes to give worse care and at least reducing visit coverage limits size of disincentive.
> 2) In single payer systems like the NHS? Or do these systems inevitably use cost in time to deter expenditure as well?
It's not as strictly single-payer as the NHS from my understanding, but the Australian system is a lot less time consuming. Medications that are covered on the PBS are either unrestricted (can be prescribed for any indication), restricted (e.g. prozac is covered for depression or OCD only, honour system), or authority (like restricted but with some hurdles that basically break down the restriction and make you promise you're following each part of them).
Getting an authority prescription approved used to need a phone call and a wait on hold, but these days it can be done online in <5mins. The disincentive to inappropriate prescribing? If you're audited and you've lied on the forms then you'd be open to fraud charges I guess. I don't know how much that actually happens, but it'd be pretty rare.
Ok so I'm guessing it becomes virtually impossible to demand the name brand? That's probably a reasonable tradeoff.
Like this seems mostly good but I'm curious how it works with drug approvals? I mean does this mean that if prozac did trials to show ocd effectiveness but another SSRI didn't you (theoretically) shouldn't be able to script that other SSRI for OCD?
I don't necessarily disagree... the whole requirement the you prove efficacy for one condition get prescribed for anything is kinda fucked up but I wonder how that would work for pharma incentives if every country did it this way? Do you just lower the burden to show efficacy? That could be good.
Also, if a patient is willing to pay out of pocket can you prescribe outside those indications?
Idk about Australia but UK private prescriptions are mostly handled by pharmacists (or private GPs if you need something that can't be directly pharmacist prescribed) rather than your regular GP.
An alternate ending - the block is lifted, but when Jane Smith goes to get the prescription, it can’t be filled because the medication is out of stock there. And then she gets the prescription transferred to another pharmacy but by the time she gets there, it’s closed because the pharmacist takes a lunch from 1:30 to 2 pm and techs can’t dispense meds unless the credential is on duty.
Or, in the version with the meaner doctor, Jane hasn’t kept up with the constant blood draws so the physician won’t write the refill until she gets a blood draw and makes an appointment (at which they say it’s fine to remain on the same dose). It’s not just the customer service misery. Maintenance medication by prescription somehow insults the universe and obstacles proliferate in front of it.
The other great version - the doctor no longer works there and if Jane wants her pill, she’ll have to reestablish care with a new “care provider.” Which will take three months. Better hit ACX for some advice on nootropics, Ms. Smith.
That's not even the half of it if you want to deal with a medication like buprenorphone that has special approvals needed.
Moving is almost impossible as most receptionists won't even know or be able to tell you if their doc handles the med (unless you go to a shady place that's basically built to rip off medicaid) but you need the meds within a month of moving.
> "Jane hasn’t kept up with the constant blood draws so the physician won’t write the refill until she gets a blood draw and makes an appointment (at which they say it’s fine to remain on the same dose)."
I have this problem with my rheumatologist. It synergizes excellently with the complete inability to get a human on the phone to *make* said appointment. More often than not I physically drive over there to do so. Also appointment waiting room times are 3-4 hours.
And there are no other rheumatology clinics within a 20-mile radius, as far as I can tell.
I spent an hour and two minutes on the phone with Cigna today *before I'd even reached the correct department*. It takes 3-5 minutes just to get through the automated phone system and get to sitting on hold.
I promise I'll read more than the opening paragraphs, in a moment. I opened this to do some light reading in bed and now I am wide awake.
If you work for Cigna, no offense to you at all, but *fuck* Cigna. I could have seen at least four people from start to finish in the time it took to start unraveling the knot that took me to them. Third call today, fifth since the start of the week, all for the same problem.
Aaaagh!
Edit: I hate how close this is to what I've been doing for the past two days. Dammit, Scott!
Argh! This should probably have a trigger warning. Very accurately observed, and left me almost shaking with anger.
I'm thankful that a) I don't have to deal with this in my day job and b) I don't have to deal with it for anything medical, thanks to the NHS. But it's still an unavoidable part of being an ordinary citizen in the modern world and dealing with banks, utilities companies (including phone and internet), mortgage providers, insurance (non-medical), companies you order things from and they don't send it or they send the wrong thing (except Amazon, who let you do it online, which is a fraction of the stress).
And you missed the bits where the company's phone line is so bad you can't make out what they're saying, or the person's accent is unintelligible (maybe Glaswegian, to avoid the appearance of racism). I once tried to make a trivial change to a life insurance policy, which I thought would be a 5-minute phone call, but they made me stay on the line for an hour so they could basically reassess eligibility from scratch. "Have you ever suffered from any of the following conditions: (long string of nonsense syllables in a very strong accent)?"
Maybe hire an assistant? (Although once the assistant gets through to a human, maybe they'd be told "sorry, I can only speak with Dr Alexander himself," as this is what happens when the wrong member of a married couple phones the bank or utility company to discuss their joint account.)
Maybe move to the UK, where at least you won't have to deal with this for medical stuff?
On the one hand, crazy that doctors whose time is ultra valuable have to spend a significant portion of their time on nonsense like this.
On the other hand, the phone maze described here, humorous exaggeration and all, is still pretty good compared to the experience of trying to get a large tech company on the line. Some common tropes:
* There is no phone number or other way to contact them given *at all*. You go to the customer support page, you just get a FAQ or some kind of keyword-matching textbox which attempts to guess what your problem is and gives you a cookie-cutter answer. In order to be allowed to contact the helpdesk, you have to find the one path through the FAQ maze which will give you the phone number plus a one-time passcode. If such a path exists at all.
* Variant: to get the passcode, you need to already have a customer account and a specific transaction (e.g. in the case of a hotel booking website, a specific booking ID) which your question is about. If your problem is that you can't login or can't create a booking, you're stuck.
* The only way to contact the helpdesk is via a little chatbox in a corner of the website. It always pops up automatically as soon as you linger on the site's main page for more than a few seconds, making you feel watched and pressured. It opens with an automated message like "hi, I am Dan, how may I help you" but then when you type something in there, you either get no response, or a "there is currently nobody available" message, or a chatbot that makes 1970-era ELIZA look like GPT-4 by comparison.
It's even better if you're an in-patient, as then all your frustration is evidence of emotional disregulation, and your attempts to communicate your previous medical service interactions is evidence of mania and psychosis. Here, have a lorazapam while we schedule you for E.C.T.
I realize this is probably exaggerated by about 15±5%, but why does every single aspect of the US medical system - aside from, idk, maybe getting the most super cutting edge surgery or treatment (not relying on any kind of mass-market drug) for something - seem, on average, to be slightly to very much worse/inefficient than what I know of the one in Germany?
I think I need to read more blogs/Twitter/etc of German doctors/healthcare people complaining about all the bullshit they encounter, I'm probably availability-biasing a bit here.
Though it seems pretty clear that Germamy's is more efficient at least in the sense that it gets similar outcomes with a lot less per capita healthcare spending.
As someone from elsewhere in Europe, my impression is that Germany makes up for any reduced inefficiency in dealing with its medical system by its other government/state bureaucracies being extra inefficient, requiring personal appointments, not having online forms (and requiring many, long forms for simple things) etc. My impression is *also* that Germans often don't see these things as issues because of your national psychology, to put it vaguely, i.e. the same reason why Germans are a decade behind the rest of Europe in terms of electronic banking services and uptake (and why they don't consider their difference in this as being "behind"), why the stupidest EU digital regulation proposals are usually pushed by some German politician or weird German NGO, etc.
Each country seems to have its own issues with difficult bureaucracy (and often don't consider them to be problems), but Germany has an especially poor reputation in this regard.
Students in Germany can now fill in their requests for financial aid digitally which promptly led to a paper shortage where the requests are processed. I wish I was joking.
That's definitely a classic.
"We've changed process X so it can be completed digitally!"
is actually German government language for
"The citizen-facing, initial phase of process X can now (maybe?) completed entirely digitally; we'll then print the received information and process them using paper & fax machines, to honour the spirits of our ancestors."
Oh, hard agree on German government, bureaucracy & politicians (who then push legislation) being, generally speaking, truly abysmal when it comes to anything digital/IT/internet-related.
Please accept my deepesr apologies for Axel Voss in particular :(
I think the electronic banking uptake & use has gone up a lot in recent decades, partly because offers got better, partly because banks implemented charges for many traditional paper-based/bank teller interactions.
I was wondering, though:
Were you thinking of any specific "weird German NGO" pushing any specific stupid digital legislation?
I'm sure there's generally organisations doing that, but they're often more like... disguised industry associations/lobby groups.
The pattern I'm seeing is usually that with these stupid proposals, any NGOs that can be described as both financially independent from/not associated with the supposed beneficiaries of the proposal, and as having some relevant expertise, are very publicly tellinf everyone who'll listen how bad an idea the stupid proposal is, only to be roundly ignored by the politicians.
https://www.youtube.com/watch?v=8jDUVtUA7rg&t=149s&ab_channel=Perun
If you want to laugh and/or cry, watch this video about the problems the German military getting its weapons. And possibly other supplies, I'm not sure about that.
Germany makes excellent weapons, and sells them to other countries because the bureaucratic process is so onerous for trying to get German weapons for the German military.
I gotta say, I saw the "drugs that belong to the Emperor" coming a mile (or, ahem, most of that paragraph) away - like I literally had it formulated in my head and was anticipating the sensory input
Was that a reference to something? How did you see it coming?
https://en.wikipedia.org/wiki/Celestial_Emporium_of_Benevolent_Knowledge (and congratulations on being one of today's lucky ten thousand!)
I am likewise being clueless here. Can you give us a hint?
All I get in my head is a variant of Kipling's "Cold Iron": "Drugs are for the Emperor..."
What Grant Gould above replied.
Scott has referenced this "classification system" multiple times in the past. Particularly, the list of other recommended blogs on SSC was organised according to the classification.
Odd thing was, it made sense somehow?
Eg, it listed SSC itself under the category "those included in this classification", and under "those that have just broken the vase" it had Zvi's "Don't worry about the vase".
Yeah, once I read Grant's reference, a lot of them sounded familiar. :-) Thanks!
I have a similar problem with Amazon and auto blocking. Which led to the phone tree hell.
1) Amazon deemed as suspicious an e-card I sent to myself.
2) I talked to Amazon.de on chat when the e-card was processing after about an hour (it should take 5 minutes) - this got through quickly but the guy said it was an issue with the bank. I knew it wasn’t as I had verified in the app but I ended the chat.
3) Amazon sent an email and disabled my Amazon.de account the next day.
4) text chatted to a guy on Amazon.co.uk. Said he would look into it.
5) Amazon.co.uk disabled my U.K. account that same day.
So I’m locked out which means i have to use the phone. Always worse.
On the first call the automatic voice said that they could send a link to the known registered mobile I was calling from to allow me to get called back. I agree to this, get the link, and it links to a login screen. I have to login to use it but I’m disabled so can’t.
Wait a day. No kindle books or prime TV available. I have about 15 years of kindle books.
Call next day. Can’t get past the initial human operator to security because I live in an apartment which is the street and the number is 11. The postal address is therefore:
11 Building Name, street, city
But the software knows it’s an apartment and expects:
Apt 11, street number, Building name, street, city
So they are taking 11 as the street number.
The building doesn’t have a street number. No apt number works. Even though I have a postal code which maps exactly to my address, and they can see that, this doesn’t work. He agrees it’s me, that the address is correct but typing 11, or 1, or anything into the apartment number doesn’t work. End call.
Wait a day. Call again. Same issue. The operator asks for another delivery address. I give my parent’s address. There’s no number on my parents rural house so I don’t expect that to work. I just in exasperation ask him to type in 1. That works.
I need to get to account security. The original
Operator trues to pass me over to the correct department, but that department says I have to wait longer as I just received an email. But I hit the email a day or two before?. The operator can see that. But checking my mail it turns out they’ve sent out another one saying I’m still blocked just before the call. The emails say to call in a 24 hours and not before. I take this as a glitch rather than being deliberate.
Wait a day.
Call again. Get eventually to accounts, after the initial operator went though the two addresses again.
Talk to a frazzled guy who has a strong Scottish accent. He asks me about my recent purchases and my basket. Well I can’t login so I fire up my email to find the most recent purchases. This was a pain since Amazon email me *a lot*. The basket I just remembered. That worked, I passed that test.
Then he wanted any credit card associated with the account, last 4 digits and expiry. I have more than one but gave two I was certain off. He kept telling me I was wrong and was actually getting annoyed to the extent of cursing, albeit softly, but it turns out that the cards I gave were disabled (as well as the account?). He agreed it was me and should have check those as well.
Then he told me he would call me back. I said ok, and he probably has the mobile number I was calling from. He did not. I said it was the mobile that Amazon uses to send an sms to verify me logging on when I use a new device, or from a new location. He said that he didn’t have that on record.
The phone number *has* to be associated with a delivery address. He reads out the last 4 digits of numbers he could call me back on. I recognise some of them as perhaps old delivery address land line numbers but I’ve been on Amazon for 15 years and have sent to multiple addresses.
The only last 4 digits I recognised were my parents. But I am not there until after Christmas. It looks like phone numbers are not obligatory as otherwise I would have given my mobile number for my present permanent address. Hard to tell as I can’t login.
He said he could create a whole new account and reset everything, but that deletes my kindle purchases. Didn’t do that. That’s what I’m trying to avoid. It’s probably a few hundred euro. And it’s my book collection
So that’s where i am. Possibly I can recover at Christmas or they might permanently delete my account. There’s no recourse if this fails again, no obvious higher authority on Amazon. All emails are no reply.
(All the operators can see that e-card was sent to the same address as the account but that’s not something they can do anything with).
That is one of the reasons why I refuse to "buy" DRM protected media. (Well, non-games. I have a Steam account with some games I "bought" on it. I could claim that the situation is different for Turing-complete media, especially if you want to play online. Or I am just lazy/inconsequential there. But paying as much as I would pay for a softcover for a file which I can only view on the devices of one particular vendor and until they decide that they cancel my account? While the 5th Amendment Online Bookstore offers the same without any DRM at a rather competitive price? Totally worth the hassle of converting file formats.)
Yeh. I didn’t realise I was renting my books.
Do you now own your books? I have a good toolchain for it but the setup is annoying. Download all the books locally with the Kindle desktop app, figure out where this version of the app stores its files, import them into Calibre, install the DeDRM plugin, convert all the books to epub, upload them to libgen.
If you need help with that, I'm happy to 1) help you set it up, 2) run your books through it if you send me the azw files, or 3) run your books through it if you let me log into your account to do so.
Jeff at amazon dot com (as in Bezos) is purportedly an escalation email address monitored by a real team of highly powered exec assistants. I'd try that in your situation, with the description you've given here prefaced by a one or two line "here is what I need".
Healthcare press/researchers/executives: “The NIH has mercifully allocated $1,000,000,000 towards understanding the root causes of “burnout,” a condition afflicting a growing number of healthcare professionals. While theories abound, nothing has been proven with science numbers and words aplenty. Until then, healthcare professionals will need to survive on, uh, passion and the clapping of children’s hands.”
Funded study- “Godspeed: A 10-year prospective study into the root causes of “burnoutre” in healthcare, a pilot study, proof of feasibility”
Researcher in 10 years: “I dont want to get ahead of the data, as the root causes of burnout are themselves multi-determined and with many intercorrelated socioeconomic sub-factors, BUUUUUT...we think burnout is caused by, well, bullshit.”
They say laughter is the best medicine, and fortunately, it isn't under the control of insurance companies.
There's a theory that humans behaving like machines is a fundamental source of humor, but machines behaving like machines while pretending to be human is also funny, especially when it happens to someone else.
I've gotten excellent customer service from calligraphy supply companies, but no doubt, if a lot of people tried calligraphy as a career, the companies would start using phone trees.
Maybe they'd like to start covering Prozac prescriptions?
Earlier this year I got told, "You're going to have to pay out of pocket for this Rx refill. We can't bill your insurance because your PCP retired and their provider ID is no longer active. You'll need a new doctor and a new prescription." So I got a new PCP, booked the next available new patient appointment because they refused to reissue the Rx until I saw them, and had to pay out of pocket for the six months it took to see them.
Would this problem be solved by more freedom or less freedom?
It is not more or less, it is the wrong kind fo freedom. The regulations regulate the wrong things.
My impression is that this is less of a problem in other countries, because there either the national government or some large quasi-governmental organization steps in and negotiates drug prices with the pharma companies. This lower price then applies to everyone in the country. This often makes medicines cheap enough to pay for out of pocket, with no complicated pricing bureaucracy on the consumer end.
The American approach is different in that the sticker price of medicines is high, but every major medical insurance provider separately negotiates a lower price for their cients. Unfortunately this tends to introduce rather a lot of bureaucracy, since each company is a bit different in what drugs they cover, under what conditions, and to what extent. You really don't want to be in the position of being prescribed a medication that your insurance provider doesn't cover, since you'd be stuck paying the (high) sticker price yourself.
I'm so sorry for your suffering, but so glad to know that my doctor's experience of trying to get my prescriptions refilled is precisely identical to my own.
A) this is beautiful
B) this makes me sympathize with anyone who wants to burn it all down
How much of this is real? For example, does it actually happen that a patient is put on hold for some stupid, paranoid reason? What is actually a common reason for this?
Does it actually happen that they have some fake or obsolete entry in their system like Medical Assessment Number, and you need to answer that to get through?
Yes, it absolutely happens that a patient is put on hold for a stupid reason.
For example, just last month I had a prescription (for a maintenance medication that I've been on for a decade and that people with my diagnosis are expected to remain on for life) put on hold because I didn't refill it on time. Except I did request the refill on time. My pharmacy just didn't fill it because, ever since they were acquired by a national chain, they no longer actually process refills that patients request online or through the automated phone system.
The new procedure appears to be request refill 7 days in advance -> show up in person the day you run out -> be told it's not ready but you can come back in an hour -> go home and wait -> come back and pick it up. Which is what I've been doing.
The problem, apparently, is that the prescription in question was desynchronized from my other monthly refills, so I waited until I ran out of the others to do the "show up in person" step so I wouldn't have to do it twice in a week. Turns out it's that step that causes the refill request to actually be submitted to the insurance company, so I was "late" requesting my refill, so I had to wait another week for a preauthorization, because that makes sense.
Oh god, I once had a place (Walgreens) where they had screwed me on the "your perscription is ready" so many times where I came in and STILL had to wait an hour or two.
So I called in to double check, make sure it was actually really ready, and they assured me yes my perscription was ready and I could come in and pick it up immediately.
And of course it was like a 3 hour wait this time. Made worse by them the whole time making it sound like it would be ready any minute. It is a good thing I didn't have the home address of the CEO that day.
Ready as in ready for them to start putting it in a bottle.
But, you know, the arthritis...
I'm a bit surprised to hear that *you* are the one who has to deal with this. Isn't "insurance wrangler" already a job, with every medical practice having one on staff?
Many patients understandably get the impression that "insurance wrangler" is their own job.
I know of workplaces who've had dedicated insurance wrangler for employees on the company plan. My most recent experience with a company wrangler suggests even wranglers are having a tougher time navigating their plans' latest innovations. Company plans are no longer of much interest to private-plan providers, anyhow. Medicare Advantage is the new hotness: the biggest players in the US "private" health-plan game are increasingly hired by the US government with taxpayer dollars to run quasi-privatized public plans:
https://wendellpotter.substack.com/p/the-majority-of-big-insurers-health
At larger healthcare organizations, there definitely are. Maybe Scott's practice, being pretty new, is too small to add someone in this role, just yet?
And all this time, I've been jealous of the "if you're a provider, press 2" option, as I assumed they got special treatment compared to the mere mortal patients.
Seems like that was a mistaken assumption!
Anyone else read Vladimir Voĭnovich‘s The Ivankiad? It’s a Soviet-era tale of the bureaucracy involved in getting a new apartment. Scott’s piece strongly reminded me of it. Funny, but in a wanting-to-tear-my hair-out kind of way.
Why isn't your virtual assistant in India doing all of this calling?
Moloch, who hides customer service in a forest of phone trees, FAQs and chatbots.
This seems to be the bane of big corporations. My trash is picked up by Waste Management, whose corporate office is somewhere in Texas. Customer service is frustrating and worthless. I dream of some local competition.
Giant Meteor 2024. Giant Meteor pledges to resolve all problems related to patients not getting reimbursed for care, and to more generally correct all issues with the medical system once and for all.
...
...
...
...
I recently had the pleasure of going to a hospital emergency room with someone having heart problems, made it clear we need to see a cardiologist. We have "excellent insurance" (not sure that is actually a real thing no matter how much you pay these days).
It took ~4 hours to see anyone, probably another 4-6 to see a doctor, who just got us admitted to a cardiology department, and then said it was time to sleep for the night (~12 hours), and then in the morning it took another good 6 hours to see a cardiologist. At which point googling the results of the various procedures/tests which had been previously done had already found me the Cleveland Clinic webpage the cardiologist then basically read to us when they saw us.
As a bonus we later found out the doctors we saw were covered, and the hospital we were in was covered, but not the cardiology department we were in..............................................................................
Made me want to start a new hospital called "there are actual fucking doctors at this hospital and if you have money you can pay them to provide services for you". But of course that would be illegal.
No, they have (had?) one of those in Oklahoma. Some people fly (flew?) to it from across the nation. because the prices were transparent and reasonable.
Doesn't really work the same for urgent situations, but....
But you point at my favorite regulation I would love to see: if you go to the hospital, only the hospital can bill you. Only the hospital needs to be covered. If they hire/contract/allow non-covered / non-network providers into their facility, that is their own problem.
We really need to move to a cash-based, market-based healthcare system. Here's what I think should happen:
1) The average American pays $456 per month in health insurance premiums. Instead, the government should make them pay $456 each month into a health savings account. The money would be automatically subtracted from their paychecks, just like Social Security funds.
2) The health savings account money could only be spent on medical services and items. The government would decide what things counted. Yes, there would be disagreement at the margins, but things like Prozac would definitely be counted.
3) The government would copy one of the online account portals used by a big bank, like Bank of America or Capital One, and use that for the health savings accounts. Each person would be able to easily log in through the internet and see what his account balance was, along with previous transactions. There would also be a smartphone app and a debit card.
4) All medical services providers and pharmacies would have to publicly post prices for their goods and services, and to honor them. Charging different prices for different people would be illegal.
5) People could transfer additional money into their health savings accounts from any outside sources (e.g. - personal checking account, GoFundMe account to pay for my heart surgery, anonymous gift to other person), but they could not do the reverse.
6) Every health industry bureaucrat who spends his time re-writing rules about what things health insurance covers and fighting with people over the phone about the rules would lose his job.
This is the structure of alternatives to Obamacare that sounded good to me. Insurance that specifically covers extreme events that you could not normally afford and a savings account to ensure people do have the money to pay for everyday things. They might even have an effective incentive to price shop!
Right. It's like owning a car: You pay out-of-pocket for routine maintenance and smaller repairs, but you have insurance for rare, major problems.
So how does point 7, the rare, major problems work?
(of note, parts 1, 2, 5 and kind of 3 but it's private are how I do it currently, of course it isn't required, just optimal. And you'd need to tweak 4 so not just charging different prices is illegal, but providing any kind of rebates or kickbacks is also illegal even if they are "charging" the same amount)
I have an HSA with a high deductible insurance plan. Anything under 6000/yr I pay out of pocket (via the HSA). After that, insurance starts covering things. That seems pretty reasonable to me. Routine medical procedures are probably going to be well under that limit and anything major is likely to be _way_ over (a single bad injury/surgery is almost certainly going to cross that limit).
"So how does point 7, the rare, major problems work?"
I still want prices to be market-based, so all medical providers would still need to post their prices publicly and to honor them. The insurance company or government health agency would pick the cheapest treatment provider.
> 6) Every health industry bureaucrat who spends his time re-writing rules about what things health insurance covers and fighting with people over the phone about the rules would lose his job.
Congratulations, you've successfully identified the special interest group who will spend money to lobby to ensure that your bill dies in committee.
My understanding is that this is somewhat how the Singaporean system works?
Now how did you get the transcript of the two weeks I was trying to get a work problem with a phone bill sorted out? 😂
It's a bandaid for the problem, but I really hate it when companies don't have online chat for customer support. I can use that asynchronously much better than a phone call.
But it has to be real support rather than one of these places where the chat support agent has no ability to actually fix anything.
This is why medical billing/coding is an entire profession unto itself, complete with it's own professional exams and certification programs!
no way, ACX locked banger era?
I'm surprised it doesn't wok to hire a secretary or other support staff to do this work, at least for larger practices with several doctors. Even if they couldn't handle the actual conversation with the person, they could do the phone tree navigation and waiting on hold, then transfer the call to the doctor.
Pharmacy phone trees are indeed terrible. I can't tell you how many hours I've spent going through them as I try to find a single pharmacy anywhere within 2 hr of me that has any stimulant medication of any dose in stock whenever there is a shortage (like the past 3 months). Even worse, the big boys generally refuse give stock check or backorder status over the phone without a prescription being sent to them.
Also, sometimes they refuse to even pick up if you select that you are a patient rather than a doctors office - for multiple days at a time.
It wasn't like this in the 90's or early 00's...
Contrast to Kaiser: here is the prescription, go next door to fill it.
hope that prescription isn’t for ADHD medication, though, otherwise Kaiser will subject you to random drug testing...
I live on a state road, and a few years ago there was a tree down that was mostly blocking it. The company that contracted with the state DOT to clear trees refused to touch it, because it was sitting on wires. The power company refused to touch it because it was on data lines, not power lines. The cable company doesn't do tree work, have we considered contacting the DOT? This took several days and at least 30 phone calls to resolve. Top tip though, going directly to local officials can grease a lot of wheels. Desperate, we eventually called our state rep and explained things. I don't know whose heads they knocked together, but the DOT people were out clearing the tree the next day.
Having an alternative to phone-system bullshit is one of the few remaining advantages of patronizing companies with brick-and-mortar locations. If I have, say, a bank problem, I drive to the bank rather than even attempting to call them. Same for (some of) my doctors' offices.
I do wonder: suppose companies charged per-case to skip the bullshit and immediately get a human being for all calls related to that case. What would the price settle at?
I've had plenty of instances of going into a brick-and-mortar place and having them make me pick up a phone in their lobby that connects to their customer service and makes me go through the same annoyances as when you do it from home.
I used to work for a medical answering service. Basically a human phone tree / answering machine for patients calling their doctors (usually after hours) or hospitals paging doctors. I ran the department that met with doctors and tweaked their scripts to their liking.
It was not an easy job. I had some basic suggestions and framework for their script, but depending on their preferences and how they structured their on-call schedule it could get rather complex, and often the doctors (or their administrative staff) couldn't see the impact of their decisions. I made sure to pack our meetings with cautionary tales of logic loops and we would make sure to check everything ourselves before implementing. A common one was a doctor who would only take emergency calls, and his on-call partner would only take non-emergency calls. Even getting past the whole "what is an emergency, everybody interprets that differently" bit we'd have to explain that if him and his partner have different instructions, we'd have to follow each of them and it was best to get everyone on the same page.
And then there were the practices that had complex routing protocols based on specialty, who was calling, where the patient was located, what the call was about, whether it was a new or existing patient, etc etc etc. I'd do up their flowchart and get it printed on a giant posterboard, and show up at their office with sandwiches and sharpies. Every time I'd get the comment "This looks really complex" I'd just nod and say "yes, every one of those diamonds on that chart is a question we have to ask your caller, and I'd love to make it simpler for your callers and our operators (and your wallet, since we bill by the minute) but if we didn't ask those questions the call might end up going to the floor doctor instead of the wing doctor, or after 2 pm on days before weekends and holidays it might go to the attending admitting doctor instead of the primary admitting doctor. I mean, we could always ask the caller who they wanted to speak with, but last time we did that you got quite upset when you were paged instead of the doctor you were in the break room with, not every nurse is going to know the difference between the circle doctor and the rounder doctor."
And usually I'd walk out of those meetings without many changes to the flowchart, but with perhaps a bit more empathy from the doctors.
One thing I did spend a number of years fighting for, and only managed to get a bit of success towards the end, was to stop answering the phone "_______, how may I help you" and instead answer the phone "______, <insert the first question we need from the caller right here, usually something like "are you a patient?">" when HMIHY invariably generated a story that took up 15% of the target call length and the operator couldn't even write down until they got five more screens into the system.
I've been refusing to buy health insurance and instead paying the Obamacare penalty for the last 4 years because:
1. I don't want to deal with this insurance company bullshit
2. I'm rich enough to handle the fluctuations
3. goodRX gets me good prices on prescriptions and my GP takes $100 cash for office visits
4. It's a positive CE wager for me, even before considering the value of all the time I save by not dealing with insurance company bullshit.
In gambling, a bet where you can win but you can't lose is called a "freeroll".
Every time an insurance company denies a claim they're freerolling the patient. Some percentage of the time, the patient won't find it worthwhile to go through this red tape, and the insurance company saves the money. Otherwise the insurance company is no worse off than if they had paid the claim in the first place. Ignoring second order effects on reputation and attrition (individual attrition may not even be possible in employer sponsored plans), the optimal strategy for insurance companies is to deny valid claims and make it maximally inconvenient to dispute them. Other product-sellers can have perverse incentives to sell shoddy products, but customers are particularly vulnerable when the product is complex illegible promises about the future behavior of the seller, and the reputations of the sellers are unclear and undifferentiated. Recourse exists on paper, but in practice you're totally at the mercy of the insurance company's goodwill when the claim is worth less than the opportunity cost of disputing it (i.e., the vast majority of claims, especially for high earners).
Routine expenses like generic prescriptions that you take for 10 years straight probably shouldn't be a thing that people buy insurance for, and I'm going to argue this based on my experience as a professional gambler. In the outside view, insurance is a negative expectation wager, because the insurance companies have overhead expenses and profits. A negative expectation wager can have a positive CE (certainty equivalent) if it reduces variance enough relative to your bankroll. A wager is worth making if and only if it has a positive CE. CE is defined as the amount you would need to get paid to raise the expectation of the log of your bankroll by the same amount as placing the wager. In the case of routine expenses, the reduction in variance is negligible so buying insurance for that will have negative CE. Only catastrophic insurance is worth having. The log of 0 is negative infinity but this never actually occurs in real life because your future earnings have a discounted present value which is not taken away by bankruptcy. Your primary residence is also except from bankruptcy in most states. Your partner/friends/parents/children are not on the hook for your debts and can help support you when you are legally bankrupt -- this is essentially another asset you have which is immune from bankruptcy proceedings. For most people young enough to be reading this blog, the present value of their predictable future earnings far exceeds their net worth, so the relevant logarithms become approximately linear, so it wouldn't be very wrong to just maximize EV, except for life insurance if you have dependents and not much savings. If it gets to the point that your medical bills are seven figures, you're probably a goner anyway, and they're probably just wasting money torturing you with overpriced surgeries for the last week of life instead of sending you to a nice cheap hospice with lots of heroin.
(Personally I don't buy any insurance whatsoever, except the minimum required by the DMV and my landlord. The DMV makes me waste 1k/year on 25k/person of liability coverage, but the renter's insurance is only $85/yr through lemonade.)
This sounds mostly right, until my wife is pregnant... then I want insurance. With the big hope that it isn't needed.
This is the kind of situation where Scott could just leave the problem to the patient to solve. The problem doesn't affect him directly -- does not, for instance, affect his receiving payment -- and is not his fault. However, he's more likely than most patients to be able to solve it. Good for you for taking it on, Scott. The The situation's full of unfairness, but you're probably much more able than the patient to absorb a dose of unfairness, and if you don't take it on nobody else will.
Not as frequently as docs I suppose, but everyone has pent half a day doing this for insurance, banking,, whatever.
The only missing part is "...for faster service find us on the web at www...." and "there is a $9 convenience fee for credit card payments"
How do you keep it down to 80%? Thank you for writing this up - the same holds for all calls to Bank of America. I used to spend 95% of my time on the phone attempting to talk to Bank of America, before I moved into this Faraday cage deep underground.
May...may...may I have some Prozac?
this post is so good at conveying this experience that it made me stressed out and furious just reading it :'(
My condolences!
When I saw the title of the post, I thought this was going to be about dealing with an EMR system. I think that's what doctors at big hospitals spend 80% of their time doing, and what you described gets outsourced to nurses, secretaries, or patients.
I do most of these calls for our family of 4. Sometimes there's nobody in the system who can figure out what's going on, and it can take months for the process to reach someone who can override something that nobody can understand.
It comes full circle!! (My first blog post of yours was "Who By Very Slow Decay"). Wonderful stuff. Also, my condolences. ☎️
An MD friend of mine said of this: "If you could charge an iPhone with hate, I would never need AC power again."
I have phlegm constantly collecting in my throat. This is, notably, the exact approach taken by doctors when I try to get my throat cured.
It's not a problem to speak to a human doctor. But they are completely unwilling to try to determine what might be happening to me, or to make any effort at all to improve my situation. The state of the art is:
General Practitioner: Let me refer you to Specialist A.
Specialist A: I can test you for condition A, which affects 2/3 of all Americans without causing any symptoms of any kind. But there is, technically, also a chance it's causing your problem.
Specialist A: Sure enough, you have the same condition that 2/3 of all Americans also have. Let's try doing something about that.
Specialist A: Well, I guess that wasn't related to your problem. You should see Specialist B.
Specialist B: Since you've been referred to me, I assume you need to be tested for condition B.
Specialist B: Good news! You don't have a medical problem!
General Practitioner: I have no advice for you other than to follow the advice of a specialist.
My mother is a practicing obstetrician, and her opinion is that I should stop complaining about the doctors because addressing my problem is not part of their job.
Alternate title: Aural Mazes
Random thought I had lately. Could local governments pass legislation against local pharmacies and insurance to ensure proper care? It could be a lot easier than agitating at the state or national level.
Sure! Given that the existing situation is due to state and national governments passing legislation against pharmacies, insurance, and health care providers to ensure proper care, I’m sure local governments doing the same thing will fix everything!
How much would you pay, per hour, to have someone else do this? This sounds like a business opportunity, and I’m currently unemployed.
Or would they say, “You’re not the doctor, go to Hell!”
You'd probably have to spend more time filling out forms for HIPAA compliance than you spend on the phone.
It's hard enough for me to make these sorts of calls on behalf of other members of my family; insurance companies are set up to deal with providers and patients, and in extreme cases spouses or parents. Even trying to get help for my mother who physically can't call on her own behalf is a struggle above and beyond the issues described in the OP.
So yes, I'd expect that "you're not the doctor, go to hell!" is a very likely outcome. I think in order for a business like that to succeed, you'd need to get the insurance companies to alter their phone trees, which they have no incentive to do.
Of course, if you wanted to go through with it anyway and they do require speaking directly to the doctor or patient, you could try putting customer support on hold while you fetch them. I think they might be disallowed from hanging up on their end—I've sometimes been absent-minded about hanging up when I'm using my headset, and only realized the line was still open several seconds later. Even if you need to call the doctor/patient in order to connect the lines, "hang on, they're in the other room" isn't *technically* a lie.
Was just buying a small medical device under my plan. Insurer gives us a list of covered manufacturers.
Mfg insists I'm not covered, insurer insists I am. Each says the other is a filthy liar.
Insurer says mfg should just call the provider line. Mfg refuses, says insurer should fix it on its end. We try a conference call, mfg line is just a busy signal all day, no call handling or menus at all.
I ask the insurance if, after all this hassle, can I just buy my own?
Insurance says absolutely not! Though this mfg is staffed entirely by filthy liars, far better the devil we know...
This isn't complete without the regular breaks in the hold music to remind you to try to use their website to solve your problem, which of course you have tried endlessly before resorting to going to hell and using their phone tree.
This reminds me of trying to work with Kaiser without going through their website. Luckily, I have access to the website now.