Speaker 1: The real question I have to ask myself, is this
Speaker 1: this really medically necessary? Do I need prior authorization for
Speaker 1: this speech? And if so, will I get denied by
Speaker 1: the algorithm? Jonathan.
Speaker 2: The article explains how insurance companies outsource their denial or
Speaker 2: approval of claims for pre approved medical procedures. Companies like
Speaker 2: evicre that use an algorithm to sort through the requests
Speaker 2: and approve most of them, but if it sees any
Speaker 2: possible discrepancies or anything they don't like, they shunt the
Speaker 2: request for the review of a doctor. These doctors have
Speaker 2: about four minutes per review generally, and four minutes is
Speaker 2: not a long time to get a case reviewed. To
Speaker 2: approve or deny it doctors, it requires a doctor to
Speaker 2: deny a request, so the company makes money. With every denial,
Speaker 2: the requests have to be denied again by a doctor.
Speaker 2: Some of the companies medical personnel report that they were
Speaker 2: given requests for services for service that were not in
Speaker 2: their area of expertise. A cardiologist reviewing a gastro intensinal
Speaker 2: or oncology request. This is a long but disturbing article.
Speaker 2: Story is from pro Publica by T Christian Miller on
Speaker 2: October twenty third, twenty twenty four.
Speaker 1: So is this medically necessary to be run by the algorithms,
Speaker 1: to be run up the dial, and to be denied
Speaker 1: by somebody who frankly doesn't have a clue. I mean, yes,
Speaker 1: they'll have some medical clue, but you're not going to
Speaker 1: have a clue if you're a p dietrist talking about
Speaker 1: you know, stomach cancer, now are you? I mean, this
Speaker 1: is the level of what we're talking about here, because
Speaker 1: these doctors who work there, they're going to have multiple specialsts.
Speaker 1: You're going to have dermatologists, You're going to have gastro entropologists, cardiologists, pulmonologists, endocrinologists,
Speaker 1: et cetera, all doing these things that they enjoy doing
Speaker 1: and thinking of going to do my bit to help
Speaker 1: the American healthcare system. If you think you're doing a
Speaker 1: bit to help the American healthcare system, help dismantle the
Speaker 1: American healthcare system. But that's a discussion for another day.
Speaker 1: Because the American health care system is it currently is.
Speaker 1: Constitution needs a good root and grand to rip up
Speaker 1: and start again, as I have found through my time
Speaker 1: living here. So a j do you enjoy the American
Speaker 1: medical system?
Speaker 3: I have ample experience with the American medical system. You know,
Speaker 3: I have a whole lot of of health issues myself,
Speaker 3: and so I have actually personally had experience with this
Speaker 3: type of you know, requests because my my insurance is
Speaker 3: an HMO, so you are required to submit pretty much
Speaker 3: for outtervization for anything you want to.
Speaker 1: Do in health organization.
Speaker 3: Yeah, the best worst. So so I had, for example,
Speaker 3: I have a pain condition, right, it's very painful and
Speaker 3: will affect my leg. You know, I couldn't walk, I
Speaker 3: had to be unconscious sometimes in a wheelchair. And there
Speaker 3: were times where I only need a nerve block, and
Speaker 3: so my doctor would submit the request for the nerve
Speaker 3: block and they will deny it and we will look
Speaker 3: into it, and it was just such dumb things like
Speaker 3: often it will be like a small wording or like oh,
Speaker 3: you're going to use this type of.
Speaker 4: Anesthesia and we don't, we don't cover that.
Speaker 3: So they deny it just because they were going to
Speaker 3: use some type of anesthesia that wasn't under the specific
Speaker 3: I guess under the dial or mailing the dial that's
Speaker 3: mentioned on the article. So yeah, it's it's a mess.
Speaker 3: And I had this happened so many times and you
Speaker 3: get tired of having to appeal and having to try
Speaker 3: again and again for something.
Speaker 4: That you know you're in your extreme pain.
Speaker 3: You're like, I hope I can have this procedure in
Speaker 3: the next few days, but no, you have to wait
Speaker 3: weeks sometimes months.
Speaker 1: Yes, so you remind me a friend of mine, and
Speaker 1: I'm allowed to shock. They posted this publicly on social
Speaker 1: media that they have a medical condition, they have Chrohn's disease,
Speaker 1: and they have a thirty thousand dollars drug. But that's
Speaker 1: the list price of the drug before insurance comes in.
Speaker 1: And without this drug, they will die. Straight up. They
Speaker 1: will just die because, you know, Chrome's disease in severest
Speaker 1: forms you just cannot digest and absorb nutrients from your food.
Speaker 1: You just can't do it, so they will. They recently
Speaker 1: denied her same drugs she's been getting forever, same drugs.
Speaker 1: You'll need it. The other day she dies. No, don't
Speaker 1: need it this time. It's not medically necessary, they say,
Speaker 1: just because, and then they resubmitted. Oh no, no, no,
Speaker 1: you're going to resubmit that again in ninety days. And
Speaker 1: then they'reday, oh yeah, just have it, no rhyme, no reason,
Speaker 1: no understanding of the ins and out. No conclusion here
Speaker 1: or anything. It's just the whim of a computer, the
Speaker 1: whim of the administrator because they have sent it from
Speaker 1: being robber stamped to denied I don't care what they say,
Speaker 1: or to go to denied by a doctor. The delay
Speaker 1: is denial. Sending it to the doctor is a form
Speaker 1: of delay denial. And you have to accept that some
Speaker 1: of these things will kill people. Like the gentleman in
Speaker 1: the article. He died because they said no through delay
Speaker 1: and delay and delay, and he is dead now. The
Speaker 1: American healthcare system is sometimes the American death care system
Speaker 1: because it is just there to facilitate people not to
Speaker 1: get better, but to be money milked and then they die. So, Jonathan,
Speaker 1: you've got a slightly different view on this. You're a
Speaker 1: member that can access the Veterans Affairs Department if I'm
Speaker 1: accurate here, So how does it work there?
Speaker 2: Well, the VA is a different system. It's a government system,
Speaker 2: and if you are have a service related injury or condition,
Speaker 2: it's rated. It's given a percentage disability rating. But you
Speaker 2: can go with no if you just have health issues, uh,
Speaker 2: and they're not related to your military stove. You can
Speaker 2: still use the VA, but it's it's you're gonna be
Speaker 2: charged a nominal fee for things and sometimes not so
Speaker 2: nominal uh, and you're gonna have to pay for a
Speaker 2: lot more of your medications and things. But if you're
Speaker 2: like me and have a high enough rating, and most
Speaker 2: of it's free and you get priority for appointments in
Speaker 2: that So it's not really a perfect system because not
Speaker 2: everybody gets treated the same and not everybody gets the
Speaker 2: uh the service in the same rapidity that someone like
Speaker 2: me would get it. And but it does work fairly well.
Speaker 2: The the VA hospitals I've been at, some of them
Speaker 2: were okay, others were outstanding. I happen to live in
Speaker 2: an area with an outstanding hospital here. They've taken care
Speaker 2: of me through a lot of serious problems and have
Speaker 2: come out more or less on top, if not completely
Speaker 2: on intact. So it's it's been a it's been a
Speaker 2: good experience for me. A lot of people don't like
Speaker 2: the weights. The appointments can be a little bit hard
Speaker 2: to get sometimes there's but they've been improving on that
Speaker 2: over the last couple of three years and things have
Speaker 2: gotten a lot better. There's not as much of a
Speaker 2: backlog on determining if you're service connected or that, or
Speaker 2: getting your rating. But and it's not as difficult as
Speaker 2: it was when I first got mine, So it's but
Speaker 2: it's still not an easy road. But there the attitude
Speaker 2: has changed to like, let's see how we can help
Speaker 2: this guy, rather than let's pick apart whether or not
Speaker 2: we should help them, you know. So it's been very good.
Speaker 2: I think that it can be a somewhat of a
Speaker 2: model for what could be a universal healthcare system with
Speaker 2: some tweaks and changes to it. But I'm just glad
Speaker 2: I have because it would be impossible for me to
Speaker 2: afford anything close to what I have to do now.
Speaker 1: So the three of us come from three very different
Speaker 1: backgrounds when it comes to interact with healthcare. I come
Speaker 1: from personal which has National Health Service for a point
Speaker 1: of view, Ajau comming it from an HMO, and Nathan
Speaker 1: you comming it from the Department of Veterans Affairs. So
Speaker 1: why are so many Americans comfortable with this as their
Speaker 1: health gare system? Why are they so comfortable with this
Speaker 1: is their healthcare system?
Speaker 2: Measure?
Speaker 3: I don't think that you're comfortable with it necessarily. I
Speaker 3: think there is so much going on in our country
Speaker 3: and you know, in our personal lives at all times
Speaker 3: that at some points we just have to choose why
Speaker 3: do we put certain issues aside and just deal with it.
Speaker 3: We often feel that the problem can be so massive
Speaker 3: that or in the middle or fight back is just
Speaker 3: not enough to affect any kind of change. And you know,
Speaker 3: I feel this way, you know, because of all of
Speaker 3: the health issues that I have, not just the pain
Speaker 3: I have, like like I'm therefore have, it's just with
Speaker 3: my eyes. I have had corner of transplants, have had
Speaker 3: a nerve stimulator put in, and so I have gotten
Speaker 3: good care, you know, when it is approved on time
Speaker 3: is good. But yeah, it definitely does bring a lot
Speaker 3: of stress sometimes to the way that you have to
Speaker 3: jump through all these hooks in order to get that
Speaker 3: type of care.
Speaker 1: So as someone who comes from your where, you know,
Speaker 1: health care is you know, considered to be you know,
Speaker 1: one of these things called a right, not you know,
Speaker 1: a luxury as it seems to be in America, or worse,
Speaker 1: an employment perk. Wooh, aren't we you pleasant in America
Speaker 1: to have a healthcare as an employment perk? This is
Speaker 1: bonkers to me, This is absolutely bonkers to me because
Speaker 1: it flips the whole system on his head because you're
Speaker 1: not giving a toss about the patient here. And especially
Speaker 1: as these companies I ever Care or they should be
Speaker 1: sometimes called never Care.
Speaker 2: Evil Core works to.
Speaker 1: Slash Evil Core slash not for not ever Core decide
Speaker 1: that they're going to take on these companies contracts, and
Speaker 1: then you see who the parent company is, which is
Speaker 1: Insurance Congloberate LLC or Insurance Provider LLC.
Speaker 2: Or anther cores case Signa, which is yeah cases.
Speaker 3: Yeah, I was going to mention that that to me,
Speaker 3: that was like the worst part. It's like all these
Speaker 3: giant companies were all interconnected. Like you said, every Core
Speaker 3: is run by Overnothe, which is a brand of Signa,
Speaker 3: which is the you know, insurance giant. And then the
Speaker 3: next big player that does the same job as as
Speaker 3: every Core it is called Karelian Medical Benefit Management. And
Speaker 3: guess what, there are a subsidiary of Elevants Hope, which
Speaker 3: is actually the insurance company formerly known as Anthem, so
Speaker 3: it's the same company just a different name.
Speaker 1: And EDNA getting on the action with another company. And
Speaker 1: then do you know what makes this so egregious when
Speaker 1: it comes to ETNA. ETNA own CVS pharmacies. Ethna are
Speaker 1: the parent company of CVS Pharmacies. So your pharmacist is
Speaker 1: in the same group as the people denying you your drugs.
Speaker 4: For a second, yeah, there are those to benefit each other.
Speaker 1: They are in each other's pockets, in each other's pies.
Speaker 1: This is how ludicrous we have allowed the American Health Institute.
Speaker 1: And it's not a design flaw, it's an absolute design outcome.
Speaker 2: Of all of this design attribute.
Speaker 1: Yeah, it's a criterion to maximize because at the end
Speaker 1: of the day, the three of us are not humans
Speaker 1: as far as concern. The three of us are a price.
Speaker 1: The very article who is Dead was a price tag,
Speaker 1: and we know they're a price tag because when they
Speaker 1: try to sue them, their price tag to be sued
Speaker 1: was too great. I find it quite weird that the
Speaker 1: doctor is being sued here when the doctor went do
Speaker 1: the healthcare and then they went no. So now the
Speaker 1: family suing the doctor who you didn't know because they're
Speaker 1: the bottom of the ladder, and.
Speaker 2: The hospital and the doctor can be sued, but you
Speaker 2: have to sue the other people in federal court, which
Speaker 2: is a whole other animal. And they have a lot
Speaker 2: of case law that denies those kinds of things behind it.
Speaker 2: So until we can get judges with a sense of
Speaker 2: morality about it's just going to stay that way.
Speaker 1: Good luck with that.
Speaker 4: Good luck with that yet.
Speaker 3: Yeah, I mean, and this company inside profiting and squatching
Speaker 3: each other's backs at the expense of the human beings
Speaker 3: on the other side waiting for you know, often life
Speaker 3: saving procedures.
Speaker 5: The thing that bothers me the most is that all
Speaker 5: these billions and billions upon hundreds of billions of dollars
Speaker 5: that they're making could could make it affordable for universal
Speaker 5: healthcare system if all that money was just spent on
Speaker 5: everybody's health care.
Speaker 2: You know, there is so much money they're making, but
Speaker 2: if you just got rid of all that management and
Speaker 2: profit and just put it into a system that's already there.
Speaker 3: Yeah, but that is the whole goal for this ev
Speaker 3: core type thing that they you know, their structure to
Speaker 3: provide higher payout based on more denial, so they get
Speaker 3: a financial incentive whenever they achieve created reduction in medical
Speaker 3: spending for the hardcre you know, organizations that they're working for.
Speaker 1: Here's question for the two of you, Government run programs
Speaker 1: are wastefully inefficient, right, so not necessarily so. How much
Speaker 1: as an overall percentage do you think Medicare spends on
Speaker 1: administration costs? What as a percentage, what do you think
Speaker 1: the number is?
Speaker 3: Yeah, I mean I don't know. I will take a
Speaker 3: wild guest, like fifteen percent.
Speaker 4: I don't knoween percent.
Speaker 1: What's your number? I go twenty two two two percent?
Speaker 3: Wow?
Speaker 2: Is it staff by ten times that amount? Okay?
Speaker 1: Medicare in America spends two percent of the money it
Speaker 1: receives on administration costs two percent, whereas on average, the
Speaker 1: US healthcare system spends thirteen to nineteen percent on administrative
Speaker 1: cost just on filling out paperwork, denying your requests. Computer
Speaker 1: algorithms like this government run system medicare two percent, thirteen
Speaker 1: to nineteen percent government less efficient.
Speaker 3: Right, they're usually like all these very complicated systems like
Speaker 3: AI and you know, like doing that a whole algorithm
Speaker 3: like what they call they die.
Speaker 4: Also, yeah, I can imagine that they spend a lot
Speaker 4: of money on that.
Speaker 1: Well, of course they do. So people hear this, We're
Speaker 1: being overrun by the machine. How do we get the
Speaker 1: machine to stop running the healthcare system? Jonathan how do
Speaker 1: we do that?
Speaker 2: You, I mean, make it a government agency that gives
Speaker 2: all the healthcare. You make it a single not a
Speaker 2: single payer system, but a uh you turn all these
Speaker 2: silly for profit things into a nonprofit thing or not
Speaker 2: for profit thing in the government where and that you
Speaker 2: take all those resources that those people had and you
Speaker 2: give them to this thing, and you give everybody a
Speaker 2: basic level of health care in any emergency healthcare or
Speaker 2: complicated healthcare. They need to maintain their lives. And it
Speaker 2: shouldn't be a matter of where you are in the society,
Speaker 2: or whether you have billions or millions of dollars or
Speaker 2: you know, or whether you have hundreds of thousands of
Speaker 2: dollars to drop on it, or whether you have to
Speaker 2: sell your house, your car, your go kart, and your
Speaker 2: boat in order to pay for one month's worth of medication.
Speaker 2: You know, that's just you know, that's where it is.
Speaker 2: And the leading cause of bankruptcy in the United States
Speaker 2: is medical.
Speaker 3: Expousely, I've had good yeah, I've had several procedures. Then
Speaker 3: if it wasn't for the way that you know, my
Speaker 3: insurance was set up, but you know, paid the complete
Speaker 3: out of pocket, and I always get everything done towards
Speaker 3: the end of a year, like in a hurry, because
Speaker 3: that's when I know that it's going to cover everything
Speaker 3: no matter what. But otherwise, you know, I will be
Speaker 3: paying like what thirty thousand dollars for just to get
Speaker 3: a replacement for my cochlear implant, the surgery itself with
Speaker 3: like fifty thousand dollars, Like, there's no way, you know,
Speaker 3: people can afford something like that.
Speaker 1: It's it's ludicrous, It's absolutely ludicrous.