[civilized]

Aside from someone being denied life-saving medication, the most awful thing for me in these stories is the relentless Kafkaesque quality. We never get any answers to our basic sense-making questions about the bureaucratic process:

- What did the insurer expect to happen, in order for this person to keep getting their medicine?

- Why did those things not happen?

- Whose job was it to make sure those things happened?

- Did that person know it was their job?

- ...etc.

I get that it was about prior authorization, but whose job was it to make sure the prior authorization happened? Why didn't that person do it in a timely fashion? Why isn't there an understanding within the insurer's system that Type 1 Diabetes is a life-long condition and not something that will just go away when the insulin runs out?

Was there a "happy path" here or does a scenario like this invariably degenerate into a scramble involving dozens of calls and day-destroying last-minute errands?

[lotsofpulp]

I find the article written in a circuitous way, that does not clearly lay out the timeline.

This statement about what a prior authorization is is also incorrect:

> They’re essentially requirements that a physician get approval from an insurance company before prescribing a treatment.

Doctors need no approval from anyone to prescribe. A prior authorization is approval from the insurance company that they agree with the treatment option and will pay for it (subject to deductible/copay/oop max).

The theory here is that the end user has no idea what they are getting since they are not knowledgeable about medicine. Doctors could be prescribing unnecessarily expensive medicine or treatment, so the managed care organization (MCO, or insurance company) “manages” the healthcare for the uninformed buyer by having the healthcare professionals employed by the MCO double check things.

In this specific person’s case, it looks like the biggest delay was in getting a doctor’s appointment when he needed both a new MCO and a new doctor. Technically, you can pin this on undersupply of doctors, MCOs tied to employer, MCOs not hiring good people and causing unnecessary delays, incompatible electronic documentation systems that do not talk to each other, and I could go on and on.

Ideally the doctor should be able to see what medications the MCO will cover on their computer while the doctor is seeing the patient so before they even leave the doctor’s office.

Another concern in the long list of concerns is the MCO is not necessarily the one deciding the rules for what treatment/medications to pay for or not. Many, many times it is state government (e.g. Medicaid), federal government (e.g. Medicare/Tricare), or other entity that is actually paying for the healthcare who will hire the MCO and give them the rubric on how much to pay for people’s healthcare/what treatment courses or brands of medications will be covered. This is how poor people (Medicaid) can be restricted access to healthcare by limiting the reimbursement for their healthcare so fewer doctors accept it while older people or members of military get access to better healthcare because their healthcare gets reimbursed at higher prices (Medicare/Tricare).

The system allows for a lot of opacity to allow for a lot of price segmentation while also providing political cover for such decisions due to the complexity of understanding it.

[civilized]

We went through this with a relative recently. She needed a surgical operation. We were asked to either

1. Wait for prior authorization and allow our appointment to be canceled and rescheduled (for the fourth time, having already wasted several weeks)

2. Pay out of pocket

We decided to pay out of pocket, since we knew that the prior authorization could delay us by an arbitrary amount of additional time and had recently read that the insurance might not even help us anyway.

The twisted thing is that you can't just get the operation done and let the prior authorization work itself out later. It truly has to be prior or you get stuck paying out of pocket, even if the operation is obviously medically necessary.

This structure seems expressly designed to screw the patient over. Maybe it doesn't prevent the doctor from prescribing, but it has a similar impact in the end.

And regardless of my anecdote about prior authorization, there is the question of why someone with Type 1 Diabetes is being denied their medicine. I feel like the only potentially valid excuse would be if the insurer literally didn't know the person had Type 1 Diabetes.

[lotsofpulp]

> The twisted thing is that you can't just get the operation done and let the prior authorization work itself out later. It truly has to be prior or you get stuck paying out of pocket, even if the operation is obviously medically necessary.

I have had doctors collect payment, and then refund me once they get paid by the MCO.

One more thing that would help here is decoupling employers from your MCO. That way, when you change employer and location at the same time, it does not mean you change your MCO. If the person who wrote the article had the same Blue Cross Blue Shield MCO (or other MCO part of a nationwide network) with old and new employer, then he would have had no reason to seek out a new doctor and new medication.

[civilized]

Well, we were told this is impossible, so either everyone involved lied to us or your experience isn't universal.

While insurance tied to your employer sucks, I think the best thing to do here is for the law to iron out the data interchange between MCOs. In a "marketplace" like the US, insurers must be under a dire legal obligation to transfer your data in a comprehensive and timely fashion to whoever is currently administering payment for your care. Especially when lifesaving medication is involved.

The patient should not be held hostage by the incompetence of MCOs at communicating medical data.

[lotsofpulp]

> , there is the question of why someone with Type 1 Diabetes is being denied their medicine. I feel like the only potentially valid excuse would be if the insurer literally didn't know the person had Type 1 Diabetes.

I forgot to respond to this in your prior reply. The answer here is because insulin is not just insulin. There are many different formulations and brands with many different prices.

Even the federal government does not want to pay for all of them:

https://www.healthline.com/diabetesmine/new-medicare-program...

So one could say it is about money, or how much extra money is politically available to spend for the marginal benefit (population wise) of certain insulin.

[civilized]

If the problem is around different insurers paying for different brands, then yes, I think the solution is for the consumer to have the choice of MCO rather than it being tied to the employer. But I'm sure this would create other problems and snarl the system with even more complexity.

That's ignoring the fundamental cosmic absurdity of this entire system, with its pretense to be some kind of competitive private market with the usual benefits of such. When in reality, insurers are just a bunch of hogs at the trough that you're shuffled between as you change employers. The private market does not seem to create any sort of incentive for efficiency or a better consumer experience.

[alistairSH]

> They’re essentially requirements that a physician get approval from an insurance company before prescribing a treatment. Doctors need no approval from anyone to prescribe. A prior authorization is approval from the insurance company that they agree with the treatment option and will pay for it (subject to deductible/copay/oop max).

To the consumer, the experience is the same - they can’t get a necessary drug before spending hours or days playing telephone tag with their doctors office and insurance company. Often, this happens for a drug they’ve taken their whole life. Insulin, thyroid hormone, etc.

[pessimizer]

I'm not seeing an important difference between the way you describe prior authorization and the quote from the article. Nobody in the world thought that doctors need to get permission from insurance companies to practice. This was about getting coverage. I doubt that many people were confused about the rationale from insurance companies for prior authorization: so the insurance company can decide if they approve of the doctor's action. That's the traditional definition of authorization.

[beerandt]

>Technically, you can pin this on undersupply

Well said overall, but the supply of doctors isn't the issue here (regardless of if it's a separate, bigger problem).

1) This case is what mid-levels are ideally suited for. Routine and can be seen within a day or two. Would have moved the whole timetable forward.

2) It's the supply of doctors participating in any given insurance plan or govt reimbursement scheme, not overall supply.

It's pretty easy to find a doctor to see same-day if you pay cash (either straight cash or front cash and submit your own reimbursement).

Which is itself more an issue about regulation being so burdensome and costly that doctors can't afford it without joining a large group or hospital owned practice. Especially the cost of required electronic records.

Which is why it seems like all the small private practices are being bought out by hospitals. Because they either are, or their docs are retiring, or they are opting out of all insurance and govt plans and going concierge/prepaid/membership/cash-only.

What I'm curious about is #1: why couldn't this person get in to see a mid-level sooner? They rarely book more than a few days out.

It's exactly the type of issue that they are meant to help with to reduce demand on the doctors and get patients seen quicker. A routine refill without any nontypical complexities or changes to report.

Did approval specifically require a physician? That would be more of a system problem that needs resolving.

[erenyeager]

Honestly doctors don’t have enough time to juggle all this along with treating the patient. Many times it is the case that the patient cannot afford the medication and/or their insurance will not cover it. Shifting this burden on the physician and patients to figure out these economic problems interferes with healthcare.

[lotsofpulp]

Definitely, but it is a result of the mismatch in costs relative to expectations of quality and quantity of healthcare with current supply of doctors and medicines (out of patent).

I am in favor of the US federal government to spend money on R&D for medicines resulting in fewer patented medications resulting in lower cost medications. And also reforming the process to becoming a doctor because obviously people want more doctors. Not necessarily making doctors less qualified, but the whole spend your 20s torturing yourself is unnecessary, along with wasting 4 years on a bachelors.

[stefan_]

None of this is making any sense. There is no cure for T1 Diabetes and it is lifelong. There is no reason to have any of these requirements, middlemen, authorizations or whatever.

[lotsofpulp]

There are many different kinds of insulins at different prices, and apparently, in the US there is not though political will to pay for any choice of them as even the federal government restricts which one it pays for.

https://www.healthline.com/diabetesmine/new-medicare-program...