I have Crohn's disease, and I'm fairly certain dealing with health insurance's ineptitude directly led to multiple hospitalizations and a major surgery last year.
Had it not been for their constant denials of a drug I had been on for over two years prior, I might still be taking that medication instead of having developed antibodies for the 6 months they denied.
My doctors office gave me free samples as long as they were able, but in 2022 they were wiped out as all patients that were on that drug were being denied coverage.
Worse still, insurance recommended "use drug X, which is similar"... but I couldn't because I was on drug X—until I had anaphylaxis from it!
I also have Crohn's and am going through this right now. Months of delays and denials for a new drug lead to two hospitalizations. I'm currently on TPN (IV nutrition) while I taper my Prednisone dose as low as possible prior to surgery.
The funny/sad thing is: between my hospitalizations, TPN and related home health care, and surgery, this is all going to cost my insurance far more than the drug they were denying would have. One would hope this provides them with motivation to better judge the necessity of treatments, but I'm not holding my breath.
It's simple. Some executive gets a bonus soon if he saves the company money right now. Nobody gets a bonus for saving the company money over a 5-year period, and nobody gets punished for costing the company money over a long period either. The incentives are all about the next quarter.
It still doesn't make sense. This whole ordeal has taken place over about 6 months. If anything, forcing me down the surgery route has pulled their costs forward in time, not pushed them back.
Situations like this are infuriating to me. Our healthcare system needs to have some kind of provision for "this patient needs to be on treatment X probably for life. They are authorized for this treatment and subsequent claims will be approved unless there is a qualifying event (e.g. a recall, condition changes, patient and their doctor switch treatment, etc)."
I have UC that's well-controlled with mesalamine, and I've had a few scares (my insurance rolls out a new prior auth every year, and I have to call my provider to have them sign it for some reason, or the new insurance only covers the name brand (not generics) because of PBM antics). The thought of having to come off of mesalamine for even a week is terrifying. I really feel for you because your condition seems much more severe/hard to control.
Why do I need a new prior auth every year? My medication hasn't changed, and neither has my condition. It's a bureaucratic hoop, and if I don't jump through it I get to spend my whole day on top of a toilet. That's a terrible way to treat a human being.
Even from a purely amoral capitalist perspective, I know the cost of my medication is a small fraction of the dollar value that doesn't get generated if I can't take it. I don't benefit and society doesn't benefit if I'm sick - the only group who benefits is the insurance company who gets to pocket my premiums and avoid paying out. It makes me furious.
Here's a simple solution. Insurance HAS to pay if a doctor recommends it. This is what premiums are for. If insurance cannot pay, they can go out of business.
I don't love insurance companies and I don't love the profit incentive they have.
If a patient breaks a leg and a doctor recommends not experiencing gravity for a while, do we fly them to space?
I am using hyperbole to demonstrate a point: there are meaningful economic limits that must be created by some entity and enforced.
What is the value of a human life? The GDP of a nation is a hard upper limit. The total money a particular person in question has access to is the lower limit.
If you run an insurance company (or you run government run healthcare) you can't avoid answering that question with an actual real dollar amount.
At some point spending money on a person with a particular condition does mean that someone else with a different condition can't have money spent on them.
That's why it's better to have everyone covered under insurance, so that the risk pool is larger, and the cost to the individual is lower.
That's why it's important to spend money on research; to develop new technologies and techniques, and improve existing technologies and techniques; that can make cost of care lower.
That's why it's important to have standards of care and treatment, for all medical providers to follow.
I get your example is hyperbole, but just for fun: the space flight would be recognized as an experimental treatment since it’s known not to be a routine/established procedure. Expenses would be covered if a legitimate clinical trial of space flights were being conducted. Otherwise, costs would be out of pocket unless a special approval were granted. If space flight were being seriously studied for an extremely rare disease, it would likely be paid for by the research institution.
You aren't wrong, per se, but until the incitive for the insurance company stops being "maximize profit", they shouldn't be allowed to make decisions about how health care dollars are allocated.
"For every complex problem there is an answer that is clear, simple, and wrong." - H. L. Mencken
Even a moment's thought about the power disparity between an insurer and an individual facing medical problems leads me to conclude your "simple solution" has little to recommend it.
Had it not been for their constant denials of a drug I had been on for over two years prior, I might still be taking that medication instead of having developed antibodies for the 6 months they denied.
My doctors office gave me free samples as long as they were able, but in 2022 they were wiped out as all patients that were on that drug were being denied coverage.
Worse still, insurance recommended "use drug X, which is similar"... but I couldn't because I was on drug X—until I had anaphylaxis from it!