Despite paying $117.7 million to settle allegations it inflated Medicare Advantage diagnoses, Aetna still uses automated software to downcode ER claims without reviewing medical records.
Hypocrisy is too mild a word to describe the conduct discussed in your brilliant piece. Perhaps the correct term is fraud. Every member of Congress should be made to read this article so they can get to work fixing our broken system starting with removing for-profit insurers from the decision-making process.
they know. they are complicit. worse than that- they set up this system. they are in on the grift. remember that they get a piece of the action when aetna and other government contractors send our embezzled tax dollars to members’ leadership PACS, which members of Congress use for personal expenses like luxury vacations and golf memberships.
Man, We the People get it going and coming, don’t we? Going and coming.
Upcoding to us as in US citizens when Medicare is paying, and downcoding to us the doctors when they’re paying.
Duplicitous is not quite the word. I want some cross between evil and lying bastards…. Y’all got some words for me?
Despise and hate don’t quite cover it for me, given the years of having my work demeaned and my reimbursement diminished by capricious downcoding and always changing the rules.
Republicans did this, with their lack of governance and degraded values. Call it out.
Interesting. I did a search on the average income for ER doctors and it's about $425,000 for 2025. Although they can work crazy hours early in their career, this amount of pay is not bad.
That's true and I would argue that anyone that does that job should be paid very well. The other thing to keep in mind is that ER doctors have a career length about 10 to 17 years shorter than the average white collar worker. That is because of the length of time they are in school and the physical and mental toll the job takes on a person that causes them to retire earlier. Add to that the huge amount of student loan debt they start with. Once you add those factors in you realize it's not a great economic decision to be a ER doctor.
Early in the career, middle of the career, and end of the career. If the number is true, that is a distraction from the issue. ER is an incredibly high pressure job, taking abuse from all sides, at all hours of the day and night. I wouldn't/couldn't do it for any amount of money. Even this number is a pittance compared to the money made by those sitting around in their insulated, swanky offices- NOT getting vomited on, bloodied, verbally abused by sick patients or angry family members, nor emotionally abused by the employer- only pontificating on the "worth" of these physicians' work.
Don't disagree. The other factor is that increasingly private equity is purchasing ER groups and folding them into a portfolio. Then they bill higher fees to the payer. Further, very few if any ER groups are members of provider networks so invariably claims are considered out-of-network.
It's all too easy - and very popular - to vilify payers as the root-cause of all that ails in our Casino Healthcare - but it's really a holy war between both payers AND providers. Keep in mind - commercial rates for healthcare products and services are uncapped and insurance is the only segment that's heavily regulated. Yes, single-payer works - but we're no closer to it than we were 80yrs ago when it was first proposed. It's unnecessary, a bad fit culturally and far too easy to defeat politically. In the end - it's not the NUMBER of payers that matters - it's the price - and what we ABSOLUTELY need is single PRICING. http://hc4.us/oneprice
Your article brings up a number of very good points. While I won't pretend that providers of care are completely without blame or responsibility in this discussion, I do think that the egregious actions of the payers to deny or under pay for care far outweighs any offenses by providers of care especially physicians. That being said, the big question for me about single pricing (Medicare for all would accomplish this) is who sets the price and how much is it? If we adopted the Medicare pricing for all care the delivery system would collapse and/or the care we receive would change dramatically. Another question is why stop at health care? Housing is too expensive, why don't we have one price per square ft for housing. Let's keep going and have centralized government planning of all production and distribution. Of course we know none of that would happen. I not suggesting we do that just pointing out that once you adopt universal price controls it is both a slippery slope and comes with some harmful side effects that may be worse than the disease you are trying to fix.
So - the American Exceptionalism argument? We're so different from every other industrialized country that universal coverage won't work here?
If we zeroed out the profits (~$50-70B/yr) of ALL the health insurance companies - we wouldn't make a dent in our $5.7 trillion NHE.
You are correct - that Medicare-For-All pricing wouldn't work (and we know this from Maryland which uses All-Payer pricing for inpatient rates) so just using the phrase isn't a solution.
The real solution - which every other industrialized country has chosen - is universal coverage (as the delivery mechanism for monopsony/one buyer pricing) and they get *much* better results (both clinically and fiscally).
Healthcare isn't like any other consumer product or market - so saying it's a slippery slope to price controls for ALL markets is a common logical fallacy that favors keeping the status quo. Next stop for NHE? $6.2 trillion in 2028. The math just keeps mathing ;-(
It feels like you are shifting the argument. I never said that we couldn't or shouldn't pursue universal coverage nor did I say that eliminating the payer profits would solve our cost issues. I agree with you on both. My questions was really around your point that we need a single price. Again, my big question is who sets that price, how does it get set and how do we make sure that price doesn't kill doctors? The only example we have of a single price is how Medicare works and that hasn't turned out so well. What are your ideas about that question?
... and I highlighted Maryland. It's among the last to keep it's CMS Waiver (which allows single-pricing for inpatient services). There would - of course - need to be regional adjustments (and we'd need to add outpatient), but there were other states that had All-Payer solutions through the years, so I don't think it's a big economic exercise - or much of a gating factor.
So what is the big hurdle? Three words: campaign finance reform. Lawrence Lessig summarized this best: "Campaign finance reform isn't the biggest problem facing the country - but it's the first." Now that we have billionaires influencing elections individually - we're losing ground on that battlefront and I'm not sure when or how we'll reverse course. Until we do reverse course, most of the "ideas" to "reform" healthcare are just tweaks - like rearranging deck chairs - and vilifying payers falls squarely into that category.
First of all, I think the payers have done more than enough to deserve to be vilified. That being said, I appreciate and encourage discussion and an exchange of ideas. However, this discussion has wandered into areas that don't have anything to do with my primary question to you or the article that I wrote. Things like universal coverage and campaign finance reform don't have anything to do with the article. I tend to agree with you on both of those points but still don't think they address your statement that what we need is a single price. I thought my question was pretty straightforward but since you either can't or won't provide any detailed answer to my question I think this discussion has run its course. Thank you for your comments.
Again - it's easy and currently very popular to vilify payers - which is exactly what your article does (using a single phrase like a hammer), but the question remains - what's the objective of the vilification? To what end? To simply generate likes and agreement that payers are to blame for systemic flaws? And then walk away from any discussion that challenges the vilification? Ok - I guess. Mission Accomplished.
Hypocrisy is too mild a word to describe the conduct discussed in your brilliant piece. Perhaps the correct term is fraud. Every member of Congress should be made to read this article so they can get to work fixing our broken system starting with removing for-profit insurers from the decision-making process.
unfortunately, fraudsters are pardoned and elevated to office, while facts are "fake news". Everyday.
they know. they are complicit. worse than that- they set up this system. they are in on the grift. remember that they get a piece of the action when aetna and other government contractors send our embezzled tax dollars to members’ leadership PACS, which members of Congress use for personal expenses like luxury vacations and golf memberships.
Man, We the People get it going and coming, don’t we? Going and coming.
Upcoding to us as in US citizens when Medicare is paying, and downcoding to us the doctors when they’re paying.
Duplicitous is not quite the word. I want some cross between evil and lying bastards…. Y’all got some words for me?
Despise and hate don’t quite cover it for me, given the years of having my work demeaned and my reimbursement diminished by capricious downcoding and always changing the rules.
Republicans did this, with their lack of governance and degraded values. Call it out.
It's from both sides of the aisle.
Theres a decided difference in which party cares about human beings, and which party cares about corporations.
Schumer and Jeffries are white bread pussies, but give me Warren over Cornyn any day
I completely agree this is abusive. Payers need to go. Medicare for all, single set and transparent adjudication rules.
I would note that payers downcoding ER visits have diagnosis on the claim (the ICD-10 codes are not nothing).
Thank you
I was thinking about the words lie and corrupt today.
I'll say it again: We need single-payer universal healthcare.
Interesting. I did a search on the average income for ER doctors and it's about $425,000 for 2025. Although they can work crazy hours early in their career, this amount of pay is not bad.
That's true and I would argue that anyone that does that job should be paid very well. The other thing to keep in mind is that ER doctors have a career length about 10 to 17 years shorter than the average white collar worker. That is because of the length of time they are in school and the physical and mental toll the job takes on a person that causes them to retire earlier. Add to that the huge amount of student loan debt they start with. Once you add those factors in you realize it's not a great economic decision to be a ER doctor.
Early in the career, middle of the career, and end of the career. If the number is true, that is a distraction from the issue. ER is an incredibly high pressure job, taking abuse from all sides, at all hours of the day and night. I wouldn't/couldn't do it for any amount of money. Even this number is a pittance compared to the money made by those sitting around in their insulated, swanky offices- NOT getting vomited on, bloodied, verbally abused by sick patients or angry family members, nor emotionally abused by the employer- only pontificating on the "worth" of these physicians' work.
Don't disagree. The other factor is that increasingly private equity is purchasing ER groups and folding them into a portfolio. Then they bill higher fees to the payer. Further, very few if any ER groups are members of provider networks so invariably claims are considered out-of-network.
It's all too easy - and very popular - to vilify payers as the root-cause of all that ails in our Casino Healthcare - but it's really a holy war between both payers AND providers. Keep in mind - commercial rates for healthcare products and services are uncapped and insurance is the only segment that's heavily regulated. Yes, single-payer works - but we're no closer to it than we were 80yrs ago when it was first proposed. It's unnecessary, a bad fit culturally and far too easy to defeat politically. In the end - it's not the NUMBER of payers that matters - it's the price - and what we ABSOLUTELY need is single PRICING. http://hc4.us/oneprice
Your article brings up a number of very good points. While I won't pretend that providers of care are completely without blame or responsibility in this discussion, I do think that the egregious actions of the payers to deny or under pay for care far outweighs any offenses by providers of care especially physicians. That being said, the big question for me about single pricing (Medicare for all would accomplish this) is who sets the price and how much is it? If we adopted the Medicare pricing for all care the delivery system would collapse and/or the care we receive would change dramatically. Another question is why stop at health care? Housing is too expensive, why don't we have one price per square ft for housing. Let's keep going and have centralized government planning of all production and distribution. Of course we know none of that would happen. I not suggesting we do that just pointing out that once you adopt universal price controls it is both a slippery slope and comes with some harmful side effects that may be worse than the disease you are trying to fix.
So - the American Exceptionalism argument? We're so different from every other industrialized country that universal coverage won't work here?
If we zeroed out the profits (~$50-70B/yr) of ALL the health insurance companies - we wouldn't make a dent in our $5.7 trillion NHE.
You are correct - that Medicare-For-All pricing wouldn't work (and we know this from Maryland which uses All-Payer pricing for inpatient rates) so just using the phrase isn't a solution.
The real solution - which every other industrialized country has chosen - is universal coverage (as the delivery mechanism for monopsony/one buyer pricing) and they get *much* better results (both clinically and fiscally).
Healthcare isn't like any other consumer product or market - so saying it's a slippery slope to price controls for ALL markets is a common logical fallacy that favors keeping the status quo. Next stop for NHE? $6.2 trillion in 2028. The math just keeps mathing ;-(
It feels like you are shifting the argument. I never said that we couldn't or shouldn't pursue universal coverage nor did I say that eliminating the payer profits would solve our cost issues. I agree with you on both. My questions was really around your point that we need a single price. Again, my big question is who sets that price, how does it get set and how do we make sure that price doesn't kill doctors? The only example we have of a single price is how Medicare works and that hasn't turned out so well. What are your ideas about that question?
... and I highlighted Maryland. It's among the last to keep it's CMS Waiver (which allows single-pricing for inpatient services). There would - of course - need to be regional adjustments (and we'd need to add outpatient), but there were other states that had All-Payer solutions through the years, so I don't think it's a big economic exercise - or much of a gating factor.
So what is the big hurdle? Three words: campaign finance reform. Lawrence Lessig summarized this best: "Campaign finance reform isn't the biggest problem facing the country - but it's the first." Now that we have billionaires influencing elections individually - we're losing ground on that battlefront and I'm not sure when or how we'll reverse course. Until we do reverse course, most of the "ideas" to "reform" healthcare are just tweaks - like rearranging deck chairs - and vilifying payers falls squarely into that category.
First of all, I think the payers have done more than enough to deserve to be vilified. That being said, I appreciate and encourage discussion and an exchange of ideas. However, this discussion has wandered into areas that don't have anything to do with my primary question to you or the article that I wrote. Things like universal coverage and campaign finance reform don't have anything to do with the article. I tend to agree with you on both of those points but still don't think they address your statement that what we need is a single price. I thought my question was pretty straightforward but since you either can't or won't provide any detailed answer to my question I think this discussion has run its course. Thank you for your comments.
Again - it's easy and currently very popular to vilify payers - which is exactly what your article does (using a single phrase like a hammer), but the question remains - what's the objective of the vilification? To what end? To simply generate likes and agreement that payers are to blame for systemic flaws? And then walk away from any discussion that challenges the vilification? Ok - I guess. Mission Accomplished.