| I worked at one of the companies mentioned in this article for a brief period of time as a junior employee. The entire framing on the inside is about helping the industry adhere to evidence-based medicine and reign in the skyrocketing costs of healthcare. The analysts would periodically share results of their anomaly detection, finding physicians who order MRIs at rates multiple standard deviations above the average physician, and further find that these physicians own their machines. There are a lot of examples of this kind of fraud. There’s also bloat and over prescription as doctors are terrified of malpractice and have patients demanding tests or procedures they read about online. When I was working in the company, I really felt like I was helping reign in unnecessary costs. We had many people reading medical literature, consulting with other physicians, scientists and others to create guidelines that form the basis of the pre-approval decisions. It felt like we were centralizing all of that knowledge and “providing it” as a service to society. One day, a brave junior employee asked the company CFO at a lunch and learn, “If we’re doing such a great service for patients, why is it the insurance companies paying us, instead of patients?” The CFO gave one of those replies that is only memorable because of how fumbled it sounded. I realized quickly after that what purpose the company really served and how the incentives created a serious conflict of interest. But my time at the company has convinced me to this day that there are no “innocent” parties in the payer-provider-patient triangle. Every party involved has their own set adverse incentives against each other and the balance of power swings like a pendulum with every merger, acquisition, or regulation passed. |
not the patient?