When United Denied Life Saving Treatment, They Fought Back with Lawsuits
March 3, 2023 2:00 AM Subscribe
UnitedHealthcare Tried to Deny Coverage to a Chronically Ill Patient. He Fought Back, Exposing the Insurer’s Inner Workings. After a college student finally found a treatment that worked, the insurance giant decided it wouldn’t pay for the costly drugs. His fight to get coverage exposed the insurer’s hidden procedures for rejecting claims.
“Bill Truxal, the president of UnitedHealthcare StudentResources, the company’s student health plan division, told a Penn State official that the insurer wanted the “best for the student” and it had “nothing to do with cost,” according to notes the official took of the conversation.
Behind the scenes, however, the price of McNaughton’s care was front and center at United.
In one email, Opperman asked about the cost difference if the insurer insisted on only paying for greatly reduced doses of the biologic drugs. Kavanaugh responded that the insurer had paid $1.1 million in claims for McNaughton’s care as of the middle of May 2021. If the reduced doses had been in place, the amount would have been cut to $260,218, she wrote.
United was keeping close tabs on McNaughton at the highest levels of the company. On Aug. 2, 2021, Opperman notified Truxal and a United lawyer that McNaughton “has just purchased the plan again for the 21-22 school year.”
A month later, Kavanaugh shared another calculation with United executives showing that the insurer spent over $1.7 million on McNaughton in the prior plan year.
United officials strategized about how to best explain why it was reviewing McNaughton’s drug regimen, according to an internal email. They pointed to a justification often used by health insurers when denying claims. “As the cost of healthcare continues to climb to soaring heights, it has been determined that a judicious review of these drugs should be included” in order to “make healthcare more affordable for our members,” Kavanaugh offered as a potential talking point in an April 23, 2021, email.
Three days later, UnitedHealth Group filed an annual statement with the U.S. Securities and Exchange Commission disclosing its pay for top executives in the prior year. Then-CEO David Wichmann was paid $17.9 million in salary and other compensation in 2020. Wichmann retired early the following year, and his total compensation that year exceeded $140 million, according to calculations in a compensation database maintained by the Star Tribune in Minneapolis. The newspaper said the amount was the most paid to an executive in the state since it started tracking pay more than two decades ago. About $110 million of that total came from Wichmann exercising stock options accumulated during his stewardship.
The McNaughtons were well aware of the financial situation at United. They looked at publicly available financial results and annual reports. Last year, United reported a profit of $20.1 billion on revenues of $324.2 billion.
When discussing the case with Penn State, Light said, she told university administrators that United could pay for a year of her son’s treatment using just minutes’ worth of profit.
[…] Penn State declined to provide financial information about the plan. However, the university and United share at least one tie that they have not publicly disclosed.
When the McNaughtons first reached out to the university for help, they were referred to the school’s student health insurance coordinator. The official, Heather Klinger, wrote in an email to the family in February 2021 that “I appreciate your trusting me to resolve this for you.”
In April 2022, United began paying Klinger’s salary, an arrangement which is not noted on the university website. Klinger appears in the online staff directory on the Penn State University Health Services webpage, and has a university phone number, a university address and a Penn State email listed as her contact. The school said she has maintained a part-time status with the university to allow her to access relevant data systems at both the university and United.”
“Bill Truxal, the president of UnitedHealthcare StudentResources, the company’s student health plan division, told a Penn State official that the insurer wanted the “best for the student” and it had “nothing to do with cost,” according to notes the official took of the conversation.
Behind the scenes, however, the price of McNaughton’s care was front and center at United.
In one email, Opperman asked about the cost difference if the insurer insisted on only paying for greatly reduced doses of the biologic drugs. Kavanaugh responded that the insurer had paid $1.1 million in claims for McNaughton’s care as of the middle of May 2021. If the reduced doses had been in place, the amount would have been cut to $260,218, she wrote.
United was keeping close tabs on McNaughton at the highest levels of the company. On Aug. 2, 2021, Opperman notified Truxal and a United lawyer that McNaughton “has just purchased the plan again for the 21-22 school year.”
A month later, Kavanaugh shared another calculation with United executives showing that the insurer spent over $1.7 million on McNaughton in the prior plan year.
United officials strategized about how to best explain why it was reviewing McNaughton’s drug regimen, according to an internal email. They pointed to a justification often used by health insurers when denying claims. “As the cost of healthcare continues to climb to soaring heights, it has been determined that a judicious review of these drugs should be included” in order to “make healthcare more affordable for our members,” Kavanaugh offered as a potential talking point in an April 23, 2021, email.
Three days later, UnitedHealth Group filed an annual statement with the U.S. Securities and Exchange Commission disclosing its pay for top executives in the prior year. Then-CEO David Wichmann was paid $17.9 million in salary and other compensation in 2020. Wichmann retired early the following year, and his total compensation that year exceeded $140 million, according to calculations in a compensation database maintained by the Star Tribune in Minneapolis. The newspaper said the amount was the most paid to an executive in the state since it started tracking pay more than two decades ago. About $110 million of that total came from Wichmann exercising stock options accumulated during his stewardship.
The McNaughtons were well aware of the financial situation at United. They looked at publicly available financial results and annual reports. Last year, United reported a profit of $20.1 billion on revenues of $324.2 billion.
When discussing the case with Penn State, Light said, she told university administrators that United could pay for a year of her son’s treatment using just minutes’ worth of profit.
[…] Penn State declined to provide financial information about the plan. However, the university and United share at least one tie that they have not publicly disclosed.
When the McNaughtons first reached out to the university for help, they were referred to the school’s student health insurance coordinator. The official, Heather Klinger, wrote in an email to the family in February 2021 that “I appreciate your trusting me to resolve this for you.”
In April 2022, United began paying Klinger’s salary, an arrangement which is not noted on the university website. Klinger appears in the online staff directory on the Penn State University Health Services webpage, and has a university phone number, a university address and a Penn State email listed as her contact. The school said she has maintained a part-time status with the university to allow her to access relevant data systems at both the university and United.”
Given the new ACA selecting your insurer option - has anyone bothered to sue the hospital systems and insurers for the cost structures BEFORE insurance selection so one can then make an informed choice over what insurer to select?
posted by rough ashlar at 3:35 AM on March 3, 2023 [4 favorites]
posted by rough ashlar at 3:35 AM on March 3, 2023 [4 favorites]
Thanks, Bottlecap! My buddy who had pancreatic cancer and died from it had to fight like hell to get the benefits he was legally entitled to but didn’t sue because California is one of those states that limits pain and suffering awards. Plus US insurance companies are delighted to drag out court cases in hopes of having the patient die before the case is resolved. Which happens. So yeah, fuck these insurance companies.
posted by Bella Donna at 4:46 AM on March 3, 2023 [12 favorites]
posted by Bella Donna at 4:46 AM on March 3, 2023 [12 favorites]
Multiple chronic illnesses, formerly insured through UHC, wish I could say I was surprised.
posted by The Underpants Monster at 5:01 AM on March 3, 2023 [9 favorites]
posted by The Underpants Monster at 5:01 AM on March 3, 2023 [9 favorites]
Figures it's UnitedHealthcare.
Also figures that Penn State would be in league with UnitedHealthcare.
Before the ACA when I was at community college and later an undergraduate at a regional UMass school, Massachusetts had a pretty decent mandate+subsidy program for students. Everyone taking more than 9 credits had to have health insurance and the state leveraged this large pool of students to offer a pretty good Blue Cross plan for decent money. (I think it was like $1000/year or something like that--still expensive at the time, but cheap money compared to all the alternatives). The plan kept me with my primary care doctor and more importantly had pretty generous mental health benefits which I used frequently.
Things changed when I entered graduate school at a private, upper-middle-tier university. They only offered a UnitedHealthcare plan. It was shitty. It cost twice as much, had a deductible, and the copays were enormous. Neither my primary care doctor nor the counselor I was seeing accepted it. My counselor even told me all the reasons he didn't accept UnitedHealthcare and even bluntly told me that if he were in my position and were selecting schools, UnitedHealthcare would have been a deal-breaker.
posted by RonButNotStupid at 5:15 AM on March 3, 2023 [8 favorites]
Also figures that Penn State would be in league with UnitedHealthcare.
Before the ACA when I was at community college and later an undergraduate at a regional UMass school, Massachusetts had a pretty decent mandate+subsidy program for students. Everyone taking more than 9 credits had to have health insurance and the state leveraged this large pool of students to offer a pretty good Blue Cross plan for decent money. (I think it was like $1000/year or something like that--still expensive at the time, but cheap money compared to all the alternatives). The plan kept me with my primary care doctor and more importantly had pretty generous mental health benefits which I used frequently.
Things changed when I entered graduate school at a private, upper-middle-tier university. They only offered a UnitedHealthcare plan. It was shitty. It cost twice as much, had a deductible, and the copays were enormous. Neither my primary care doctor nor the counselor I was seeing accepted it. My counselor even told me all the reasons he didn't accept UnitedHealthcare and even bluntly told me that if he were in my position and were selecting schools, UnitedHealthcare would have been a deal-breaker.
posted by RonButNotStupid at 5:15 AM on March 3, 2023 [8 favorites]
This story broke last month exactly when I realized I would be forced onto UHC. I'd say that realization made me sick, but of course, I mustn't get sick.
posted by CheesesOfBrazil at 5:38 AM on March 3, 2023 [8 favorites]
posted by CheesesOfBrazil at 5:38 AM on March 3, 2023 [8 favorites]
One thing I'm amazed at here is the amount of people involved that have nothing to do with creating medications, delivering medications, or providing medical care. Just admin on admin on admin to make sure the money comes in but does not go out.
It's almost like they could be removed and the quality of care wouldn't be affected.
Total revenue was what, $320 billion with profit of $20 billion?
That's $300 billion spent on salary, infrastructure, legal, and I guess care.
How is the open market more efficient for this again?
This story was a sad and frustrating read, and I'm thankful they're pointing more sunlight into the insurance industry, but we already know the solution. It needs to go. It's an inefficient, ineffective, corrupt parasite.
posted by jellywerker at 5:38 AM on March 3, 2023 [24 favorites]
It's almost like they could be removed and the quality of care wouldn't be affected.
Total revenue was what, $320 billion with profit of $20 billion?
That's $300 billion spent on salary, infrastructure, legal, and I guess care.
How is the open market more efficient for this again?
This story was a sad and frustrating read, and I'm thankful they're pointing more sunlight into the insurance industry, but we already know the solution. It needs to go. It's an inefficient, ineffective, corrupt parasite.
posted by jellywerker at 5:38 AM on March 3, 2023 [24 favorites]
About 1/3 of premiums go to admin and sales.
https://www.marketwatch.com/investing/stock/unh/financials
Then there is the fraction of claims that go to pay for admin work on the part of care providers.
Then there is the admin work done by consumers of health care to get their claims processed.
Such efficiency.
posted by NotAYakk at 6:09 AM on March 3, 2023 [7 favorites]
https://www.marketwatch.com/investing/stock/unh/financials
Then there is the fraction of claims that go to pay for admin work on the part of care providers.
Then there is the admin work done by consumers of health care to get their claims processed.
Such efficiency.
posted by NotAYakk at 6:09 AM on March 3, 2023 [7 favorites]
Yes, but won’t somebody think of the shareholders?
posted by chasing at 6:39 AM on March 3, 2023 [4 favorites]
posted by chasing at 6:39 AM on March 3, 2023 [4 favorites]
Ah my former employer. *gestures obscenely* Glad to see their garbage behavior exposed.
posted by Orange Dinosaur Slide at 6:46 AM on March 3, 2023 [14 favorites]
posted by Orange Dinosaur Slide at 6:46 AM on March 3, 2023 [14 favorites]
America is an absolute shitshow.
posted by DarlingBri at 6:51 AM on March 3, 2023 [12 favorites]
posted by DarlingBri at 6:51 AM on March 3, 2023 [12 favorites]
Why help patients when you can buy companies! The $5.4 billion transaction between UnitedHealth Group, its subsidiary Optum and home health giant LHC Group has closed.
posted by Orange Dinosaur Slide at 7:05 AM on March 3, 2023 [2 favorites]
posted by Orange Dinosaur Slide at 7:05 AM on March 3, 2023 [2 favorites]
I've said it before and I'll say it again: Some things should not be privatized.
This is awful. As are so many aspects of the U.S. health system.
But national, government run health care would not necessarily guarantee coverage of all treatments. Britain, for example, explicitly rations care. In many ways it's better than the morass we have here, but "if a treatment will give someone another year of life in good health and it costs less than 20,000 pounds, it clears NICE’s bar. Between 20,000 and 30,000 pounds, it’s a closer call. Above 30,000 pounds, treatments are often rejected — though there are exceptions, as in some end-of-life care and, more recently, some pricey cancer drugs."
I'm curious as to what the NHS would have provided in this case.
posted by Mr.Know-it-some at 7:10 AM on March 3, 2023 [4 favorites]
This is awful. As are so many aspects of the U.S. health system.
But national, government run health care would not necessarily guarantee coverage of all treatments. Britain, for example, explicitly rations care. In many ways it's better than the morass we have here, but "if a treatment will give someone another year of life in good health and it costs less than 20,000 pounds, it clears NICE’s bar. Between 20,000 and 30,000 pounds, it’s a closer call. Above 30,000 pounds, treatments are often rejected — though there are exceptions, as in some end-of-life care and, more recently, some pricey cancer drugs."
I'm curious as to what the NHS would have provided in this case.
posted by Mr.Know-it-some at 7:10 AM on March 3, 2023 [4 favorites]
This story was a sad and frustrating read, and I'm thankful they're pointing more sunlight into the insurance industry, but we already know the solution. It needs to go. It's an inefficient, ineffective, corrupt parasite.
There are plenty of jurisdictions that have sensible regulations on health insurers, where insurers are an important part of the ecosystem. I don't think the problem is private health insurance per se as much as the lack of a proper public option / universal coverage and corporate lobbyists/ legislator collusion preventing any kind of proper regulation or reform.
posted by sid at 7:11 AM on March 3, 2023
There are plenty of jurisdictions that have sensible regulations on health insurers, where insurers are an important part of the ecosystem. I don't think the problem is private health insurance per se as much as the lack of a proper public option / universal coverage and corporate lobbyists/ legislator collusion preventing any kind of proper regulation or reform.
posted by sid at 7:11 AM on March 3, 2023
Yes, but won’t somebody think of the shareholders?
I do. I think of them struggling as they get led up to Madame Guillotine.
posted by mephron at 7:27 AM on March 3, 2023 [14 favorites]
I do. I think of them struggling as they get led up to Madame Guillotine.
posted by mephron at 7:27 AM on March 3, 2023 [14 favorites]
I have a lot of experience dealing with UHC in different capacities and absolutely nothing in this article surprised me in the least and isn't something I haven't heard before from other UHC plan members, healthcare providers and UHC/Optum/UBH employees. There's a part of me that feels they've positioned themselves to be the insurer of choice for employers that want the veneer of offering medical insurance benefits but without actually providing any, but I'm guessing they screw over employers just as much, if not more, than their plan members. Just like they screw over healthcare providers, and everyone else they deal with.
Burn. It. All. Down. Also, remember that there is a very good chance your local friendly Democrat is just as complicit in this mess as the slimiest Republican, so that's cool.
posted by flamk at 7:31 AM on March 3, 2023 [2 favorites]
Burn. It. All. Down. Also, remember that there is a very good chance your local friendly Democrat is just as complicit in this mess as the slimiest Republican, so that's cool.
posted by flamk at 7:31 AM on March 3, 2023 [2 favorites]
I've said it before and I'll say it again: Some things should not be privatized.
Now, now, say that quietly and not in public or you're likely to get some crazed gun-toting QAnon-style psychopath swiveling his empty head in your direction.
posted by aramaic at 7:34 AM on March 3, 2023 [1 favorite]
Now, now, say that quietly and not in public or you're likely to get some crazed gun-toting QAnon-style psychopath swiveling his empty head in your direction.
posted by aramaic at 7:34 AM on March 3, 2023 [1 favorite]
I feel for Christopher McNaughten and his family. My BFF suffers - and it is true suffering - from ulcerative colitis and it is a nightmare of an illness. She's had four colonoscopies this year (yes, THIS YEAR) alone. It's the best way to see what damage is happening during a flare-up. So that's at least two days out of commission each time, usually with a day or so tacked on afterward for recovery, not to mention the days of flare-up before she even starts the prep. She's on a biologic that has worked well for her in the past but they have to keep increasing the dosage. She's a young, active woman who owns a yoga studio and this disease just fucks with her life in so many ways.
The unmitigated gall of an insurance company making these life and death decisions, with zero regard for what the patient's doctor - the person who ostensibly knows the most about said patient and their treatment - just makes me rage.
posted by cooker girl at 7:38 AM on March 3, 2023 [9 favorites]
The unmitigated gall of an insurance company making these life and death decisions, with zero regard for what the patient's doctor - the person who ostensibly knows the most about said patient and their treatment - just makes me rage.
posted by cooker girl at 7:38 AM on March 3, 2023 [9 favorites]
How is the open market more efficient for this again?
You probably have the wrong referent for the word "this".
posted by srboisvert at 7:44 AM on March 3, 2023 [1 favorite]
You probably have the wrong referent for the word "this".
posted by srboisvert at 7:44 AM on March 3, 2023 [1 favorite]
Yes, but won’t somebody think of the shareholders?
I do. I think of them struggling as they get led up to Madame Guillotine.
Tragically, thanks to America's retirement system almost everyone is a shareholder in these evil companies. It's a "heads we win, tails you lose" system through and through.
posted by srboisvert at 7:49 AM on March 3, 2023 [1 favorite]
I do. I think of them struggling as they get led up to Madame Guillotine.
Tragically, thanks to America's retirement system almost everyone is a shareholder in these evil companies. It's a "heads we win, tails you lose" system through and through.
posted by srboisvert at 7:49 AM on March 3, 2023 [1 favorite]
I'm legitimately (have seen my own "data" file...it's eerie) starting to think that I've had a hard time getting a job (which I NEED for health insurance) because I'm chronically ill (asthma and another autoimmune disease). I don't think we realize how badly our insurance companies are ruining our chances of more than treatment.
We should really be investigating what they are doing with our data outside of killing us for profit.
posted by lextex at 8:26 AM on March 3, 2023 [10 favorites]
We should really be investigating what they are doing with our data outside of killing us for profit.
posted by lextex at 8:26 AM on March 3, 2023 [10 favorites]
Srboisvert, yes I'm sure it's working very efficiently for the former CEO.
I don't get it. How is nearly everything the pits? Like, you have to be a callous motherfucker to look around America and be content with what you see.
posted by jellywerker at 8:28 AM on March 3, 2023 [6 favorites]
I don't get it. How is nearly everything the pits? Like, you have to be a callous motherfucker to look around America and be content with what you see.
posted by jellywerker at 8:28 AM on March 3, 2023 [6 favorites]
I'm a grad student right now (again). I have UHCSR. As a recruited student who is fully funded, it is required for me to accept it at my institution. Even though I am fully funded, I still pay for the insurance partially through my student fees ($1700 per semester).
I am a nontraditional student, I'm middle-aged. I have had kidney stones twice this year. I had surgery to remove a bone spur on my foot that was preventing me from being able to wear most shoes. I had to pay thousands for each hospital visit. With. the. insurance.
I've had good University healthcare (hello UCLA). This is the worst I've ever experienced. If I were not a non-tradtional student with a spouse that makes good money, this year would have broke me financially because of healthcare costs. I would not have been able to complete my degree.
Fuck UHCSR. Burn it to the ground.
posted by anansi at 8:32 AM on March 3, 2023 [13 favorites]
I am a nontraditional student, I'm middle-aged. I have had kidney stones twice this year. I had surgery to remove a bone spur on my foot that was preventing me from being able to wear most shoes. I had to pay thousands for each hospital visit. With. the. insurance.
I've had good University healthcare (hello UCLA). This is the worst I've ever experienced. If I were not a non-tradtional student with a spouse that makes good money, this year would have broke me financially because of healthcare costs. I would not have been able to complete my degree.
Fuck UHCSR. Burn it to the ground.
posted by anansi at 8:32 AM on March 3, 2023 [13 favorites]
But national, government run health care would not necessarily guarantee coverage of all treatments. Britain, for example, explicitly rations care. In many ways it's better than the morass we have here, but "if a treatment will give someone another year of life in good health and it costs less than 20,000 pounds, it clears NICE’s bar. Between 20,000 and 30,000 pounds, it’s a closer call. Above 30,000 pounds, treatments are often rejected — though there are exceptions, as in some end-of-life care and, more recently, some pricey cancer drugs."
I'm curious as to what the NHS would have provided in this case.
I completely agree with the analysis above.
We can believe many things
1) The NHS would approve this drug through NICE; maybe not at the dosages involved.
2) Insurance companies are parasites.
3) but The doctor was paid as a consultant by the drug company that developed the (in this case!) efficacious drug! there are real reasons why moral people would question this prescription.
The higher order problem here is capitalism.
What we are willing to do as a society to fund the discovery and development and distribution of new drugs to lengthen life and minimize human suffering - which under any system costs billions of dollars of real money and efforts of tens of thousands of scientists and clinicians. This isn't solely "the eeevil drug companies are wasting money on shareholders an CEOs" - they do that! for sure! - but the VAST costs for making drugs are non-negotiable below a certain point. You can't silicon valley it away. You can't socialize it away (you can sure lessen it!).
Human biology is the most complex subject we deal with as a fucking species, and it requires tens of thousands of person years of effort to address tiny parts of it. How do we pay for that effort?
posted by lalochezia at 8:35 AM on March 3, 2023 [1 favorite]
I quit my job this week, and it all started with insurance.
One too many claims denied made me look elsewhere, and when I discovered everyone's insurance sucked equally, I simply looked for the place that could pay me the most reasoning that the only input I had into the situation was the amount of cash I could throw at it.
There were other reasons for leaving as there always are, but if I had simply been able to take my kid to therapy and have the claims paid by the insurance company I pay half as much as my rent to every month I would have continued to hang up on recruiters when they called.
posted by The Monster at the End of this Thread at 8:52 AM on March 3, 2023 [7 favorites]
One too many claims denied made me look elsewhere, and when I discovered everyone's insurance sucked equally, I simply looked for the place that could pay me the most reasoning that the only input I had into the situation was the amount of cash I could throw at it.
There were other reasons for leaving as there always are, but if I had simply been able to take my kid to therapy and have the claims paid by the insurance company I pay half as much as my rent to every month I would have continued to hang up on recruiters when they called.
posted by The Monster at the End of this Thread at 8:52 AM on March 3, 2023 [7 favorites]
Remember Sarah Palin's whole Death Panel stuff? The most infuriating thing about that whole episode is that "death panels" absolutely do exist, they just happen to be located in for-profit health insurance companies. Actually, no lemme take that back. The most infuriating part of that episode was that liberals/the Democratic Party/the Lefttm/etc... weren't able to capitalize on the "death panel" remark to initiate a public reckoning of insurance company practices like this.
posted by mhum at 9:09 AM on March 3, 2023 [24 favorites]
posted by mhum at 9:09 AM on March 3, 2023 [24 favorites]
a part-time status with the university to allow her to access relevant data systems at both the university and United
"But that’s worse. You do see how that’s worse?"
posted by clew at 9:22 AM on March 3, 2023 [8 favorites]
"But that’s worse. You do see how that’s worse?"
posted by clew at 9:22 AM on March 3, 2023 [8 favorites]
But national, government run health care would not necessarily guarantee coverage of all treatments. Britain, for example, explicitly rations care.
I'm a GI in a socialized healthcare system (Poland).
Let me tell you one thing.
These same drugs mentioned in the article are So Much Cheaper over here. And I don't just mean the out of pocket cost for the patient (which is zero). I mean the cost of purchase paid by the hospital.
I know the exact price that the drugs get sold for by the manufacturer to the NHS because I had to use these numbers in a grant application.
The prices are no mystery and can be looked up on our gov website if you know Polish and Excel but basically they are on par with pricier US insulin? Or a biggish mortgage payment for an apartment (Polish apartment, not US prices)? Again these are not patient costs but what the NHS pays.
Y'all are getting ripped off. Massively.
posted by M. at 11:55 AM on March 3, 2023 [20 favorites]
I'm a GI in a socialized healthcare system (Poland).
Let me tell you one thing.
These same drugs mentioned in the article are So Much Cheaper over here. And I don't just mean the out of pocket cost for the patient (which is zero). I mean the cost of purchase paid by the hospital.
I know the exact price that the drugs get sold for by the manufacturer to the NHS because I had to use these numbers in a grant application.
The prices are no mystery and can be looked up on our gov website if you know Polish and Excel but basically they are on par with pricier US insulin? Or a biggish mortgage payment for an apartment (Polish apartment, not US prices)? Again these are not patient costs but what the NHS pays.
Y'all are getting ripped off. Massively.
posted by M. at 11:55 AM on March 3, 2023 [20 favorites]
I’ve started to have gallbladder attacks last autumn. Long story short after an echo and an MRI to verify the biliary duct width, I had to get it removed which actually occurred last week. For those who don’t know, having attacks usually means you have to massively reduce your fat intake to avoid triggering them. So for this reason and for general curiosity I started looking on the internet
for people sharing this issue to see how they coped. I ended on r/gallbladder which as far as Reddit goes isn’t terrible.
The real shock to me was reading stories of Americans postponing their cholecystectomy or suffering massive attacks alone at home because your health system is hot garbage how they’ll be ruined if they act. Now I’ve always know this fact, but being in a community and reading those stories really drove it home a notch further.
Canadian healthcare certainly has its issues, but not those issues. None of this is normal and I just dont know what can be done to drive this point in the head of enough Americans to actually have some real change, you should be rioting in the streets this makes no sense at all.
posted by WaterAndPixels at 1:19 PM on March 3, 2023 [6 favorites]
for people sharing this issue to see how they coped. I ended on r/gallbladder which as far as Reddit goes isn’t terrible.
The real shock to me was reading stories of Americans postponing their cholecystectomy or suffering massive attacks alone at home because your health system is hot garbage how they’ll be ruined if they act. Now I’ve always know this fact, but being in a community and reading those stories really drove it home a notch further.
Canadian healthcare certainly has its issues, but not those issues. None of this is normal and I just dont know what can be done to drive this point in the head of enough Americans to actually have some real change, you should be rioting in the streets this makes no sense at all.
posted by WaterAndPixels at 1:19 PM on March 3, 2023 [6 favorites]
Mr know-it-some's specific point about the UK's NHS rationing care through decisions made by the National Inst for Health and Care Excellence (NICE) is certainly true.
But it would be deeply misguided to suppose that the UK's socialized system rations healthcare--and therefore denies needed medical treatment--to the same degree as the USA. In the latest figures i could find, a little over 4% of the UK population reported "unmet needs for medical care" (OECD, 2019, from this broader report). The best comparable* reporting for the US that that I found states that 8% of the US population "delayed or did not receive needed medical care due to cost during the past 12 months" (CDC, 2018).
And that UK figure is from 2019, after almost a decade of the Tories' deliberately undermining (dismantling?) the NHS at every opportunity!
Not that full nationalization is necessarily best: I know that at least a few of the countries that scored way better than the UK on that OECD list use well-managed private healthcare insurance as part of their overall system.
(Also, I realize Mr know-it-some and I are almost certainly on the same side and I don't mean this as a call-out.)
*IANAhealth statistician or indeed any sort of healthcare or stats expert**; I'm sure there are differences between these measures. Pinch of salt, open to better stats.
**IAA social scientist with good google/DDG skills. And the OECD and CDC turn out to have lots of readily-available reports that show up well in searches.
posted by col_pogo at 1:24 PM on March 3, 2023 [7 favorites]
But it would be deeply misguided to suppose that the UK's socialized system rations healthcare--and therefore denies needed medical treatment--to the same degree as the USA. In the latest figures i could find, a little over 4% of the UK population reported "unmet needs for medical care" (OECD, 2019, from this broader report). The best comparable* reporting for the US that that I found states that 8% of the US population "delayed or did not receive needed medical care due to cost during the past 12 months" (CDC, 2018).
And that UK figure is from 2019, after almost a decade of the Tories' deliberately undermining (dismantling?) the NHS at every opportunity!
Not that full nationalization is necessarily best: I know that at least a few of the countries that scored way better than the UK on that OECD list use well-managed private healthcare insurance as part of their overall system.
(Also, I realize Mr know-it-some and I are almost certainly on the same side and I don't mean this as a call-out.)
*IANAhealth statistician or indeed any sort of healthcare or stats expert**; I'm sure there are differences between these measures. Pinch of salt, open to better stats.
**IAA social scientist with good google/DDG skills. And the OECD and CDC turn out to have lots of readily-available reports that show up well in searches.
posted by col_pogo at 1:24 PM on March 3, 2023 [7 favorites]
My sister lives in the US. Last year, her husband needed a small operation. So they packed their bags and together with their 8 months old child they flew here to Estonia, he had the operation, and then they flew back. The cost of this trip to the other side of the world? About half the price of the operation in the US.
Around here everybody knows that the US healthcare system is fucked, but then you provide them with specific examples and everybody is still completely stunned.
posted by Pyrogenesis at 11:07 PM on March 3, 2023 [8 favorites]
Around here everybody knows that the US healthcare system is fucked, but then you provide them with specific examples and everybody is still completely stunned.
posted by Pyrogenesis at 11:07 PM on March 3, 2023 [8 favorites]
This may be in the ProPublica article, I can't recall, but it may bear noting that (according to Wikipedia) United is one of the largest companies by revenue on the planet—bigger than ExxonMobil, Toyota, and Berkshire Hathaway, and not too far behind Saudi Goddamn Aramco. So that…says a lot.
posted by CheesesOfBrazil at 2:36 AM on March 4, 2023 [2 favorites]
posted by CheesesOfBrazil at 2:36 AM on March 4, 2023 [2 favorites]
I'm curious as to what the NHS would have provided in this case.
Both the biologics he was prescribed are available on the NHS where other treatments are not working. That's exactly what this case is, and given the risks you wouldn't want biologics to be first-line treatment even if they were cheap. Here's what's available in terms of biologics for people with Crohn's or UC in the UK.
The NHS uses its collective buying power, and its de facto UK monopoly to negotiate lower prices for various drugs. It will fund some very expensive treatments if they provide enough benefit.
posted by plonkee at 5:00 AM on March 4, 2023 [4 favorites]
Both the biologics he was prescribed are available on the NHS where other treatments are not working. That's exactly what this case is, and given the risks you wouldn't want biologics to be first-line treatment even if they were cheap. Here's what's available in terms of biologics for people with Crohn's or UC in the UK.
The NHS uses its collective buying power, and its de facto UK monopoly to negotiate lower prices for various drugs. It will fund some very expensive treatments if they provide enough benefit.
posted by plonkee at 5:00 AM on March 4, 2023 [4 favorites]
To add to the pricing conversation, I get a monthly MS drug called Tysabri. It's infused at an infusion centre every 4 weeks. When my MS care team and I were discussing which DMT (drug management therapy) to put me on, it was a choice of six drugs and a match to what was best for my lifestyle, disease progression, and rate of progression. I went straight on Tysabri, because it was the best drug for me. There was zero discussion of cost.
In the US, this drug is $8,500 out of pocket to $25,000+ for insured patients per dose. The MS subreddit is filled with Americans talking about how they are forced by their insurers to fail on two DMTs before they are allowed to switch to Tysabri, or how they can't get covered for it, and how when they are covered, they are commonly only covered for 6-week infusion cycles.
The same drug is around €1,400 in Ireland because, as described above, our national health system cost negotiates supplies. There are only 9,000 people in this entire country with MS and only 12% of us are on Tysabri but the cost is less than 25% of the cost in the US.
So basically: the chances of the man in the article not being covered at all in a national health scheme are tiny because the cost of his drugs would likely be a literal fraction of the cost being charged in a private insurance racket.
posted by DarlingBri at 11:16 AM on March 4, 2023 [9 favorites]
In the US, this drug is $8,500 out of pocket to $25,000+ for insured patients per dose. The MS subreddit is filled with Americans talking about how they are forced by their insurers to fail on two DMTs before they are allowed to switch to Tysabri, or how they can't get covered for it, and how when they are covered, they are commonly only covered for 6-week infusion cycles.
The same drug is around €1,400 in Ireland because, as described above, our national health system cost negotiates supplies. There are only 9,000 people in this entire country with MS and only 12% of us are on Tysabri but the cost is less than 25% of the cost in the US.
So basically: the chances of the man in the article not being covered at all in a national health scheme are tiny because the cost of his drugs would likely be a literal fraction of the cost being charged in a private insurance racket.
posted by DarlingBri at 11:16 AM on March 4, 2023 [9 favorites]
About 1/3 of premiums go to admin and sales.
For Medicare & Medicaid, that figure is 1/50 to 1/20.
posted by neuron at 11:45 AM on March 4, 2023 [3 favorites]
For Medicare & Medicaid, that figure is 1/50 to 1/20.
posted by neuron at 11:45 AM on March 4, 2023 [3 favorites]
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posted by gible at 3:28 AM on March 3, 2023 [44 favorites]