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<v Speaker 1>The real question I have to ask myself, is this

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<v Speaker 1>this really medically necessary? Do I need prior authorization for

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<v Speaker 1>this speech? And if so, will I get denied by

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<v Speaker 1>the algorithm? Jonathan.

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<v Speaker 2>The article explains how insurance companies outsource their denial or

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<v Speaker 2>approval of claims for pre approved medical procedures. Companies like

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<v Speaker 2>evicre that use an algorithm to sort through the requests

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<v Speaker 2>and approve most of them, but if it sees any

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<v Speaker 2>possible discrepancies or anything they don't like, they shunt the

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<v Speaker 2>request for the review of a doctor. These doctors have

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<v Speaker 2>about four minutes per review generally, and four minutes is

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<v Speaker 2>not a long time to get a case reviewed. To

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<v Speaker 2>approve or deny it doctors, it requires a doctor to

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<v Speaker 2>deny a request, so the company makes money. With every denial,

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<v Speaker 2>the requests have to be denied again by a doctor.

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<v Speaker 2>Some of the companies medical personnel report that they were

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<v Speaker 2>given requests for services for service that were not in

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<v Speaker 2>their area of expertise. A cardiologist reviewing a gastro intensinal

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<v Speaker 2>or oncology request. This is a long but disturbing article.

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<v Speaker 2>Story is from pro Publica by T Christian Miller on

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<v Speaker 2>October twenty third, twenty twenty four.

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<v Speaker 1>So is this medically necessary to be run by the algorithms,

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<v Speaker 1>to be run up the dial, and to be denied

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<v Speaker 1>by somebody who frankly doesn't have a clue. I mean, yes,

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<v Speaker 1>they'll have some medical clue, but you're not going to

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<v Speaker 1>have a clue if you're a p dietrist talking about

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<v Speaker 1>you know, stomach cancer, now are you? I mean, this

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<v Speaker 1>is the level of what we're talking about here, because

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<v Speaker 1>these doctors who work there, they're going to have multiple specialsts.

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<v Speaker 1>You're going to have dermatologists, You're going to have gastro entropologists, cardiologists, pulmonologists, endocrinologists,

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<v Speaker 1>et cetera, all doing these things that they enjoy doing

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<v Speaker 1>and thinking of going to do my bit to help

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<v Speaker 1>the American healthcare system. If you think you're doing a

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<v Speaker 1>bit to help the American healthcare system, help dismantle the

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<v Speaker 1>American healthcare system. But that's a discussion for another day.

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<v Speaker 1>Because the American health care system is it currently is.

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<v Speaker 1>Constitution needs a good root and grand to rip up

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<v Speaker 1>and start again, as I have found through my time

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<v Speaker 1>living here. So a j do you enjoy the American

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<v Speaker 1>medical system?

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<v Speaker 3>I have ample experience with the American medical system. You know,

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<v Speaker 3>I have a whole lot of of health issues myself,

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<v Speaker 3>and so I have actually personally had experience with this

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<v Speaker 3>type of you know, requests because my my insurance is

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<v Speaker 3>an HMO, so you are required to submit pretty much

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<v Speaker 3>for outtervization for anything you want to.

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<v Speaker 1>Do in health organization.

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<v Speaker 3>Yeah, the best worst. So so I had, for example,

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<v Speaker 3>I have a pain condition, right, it's very painful and

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<v Speaker 3>will affect my leg. You know, I couldn't walk, I

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<v Speaker 3>had to be unconscious sometimes in a wheelchair. And there

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<v Speaker 3>were times where I only need a nerve block, and

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<v Speaker 3>so my doctor would submit the request for the nerve

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<v Speaker 3>block and they will deny it and we will look

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<v Speaker 3>into it, and it was just such dumb things like

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<v Speaker 3>often it will be like a small wording or like oh,

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<v Speaker 3>you're going to use this type of.

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<v Speaker 4>Anesthesia and we don't, we don't cover that.

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<v Speaker 3>So they deny it just because they were going to

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<v Speaker 3>use some type of anesthesia that wasn't under the specific

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<v Speaker 3>I guess under the dial or mailing the dial that's

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<v Speaker 3>mentioned on the article. So yeah, it's it's a mess.

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<v Speaker 3>And I had this happened so many times and you

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<v Speaker 3>get tired of having to appeal and having to try

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<v Speaker 3>again and again for something.

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<v Speaker 4>That you know you're in your extreme pain.

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<v Speaker 3>You're like, I hope I can have this procedure in

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<v Speaker 3>the next few days, but no, you have to wait

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<v Speaker 3>weeks sometimes months.

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<v Speaker 1>Yes, so you remind me a friend of mine, and

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<v Speaker 1>I'm allowed to shock. They posted this publicly on social

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<v Speaker 1>media that they have a medical condition, they have Chrohn's disease,

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<v Speaker 1>and they have a thirty thousand dollars drug. But that's

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<v Speaker 1>the list price of the drug before insurance comes in.

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<v Speaker 1>And without this drug, they will die. Straight up. They

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<v Speaker 1>will just die because, you know, Chrome's disease in severest

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<v Speaker 1>forms you just cannot digest and absorb nutrients from your food.

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<v Speaker 1>You just can't do it, so they will. They recently

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<v Speaker 1>denied her same drugs she's been getting forever, same drugs.

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<v Speaker 1>You'll need it. The other day she dies. No, don't

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<v Speaker 1>need it this time. It's not medically necessary, they say,

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<v Speaker 1>just because, and then they resubmitted. Oh no, no, no,

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<v Speaker 1>you're going to resubmit that again in ninety days. And

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<v Speaker 1>then they'reday, oh yeah, just have it, no rhyme, no reason,

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<v Speaker 1>no understanding of the ins and out. No conclusion here

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<v Speaker 1>or anything. It's just the whim of a computer, the

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<v Speaker 1>whim of the administrator because they have sent it from

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<v Speaker 1>being robber stamped to denied I don't care what they say,

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<v Speaker 1>or to go to denied by a doctor. The delay

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<v Speaker 1>is denial. Sending it to the doctor is a form

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<v Speaker 1>of delay denial. And you have to accept that some

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<v Speaker 1>of these things will kill people. Like the gentleman in

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<v Speaker 1>the article. He died because they said no through delay

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<v Speaker 1>and delay and delay, and he is dead now. The

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<v Speaker 1>American healthcare system is sometimes the American death care system

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<v Speaker 1>because it is just there to facilitate people not to

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<v Speaker 1>get better, but to be money milked and then they die. So, Jonathan,

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<v Speaker 1>you've got a slightly different view on this. You're a

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<v Speaker 1>member that can access the Veterans Affairs Department if I'm

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<v Speaker 1>accurate here, So how does it work there?

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<v Speaker 2>Well, the VA is a different system. It's a government system,

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<v Speaker 2>and if you are have a service related injury or condition,

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<v Speaker 2>it's rated. It's given a percentage disability rating. But you

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<v Speaker 2>can go with no if you just have health issues, uh,

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<v Speaker 2>and they're not related to your military stove. You can

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<v Speaker 2>still use the VA, but it's it's you're gonna be

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<v Speaker 2>charged a nominal fee for things and sometimes not so

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<v Speaker 2>nominal uh, and you're gonna have to pay for a

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<v Speaker 2>lot more of your medications and things. But if you're

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<v Speaker 2>like me and have a high enough rating, and most

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<v Speaker 2>of it's free and you get priority for appointments in

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<v Speaker 2>that So it's not really a perfect system because not

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<v Speaker 2>everybody gets treated the same and not everybody gets the

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<v Speaker 2>uh the service in the same rapidity that someone like

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<v Speaker 2>me would get it. And but it does work fairly well.

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<v Speaker 2>The the VA hospitals I've been at, some of them

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<v Speaker 2>were okay, others were outstanding. I happen to live in

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<v Speaker 2>an area with an outstanding hospital here. They've taken care

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<v Speaker 2>of me through a lot of serious problems and have

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<v Speaker 2>come out more or less on top, if not completely

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<v Speaker 2>on intact. So it's it's been a it's been a

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<v Speaker 2>good experience for me. A lot of people don't like

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<v Speaker 2>the weights. The appointments can be a little bit hard

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<v Speaker 2>to get sometimes there's but they've been improving on that

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<v Speaker 2>over the last couple of three years and things have

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<v Speaker 2>gotten a lot better. There's not as much of a

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<v Speaker 2>backlog on determining if you're service connected or that, or

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<v Speaker 2>getting your rating. But and it's not as difficult as

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<v Speaker 2>it was when I first got mine, So it's but

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<v Speaker 2>it's still not an easy road. But there the attitude

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<v Speaker 2>has changed to like, let's see how we can help

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<v Speaker 2>this guy, rather than let's pick apart whether or not

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<v Speaker 2>we should help them, you know. So it's been very good.

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<v Speaker 2>I think that it can be a somewhat of a

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<v Speaker 2>model for what could be a universal healthcare system with

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<v Speaker 2>some tweaks and changes to it. But I'm just glad

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<v Speaker 2>I have because it would be impossible for me to

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<v Speaker 2>afford anything close to what I have to do now.

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<v Speaker 1>So the three of us come from three very different

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<v Speaker 1>backgrounds when it comes to interact with healthcare. I come

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<v Speaker 1>from personal which has National Health Service for a point

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<v Speaker 1>of view, Ajau comming it from an HMO, and Nathan

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<v Speaker 1>you comming it from the Department of Veterans Affairs. So

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<v Speaker 1>why are so many Americans comfortable with this as their

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<v Speaker 1>health gare system? Why are they so comfortable with this

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<v Speaker 1>is their healthcare system?

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<v Speaker 2>Measure?

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<v Speaker 3>I don't think that you're comfortable with it necessarily. I

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<v Speaker 3>think there is so much going on in our country

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<v Speaker 3>and you know, in our personal lives at all times

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<v Speaker 3>that at some points we just have to choose why

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<v Speaker 3>do we put certain issues aside and just deal with it.

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<v Speaker 3>We often feel that the problem can be so massive

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<v Speaker 3>that or in the middle or fight back is just

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<v Speaker 3>not enough to affect any kind of change. And you know,

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<v Speaker 3>I feel this way, you know, because of all of

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<v Speaker 3>the health issues that I have, not just the pain

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<v Speaker 3>I have, like like I'm therefore have, it's just with

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<v Speaker 3>my eyes. I have had corner of transplants, have had

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<v Speaker 3>a nerve stimulator put in, and so I have gotten

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<v Speaker 3>good care, you know, when it is approved on time

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<v Speaker 3>is good. But yeah, it definitely does bring a lot

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<v Speaker 3>of stress sometimes to the way that you have to

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<v Speaker 3>jump through all these hooks in order to get that

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<v Speaker 3>type of care.

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<v Speaker 1>So as someone who comes from your where, you know,

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<v Speaker 1>health care is you know, considered to be you know,

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<v Speaker 1>one of these things called a right, not you know,

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<v Speaker 1>a luxury as it seems to be in America, or worse,

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<v Speaker 1>an employment perk. Wooh, aren't we you pleasant in America

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<v Speaker 1>to have a healthcare as an employment perk? This is

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<v Speaker 1>bonkers to me, This is absolutely bonkers to me because

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<v Speaker 1>it flips the whole system on his head because you're

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<v Speaker 1>not giving a toss about the patient here. And especially

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<v Speaker 1>as these companies I ever Care or they should be

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<v Speaker 1>sometimes called never Care.

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<v Speaker 2>Evil Core works to.

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<v Speaker 1>Slash Evil Core slash not for not ever Core decide

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<v Speaker 1>that they're going to take on these companies contracts, and

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<v Speaker 1>then you see who the parent company is, which is

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<v Speaker 1>Insurance Congloberate LLC or Insurance Provider LLC.

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<v Speaker 2>Or anther cores case Signa, which is yeah cases.

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<v Speaker 3>Yeah, I was going to mention that that to me,

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<v Speaker 3>that was like the worst part. It's like all these

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<v Speaker 3>giant companies were all interconnected. Like you said, every Core

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<v Speaker 3>is run by Overnothe, which is a brand of Signa,

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<v Speaker 3>which is the you know, insurance giant. And then the

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<v Speaker 3>next big player that does the same job as as

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<v Speaker 3>every Core it is called Karelian Medical Benefit Management. And

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<v Speaker 3>guess what, there are a subsidiary of Elevants Hope, which

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<v Speaker 3>is actually the insurance company formerly known as Anthem, so

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<v Speaker 3>it's the same company just a different name.

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<v Speaker 1>And EDNA getting on the action with another company. And

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<v Speaker 1>then do you know what makes this so egregious when

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<v Speaker 1>it comes to ETNA. ETNA own CVS pharmacies. Ethna are

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<v Speaker 1>the parent company of CVS Pharmacies. So your pharmacist is

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<v Speaker 1>in the same group as the people denying you your drugs.

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<v Speaker 4>For a second, yeah, there are those to benefit each other.

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<v Speaker 1>They are in each other's pockets, in each other's pies.

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<v Speaker 1>This is how ludicrous we have allowed the American Health Institute.

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<v Speaker 1>And it's not a design flaw, it's an absolute design outcome.

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<v Speaker 2>Of all of this design attribute.

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<v Speaker 1>Yeah, it's a criterion to maximize because at the end

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<v Speaker 1>of the day, the three of us are not humans

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<v Speaker 1>as far as concern. The three of us are a price.

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<v Speaker 1>The very article who is Dead was a price tag,

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<v Speaker 1>and we know they're a price tag because when they

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<v Speaker 1>try to sue them, their price tag to be sued

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<v Speaker 1>was too great. I find it quite weird that the

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<v Speaker 1>doctor is being sued here when the doctor went do

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<v Speaker 1>the healthcare and then they went no. So now the

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<v Speaker 1>family suing the doctor who you didn't know because they're

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<v Speaker 1>the bottom of the ladder, and.

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<v Speaker 2>The hospital and the doctor can be sued, but you

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<v Speaker 2>have to sue the other people in federal court, which

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<v Speaker 2>is a whole other animal. And they have a lot

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<v Speaker 2>of case law that denies those kinds of things behind it.

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<v Speaker 2>So until we can get judges with a sense of

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<v Speaker 2>morality about it's just going to stay that way.

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<v Speaker 1>Good luck with that.

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<v Speaker 4>Good luck with that yet.

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<v Speaker 3>Yeah, I mean, and this company inside profiting and squatching

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<v Speaker 3>each other's backs at the expense of the human beings

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<v Speaker 3>on the other side waiting for you know, often life

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<v Speaker 3>saving procedures.

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<v Speaker 5>The thing that bothers me the most is that all

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<v Speaker 5>these billions and billions upon hundreds of billions of dollars

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<v Speaker 5>that they're making could could make it affordable for universal

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<v Speaker 5>healthcare system if all that money was just spent on

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<v Speaker 5>everybody's health care.

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<v Speaker 2>You know, there is so much money they're making, but

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<v Speaker 2>if you just got rid of all that management and

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<v Speaker 2>profit and just put it into a system that's already there.

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<v Speaker 3>Yeah, but that is the whole goal for this ev

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<v Speaker 3>core type thing that they you know, their structure to

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<v Speaker 3>provide higher payout based on more denial, so they get

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<v Speaker 3>a financial incentive whenever they achieve created reduction in medical

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<v Speaker 3>spending for the hardcre you know, organizations that they're working for.

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<v Speaker 1>Here's question for the two of you, Government run programs

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<v Speaker 1>are wastefully inefficient, right, so not necessarily so. How much

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<v Speaker 1>as an overall percentage do you think Medicare spends on

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<v Speaker 1>administration costs? What as a percentage, what do you think

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<v Speaker 1>the number is?

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<v Speaker 3>Yeah, I mean I don't know. I will take a

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<v Speaker 3>wild guest, like fifteen percent.

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<v Speaker 4>I don't knoween percent.

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<v Speaker 1>What's your number? I go twenty two two two percent?

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<v Speaker 3>Wow?

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<v Speaker 2>Is it staff by ten times that amount? Okay?

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<v Speaker 1>Medicare in America spends two percent of the money it

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<v Speaker 1>receives on administration costs two percent, whereas on average, the

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<v Speaker 1>US healthcare system spends thirteen to nineteen percent on administrative

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<v Speaker 1>cost just on filling out paperwork, denying your requests. Computer

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<v Speaker 1>algorithms like this government run system medicare two percent, thirteen

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<v Speaker 1>to nineteen percent government less efficient.

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<v Speaker 3>Right, they're usually like all these very complicated systems like

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<v Speaker 3>AI and you know, like doing that a whole algorithm

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<v Speaker 3>like what they call they die.

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<v Speaker 4>Also, yeah, I can imagine that they spend a lot

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<v Speaker 4>of money on that.

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<v Speaker 1>Well, of course they do. So people hear this, We're

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<v Speaker 1>being overrun by the machine. How do we get the

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<v Speaker 1>machine to stop running the healthcare system? Jonathan how do

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<v Speaker 1>we do that?

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<v Speaker 2>You, I mean, make it a government agency that gives

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<v Speaker 2>all the healthcare. You make it a single not a

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<v Speaker 2>single payer system, but a uh you turn all these

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<v Speaker 2>silly for profit things into a nonprofit thing or not

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<v Speaker 2>for profit thing in the government where and that you

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<v Speaker 2>take all those resources that those people had and you

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<v Speaker 2>give them to this thing, and you give everybody a

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<v Speaker 2>basic level of health care in any emergency healthcare or

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<v Speaker 2>complicated healthcare. They need to maintain their lives. And it

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<v Speaker 2>shouldn't be a matter of where you are in the society,

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<v Speaker 2>or whether you have billions or millions of dollars or

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<v Speaker 2>you know, or whether you have hundreds of thousands of

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<v Speaker 2>dollars to drop on it, or whether you have to

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<v Speaker 2>sell your house, your car, your go kart, and your

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<v Speaker 2>boat in order to pay for one month's worth of medication.

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<v Speaker 2>You know, that's just you know, that's where it is.

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<v Speaker 2>And the leading cause of bankruptcy in the United States

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<v Speaker 2>is medical.

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<v Speaker 3>Expousely, I've had good yeah, I've had several procedures. Then

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<v Speaker 3>if it wasn't for the way that you know, my

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<v Speaker 3>insurance was set up, but you know, paid the complete

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<v Speaker 3>out of pocket, and I always get everything done towards

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<v Speaker 3>the end of a year, like in a hurry, because

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<v Speaker 3>that's when I know that it's going to cover everything

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<v Speaker 3>no matter what. But otherwise, you know, I will be

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<v Speaker 3>paying like what thirty thousand dollars for just to get

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<v Speaker 3>a replacement for my cochlear implant, the surgery itself with

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<v Speaker 3>like fifty thousand dollars, Like, there's no way, you know,

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<v Speaker 3>people can afford something like that.

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<v Speaker 1>It's it's ludicrous, It's absolutely ludicrous.