US healthcare blows: investigation reveals major insurer was using an algorithm to determine amount of care for patients

[Anonymous]

Ahhhh, good ol US healthcare is the best, right?

https://www.statnews.com/2023/07/11/medicare-advantage-algorithm-navihealth-unitedhealth-insurance-coverage/

Not sure if you have access through your library, but the gist of the story is that NaviHealth, which is now owned by UnitedHealth, was mindlessly using computer algorithms to determine how much care patients deserved. This often led to rejection of coverage despite patients still being seriously ill and requiring intensive care according to first hand reports from clinicians actually treating the patients. NaviHealth management would routinely question and slap down any case file reviewers who thought additional care should be provided based on updated case reports if it conflicted with discharge dates predicted by the computer algorithm they used to model care and expected patient recovery. In one case, a guy was sent home only half way through his rehab after major brain surgery....he complained days later about pain and ended up dying from meningitis. Similar other horror stories in the article.


What a dystopian nightmare the US is becoming. Computers will now override all clinical judgement for healthcare. If you don't recover by the time that's needed that AI predicts is needed and that will also maximize profits for insurers you can say good bye to your coverage for a procedure and recovery.

It's like th US goes out of its way to be a 3rd world country in terms of healthcare.

[Anonymous]

I've experienced health care in other countries with "socialized medicine" and it was far superior and less costly. Americans just don't understand how much our system sucks.

[Anonymous]

Anonymous wrote:I've experienced health care in other countries with "socialized medicine" and it was far superior and less costly. Americans just don't understand how much our system sucks.

I think many of us do understand, it’s more a thing of what do you want me to do about it? I think we should have some guardrails on capitalism, especially the parts like housing and medicine that are vital to life.

[Anonymous]

Anonymous wrote:I've experienced health care in other countries with "socialized medicine" and it was far superior and less costly. Americans just don't understand how much our system sucks.

Did you get stitches, or cancer treatment?

[Anonymous]

Anonymous wrote:I've experienced health care in other countries with "socialized medicine" and it was far superior and less costly. Americans just don't understand how much our system sucks.

I can't speak to this incident or every country, but in socialized healthcare systems it is very common to have health boards determine whether a treatment is worth it or not and deny care on the grounds that it is too expensive and not worth it or tell you to use a less expensive approach that is often more intense and with longer recovery. They can be brutal about it. I have a good Irish family friend who comes to the US for her major care because it's quicker and better quality.

No system is perfect. There are many things I don't like about US Healthcare, but with an elderly father dealing with multiple ongoing health issues, his insurer has paid for everything. Everything. We really can't complain.

[Anonymous]

Anonymous wrote:I've experienced health care in other countries with "socialized medicine" and it was far superior and less costly. Americans just don't understand how much our system sucks.

This! It’s only great for people who never get sick and the wealthy.

[Anonymous]

Anonymous wrote:Ahhhh, good ol US healthcare is the best, right?

https://www.statnews.com/2023/07/11/medicare-advantage-algorithm-navihealth-unitedhealth-insurance-coverage/

Not sure if you have access through your library, but the gist of the story is that NaviHealth, which is now owned by UnitedHealth, was mindlessly using computer algorithms to determine how much care patients deserved. This often led to rejection of coverage despite patients still being seriously ill and requiring intensive care according to first hand reports from clinicians actually treating the patients. NaviHealth management would routinely question and slap down any case file reviewers who thought additional care should be provided based on updated case reports if it conflicted with discharge dates predicted by the computer algorithm they used to model care and expected patient recovery. In one case, a guy was sent home only half way through his rehab after major brain surgery....he complained days later about pain and ended up dying from meningitis. Similar other horror stories in the article.


What a dystopian nightmare the US is becoming. Computers will now override all clinical judgement for healthcare. If you don't recover by the time that's needed that AI predicts is needed and that will also maximize profits for insurers you can say good bye to your coverage for a procedure and recovery.

It's like the US goes out of its way to be a 3rd world country in terms of healthcare.

OP, a corporate bottom line and value for the shareholders is far more important than people’s lives.

[Anonymous]

Anonymous wrote:

Anonymous wrote:I've experienced health care in other countries with "socialized medicine" and it was far superior and less costly. Americans just don't understand how much our system sucks.

I can't speak to this incident or every country, but in socialized healthcare systems it is very common to have health boards determine whether a treatment is worth it or not and deny care on the grounds that it is too expensive and not worth it or tell you to use a less expensive approach that is often more intense and with longer recovery. They can be brutal about it. I have a good Irish family friend who comes to the US for her major care because it's quicker and better quality.

No system is perfect. There are many things I don't like about US Healthcare, but with an elderly father dealing with multiple ongoing health issues, his insurer has paid for everything. Everything. We really can't complain.

Insurance companies deny treatments all the time. It's no different than having a health board decide. And that's after we pay thousands just to have the insurance.

[Anonymous]

Anonymous wrote:

Anonymous wrote:I've experienced health care in other countries with "socialized medicine" and it was far superior and less costly. Americans just don't understand how much our system sucks.

I can't speak to this incident or every country, but in socialized healthcare systems it is very common to have health boards determine whether a treatment is worth it or not and deny care on the grounds that it is too expensive and not worth it or tell you to use a less expensive approach that is often more intense and with longer recovery. They can be brutal about it. I have a good Irish family friend who comes to the US for her major care because it's quicker and better quality.

No system is perfect. There are many things I don't like about US Healthcare, but with an elderly father dealing with multiple ongoing health issues, his insurer has paid for everything. Everything. We really can't complain.

That is the case under ObamaCare as well. There is an individual payment advisory board. The ACA actually changed Senate rules so that they cannot vote to eliminate the IPAB except under very specific circumstances.

[Anonymous]

It is ridiculous that care that is in network will come up as denied due to insurance listing the provider is out of network. I appeal and win. I suppose insurance just counts on most people not figuring out how to appeal. It’s such a racket.

[Anonymous]

Prosecutors need to dig through this and file criminal charges against individuals involved in any case where a patient was harmed by a denial. Fining companies does nothing, people need to end up behind bars and any nurse or doctor who signed denials needs to lose their license

[Anonymous]

Anonymous wrote:Prosecutors need to dig through this and file criminal charges against individuals involved in any case where a patient was harmed by a denial. Fining companies does nothing, people need to end up behind bars and any nurse or doctor who signed denials needs to lose their license

+1
Stop nibbling around the edges on this stuff, insurance companies have more money than god. Start prosecuting for people getting maimed and killed. But I wouldn’t start with the doctors and nurses, I’d start with the CEOs. Why should they benefit so well and avoid all the negative effects?

[Anonymous]

Anonymous wrote:

Anonymous wrote:I've experienced health care in other countries with "socialized medicine" and it was far superior and less costly. Americans just don't understand how much our system sucks.

I can't speak to this incident or every country, but in socialized healthcare systems it is very common to have health boards determine whether a treatment is worth it or not and deny care on the grounds that it is too expensive and not worth it or tell you to use a less expensive approach that is often more intense and with longer recovery. They can be brutal about it. I have a good Irish family friend who comes to the US for her major care because it's quicker and better quality.

No system is perfect. There are many things I don't like about US Healthcare, but with an elderly father dealing with multiple ongoing health issues, his insurer has paid for everything. Everything. We really can't complain.

Plenty of Canadians drive over the US border to get surgeries as they can get them scheduled in less than 30 or less than 45 days. Border hospitals make a lot of profit from the Canadian business.

[Anonymous]

Anonymous wrote:

Anonymous wrote:Prosecutors need to dig through this and file criminal charges against individuals involved in any case where a patient was harmed by a denial. Fining companies does nothing, people need to end up behind bars and any nurse or doctor who signed denials needs to lose their license

+1
Stop nibbling around the edges on this stuff, insurance companies have more money than god. Start prosecuting for people getting maimed and killed. But I wouldn’t start with the doctors and nurses, I’d start with the CEOs. Why should they benefit so well and avoid all the negative effects?

Have we learned anything from the financial crisis? CEOs don't get prosecuted even when their company acts in criminal ways. Heck, healthcare fraud gets you elected Senator in Florida! I think a few perp walks of CEOs is all you need though to start cutting through the rot. Or, you know, just do Medicare for all and remove the middlemen - all of them.

[Anonymous]

Anonymous wrote:

Anonymous wrote:I've experienced health care in other countries with "socialized medicine" and it was far superior and less costly. Americans just don't understand how much our system sucks.

I can't speak to this incident or every country, but in socialized healthcare systems it is very common to have health boards determine whether a treatment is worth it or not and deny care on the grounds that it is too expensive and not worth it or tell you to use a less expensive approach that is often more intense and with longer recovery. They can be brutal about it. I have a good Irish family friend who comes to the US for her major care because it's quicker and better quality.

No system is perfect. There are many things I don't like about US Healthcare, but with an elderly father dealing with multiple ongoing health issues, his insurer has paid for everything. Everything. We really can't complain.

So, since you are lucky with your coverage, there is no problem?