Aetna Builds Empire: One Denial at A Time

[eridani]

http://www.healthcare-now.org/aetna-builds-empire-one-denial-at-a-time

Aetna’s willingness to leverage and to “risk” so much in order to close the Coventry deal tells us much about the profits they expect to gain from it: “In all, Coventry will add more than 5 million customers to the 26.7 million already on medical and prescription drug plans with Aetna, according to the companies’ quarterly reports.” And the company is especially interested in gaining the Medicaid and Medicare (government paid programs) business. Again, that’s cold, hard cash from outside the company.

So, in the short term, how does Aetna shore up the bottom line for investors? How about denying some claims for medications? Over the past three months, all three of the new medications my doctors ordered to help me with serious medical issues were initially denied. One denial was overturned last week on appeal, but two still remain outstanding. That’s a saving to Aetna of about $400 each month. And how does Aetna plan to cover the $2.5 billion in new debt they’ll take out to close the new business deal? As one dear friend of mine said to me recently, “One denial at a time.” It all adds up.

Hmmm, let’s do that math. Aetna could deny just $400 for just a quarter of its 26.7 million current “customers,” sign them up for $400 worth of disease management program support, and end up paying off that debt in no time at all as they’d retain far more of their premium dollars in house rather than paying those dollars out. $400 in profit times 6.5 million patients denied adds up to pay off that $2.5 billion debt.

In the books it would look like they were fully compliant with the medical loss ratios required in the ACA. But in the lives of patients, the pain and suffering could tell a much different story. I know it does in mine. That $400 denial causes me not just gut pain but consequences in my life that are far reaching beyond what needs to be listed here.

If you think your for-profit insurance company is very different from mine, think again. But it’s sure deceptive, isn’t it, when just a few people have to be really hurt to allow for such massive profits. It’s a business, folks. And until we finally decide a Medicare for all for life system would better serve us all, the deceptions will grow ever more complex and deadly.

[Hoyt]

1. I agree with Medicare for all. But they too limit certain drugs, treatment,etc.

If we want affordable care, we will all have to change certain expectations. But, I'd rather elected officials make the ultimate policies on what is covered, what new technology gets covered, etc.

Sorry about your situation, and hope it gets better. When profits are involved, you don't know whether such decisions are legitimate. I've had meds rejected under formularies, fortunately the much cheaper drugs eventually worked fine. But, that's not always the case.

[eridani]

2. This was written by Donna Smith of Health Care Now

She was in sIcko, Michael Moore's health care move. Every other developed country in the world takes care of everybody at about 1/2 the per capita cost. Keeping our current spending constant but with universal care, everyone would have platinum coverage.

[Hoyt]

3. Great ducumentary. Would love to have Canadian system. But, they have limits too

Great ducumentary. Would love to have Canadian system. But, they have limits toooice, etc. I'm fine with that.

Have been quite pleased with Kaiser, but I had to stop taking much more expensive drugs allowed under my previous (higher cost) plan and substitute lower cost drugs. They've worked fine. And I find giving up freedom of choice in providers, for much better coordinated care, is OK too.

Unfortunately, I don't think everyone will accept those changes.

[eridani]

4. All systems have limits, but 96% of Canadians do not want the US system

There is no such thing as being bankrupted by health care expenses, or dying because you don't have the money to pay for the treatment to save you.

[Scuba]

10. Here's the complete list of countries that repealed their single-payer plan after implementing...

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[Hoyt]

11. I agree, our system sucks. But, these other countries still have drug formularies, little choice of

providers, rigid treatment protocols, etc. I'm for that because then we are all equal, getting the same care. And the money we save from taking profits out of the system, ensuring best treatments, and coordinating care more closely can go to a war on cancer, etc.

I'm just saying, a lot of folks are going to gripe about that utopian plan we hope to get.

[Scuba]

12. Just wondering why you assume we would adopt the worst of various plans instead of the best?

Sees as "exceptional Americans" we should be able to have a better plan than those other countries.

[Hoyt]

13. I hope we do better. But, Medicare right now doesn't cover a lot of things -- including dental care.

Canada's system and the NHS have strict drug formularies that I'd venture would have steered the person in OP to a cheaper med from the new one her doctor prescribed (perhaps because a pretty drug rep took him to lunch).

[meaculpa2011]

5. Recent editorial in the Toronto Star was headlined...

"Tackle the Health Gap."

The message: More than 1 in 4 low income Canadians have delayed or stopped buying prescription medications because they don't have the money. Canadians making less than $30,000 report poorer health as well.

Face it. Single payer does nothing to control costs and little to increase access.

Single provider is the only logical path. For profit health care is just as corrupt as for-profit health insurance.

BTW: No system of health care delivery will have any effect if Americans refuse to take control of their own well being.

[eridani]

6. Prescription medications are by private insurance in Canada

That's a major problem. Single payer sure the hell does control costs. Canada's costs in 1973 per capita were roughly equal to ours, and since then ours have doubled. If by single provider you mean government employee provision of health care as in Britain, that is unlikely to ever happen here.

The notion that "well-being" has anything whatsoever to do with health care costs is bullshit. If 5% of the population (in every demographic) accounts for 50% of all health care costs, and 15% for 85% of all costs, it doesn't matter diddlysquat how well the healthy 85% conforms to your notion of "taking control."

[meaculpa2011]

8. The main point of the editorial...

is that all factors that contribute to ill-health, including access to health-care services, fall disproportionately on the poor. Health care spending in Canada has lagged the inflation rate making access for the poor especially critical. When that's added to the lack of medicine, poor nutrition, the effects of added stress--the results are predictable.

Are you suggesting that lifestyle has no effect on health?

An NHS style system is very unlikely if nobody demands it. Why are health insurance profits immoral, but not health provider profits?

[eridani]

9. Lifestyle has an effect on healh--it just has no effect on health care expenses

In fact, prevention raises health care costs substantially. My grandmother died at age 53, my father at age 59, and here I am (same genetics) at age 65 and I don't even need insulin yet. That is because far more is known about how people with Syndrome X can postpone developing diabetic symptoms by lifestyle modification and other early interventions.

Which of the three of us will have the highest lifetime health care expenses? That would obviously be me, given that I've earned thousands of extra life lottery tickets good for being cashed in for getting badly creamed by a drunk driver some day. Dead people do not incur health care expenses.

Of course poor people have poorer health regardless of what kind of health care system you have, but nowhere in the developed world is the disparity as great as it is here. Hell, Americans in the highest 20% income level are slightly more likely to have heart disease and diabetes than the poorest 20% of the British.

[meaculpa2011]

18. If by prevention you mean medical interventions that...

keep you alive through the long steady decline into the grave, you're right. So called "preventive medicine" is extremely expensive.

But prevention has nothing to do with more trips to the doctor. Prevention is a way of life.

The prevention lifestyle (compression of morbidity) results in an active life, fewer trips to the doctor and lower lifetime health-care costs. Dead people may not incur health-care costs, but unhealthy people cost a fortune whether die at 50 or 90.

My grandmother died at 102 and only went into the hospital one week before she died. It was the first time in her life she was there, except as a visitor, and she gave birth to four children. My uncle died at 58 and used up more health-care dollars in the last 10 years of his life than my grandmother did in her 102 years.

[eridani]

19. Anecdotes are not statistics

Prevention costs money, even though it saves lives. Most of the 85% who account for only 15% of health care expenses are not paragons of healthy living. Few get enough exercise for optimum health, but yet the vast majority--85%--don't incur lots of health care expenses.

http://www.acefitness.org/healthandfitnesstips/healthandfitnesstips_display.aspx?itemid=181

Only one in four U.S. adults get the recommended amount of daily exercise, which is 30 minutes of moderate activity on most days of the week, or 20 minutes of vigorous activity three days per week.

Even worse: Nearly one in three Americans admits they don’t exercise at all.

[meaculpa2011]

20. According to Health Reform dot Gov...

chronic diseases account for 85% of healthcare costs and nearly two thirds of chronic diseases are preventable.

Americans are far more likely to suffer from chronic diseases than their counterparts in other developed countries.

The leading causes of premature death and disease are self inflicted.

My observation:

Compression of morbidity is the surest way to reduce health care costs. Ergo, my anecdote.

True. Anecdotes are not statistics. Then why did you choose to begin the conversation with an anecdote?

Preventive medicine costs money. The whole concept of of preventive medicine is a scam perpetrated by the medical establishment. Exercise and good nutrition cost nothing. In fact, once the booze, cigarettes and junk foods are out of your household budget, living healthy saves a ton of money. More trips to the doctor may catch a disease in its early stages. Living healthy can prevent the disease from occurring in the first place.

[eridani]

21. You don't prevent chronic diseases--you postpone their onset

Doing so makes people with lousy genes live longer and therefore cost more over their lifetimes.

Even with comparatively bad rates of clean living, 85% of Americans (accounting for 15% of costs) are HEALTHY. And we are at the bottom of the heap of developed countries when it comes to actual use of health care.

http://epianalysis.wordpress.com/2012/07/18/usversuseurope/

Do we simply use a lot more healthcare? The average number of physician visits per person in the U.S. is 4, below the OECD median of 6.4, and far below Japan’s 13 visits per person. Similarly, we have fewer hospital discharges at 131 per 1,000 people versus the OECD median of 160 and France’s 263 per 1,000. The average hospital stay per person is also lower in the U.S., at 5.4 days versus the OECD median of 5.9 days and Canada’s average of over one week.

[meaculpa2011]

22. Postponing the onset, by definition...

reduces health care costs. You also make the assumption that all chronic diseases are caused by lousy genes. Some chronic disease cannot be prevented, or even postponed, while many can.

Given that nearly one third of health care costs are incurred in the last six months of life, I'm skeptical of your 85% figure.

I'm 61. Except for a motorcycle crash a few years ago I've never been hospitalized. My sister is 16 years younger, overweight, smokes and gets no exercise. Her COPD, knee and ankle problems, and Type II diabetes are not the result of lousy genes. Since medical science has done a remarkable job of extending life, while we (as a society) have done a miserable job of promoting health and fitness, which one of us is more likely to consume health care dollars?

Hint: She has probably already used more than ten times the $s I have and I've lived 25% longer.

Like my father always says: "Life is like baseball. You have to play the percentages."

Ninety and still living a healthy, active life.

[eridani]

23. No, postponing onset increases costs

On a lifetime basis, I will have far more health care expense than my father, dead at age 59, and my grandmother dead at age 53. If your sister dies comparatively young, her health care expenses will be less than yours on a lifetime basis.

With 85% of the population accounting for only 15% of costs, it doesn't matter one way or another how "healthy" their lifestyles are--at least in the matter of health care costs. It will make their lives better, of course.

[meaculpa2011]

24. Apples and oranges.

My sister has already used more healthcare dollars in her 46 years than my mother has used in her 83 years. You're comparing a long healthy life with a short unhealthy life. The relevant comparison is:

1- A long healthy life with occasional trips to the doctor.

2- A long unhealthy life with years of medical interventions and a long, slow descent into decrepitude.

In the first instance the person is healthy until age ninety and dies after a short illness.

In the second, the person gets sick in his 50s and lives until 90 having spent 40 years in and out of hospitals, hooked up to machines with tubes running in and out of him.

If your solution to the health care cost problem is to die young... buona fortuna.

A statistic is like a g-string. What it reveals may be interesting, but what it hides is vital.

[HiPointDem]

7. aetna founded by jp morgan's grandfather.

The House of Morgan, one of America's wealthiest families, began with Joseph Morgan. He worked as a farmer until his father's death, and then, with a substantial inheritance from his father's estate, he bought a tavern, then a stagecoach line, a second tavern, and a fifty-room hotel in Hartford, Connecticut. He invested his profits in industries that boomed as America began its transition from rural to urban -- banks, canals, railroads, and steamship lines. In 1819 he was one of the founders of the Aetna Fire Insurance Company, and purchased Aetna's first insurance policy for his property. Unlike earlier insurance companies that had been primarily local concerns, Aetna made itself a major player by opening branch offices in numerous cities beyond Hartford. Aetna made Morgan a millionaire several times over, in an era when America had few millionaires.

(Though related to the company that sells insurance in the 21st century, Morgan's Aetna is technically not the same company. In 1853, several years after his death, executives at Morgan's Aetna started a second business, the Aetna Life Insurance Company -- as a separate company under separate ownership, in order to keep Aetna Fire legally unfettered from Aetna Life's risks.)

http://www.nndb.com/people/958/000171445/

[Trillo]

14. It's all just creative accounting.

But it doesn't feel that way when your life is on the line. How long will you keep fighting your health-care insurance providers?

Perhaps the U.S.'s patent-medicine era was a better system. When you got in too much pain, you could just go buy some bottles of something mixed with opium, and drink like there's no tomorrow specifically so there would be no tomorrow.

[Egalitarian Thug]

15. Perfect example of only one of the ACA's glaring defects, and this is only the beginning.

For those that passed elementary school math; If you are limited to keeping a fixed percentage of a total amount and you want to keep as much as possible, how do increase the amount you keep?

[woo me with science]

16. DU Rec. Suffering and death for profit.

Just another day in carefully constructed corpoAmerica.

[woo me with science]

17. kick

[TBF]

25. At the most recent doctor visit for my child the doctor mentioned

that lately she is noticing more drugs being rejected (not being paid for) by insurance companies. She finally came up with a couple for my son, but they ended up being large pills that I have to crush. I didn't really mind in this case but my co-pays are high under the new plan (new drugs are $50) so I am asking more for generics when I can etc ... This must be one of the ways they are looking to make extra cash with the new health care laws going into effect. You know they are still going to search for ways to make their profits ...