I know it’s funny to say this but it’s not actually what the article says or calls out. They’re saying that hospitals are using AI to say the patients are more complex and deserve to be compensated more due to that complexity, but the gap that insurers are calling out is that there’s not actually treatments happening that are aligned with the increased medical complexity being documented.
At the end of the day I think we all acknowledge that single payer is the optimal setup, but that’s not to say that there aren’t incentives on the provider side to maximize their payout.
While insurers have denials as their lever, providers have full coding and revenue cycle teams to ensure that they’re charging as much as possible. Both sides of the equation need to be addressed to bring costs down.
I know what the hospitals are doing, and I also know insurance companies are using the same bullshit in reverse to make it harder for hospitals, and patients, make claims. The reality is that private health insurance shouldn’t be a thing, and procedures should have standards that are overseen by qualified doctors without financial stakes. But neither is true, so we end up with the most expensive and mediocre health care system on the planet.
What if… the government set expected prices for things? Say they set the price for 90% of treatments. That includes life long medications and multiple tentative surgeries.
If it’s on the government register, the cost is known.
Like, they say that 90% of medical treatment will be a fixed cost. And it starts off fairly expensive. But with aggregate data it gets cheaper. And the fact that the government mandates it. And I’m sure there is already a lot of data…
It costs 1$ for a dose of paracetamol (or whatever). Starts off whatever the average is, then trends towards the actual cost to acquire. Takes a year or 2 to bring costs inline, paracetamol is $20 per dose but 20¢ per dose, etc.
I mean, who the fuck is licencing these hospitals to charge this much? The government, right?
Who the fuck is licencing these pharma companies to sell the drugs this expensive? The government, right?
And who is letting medical insurance companies this much power? The government!
Why the fuck doesn’t the government actually align price with cost?
Oh, money. Yeh, it’s money.
It’s about senators being bought for $10k.
It’s about “lobbying” $10m, and generating a $1bn gap.
Here is a good essay on the topic comparing a system like Japans with strict price controls with the US free for all system. The premise is Japan has offered incentives to close the gap of drug availability and their price, even after this premium, is still significantly less than the US.
Insurance companies are mad the hospital AI is getting around their AI to deny coverage.
I know it’s funny to say this but it’s not actually what the article says or calls out. They’re saying that hospitals are using AI to say the patients are more complex and deserve to be compensated more due to that complexity, but the gap that insurers are calling out is that there’s not actually treatments happening that are aligned with the increased medical complexity being documented.
So a more sophisticated form of upcoding?
Yes, exactly that.
At the end of the day I think we all acknowledge that single payer is the optimal setup, but that’s not to say that there aren’t incentives on the provider side to maximize their payout.
While insurers have denials as their lever, providers have full coding and revenue cycle teams to ensure that they’re charging as much as possible. Both sides of the equation need to be addressed to bring costs down.
I know what the hospitals are doing, and I also know insurance companies are using the same bullshit in reverse to make it harder for hospitals, and patients, make claims. The reality is that private health insurance shouldn’t be a thing, and procedures should have standards that are overseen by qualified doctors without financial stakes. But neither is true, so we end up with the most expensive and mediocre health care system on the planet.
What if… the government set expected prices for things? Say they set the price for 90% of treatments. That includes life long medications and multiple tentative surgeries.
If it’s on the government register, the cost is known.
Like, they say that 90% of medical treatment will be a fixed cost. And it starts off fairly expensive. But with aggregate data it gets cheaper. And the fact that the government mandates it. And I’m sure there is already a lot of data…
It costs 1$ for a dose of paracetamol (or whatever). Starts off whatever the average is, then trends towards the actual cost to acquire. Takes a year or 2 to bring costs inline, paracetamol is $20 per dose but 20¢ per dose, etc.
I mean, who the fuck is licencing these hospitals to charge this much? The government, right?
Who the fuck is licencing these pharma companies to sell the drugs this expensive? The government, right?
And who is letting medical insurance companies this much power? The government!
Why the fuck doesn’t the government actually align price with cost?
Oh, money. Yeh, it’s money.
It’s about senators being bought for $10k.
It’s about “lobbying” $10m, and generating a $1bn gap.
Here is a good essay on the topic comparing a system like Japans with strict price controls with the US free for all system. The premise is Japan has offered incentives to close the gap of drug availability and their price, even after this premium, is still significantly less than the US.
https://pmc.ncbi.nlm.nih.gov/articles/PMC12777408/