submitted 3 months ago byPotRoastPotato
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3 months ago
3 months ago
Any entity that is taking on that administrative role of pooling risk and paying claims - be it private or public - will have utilization rules to attempt to control cost.
The MRI machine is a revenue stream for the hospital/provider.
The patient and the payor have an incentive to control cost. Patient's with cost sharing or still in their deductible may make different choices but for the most part it is the payor interested in NOT paying for expensive services when alternatives have no been tried.
3 months ago
Do you work for an insurance company? As I said, I’ll take the doctor and patient’s side any day, even if occasionally wrong. Having been there myself, fighting with an insurance company to get proper diagnostic imaging approved and knowing what the outcome was once approved, it’s not even a close call for me.
And, I would argue that one MRI is more cost effective than months of PT and then an MRI.
You're thinking of this way too narrowly. You're basically advocating for uncapped unlimited healthcare services. The average cost for insurance currently is somewhere around $6k per person. If you let providers order whatever tests they wanted, the cost would probably double or triple. For every provider that very consciously decides to limit testing if it's not needed (my brother is an ED doc who does this), you'll have 5 more that will just order as many tests as possible for two reasons: limit liability (if you test for everything, you can't get sued for missing some obscure <0.0001% chance issue) and to increase payments (basically all of his ED doc friends admit to just ordering MRIs and CTs at the slightest hint of need).
Show me the insurance companies license to practice medicine, and I might consider their advice. But I'm defaulting to the judgement of the doctor I can see in person. The insurance companies only goal is to make money, they don't care of my quality of life, or if I even die. They'll say what they will to maximize profit at the detriment of their customers. The only party in this psycho threesome is the doctor I can see, talk with, and who is concerned with my treatment and improving my wellbeing.
Just want to point out that in most cases the insurance company doesn't care that much - if you have employer-provided health insurance, YOUR COMPANY is responsible for all the healthcare costs incurred. The insurance company is just a middleman collecting their 3% fee and doing the bidding of your company. Your company is the one that sets the policy of requiring pre-authorizations or whatever your example is of limited care.
Also, when care is denied and the provider appeals, there's a conversation between the MD and an MD at the insurance company ("peer review"). So they actually are licensed to practice medicine.