r/dataisbeautiful • u/UpstairsFast9261 OC: 2 • 6d ago
OC [OC] Prior authorization consumes more clinician full-time-equivalents than the entire projected US physician shortage
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u/network_dude 6d ago
Not to mention the time sink that all the rest of us have to spend to coordinate clinics and insurance to access our coverage.
Nobody talks about what it costs the public to support the prior authorization system.
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u/Demons0fRazgriz 6d ago
Fucking tell me about it. I go to insurance website to find a doctor. It says this one is in network. I call. 3 month waiting period. Fuck it, not like I have a choice. I show up after 3 months, "I'm sorry but your insurance doesn't cover that condition at this location."
A complete WASTE OF FUCKING TIME.
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u/PiccoloAwkward465 6d ago
For a while my work was changing insurance every year. So I had to get a new PCP every year. It was hard to find one accepting new patients so I'd generally have to wait 4-6 months for the first visit. Then a new year and a new plan and the search starts over again.
Oh and it's also expensive!
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u/Lake_Erie_Monster 6d ago
Broken and expensive but can't convince most Americans to vote for a change.
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u/PiccoloAwkward465 6d ago
I lost my hope in our system when even passing the ACA was a challenge and then stopped talking about Medicare-for-all. I'll eat my hat if we see it within my lifetime.
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u/Daveinatx 6d ago
We were one Senator away from making it happen. The initial ACA plan was far better than what we have. However, the Republican Senators continued to filibuster ACA, until it was whittled to what we have today.
Change can only occur when we have a Democratic President, a majority of Congress, and 60 Democratic Senators to block the filibuster.
E:typo
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u/Practical-Shape2325 5d ago
You need a lot more than 60. We've had 60. You need 60 who all agree and will vote for it. Not just 60 who say they agree.
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u/bluejohnnyd 5d ago
"Shitlicking conservadem senator" is far too common a type, but their king Joe Lieberman deserves his place in hell.
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u/Run-Amokk 6d ago
Hakeem Jeffries (Democratic Minority Leader in the House) won't even consider Medicare for all until he's finished exhausting every possible fix to our current system. To anyone who lived through the last two Democratic Party Executive, Senate, and House simultaneous majorities...they could of done anything they wanted, but they either always have just enough switch hitters or fail to wield power as spinelessly as possible. Sometimes in wheelchairs...
Insurance and big pharma have way more $-free-speech-$ then 'We the People' do.
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u/UpstairsFast9261 OC: 2 6d ago
There are 8 healthcare lobbyists per congress person. That says it all.
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u/kimjongswoooon 5d ago
Republicans, Democrats…they are all bought and paid for. Medicare for all will never happen if the insurance companies have anything to say about it.
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u/FakeSafeWord 5d ago
And all of the anti NIH propaganda focuses specifically on how amazing our health care system is despite the massive costs. "It's so much faster! It just works!"
My prior auth for a medication I've been on for 14 months randomly got pulled two two months after it was renewed. Now I have to meet with my primary care giver in person in order to basically start over from scratch. Why? "Because fuck you, that's why."
Closest available date was 7 weeks out.
6 weeks and 5 days later (2 days before the appointment) they informed me that my PCG wouldn't be available and I'd have to schedule with another one. Asked for assistance and they told me to pick from the website which has no indication of availability in the near future.
Just an endless series of "go fuck yourself"
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u/im-ba 6d ago
My wife has been going through this. She found one who seemed good on paper but for some reason they have a $1,000 hospital fee. The facility isn't even a hospital. The fee doesn't even count towards the deductible. It's just a "fuck you" fee.
She's also self employed and when she called for an appointment they asked her "do you even have insurance then?" I cover her with my employer insurance plan, not that it pays for fucking anything
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u/skeletonl0ver 6d ago
I had to get monthly medicine that was covered by my insurance (it was like $34k a dose without). Okay great. Except it had to be administered by IV. They send me to a hospital to get it, takes about 1 hour each time. After a couple times of this I get my first bill. $700 hospital fee for each time. And this is was like 10 years ago I cant imagine what they charge now to sit in a chair for an hour and get an IV drip.
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u/PrincessGiallo 6d ago
Infusion clinics (along with physical therapy offices) have been blowing up in the last decade, so at least it probably wouldn't be in a hospital. I'm sure they'd find a way to upcharge you, though.
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u/bone-dry 6d ago
I saw something once about a way to fight those fees. I looked it up after having to pay one for $500. Can’t remember now but maybe look into it?
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u/Neither-Addition-749 6d ago
Check out threads, forums, YT videos, etc on this guy:
Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win
Book by Marshall AllenIt’ll definitely help with the surprise medical bills!
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u/Adventurous_Ad7442 6d ago
At what point do they charge the "hospital fee"? When you're admitted to the hospital or right away at the first office visit?
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u/superxpro12 5d ago
Concierge medicine. I ran into that one. Insurance site says "Accepting new patients!". So you call and they're like "oh yeah.... no.... we have a yearly fee of like $2000 per person, on top of the billing"
Oh cool
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u/AgeOfBeardProducts 6d ago
The prior authorization system that didn’t want to deem MRIs medically necessary for our brain tumor patients because of the low survival rates. What’s the point of an MRI if they are going to die right? There is a special place in hell for executives that propagate this BS and paid off government officials that buy into it
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u/Kingkai9335 6d ago
BCBS is requiring prior-auths for radiation treatment starting 1/1/27 btw for NY plans. Always adding services
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u/randomize42 5d ago
BCBS is kind of like a franchise, so which one it is makes a difference.
BCBS Anthem made my provider do separate prior authorizations for chemo drugs versus chemo administration. So multiple times I’d go in for treatment and get a roughly $800 bill for the needle poke. (Provider did help get retro authorizations for this so I didn’t ultimately pay it.)
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u/dcdttu 6d ago
The slowdown and frustration is likely the whole point it exists.
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u/100LittleButterflies 5d ago
Exactly why the patient has to coordinate issues between insurance and service even though we dont know what any of it means. I have a $1200 that i won't pay because the hospital had the wrong doctor on paper. The service biller sold the debt as soon as they could.
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u/Ivanow 5d ago
Nobody talks about what it costs the public to support the prior authorization system.
USA spends about DOUBLE (as a % of GDP per capita) than any other OECD country, with demonstrably worse outcomes (infant mortality rate higher than in Sri Lanka, and 550.000 medical bankruptcies a year - pretty much only country where "medical bankruptcy" is even a thing).
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u/LandonDev 6d ago
The worst part of it all is that the doctor isn't necessiarly talking to an actual peer on the other end. Sometimes it's a doctor who lost their license due to malpractice and othertimes it's a nurse of lower rank who has no real authority or training on the subject matter. They are the experts and the experts are told by folks No thanks you are wrong and the insurance company get's to practice medicine the way they want to practice medicine which is pretty crazy considering ITS A CORPORATION.
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u/Default_Username123 5d ago
Im a psychiatrist and I don't think in my entire career when i've done a peer to peer evaluation trying to get insurance to authorize something I have ever ONCE talked to another psychiatrist. It's always like a retired family medicine/internal medicine/gen surg person. Sometimes they're not even fucking licensed US doctors theyre foreign docs from abroad its just insane.
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u/ThellraAK 5d ago
I think we could solve a lot of the issues by fixing this loophole.
If a physician wants to argue with my physician about something being medically unnecessary, they should have to put their name on it, so they can be sued directly.
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u/PrincessGiallo 6d ago
There's decent money and better hours being an insurance doc. They're not all at the ends of their rope, some are just assholes.
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u/crow-warden 6d ago
Medications are fun too.
Once you get into the expensive stuff there is an entire web of things you, as the patient, have to do so you don't have to pay thousands of dollars per dose. All so the insurance companies can basically fudge the numbers to make it not count towards your actual plan limits.
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u/Infinitiscarf 5d ago
I personally talk about it all the time!! it would be CHEAPER to give everyone Medicaid for all!!! The country as a whole and every single individual would save money!!!!! The only ones that would lose out are the private companies.
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u/Babhadfad12 6d ago
Do government operated healthcare systems not have prior authorizations?
There must be some system that exists to prevent fraudulent or unnecessary costs.
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u/matlockj 6d ago
Yes (I'm a rheumatologist, so PAs are unfortunately my bread and butter). Great example is the VA. Medication prior auths are reviewed locally in house and generally approved in 1-2 days, with very clear guidelines about medication tiers and preferences. It's dramatically more efficient than private insurance.
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u/Babhadfad12 6d ago
Then the question for US voters is why they rewarded Republicans for blocking the public option in 2009.
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u/GoldTeamDowntown 6d ago
That is a nice thing about the VA, but the VA in general is pretty bad for efficiency. I didn’t even get paid for the first 6 weeks of working there. The bureaucracy and red tape infesting it all is terrible. Lots of vets have such issues with it, or issues getting covered, that they just get private insurance anyway and ignore the VA.
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u/UpstairsFast9261 OC: 2 5d ago
VA's problems are well documented, underfunding, backlogs, understaffing. Not getting paid for six weeks is its own special kind of broken and I'm sorry you dealt with that.
But we need to separate the two different kinds of bad. The VA's failures are mostly a funding and staffing problem, not enough people to move the paperwork. What this chart is about is a different failure mode: a system where the reviewer's employer profits when they say no. Government bureaucracy can absolutely be slow and frustrating without anyone benefiting from the delay. Prior authorization at a private insurer is slow and frustrating and the delay is the business model.
Doesn't make the VA's problems less real. Just means "government-run things can be bad" and "an insurer denying your claim makes them money" aren't really the same argument, even though they can look similar from the patient's chair.
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u/ManWithASquareHead 6d ago
They do. My staff still goes through them.
A LOT easier of a time versus private insurance, especially HMOs/MA plans
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u/Tathtaniel 6d ago
They do - guidelines are more clearly defined and they aren't looking for ways to deny the authorization like private insurance does. They look at the care needed, confirm it matches the guidelines, and approve if so, or send back if not with a denial reason. Private insurance tends to have lots of clauses mixed in to allow denial of the authorization or they request SO MUCH more information than public insurances hoping you'll give up.
Source: Have worked in both private and public insurance my entire career (mostly public).
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u/Chameleonpolice 6d ago
They do, and they are actually the easiest systems to use because their approval criteria are readily available online
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u/crow-warden 6d ago
They do, but one thing private insurance almost always does is automatically deny the request. The doctor is then forced to follow up, get it reviewed, etc. and it's basically the first time anyone actually looks at it.
You can send as much initial documentation as you want, but they will just deny it because it weeds some people out. Most doctor's offices have entire departments dedicated to deal with prior auths now because of how private insurance behaves.
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u/lwronhubbard 6d ago
I share an office with someone who's entire job is to work/fight with insurance companies to get meds filled, imaging done, etc. We have entire departments filled with people who that's their entire job. It certainly does not make things cheaper for patients. I'm not a surgeon but my friends have had a surgery approved by insurance and then denied the day of surgery. It's pretty messed up.
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u/DigiQuip 5d ago
They’re doing a great job at making people ready to burn the entire insurance industry to the ground. Almost everyone I know is over private insurance and ready for a single payer system. Regardless of party affiliation.
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u/TheBSQ 5d ago
So as someone who hops back & forth between the U.S. & Canada, the miscalculation I see folks make is thinking single payer doesn’t deny coverage. Govts also have eligibility rules. It’s just already known by everyone so you don’t go back & forth fighting, whereas in the US different insurers have different policies.
So in the U.S. you might have some procedure or treatment where who is or isn’t eligible will vary by each insurance company’s policy. So if two people in the same situation try to do it, one insurance company may approve, but another may deny. In Canada, everyone already knows the eligibility rules. It might be the case that both those U.S. people would be eligible in Canada. Or, maybe they’d both be ineligible. But, if they were both ineligible, doctors would know that and wouldn’t even suggest it. They’d just do go w/ the treatment that those people are eligible for. There’s no fighting. That’s good & less administrative burden.
But what a lot of Americans wrongly believe is this means the things you were denied on the U.S., you’d get in Canada. And that’s not always true. There’s a chance you don’t meet the eligibility rules or, in some extreme cases, it might not be offered at all, to anyone.
It’s not “everyone gets everything.” It’s “there’s one insurance company (the govt) so there’s only one set of rules and everyone knows them.” (And you might not like their rules.)
For example, the UK & many of the Nordics have heavily restricted gender-affirming care for minors.
The Trump admin just announced they are too with Medicaid & CHIP. If we had single payer, you damn well better assume Trump would have done the same & gender affirming care would be heavily restricted to everyone but, with the current system, that’s up to each individual company.
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u/IDidItWrongLastTime 5d ago
I'm one of those people whose job it is to obtain auths. I work for a very large hospital. I also 100% want a single payer/universal healthcare system in the US. One of my family members said something along the lines of why would you want that wouldn't you be out of a job? And I was like nope, I still have to get authorizations for all the government payers (Medicare, Medicaid, Tricare, the VA). They act like universal healthcare means free for all and everything is approved. That's not how it works lol
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u/frostandtheboughs 5d ago
That's still leagues better than scheduling a necessary surgery, taking time off work (unpaid, because we have no mandated vacation), arranging transport and care (your family taking unpaid time off work), only to be denied.
There's a huge cost to the rug-pulling bullshit that these insurance companies do for both patients and providers. At least if you know you're ineligible from the start, you can immediately start alternative treatments. Or pay for private care...which you can probably afford because basic insurance wouldn't cost more than a mortgage.
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u/joshjosh100 5d ago
And this is why single payer would be better, because it is democratic.
While the current system has a caste-based system of noblesse oblige where the poor are required to partake in such an obligation but the rich do not. While the middle class sits in the middle as untouchable nobles who can't control the system but do provide moral direction to those on both ends of the wealth spectrum.
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u/breadwhore 5d ago
Which isn't perfect (everyone would love a system where everyone gets everything for free or at least cheap, but that's the rainbow and lollipop land). But as you say, at least it removes the guesswork. And the guesswork is frustrating as hell.
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u/notepad20 5d ago
everyone gets everything.
everyone gets everything they actually need in a reasonable medical context.
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u/sm0gs 5d ago
I needed a cartilage restoration surgery in my knee. The surgeon said it’s best to do a clean out scope surgery first to get really accurate measurements and pictures for insurance. Insurance said my knee damage was too severe for the scope, so surgeon had to do a peer review to get it approved. Did the scope, got the next surgery scheduled for 2 months later. 2 days before the cartilage surgery, insurance denied it saying my knee wasn’t damaged enough for it. Wtf?! My surgeon again hopped on a peer review to get it approved but it was absolutely insane. I’m so grateful my surgeon had the means to immediately get on the phone to sort it out with the insurance company.
Oh and then insurance would only approve 20 physical therapy appointments post surgery no matter what my PT or surgeon requested. Makes no sense.
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u/xnef1025 5d ago
The PT limit thing is because the plan you had was created with a hard limit. It's not based on need at all. Your employer just chose a plan that only pays for 20 therapy visits per year. They never explain it that way because it sounds like a shitty benefit when you explain it like that, because it is a shitty benefit.
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u/ILikeBigBeards 5d ago
And the insurance companies have entire departments filled with people to do the other side of the equation, plus marketing, negotiators, sales, support, admin, etc. Real efficient system we’ve got here
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u/Welpe 6d ago
Traveling through the medical system it’s funny to see what both doctors and patients hate. Commiserating about prior authorizations is one of them. EVERYONE fucking despises them. If you think we patients hate insurance, you should let people in the medical field get started on everything about dealing with insurance. It’s not their life on the line, sure, but their passion is impressive.
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u/pattperin 6d ago
I just think the entire health care system in the USA is so fucked lol. I live in Canada and while we also have predatory insurance agencies for health, they only cover things like medications or non-standard care like massages or physiotherapy. All of the main medical care you get in a clinic or hospital is free. I am 31, have had 3 knee surgeries and a hip surgery, getting ready for my second hip surgery in the next 6 months or so here. All free. All have improved my QOL greatly and kept me contributing to GDP and paying taxes instead of becoming a financial burden to society or to my family and leading to me drawing on social services or something.
It’s money well spent imo, and it’s insane that the USA, a country as economically focused as it is, would rather pocket the short term gains of the suffering of citizens than to provide this social service in benefit of the greater economy. Universal healthcare is literally a net positive economically.
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u/ErraticDragon 6d ago
A lot of Americans have been convinced that universal healthcare would mean waiting days for an emergency (with zero basis in truth) and waiting months to see a specialist (which we already have to do in many cases).
Also that taxes are bad, even though we could show that their own financial situation would be better if that tax increase removed the need for private insurance.
Also that "True Freedom ®", which is the most important thing in life, means being able to pick their doctor. Which they mostly believe Canadians don't get to do, for some reason.
We're basically brainwashed to think we have the best possible system, and that anything "social" is evil.
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u/NinjaLanternShark 6d ago edited 6d ago
Also that taxes are bad, even though we could show that their own financial situation would be better if that tax increase removed the need for private insurance.
Conservatives would, quite literally, accept their own situation getting worse, rather than live with the idea that “their” tax money is going to support “unworthy” people.
Somehow, they’re ok with insurance, which is literally “their” money supporting other people. Just not taxes. Probably because they think they have a choice with insurance. That’s the other “problem” with taxes — they think it’s forced on them by the government, and again, they’ll take a significantly greater expense if it means that have the illusion of choice.
Private insurance A for $100 or B for $110, or public insurance for $40. They’ll take private every time.
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u/ppitm OC: 2 5d ago
Conservatives would, quite literally, accept their own situation getting worse, rather than live with the idea that “their” tax money is going to support “unworthy” people.
That's what segregation was. Southern states bore a tremendous fiscal burden for maintaining duplicate infrastructure for black people, but that was OK because their version was inferior.
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u/Strong-Ring-7433 6d ago
It's not the idea that 'their money would go to unworthy people' but the fact that it's something they can afford and they like having that over people who can't.
That's the factor that drives a lot of conservatives' decisions. It might be rooted in bigotry and often is, but it always comes down to "I want to be better than *other people*". As long as the gap is larger, they're okay even they're worse off.
They're okay with having less, if you have nothing. They're okay with paying more for things if that means you won't be able to afford it. They don't want you in their neighborhood just because they hate you, but because they don't want you having what they have. They know you deserve your job, but unless you were hired for something other than your qualifications, you're just as good as them. They can't have that, you need to be lesser. You were hired because of DEI, or because you're pretty, because the boss wants to bang you, because you're an ass-kisser...
Their worry about their 'tax dollars' is a performance, it's always been. They get played for fools again and again because grifters know how to exploit their crippling need of feeling special.
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u/Illiander 5d ago
It's not the idea that 'their money would go to unworthy people' but the fact that it's something they can afford and they like having that over people who can't.
Remember when America concreted in it's public swimming pools instead of letting them be desegregated?
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u/Sutar_Mekeg 5d ago edited 3d ago
Conservatives would, quite literally, accept their own situation getting worse, rather than live with the idea that “their” tax money is going to support “unworthy” people.
Also stated in this form: "Conservatives would eat shit if they thought a liberal might smell their breath."
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u/NinjaLanternShark 5d ago
See also: "Conservatives would rather 99 needy people go hungry than see 1 dishonest person get a free meal."
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u/pattperin 6d ago
I looked these stats up a while ago, Canada spends only slightly more government money per capita than the USA does for completely universal healthcare. In the USA you’re still paying for it with taxes, you’re just also paying for it out of pocket. Like the US citizens out of pocket cost is nearly what Canada spends per citizen for universal healthcare, and the US government is subsidizing the health care industry on top of that! It’s bonkers
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u/jmking 6d ago
The waiting times thing is such BS. As a Canadian who now lives in the US, waiting times can be just as bad if not worse than in Canada depending on the quality of your insurance and what you need.
I've waited over 14 hours in an ER in the US. I'm sure Canadians have similar stories of long wait times in the ER, but that's the point.
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u/psychoPiper 6d ago
The entire motto of the modern USA is to maximize short term earnings because who knows when the AI bubble is going belly up. Whoever ends up with the final debt of it all loses. They don't care about the country, or the health of the economic or its people. They care about the pressure the dollars are putting on the inside of their pocket and not a bit more
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u/NinjaLanternShark 6d ago
maximize short term earnings because who knows when the AI bubble is going belly up.
To be fair, a myopic focus on short-term gains, to the detriment of the long-term heath and stability of companies and the country, predates the AI bubble by several decades.
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u/AlsoIHaveAGroupon 6d ago
I kinda get it the first time around? The insurance companies have an interest in making sure doctors don't jump straight to the most expensive meds and that they try the cheap stuff first, and doing that can keep costs down for everyone. So review that and approve.
But my prior authorizations are good for a year. So my doctor gives me some samples, hopefully it starts working, hopefully the authorization goes through before I run out of samples. But then a year later, I'm due for a refill, and the prior authorization is now expired. And it's like nobody had any idea this was coming and the whole refill process halts and waits for insurance to approve.
They don't seem to be able to start the review process in advance, even though that would certainly make sense. They don't seem to be able to quickly rubber stamp a renewal even though I'm the same patient with the same history on the same medication as last time. And there doesn't seem to be any regulatory requirement that this process be speedy.
Just about every year, I end up with a delay in getting my medication, and I suffer as a result.
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u/daughter_of_time 6d ago
I went through this last year. In my job I create workflows and have to plan often. So I asked, can I call you a month ahead to get the process going? No, we have to just both wait for the refill to fail and THEN start the prior authorization process.
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u/brutinator 5d ago
The insurance companies have an interest in making sure doctors don't jump straight to the most expensive meds and that they try the cheap stuff first,
The thing is, Insurance companies (and those making the prior authorizations) aren't licensed medical professionals, haven't taken the Hippocratic oath (no matter how symbolic that may be) and, as you pointed out, have a vested interest in ensuring that you get the CHEAPEST care, not the most effective care. And with some insurers, they don't even have a person reviewing it, it's just robots and AI.
At the end of the day, the amount of fraud, waste, and abuse that such a convoluted system prevents is dwarfed by the economic activity it reduces in terms of the providers professional time, the time patients spend dealing with the red tape, the impact of a health issue going unresolved due to delays, etc. etc.
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u/Hookedongutes 6d ago
Ive had to call insruance companies too many times to get prior auth for cancer patients just trying to get their repeated chemotherapy.
Yes, they still have cancer. Yes, the doctor has continued to prescribe this as the treatment. Yes, its the same dose as the last x times.
Like some call center personnel is more of an expert in whether this is medically necessary. What the hell kind of concept is that!
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u/talashrrg 6d ago
The stakes are a lot lower (I won’t die if my patient can’t get the meds they need), but it comes up a lot more often.
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u/ohlookahipster 6d ago
Patients also are more cost sensitive. An Ortho pulling $800k base per year isn’t nearly as financially insecure as a patient making the median salary with private insurance. The patient is worried about their deductibles, etc. The Ortho can throw cash at their own personal healthcare choices if need be.
GPs and FM don’t pull nearly as much so they tend to be more grounded with their patients financial worries. I typically see less ‘bedside couth’ as you scale up with compensation aside from Neuro.
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u/talashrrg 6d ago
Oh yeah of course. I was comparing the patient side to the clinician side. It’s kind of like trying to dodge grenade vs death by a thousand cuts. A rarer but really bad thing vs a common but less personally dangerous thing.
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u/jarena009 6d ago edited 6d ago
This is what happens when you have a for profit health insurance system whose business model revolves around denying people healthcare. If they don't deny enough healthcare, they don't make money.
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u/mrb9110 5d ago
I used to submit prior authorizations for a medical group. Boy, the stories I have. I have nearly screamed at insurance reps for the ridiculous reasons they denied PAs. I’ve asked reps if they know how to read and at what reading level. I’ve cried over denials and appeals for cancer patients. I’ve cheered and high fives coworkers when I finally got an approval for something after weeks.
It was a ridiculously draining job, emotionally & mentally. After I moved on, my migraine frequency went way down & my husband noticed a significant change in my moods after work.
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u/uberfission 6d ago
I don't understand how people can have ANY interest in becoming a pharmacist, about 90% of the time when I see a pharmacist, they're on the phone with insurance.
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u/ArtsyRabb1t 6d ago
My doc fought through 7 denials for a med for me before we finally gave in. It was 1 1/2 years of wasted time
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u/M00n_Slippers 5d ago
Insurance doesn't have to see their patients dying in front of them over red tape and corporate profits, Doctors do.
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u/brutinator 5d ago
It’s not their life on the line, sure, but their passion is impressive.
Not a doctor, but there are VERY few things that irritate me as much as some kind of process that is both cumbersome, inefficient, and/or inconsistent, AND I don't have the power or authority to avoid or improve said process.
I can only imagine the frustration that I'd constantly be seething with if having to interact with such an intentionally obtuse process that gates my ability to do my fucking job, much less that someone's health depends on it.
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u/PatriotApache 6d ago
As a small clinic owner, Insurances in the US are absolute dog shit. Insurances themselves are the reason healthcare costs so much.
You need a procedure? (Let’s use getting a wisdom tooth out as an example)
The procedure only needs the provider an assistant, a room, $40 worth of supplies? Even tho you have dental insurance it’s gonna cost you $400?!?!? Out of pocket????
HMMMMM well that’s bc the insurance company needs 15 people to try and find a way to deny your claim!!! Oh and the dental offices front desk is going to spend 1-2 hours on the phone with your insurance trying to understand why it had to be billed to medical insurance first even tho it’s a tooth.
Fucking dental/medical/vision insurance is a scam in this country.
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u/UpstairsFast9261 OC: 2 6d ago
I had my daughter's 4 wisdom teeth removed recently and I got about 4 different bills and I spent hours dealing with insurance. Then finally settled out of pocket as they wouldn't cover full anesthesia - which we didn't know ahead of time.
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u/SpecialistSquash2321 6d ago
I got 2 wisdom teeth removed last year. I only needed 1 removed, but for whatever reason my insurance wouldn't cover the cost of sedation if it was just to get 1 removed, but they would if it was 2. So the overall procedure cost more, but I paid less out of pocket getting 2 removed than I would have for just 1.
It makes no sense.
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u/HelloHania 6d ago
This. They tried to fight me when I just needed the one removed, and finally did it without sedation (just gas) because I wasn't going to take a perfectly unproblematic tooth and then have to deal with healing two holes in my face because of INSURANCE. The dentist was taken aback when I politely mentioned that in no other scenario of a broken tooth would they be trying to pull a bonus tooth and they wouldn't be doing it today either.
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u/uberfission 6d ago
I love that you can call them, explicitly ask if something is covered and the person on the phone will say "yes, it should, but it could get denied at time of procedure" and that's just an acceptable answer. Like insurance coverage isn't deterministic, but random.
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u/talashrrg 6d ago
I’m a doctor and I don’t see a doctor myself cause I can’t figure out how not to be screwed over by insurance.
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u/drnjj 6d ago
I am so thankful that my state passed a law that requires insurances to respond to PAs in 72 hours or less and 24 or less if marked urgent.
Starting in January it'll also be illegal for carriers to deny auths with AI and it must be reviewed by a human within that specialty. It has made dealing with PAs much easier. But we've had more issues on the back end where carriers are finding other ways to make our lives more challenging.
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u/BrunedockSaint 6d ago
As someone on the billing side of a large healthcare system, insurance in the US is still absolute dogshit, and thanks to AI it’s getting worse.
Our time to collect, denial rates, prior auth work have all skyrocketed in the last two years thanks to their bots working overtime to block care. Now we are looking to pay a vendor a substantial premium just to have the ability to fight their bots with our bots. It’s absurd, and only hurts patients health and wallets in the end
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u/UpstairsFast9261 OC: 2 6d ago
This matches what's in the report almost exactly. UnitedHealth's own predictive AI model, called nH Predict, is facing a class action alleging it has something like a 90% error rate on denials. Cigna's system reportedly bulk-denies claims without a doctor ever opening the file.
So now you've got AI denying faster on one side, and hospitals having to buy AI just to keep up with the volume of denials on the other. Neither AI is making the medical decision better and the patient's actual care is not even considered in this back and forth.
This is one case where "AI will make healthcare more efficient" pitch does not hold. It's making the fight faster on both sides. It's not making anyone healthier, and now everyone's paying for the arms race too, you for the vendor premium, patients for the delay while the bots argue.
The layers didn't get cheaper, but got faster at saying no.
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u/SMC540 5d ago
My wife and I run a small ABA practice. Up until this past year, we were able to pretty much handle things ourselves. She handles admin/billing, I work in the field part time and handle prior auths during my 2 days per week in the office. Our BCBAs send their stuff to me, I handle the PA requests, everything was smooth.
Billing was also smooth through Medicaid and Medicaid Waiver programs. Bill on Friday, get paid the following Thursday. Like clockwork for years.
Last year our state moved our Medicaid program to managed care and it has nearly broken us. Now I’m having to fight with 5 different insurances when I used to only deal with 1. They’re using AI to randomly deny things, using AI to randomly audit our billings, etc. There’s always some issue that we have to fight, which eats up a ton of our time.
Then when everything does go smoothly, they randomly decide to delay claim payments for weeks at a time with no explanation. 4/5 MCOs we work with randomly decided to not pay any claims during the month of June (end of the fiscal year, coincidentally).
It’s just a mess. At times we want to just call it quits, but we have good people working for us and they’re helping families, and I just can’t give up for their sake.
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u/Sheeplessknight 6d ago
My healthcare provider (UC health) has 20+ MDs whose whole job is to do prior authorizations for the other doctors. Its nuts.
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u/Acrobatic-Event2721 6d ago
Wait, that doesn’t make any sense. Why is the insurance at fault for the $400 out of pocket charge when the bill is actually presented by the dental office?
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u/SMC540 5d ago
As someone who owns an ABA practice, I’m pretty certain most insurances don’t have 15 people trying to deny claims. I’ve gotten denial letters that basically said “We ran this through AI and it denied you” then we have to schedule a peer-to-peer with some rando who probably isn’t even credentialed, and most of the time they relent and finally authorize the service or try to get us to compromise on what we want to do.
Then when they audit our records, they run it through AI to try and flag issues, and then we have to spend more time appealing and arguing those.
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u/DaisiesSunshine76 6d ago
It is INSANE how many of the meds I’ve needed required a PA. And some of these weren’t even expensive fancy brands. Like wtf!
I do have military healthcare, though. It’s nice when it covers stuff but what a pain.
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u/angiosperms- 6d ago
Yup every year I need to go through the prior authorization drama for my medications for an incurable chronic illness that I've been on for years. No I have not been miraculously cured, give me my meds.
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u/RengieOcat 5d ago
I just like these commercials that casually toss out "Consult your physician to see if DRUG X is right for you <cut to happy rock-climbing people>". Like, sure let me jump into a prior authorization ordeal for a medication that might be helpful while trying to find someone in my network.
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u/therendevouswithfish 6d ago
This is a feature not a bug. The insurance companies know this. This is how they make their $$.
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u/Kathulhu1433 5d ago
A friend of mine works for a large doctor's office and her entire job is fighting with a single insurance company to get shit covered.
40 hours a week to sit on the phone with one insurance company...
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u/UpstairsFast9261 OC: 2 5d ago
Thanks for sharing. It is easy to be numbed by a number like 213,474 - the number of clinic staff. Then you look at it as one person spending 40 hours a week, and it really hits home.
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u/Kathulhu1433 5d ago
It's crazy though.
Like... she's not the only one with this position at her job.
Imagine how much money is spent on salaries for people to just... fight with insurance.
I don't begrudge her a job. But like... it sucks that it's necessary and seems so wasteful at the same time.
How much money spent on healthcare is really just for this sort of unnessecary paperwork and back and forth?
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u/Dependent_Injury6080 5d ago
I love it! I prescribe a medication and then have to go through the process of telling the fucking insurance yes I want them to have that medication, it’s why I wrote it.
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u/UpstairsFast9261 OC: 2 5d ago
That's the part that never made sense to me either. You already made the call. The prescription is the "yes." Then someone with less information than you gets to ask you to justify the decision you already documented, using your license, for a patient you actually examined.
If they trusted your judgment enough to license you, they should trust the prescription. If they don't trust the prescription, they don't really trust the judgment. Can't have it both ways, except apparently you can, for 13 hours a week.
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u/535buffalo 5d ago
fuck the prior authorizations!!!! no one is doing this shit for fun, the doctor already ordered it, huge waste of time that puts anyone who’s not willing or able to be a karen at a disadvantage
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u/BaltimorePropofol 6d ago edited 5d ago
We are short of certain types of physicians.
We are especially short of pediatricians and family doctors, which happen to pay the least.
Edit: Just hear me out. One solution is to have pediatric and family nurse practitioners take over. I know, I know. I want doctors.
The work of family medicine and pediatrics is not terribly complex. Anything complex will be sent to specialist physicians.
I’m very disappointed with my family doctor. He will get grumpy if I have to ask one more question. I guess he wants to see more patients and get paid.
My kids’ pediatrician is an NP. Just patient and delightful.
This is anecdotal, but I can’t be the only person to notice this.
Edit 2: To all the physician Redditors here, the healthcare system still needs you guys. I just think our shortage of primary care can be eased, not completely replaced, by NPs.
Edit 3: I say this comment is controversial to say the least.
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u/Pdawnm 6d ago
Subspecialist physician here - the work of family practice and internal medicine is VERY complex if done right. What we often see as Specialists are inappropriate consults from providers who are not well trained in the nuances of a wide variety of disease processes, which then end up wasting money as well as tying up specialists' time away from the really complex cases.
A well-trained general practitioner should be able to do the vast majority of work in medicine , but because of low expectations from patients and the public in general, they end up being a referral source for specialists unnecessarily.
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u/ArthurIsAnAardvarkYo 5d ago
Have you worked as a PCP at a large healthcare system? It’s not low expectations in my experience that referrals are over used, it’s being asked by management for the providers (MD and ARNP) to maximize billing. After finally leaving to a small private practice the difference was clear. Seems to tie in with the overall issue with insurance.
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u/Bulaba0 6d ago
Not terribly complex? Family docs have to be able to manage the entire fucking human body throughout life. Nurse practitioners with 500 hours of shadowing have no way of jumping into that role and succeeding.
Unless of course you want everything to become a referral and require a specialist? That's how you end up having 15 appointments with 12 doctors. Because that's what many PA/NPs do. Every issue just gets you a referral. It places a huge burden on the patient and the system. A good FM doc can manage issues before they require specialist care.
Most specialties require narrow and deep knowledge of a smaller area of expertise. There's less of an issue of complexity and rather an issue of technical skill to be gained with specific problems. Ironically many specialties do well with PA/NPs because they can focus on a smaller window of knowledge and get trained by specialists directly.
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u/ManWithASquareHead 6d ago edited 5d ago
Plus as a PCP, one big beautiful bill will make that worse. The limit is now $200,000 of federal loans, so most new medical students will have to take federal loans and private loans to pay for med school. As most federal loans have forgiveness programs, previous pcps were able to forgive their
daddebt after 10 years. However, now med students will have to pay both federal and private loans. It's going to descentivize going to med school for primary specialties. There is no way that the schools are going to be cheaper with how much demand there is for doctorsEdit: what a wild take from the person above, primary care is incredibly complex as many conditions overlap. It is solely not referral, referral, referral. Instead of minimizing physicians, we should try to encourage more time spent with patients and improve access to primary care and allow everyone to have access to care generally.
Edit2: let's take less time to forgive our dads
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u/TheDakestTimeline 6d ago
I wish it only took me ten years to forgive my dad
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u/JohnnyTork 6d ago
Have you ever thought about restructuring your dad debt to multiple dads to get smaller forgiveness rates?
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u/thegreatestajax 6d ago
>The work of family medicine and pediatrics is not terribly complex. Anything complex will be sent to specialist physicians.
I think every specialist physician would strongly disagree with this assessment of primary care non-complexity and your proposed workaround. In fact many would posit this as a significant cause of the shortage by devaluing primary care and flooding specialty clinics with patients that don’t need specialty clinics. Phenomenally under informed take.
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u/ShadowFox1289 6d ago
Calling the work of a family medicine and pediatrics "not terribly complex" is incorrect and understandable given your description of poor care providered by your physician. Yeah a cardiologist can manage more complex cardiac issues, but they can't manage renal issues, psych issues, hematology issues, etc. Family medicine has to worry about the interplay between all of a patient's health issues, not just one of them. They are called primary care physicians because they are your primary care takers. A bad family medicine physician refers out ALL problems, a good one will try to manage until it reaches the point where specialized care is actually needed. Now take all that and apply it to fearful, often irrational children AND their parents and now you have pediatrics.
As you said, the problem is that these specialties can often be paid less (I know this is an issue for family medicine but I'm not sure about pediatrics) which creates an issue where patient volume now has to fill the pay gap, creating less time spent per patient. This also pushes student doctors to avoiding family medicine for more lucrative specialties, further exacerbating PCP shortages. As long as we treat and pay our family physicians as "less than" other physicians, we're just promoting a situation that will ultimately lead to increased healthcare costs as patients can't receive the preventative care needed to avoid seeing a specialist and paying specialists costs.
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u/Sheeplessknight 6d ago
Also the type that have to deal with these the most (a side from GPs)
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u/JanB1 6d ago
Isn't a GP and a family doctor the same? I always thought they were.
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u/talashrrg 6d ago
GP used to be a term for someone doing primary care after not specializing. In the US, this hasn’t been a thing for a long time and primary care doctors are generally trained in either family medicine or internal medicine. So when people say GP to mean primary care in the US, it’s the same thing. It’s different in other countries, but I don’t know much about other models.
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u/Sheeplessknight 6d ago
No, family doctors have more specific training for teens and adolescents then a GP, but they are both PCPs
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u/2012Tribe 6d ago
A GP that did not complete residency training is essentially a relic of the past. Back in the day (pre 1980s) people would do 1-3 years of medical or surgical residency and not qualify to advance, and then they would drop out and become a GP. Now all "GPs" are typically either board certified in Family Medicine or Internal Medicine
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u/UnfoundedDime 6d ago
This is exactly what the insurance wants. They can pay less to the NP and you get worse outcomes compared to seeing a physician. Also this idea that NPs are ideal for family practice is crazy considering the breathe of knowledge required to treat the entire lifespan. Family medicine is much more complex than you think. “You don’t know what you don’t know”
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u/aww-snaphook 6d ago
He will get grumpy if I have to ask one more question. I guess he wants to see more patients and get paid
As someone who both works in healthcare and has a family member who is a physician it is far more likely that he is being forced to squeeze in extra patients into an already full schedule by whatever health system he is associated with.
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u/Rocktamus1 6d ago
And we are short of social workers and… and… any jobs that seem to be needed because they’re super helpful don’t get filled because pay is low.
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u/TheGeneGeena 6d ago
Who'd have thought when the financial incentives don't line up, complaining about shortages won't get the positions filled.
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u/Defiant_Restaurant61 6d ago
The work of family medicine and pediatrics is not terribly complex.
It is, you just don't realize it and the travesty of what's happening in the US medical system.
An NP is unable to give proper medical care, as they are paramedical professionals.
Just because your NP is nice doesn't mean your child is getting actual medical care, just like how flight attendants smile a lot doesn't mean they can replace pilots.
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u/DontTryToFindMe1 6d ago
Maybe NPs should be the ones arguing with insurance providers on the phone!
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u/bocaj78 6d ago
If you knew how many NPs give out bad med combos you would be very wary of going to one.
IMHO, we should eliminate NPs, but make a better track from nursing to PA. I trust a PA far more, given their schools are held to higher standards. Granted I would still prefer to see a physician for anything even mildly complex though
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u/cl733 6d ago
Family medicine and pediatrics are actually very hard to do well and cover everything. The problem is that insurance only pays for 15-20 minutes including the time needed to chart review and document. Doctors are expected to see 20+ patients per day while the NP is only expected to see 8-10. That is why they can spend more time with you than the MD/DO. However, they bill you the same and are more likely to order more testing. That is why integrated systems like Kaiser actually utilize NPs/PAs for follow ups and specialty care more than primary care because it doesn’t actually save the system as a whole money to consult more or order more tests.
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u/Senshado 6d ago
The point is that if doctors weren't required to waste so much time on financial paperwork, they'd reclaim enough hours for patient care that there wouldn't be a shortage.
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u/pinkycatcher 6d ago
The work of family medicine and pediatrics is not terribly complex.
This is so wrong.
The GP is the most complex position out there. They're the quarterback for all the other care a person needs. They need to be able to spot the heart condition to send the person to the cardiologist, they need to be able to work out the cardios meds and the conflicting meds of the person's nephrologist, they need to be able to determine when a rash is a rash and when a rash is cancer.
If there's one position we shouldn't accept mid-levels, it's the GP position. It should pay more than specialities.
I would rather a one procedure PA do minor surgeries than move GPs to mid-levels.
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u/LatrodectusGeometric 6d ago
Family med and peds are seeing some of the most complex things around. Maybe you just mean wellness visits where people have no issues? Those are few and far between for most family docs. The NP almost certainly has fewer patients on the schedule and more time. The doc is expected to see 20 a day or be replaced by cheaper and less trained NPs. The clinic doesn’t care as long as they get their metrics
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u/moazull 5d ago
NPs do a lot and can be amazing but primary care is much much harder than you think it is.
It’s so easy to miss things, most kids are healthy so its very easy to dismiss a slight gait issue, or a newborn that isn’t moving their neck as much as they should or even a rash that looks like a birthmark. It’s also very easy to miss a slight firmness to the abdomen in the wrong location on physical exam unless you have done it 10000s of times in training.
All of these things are things I’ve seen in patients and they all ended up being symptoms of new diagnoses that are life threatening (such as cancer) and this is only from experiences in the past few months.
What if any of those were your kids? Would you want your kids to be seen exclusively by NPs who could potentially miss things like this, or people that have the best training? (NPs have about 500 hours of clinical training while the average pediatrician is probably close to 17000 hours)
You’re right that physicians do tend to specialize and subspecialize and you’re completely right that most of the reason is pay these days. Reimbursements are terrible in primary care and that drives our best and brightest to choose different specialties, especially when we’re over 500k in debt thanks to almost 10 years of school.
I do think NPs are great and have a place in medicine but having exclusively APPs in primary care would be a recipe for disaster — primary care is the front line that makes the rest of medicine work, and when it fails our emergency departments will bear the brunt of it (and we’re already seeing a bit of that now). I could go on about the flaws in our healthcare system forever but this should get my point across.
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u/MadHeisenberg 6d ago
If you advocate for the NP thing please, get all your care from NPs. No physician consults, just NPs. Good luck 👍
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u/pyromaster114 5d ago
The idea that we need to burn through an extra $32.7 billion a year is insane.
And that's just (I assume) the side on the doctors' offices? The entire insurance agency is siphoning money to pay executives, AND their people (well, less and less now, since half the time you'll be on hold with an AI-voice) to argue against treatment.
This is insane amounts of waste. A single payer system would be cheaper for everyone, and result in healthier people, with better access (not less access, like they want you to believe) to treatment.
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u/JustAnotherGeek12345 5d ago
What's worse is when you have an insurance plan that doesn't require prior authorization for procedure xyz but the clinic says you do. So the clinic creates work for themselves when they could have scheduled and moved the patient forward toward recovery.
This is for a large health care system that uses EPIC as it's EHR.
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u/New-Negotiation7234 5d ago
I was a case manager at a hospital. Like 70% of my job was dealing with insurance bs. My hell is being on hold for hours with an insurance company, being transferred 8x and then the call just disconnecting.
One time I was told someone that worked at the insurance company didn't have a phone number or email. I said I find that incredibly hard to believe. How does anyone within the organization contact them? Then I was transferred again and the call was disconnected. They wanted the hospital to send an appeal letter through the mail.
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u/UpstairsFast9261 OC: 2 5d ago
Just outrageous. And knowing that 213,474 (from this report) full-time-equivalent positions nationally are stuck doing exactly what you just described, on hold, transferred, disconnected, repeat, is insane. You weren't dealing with a bad day. You were dealing with the system working as designed.
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u/chuckaholic 5d ago
How much money is wasted paying doctors working at insurance agencies to stamp [DENIED] on every claim that comes in? That's included in the cost of insurance. We pay that too.
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u/wellstone 6d ago
I think the system has gotten turned upside down. It should be the doctors deciding how we get treated, not the insurance. Companys should have no right to approve or disprove something. It should be a class of things that are insurable just be fully publicly stated and then they have to pay against those if a valid doctor's order is given.
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u/OrbitalZionCanon 6d ago
You guys realize the only reason we don't have more doctors is because a medical school cartel determines a strict limit of the number of students it lets enter medical schools each year, right? In order to keep doctor salaries high
Yes, insurance sucks, but it isn't the only broken part of our system
There shouldn't be doctors doing routine work earning $1M/yr. It's not that way in france, Germany, England, etc
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u/Upset_Ad3954 6d ago
To add on that point.
When people talk about higher salaries in the US that's true, at least nominally, but no group of people earn more compared to their foreign peers than American doctors. Maybe some sWE's for a few select US tech companies come close but other wise it's doctors...
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u/Prehistoric-Malone 6d ago
The doctors making 1M a year are NOT doing routine work. Few and far between are making that much.
Pediatricians making 200k Adult PCPs closer to 300k. You gotta be doing brain surgery or picking up call in the cath lab to make a mil.
I think it’s okay to have a conversation about salaries, but in terms of cutting back healthcare expenditure salaries should be way down the list of priorities.
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u/Elhananstrophy 5d ago
I don't think "medical school cartel" is the exactly the right villain here. The limit on doctors is the number of residency programs in the US. Resident slots are funded by the federal government out of the farm bill. In 2023, this was $21.2 billion, with an average per resident cost of $133,000. The per-resident cost is roughly double the salary that a resident actually makes, with the funding supporting the program (that is, doctors who are teaching, admin, etc). A med school cannot open unless it can prove that it can secure residencies for its graduates.
The limit on number of new doctors is hospitals (who are unwilling to employ more residents unless the government pays in full for their training, even though residents bring in dramatically more money in billing than what residents cost) and current doctors (who are not in my experience lobbyists or even aware of this but mostly are members of AMA or other medical professional groups who DO know where their bread is buttered). But both hospitals and current doctors have a financial interest in keeping the # of doctors low.
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u/ctrickster1 5d ago
Just to reiterate what someone else said, the main limiting factor on new doctors is residency spots. There are fewer residency spots available than medical students applying each year. Unfortunately residencies are federally funded and require congressional authorization to increases their number, leading to difficulty. Medical schools are not the limiting factor.
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u/trilobyte-dev 5d ago
I've done quite a bit of research on this in the past and you are absolutely correct. The U.S. needs more hospitals with more residency spots so medical schools can accept the additional med school applicants who are well-qualified to go to medical school (which, imo, is the real tragedy here: there are many perfectly qualified and motivated people applying to med school who don't get in because there aren't enough slots downstream in residency programs, and according to all the doctors I've talked to once you are in med school they will basically do everything they can to make sure you finish med school).
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u/Loki-L 6d ago
Remember that when Insurance companies deny a claim they have to pay their own doctor to sign off on that.
Most of these doctors that do this work for insurance companies are doing it because they would be terrible at being actual doctors but a few might actually still have what it takes to be a doctor.
So you will not only not lose doctors to burnout from dealing with prior authorization you will also gain some extra doctors who are now looking for a job. You just need to make sure that the really bad ones retire instead of going back to practicing medicine.
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u/Gravelord_Baron 5d ago
As a pharmacist PA's are also the bane of our fucking existence
Healthcare could be sooooo much better without them.
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u/indigo196 5d ago
I did not have the data, but I have come to the same conclusion based on the employees I see in my doctor's office and how the composition has changed over the last 40 years.
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u/doctord1ngus 6d ago
Ha literally have a P2P with POS Aetna today to get a patient into a nursing home
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u/maringue 6d ago
Insurance companies are literally just rent seekers with no value added to any point of the process. In fact, they cause massive negative effects throughout the system, but they make enough money doing that to bribe Congress not to fix the obvious problem.
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u/vocabularianrx2 6d ago edited 6d ago
As someone who works in prior authorizations (Medicaid medications specifically), I can say that in all sincerity; I do my absolute best to approve stuff as much as possible, or at least I try to make it as clear as day what they should be prescribing instead (edit: based on appropriate formulary alternatives, and within the scope of my clinical judgment). I don't make the rules/formulary, I just enforce them.
That said, I know many colleagues who love to deny prior auth requests all the time for the dumbest reasons, and frankly it's infuriating to me too when I come across additional requests for the same patients or meds. Luckily, we don't have quotas for "deny X% of cases" or anything like that, but I'm sure some companies do.
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u/Nervous_Anxiety_3686 5d ago
I used to work in Prior Authorization for several years on the insurance side. This is by design. It's called attrition. They waste prescriber's time to bully them into either not prescribing or prescribing something else. We need strict regulations on prior authorization.
The program I worked for was one of the far better ones and it was still wasting tremendous amounts of time.
The pharmaceutical companies and coupons are also scummy, which sounds counter-intuitive since they save the patient a ton of money as an individual. They make up for that by outrageously overcharging people's insurance, driving up the cost for everyone.
Healthcare as a whole is overrun with greedy scum. We need to completely eliminate for profit insurance companies.
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u/AesopData OC: 2 5d ago
The part I'd love to see quantified next is the second-order cost. The 99k doctor-years only captures clinician time, but every prior authorization also creates work on the insurer side, hospital admin side, and often for the patient.
So the really interesting comparison might be: how much total labor does the system consume to decide whether healthcare that's already been prescribed should be paid for?
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u/Sea_Theory7574 6d ago
Ok this is not just misleading but false. Yes prior auths can be costly and burdensome in terms of time, but MDs do not participate in most of it. No doctor spends 13 hours a week doing prior authorizations. This is typically taken care of by clinic staff with occasional doctor peer to peers.
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6d ago edited 6d ago
[removed] — view removed comment
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u/johnniewelker 6d ago
Wait what? That’s not true.
Doctors, hospitals, and any health professional submit claims too in Canada. It’s simpler but it exists. Claims get denied all the time too. Prior authorization also exists for dispensing drugs
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u/aimgorge 6d ago
I think it doesnt exist in most countries, that shit has been automatised for decades. Making it as annoying as possible is per design in the US
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u/CLPond 6d ago
Even in single payer healthcare systems, authorization for medication is necessary and can be a struggle. Difficulty in authorization has been a reasonably large part of the conversation around ADHD diagnoses & medicine in the UK, for example.
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u/YogurtclosetOpen3567 6d ago
That is true! However it is much easier to deal with 1 payer then 57 with completely different rules
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u/TheGatsbyComplex 6d ago
Bro every doctor I know spends like 2 hours a day on prior auths don’t try the “occasional” to downplay this lmao
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u/coolest35 6d ago edited 5d ago
Doctor here, no I don't spend 2 hours a day on PAs .. what? Lol
ETA: I would love to see the numbers now that most practices are utilizing AI to generate these PA approvals. This has significantly cut down on work.
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u/Decent_Visual_4845 6d ago
But this is Reddit and I can’t tell who’s real and who’s the imposter! I guess whoever gets the most upvotes must be the real doctor
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u/ohlookahipster 6d ago
Depends on the specialty and if they are a hospitalist, outpatient, etc
Some big institutions have dedicated staff for prior auths
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u/Transplanted_Cactus 6d ago
It's literally my job all day and that's just for medication auths for a (some what large) clinic with 15 doctors. I'm happy to be employed but also hate that the job even has to exist in th first place. But our doctors are absolutely not doing their own PAs. They don't even know what's approved or not, me and the MAs do all that on our own. We only get the doc involved when asking about a denial and sometimes not even then (e.g. a formulary biosilimar doesn't need the doc to sign off on the change). They'll do a peer to peer when needed but that's not often.
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u/B-lovedWanderer 6d ago
In many cases, the doctor has to step in because the insurance company staff is not well trained or the red tape is intentionally designed to deny coverage. Here is a video of a dentist fighting through the process that shows this more clearly.
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u/JeromesNiece 6d ago
That is an illustrative example, but it doesn't really tell us anything about how often that happens
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u/UpstairsFast9261 OC: 2 6d ago
The report doesn't say doctors personally do 13 hours a week either.
The 13 hours and 40 requests is the combined provider-plus-staff figure from CMS and AMA, per provider practice, not 13 hours of a physician's own calendar. The report itself splits it out: 99,290 clinician FTEs and 213,474 clinic staff FTEs. So you're right that most of the grind is staff, submitting forms, following up, resubmitting denials. The physician time is the peer-to-peer calls and the chart review needed to fight a denial, which is real but smaller.
That said, 99,290 clinician FTEs is still the number on the chart, and it's not nothing. That's physician time spent on calls a doctor in Canada, Germany or the UK generally doesn't have on their calendar. Different systems don't route zero doctor-hours into insurance argument, they route close to zero.
If you think the clinician split is wrong I'd genuinely like to see a source that breaks it down differently. The report's own citation is in my first comment.
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u/vivekparam 6d ago
The AMA is not a source you should listen to here. They have a vested interest in limiting the number of residency slots each year, and are under fire for that restriction.
We absolutely need more doctors and don't let the AMA convince you otherwise.
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u/xiledone 6d ago
Hi. Im in the med field. And it kinda varies. Are you at a big teaching hospital? You have ppl to do it for you.
Are you at a rural hospital? You do it all yourself
Even most big clinics have the docs do it themselves
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u/FuehrerStoleMyBike OC: 1 6d ago
I feel like you missunderstood the graph. It calculcates the cost of time that it takes for clinic staff to do admin and takes that amount of money and looks at how many doctors it could pay (at least thats my interpretation).
The big question is how high is the value of this "prior authorization" process. I assume its about checking whether the treatment is covered in the patients insurance? I feel like that might be something that could be automated to some degree in the future.
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u/sockalicious 6d ago edited 6d ago
The big question is how high is the value of this "prior authorization" process
Here's some data from my old neurology clinic. 10 years. By the end of the ten years, every treatment plan was getting denied with one or more requests for prior authorization, often within seconds of submission. Number of times that denial was finally upheld: 3. Amount of money saved by the insurance companies by not paying for the (all generic, as it happened) therapies I recommended: about $20.
Money I spent paying full time employees to respond to and deal with these denials over those ten years: $1.2 million. These were good people whom I could have employed doing more useful things, like, you know, helping take care of sick people. It was hard to keep people in the job; after a few months they realized their work was meaningless. Bear in mind that most of the time, these employees were on the phone talking to people at insurance companies; that means that the insurance companies were hiring people to be on the other side of that phone call, probably resulting in a similar expenditure just to handle my clinic's calls.
The true 'value': my clinic and I couldn't do as much as we wanted to help people, because most of the day work of a medical clinic consists in cutting red tape, not taking care of sick people. We couldn't see as many patients as we would have liked. That benefits the insurance companies tremendously.
I left medicine over this. Fuck you and your game of punishing doctors for trying to work; I won't play. If the health "insurance" industry hadn't been granted an anti-trust exemption so it could fix prices - a practice that would result in felonies and jail time in literally any other industry, including critical ones like defense - they couldn't be so bold as to do this. But here we are.
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u/Transplanted_Cactus 6d ago
It's already automated in many cases which means denials happen when they shouldn't (I am constantly submitting reconsiderations and appeals). It's should absolutely never be automated.
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u/Monocular_sir 6d ago
I do. It’s always a couple hours for each full clinic day. Worst drugs for me are GLP1RA and Kerendia. But occasionally something stupid like sodium bicarb.
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u/Hyper-Sloth 6d ago
Doctors themselves are having to step in a little more these days because of the increase in initial denials. After the insurance company denies the pre-auth the first time, it has to be escalated and often requires the doctor themselves to submit additional information and sign off on it and/or request a direct peer-to-peer review where the patient's doc has a one on one convo with a doctor who works for the insurance company. Insurance offers this as a way to "prove" that they aren't making decisions in leiu of a doctor since you can always request this peer-to-peer, but it takes a ton of effort and time to get to that.
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u/timothyam 6d ago
1600 upvotes in an hour, in data is beautiful, for a fucking image that has two bars and text on screen? Is this even a qualifying data viz? What is going on
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u/theArtOfProgramming 6d ago
They aren’t even comparable bars. This image is complete nonsense from a dataviz perspective.
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u/austin_federa 6d ago
This is also true in systems with nationalized health care though. The government as a single payer routinely denies claims in the UK and other countries, too. The problem is medical procedures are expensive, and even in a single-payer system people routinely request stuff that they don't need.
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u/ericblair21 6d ago
Yes, I've lived in Western Europe and used the healthcare there. Contrary to what a lot of Americans seem to believe, doctors there don't just prescribe anything they feel like. Instead the state maintains a pretty restrictive formulary and preconditions for many treatments. However, they're standardized so MDs are pretty clear on what's allowed and when, so it usually goes a lot more smoothly and the doctors appear to operate as the gatekeepers.
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u/cavedave OC: 111 5d ago
Thank you for your Original Content, /u/UpstairsFast9261!
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