[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.

[lotsofpulp]

The hogs at the trough have net profit margins of 5% or less, and pay out 85%+ of premiums they collect to healthcare providers. You can remove MCOs from the equation, and their function will still have to be done by whoever is paying. For example, the approving/denying is still done in the UK even though they have taxpayer funded healthcare. Or even within the Kaiser health system in the US.

It does make life easier for providers and patients when there is one system that provides quick definitive answers rather than back and forth. On that front, there is much improvement to be made in electronic communications between healthcare providers and MCOs.

On a positive note, this is happening via electronic prescriptions and integrated EMRs. I have seen my kids’ doctor pull up covered medications in their system and then quickly sending the electronic prescription to the pharmacy.

> But I'm sure this would create other problems and snarl the system with even more complexity.

There is absolutely no reason for employers to be involved in your healthcare. They currently are able to use it as a leash around your neck because paying for MCOs via your employer means you get to purchase with pre tax dollars. Paying yourself means you have to pay with post tax dollars. I am looking at my box 12 code DD total, and for me that is $32k of insurance premiums I was able to pay with pre tax dollars.

More importantly, it gives employees an additional hurdle and fear of changing employers, because what if they have to go through what the person who wrote this article did? Maybe they should not shop around to see if they can sell their labor at a higher price, and just stick to their current employer. Another unnecessary chip for employers to have over employees in the US.

[civilized]

> More importantly, it gives employees an additional hurdle and fear of changing employers, because what if they have to go through what the person who wrote this article did? Maybe they should not shop around to see if they can sell their labor at a higher price, and just stick to their current employer. Another unnecessary chip for employers to have over employees in the US.

This is horrifying to contemplate... do employers just love that chip so much that they see it as worth all the terrible customer experience and inefficiency it causes? Do they lobby to keep it this way?