To increase profits as much as possible. So for folks in the United Shooter thread bemoaning it, the nature of the beast is the company exists to make money. It literally has to to justify its existence.

What then is the solution? Figured this thread could focus more on the finer nuances of health insurance companies.

How do you create an exception for profit generating companies involved in healthcare to NOT have a fiduciary duty to shareholders and instead… what? Has a duty instead for the patients? Or is it some sort of duty subject to the care of patients? How can that be measured and how does that work? Just wondering how this mess can be cleaned up without single payer.

Every public company, in any industry, would have unchecked margins if it wasn't for market competition. One of the key problems with the insurance industry is that government regulation greatly limits market competition.

If i am paying for specific coverage then I would expect the insurance company to pay what was agreed upon when the time comes. Seems pretty simple.

I keep seeing people post long lists of why people might hate United Healthcare.

the two I accusations that seem most popular

-Highest rejection rate
-AI driven automated rejection system which leads to the above

If they are just rejecting without review, by using an automated system, then yeah, I can see people being pissed.

The problem is always the government. DC has mandated that healthcare is a right and should be free if the person receiving the care can't pay for it (Medicaid or illlegals). Private insurance is footing the bill for the best medical treatment in the world, but they have to pay for everyone.

In a perfect world, people pay for insurance and get their expenses covered when they need it. But, DC is forcing the payments on an ever shrinking number of payers. The responsible folks are not making and paying enough money to pay the tab.

2/3 of American workers are covered under self-insured plans. Meaning the big bad insurance company gets paid a contracted rate to administer the plan. The employer covers the claims. I'm amazed how few people realize this.

I say this so you know which tree to bark up. I've had claims issues that went nowhere with the TPA. I solved them by getting with my benefits office.

Not sure what the consequences of this type of policy would be, but perhaps some types of companies should not be allowed to be publicly traded. They should also actually be insurance, not distributors, for healthcare.

ntxVol said:

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If i am paying for specific coverage then I would expect the insurance company to pay what was agreed upon when the time comes. Seems pretty simple.

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This. When they won't pay for things they absolutely know they should be paying for in the hopes that the patient can't/won't fight it, all for the sake of their pursuit of profit, that is wrong and they deserve all the hate and vitriol directed their way.

A couple of questions/
Where does health care insurance fall on the scale of most to least regulated industries by government?

And which states have pulled United's ability to operate in their state?

Heath insurance could be cheaper and health insurance companies could make more money if we had real tort reform and lower taxes. These are two expenses federal and state governments could reduce if they weren't in the pockets of lawyers and if they had any spending discipline.

Hit the nail on the head. I also think you should get what you pay for. If you're not contributing then YOU get the long waits and crappy providers. As you said first class healthcare for doing nothing. Should be 2nd, 3rd rate.

The problem isn't health insurance. The problem is government interference in healthcare and the insurance market.

scoodogg said:

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2/3 of American workers are covered under self-insured plans. Meaning the big bad insurance company gets paid a contracted rate to administer the plan. The employer covers the claims. I'm amazed how few people realize this.

I say this so you know which tree to bark up. I've had claims issues that went nowhere with the TPA. I solved them by getting with my benefits office.

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Under ERISA, most third party administrators have fiduciary duties the plan beneficiaries, not just stockholders.

In the current market and regulatory environment, maximizing profits also includes not making voters angry so that they empower regulators to do things that cut into profit potential. That's the deal big insurance and corporate medicine made with the government devil. They are basically operated as a heavily regulated pseudo governmental oligopoly under Obamacare and they have some freedom and some competition only within the window regulation allows.

Consumer choices are likewise limited (and socialized through essentially forced participation and limited heavily regulated choices with few exceptions).

Premise: United healthcare is beholden to stockholder profits.

ACA: caps profits of insurance carrier at 15%.

Consumer: Why are premiums going up and service going down?

Reality: if profits are artificially capped, and profits are the #1 priority of the company whose profits have been capped, how is this not a major conflict of interest?

The primary issue is the ACA. Issue 1B is how we use health insurance. Imagine using your auto insurance every time you changed your oil or fixed a flat. How astronomically expensive and burdensome do you think that would be? That is our current issue in health insurance

RAB87 said:

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Every public company, in any industry, would have unchecked margins if it wasn't for market competition. One of the key problems with the insurance industry is that government regulation greatly limits market competition.

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Health insurance companies don't compete for consumer dollars, they compete for HR department contracts. That is a massive thumb on the scale against consumers. We don't get a choice, we get who our employers chose for us. Until health insurance companies are competing directly for individual consumer dollars (like home and auto providers), the system will stay rigged. I think employer provided health insurance should be outlawed, but that's a massive change from status quo and will never ever happen.

RAB87 said:

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Every public company, in any industry, would have unchecked margins if it wasn't for market competition. One of the key problems with the insurance industry is that government regulation greatly limits market competition.

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It's impossible to have market competition in healthcare. Demand is inelastic. In an emergency situation, you don't get to pick the hospital or the price of treatment. You will pay any price to stay alive.

From someone that's dealt with a lot of insurance company bull**** lately...

The problem isn't their competition etc... it's the fine print crap and their weasel ways of getting out of things.

they stack the deck against you and take advantage of you at some of your most vulnerable moments.

In some industries they have waaaay to much protection as well for intentionally screwing over the people they are contractually obligated to indemnify.

Erisa is something I wish the Trump admin would address... seems like something propped up by old elite types that need to GTFO of the GOP.

MouthBQ98 said:

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In the current market and regulatory environment, maximizing profits also includes not making voters angry so that they empower regulators to do things that cut into profit potential. That's the deal big insurance and corporate medicine made with the government devil. They are basically operated as a heavily regulated pseudo governmental oligopoly under Obamacare and they have some freedom and some competition only within the window regulation allows.

Consumer choices are likewise limited (and socialized through essentially forced participation and limited heavily regulated choices with few exceptions).

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Socialism by proxy is what I've called it for many years now.

Quote:

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What then is the solution?

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Pay the claims they are supposed to pay & not bend over backwards looking for ways to deny claims

RAB87 said:

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Every public company, in any industry, would have unchecked margins if it wasn't for market competition. One of the key problems with the insurance industry is that government regulation greatly limits market competition.

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Bingo! Government ruins everything.

The Banned said:

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. Issue 1B is how we use health insurance. Imagine using your auto insurance every time you changed your oil or fixed a flat. How astronomically expensive and burdensome do you think that would be? That is our current issue in health insurance

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This is extremely interesting as a metaphor. Add in that you don't know how much an oil change or tire rotation costs when you walk in.

But what's the alternative? I'd love to pay a predetermined price up front for small stuff rather than have to eff with insurance.

Jason C. said:

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The Banned said:

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. Issue 1B is how we use health insurance. Imagine using your auto insurance every time you changed your oil or fixed a flat. How astronomically expensive and burdensome do you think that would be? That is our current issue in health insurance

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This is extremely interesting as a metaphor. Add in that you don't know how much an oil change or tire rotation costs when you walk in.

But what's the alternative? I'd love to pay a predetermined price up front for small stuff rather than have to eff with insurance.

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This is kind of how an HDHP works. Aside from your annual preventative visit, you pay OOP until you hit your deductible.

Deductibles are usually a few thousand (mine is $4500 pp, max total OOP annually is $9k), and the trade off is premiums are lower. And you can put up to $8300 (for families) in a triple tax advantaged HSA. Many employers make a contribution to the account on your behalf.

The difference is, when I go to the doctor or have a medical procedure, I pay the insurance negotiated rate. So, when I go to my endocrinologist, it's roughly $120. An ultrasound is about $250.

Now, I don't often know that cost upfront, but I've been on the HDHP long enough to have an idea about what various visits cost. And I know what my max OOP spend will be in a worst case scenario. So I gave that amount (plus more, since I max out my HSA every year) on hand.

The lack of transparency about procedure pricing, and the differed between what different providers charge and what different insurance cos are willing to pay is disturbing. But it's not all that unlike airline ticket pricing (you never know what the stranger sitting next to you paid).

The problem is, insurance cos and hospital systems are allowed to treat their negotiated rates as confidential IP. Great for them but terrible for consumers.

My son had some medical issues this year, and I had issues with the various providers and BCBS. It is a huge pain to deal with and very difficult to manage on your own. Insurance companies and hospital billing departments are not set up to deal with individual patients, and that's a problem.

My company is self-insured. The fact that the post above that mentioned that doesn't have mores stars is very telling about most people's lack of understanding about their health insurance.

I believe HDHPs are part of the solution (make people take some ownership over their health care). But they are a hard sell, especially among GenX and older (the demographic with the highest health care expenses).

Why do companies need to forsake their customers on behalf of their shareholders? Why can't they benefit both by providing the best product and the best service at the lowest possible price, I.e. how capitalism is supposed to work. It seems like that's how it used to be. Companies now just find more and more creative and insidious ways to squeeze their customers and people are rightfully tired of it.

The first thing you have to understand is health insurance companies don't work or provide service for individuals. They are contracted by companies/employers to provide insurance/benefit management to employees, or by the government to provide specific plans under ACA.

They are not accountable to any individual policy holder.

I'm not saying this is right - it's just the way it is.

Not all that different from Centerpoint - CP doesn't interact with individual electricity customers. And those customers can't get electricity from another provider. The only entities that can hold them accountable for their failures are the government and (maybe) the media.

Doctors can't even hold health insurance cos accountable because most don't deal with them directly. They do so through their hospital system billing departments, which is another bureaucratic disaster that isn't customer focused.

Health insurance summed up👇🏼 pic.twitter.com/caXWOIcNOI

— Johnny Akzam (@JohnnyAkzam) December 5, 2024

UHC has essentially a national monopoly on parts of healthcare. They own both optum and changehealth, which are responsible for something like 90% of all healthcare related software and prescription routing between doctors and pharmacies and insurance. The nationwide prescription outage that happened in february was because their system was down. Start enforcing antitrust laws again. Stop creating monopolies. Our government is so often at fault it's mind goggling.

I can't imagine receiving a better Healthcare for a major illness anywhere else but the US. We provide the latest and the most advanced treatment everyday. My drug budget for a small health system is $300 million per year. No individual pays the entire bill out of pocket. Medicare and Medicaid do a fair job of reimbursing us for the services rendered.

Dealing with private insurance is more difficult.

Do we need a Healthcare coverage reform? I don't know. I've been in Healthcare for 33 years and I feel like I know nothing.

FriscoKid said:

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The problem is always the government.

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This X Eleventy Billion.

"Insurance is the only government sanctioned legalized stealing around" says my friend who has been in the industry for 37 years.




(I would argue that politicians have developed more ways over the last few decades, but that is another thread)

I have come to believe fiduciary responsibility is a short sided idea.

That concept allows for the justification of screwing over customers to make that $1 more today. It also forces companies to always grow and look to expand into other markets. This means fiduciary responsibility ends up being at odds with anti-trust and monopoly rules because growth often means consolidation.

Waffledynamics said:

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Not sure what the consequences of this type of policy would be, but perhaps some types of companies should not be allowed to be publicly traded. They should also actually be insurance, not distributors, for healthcare.

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Ive been wondering if a vesting period by industry would help to correct some of the short term motivations. If stock holders who bought an insurance company or utility knew they'd be penalized for selling shy of a decade, the impetus of those buyers would be on a decade of success rather than a quarter.

Funky Winkerbean said:

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Health insurance summed up👇🏼 pic.twitter.com/caXWOIcNOI

— Johnny Akzam (@JohnnyAkzam) December 5, 2024

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This is it, All health insurance is is privatized socialism.

The left has done such a good job at redefining "healthcare" as insurance that even most conservatives have fallen for it.

Health insurance is the worst of both worlds - it is capitalistic in its rewarding of profits for market entrants but it is socialistic in its incentives for administrative bloat and inefficient allocation of resources through separation of cost from point of consumption. This means costs are going to skyrocket the longer and more widespread it is utilized by it's very nature through its incentives.

We HAVE to stop conflating "insurance" and "healthcare" they are NOT the same thing and continuing to do so will just make the situation (not so) gradually worse.

americathegreat1492 said:

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UHC has essentially a national monopoly on parts of healthcare. They own both optum and changehealth, which are responsible for something like 90% of all healthcare related software and prescription routing between doctors and pharmacies and insurance. The nationwide prescription outage that happened in february was because their system was down. Start enforcing antitrust laws again. Stop creating monopolies. Our government is so often at fault it's mind goggling.

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This is good information, but, more importantly, it possesses the opportunity to create a new TexAgism...."mind goggling". I love it and wish this thread had more traffic so that would catch on!

Yeah, this guy will tell you it's all about "his people"

"Mutual" insurance companies were/are a better option for the majority of individuals over "stock" companies. Owned by their policyholders. Sure, incentive to make money but for the good of the policyholder. It's a different mindset and management style.

Over the years insurance company executives became jealous of their bank industry counterparts with all the bonuses etc. You saw major Mutual companies become Stock companies to attract and retain executive suite staff. Other than the initial stock payouts to the policyholders the overall benefit to insureds has been negative.