[CGMthrowaway]

Digi is correct here.

>For example Cigna requires all maintenance medication be purchased through express scripts

Important note: Cigna owns Express Scripts. Today the biggest "insurance" companies are actually massive conglomerates that own the clinics, the doctors and the pharmacies. United = Optum. Aetna = CVS + Caremark. Humana = CenterWell. Elevance/Blue Cross/Anthem/Carelon. Centene = Envolve

Once a giant like United gets big enough in a city, say ~40% of the population, they lower the reimbursement rates for independent doctors and if the doctor refuses the contract, they are kicked out of network and lose 40% of their patients. Go bankrupt or sell to Optum.

Digi is also right about Medicare upcoding. It is a well-documented $$billions scam where Medicare Advantage insurers comb through patient records to add diagnostic codes making the patient look sicker on paper than they actually are so the government pays the insurer a higher flat rate for that patient.

[bsjshshsb]

Why wasn't it set up so the government is the insurer. Rather than 3rd partying it. It is akin to federal reserve using wells fargo to store their money.

[lupire]

Because of regulatory capture and lobbying and campaigning to get people to vote against their self interest.

[actionfromafar]

That's communist talk I'm told. We must have lobbyists (remember, money is people, too) instead.

[Spooky23]

Because that is evil socialism

[tptacek]

Pharmaceuticals are a small component of overall US health spending. Upcoding is endemic across the entire system; it's endemic across the whole system. Ironically, the complaint you'd be making with upcoding under Advantage is that Medicare should be denying coverage to people; Advantage upcoding involves altering risk scores to authorize more care.