Speaker 1: From UFOs to psychic powers and government conspiracies. History is
Speaker 1: riddled with unexplained events. You can turn back now or
Speaker 1: learn this stuff they don't want you to know. A
Speaker 1: production of iHeartRadio.
Speaker 2: Hello, welcome back to the show. My name is Matt,
Speaker 2: my name is Noel.
Speaker 3: They call me Ben. We're joined as always with our
Speaker 3: super producer Dylan the Tennessee pal Fagan. Most importantly, you
Speaker 3: are you. You are here. That makes this the stuff they
Speaker 3: don't want you to know. Hurtling headlong through April. We
Speaker 3: wish you the best with your paperwork. I feel like
Speaker 3: everybody has to deal with paperwork at this point, no
Speaker 3: matter who you are.
Speaker 4: Guys, would you believe I've already done my taxes? I
Speaker 4: did them, like right away, the moment I got my
Speaker 4: W two, I feel like such an adult.
Speaker 3: Yeah, you were telling me that that's.
Speaker 4: Awesome, you know. I mean, it's not bragging, it's just
Speaker 4: for me. It's a big deal.
Speaker 2: Did you get to write off any medical expenses?
Speaker 4: No, I didn't. I wrote off a lot of modular
Speaker 4: synthesizer equipment. Though don't tell Uncle Sam. Now I do
Speaker 4: use that for business, but yeah, how does that even work? Guys? Like,
Speaker 4: I don't think I even knew that you could do that.
Speaker 3: Yeah, cand you just have to out receipt the other people.
Speaker 3: It's a war of paperwork attrition, getting your documentation right
Speaker 3: in the right place, always having the thing when it's
Speaker 3: asked for in the format it is requested. This leads
Speaker 3: us to a fascinating conversation we had back in October
Speaker 3: twenty twenty four with our conspiracy realist K Dog. K Dog,
Speaker 3: you said something that stood out to all of us,
Speaker 3: and K Dog and I had a bit of a
Speaker 3: correspondence over this. The US healthcare system is diplomatically put complicated.
Speaker 3: Supporters are going to say it's imperfect, but you know,
Speaker 3: it's better than nothing, and critics, by which we mean
Speaker 3: the majority of the US population, will say it's worse
Speaker 3: than not great. It can be predatory at times. It
Speaker 3: is not near the level of other developed countries, like
Speaker 3: right now, as we report, millions of people are attempting
Speaker 3: to get possibly life saving medications, procedures and surgery.
Speaker 2: Yeah, the rest of the world says, why can't you
Speaker 2: provide that? Don't you guys make a lot of money?
Speaker 4: Why is it a crapshoot that you might get like
Speaker 4: acceptable healthcare. It just seems kind of like a lot
Speaker 4: of people in the rest of the world look at
Speaker 4: that as a human.
Speaker 3: Right, yeah, because it is. So we're coming in here
Speaker 3: with a bit of a bias. But this is the
Speaker 3: quick skinny folks. Here in the United States, patients and
Speaker 3: doctors can't immediately agree that a procedure life saving right
Speaker 3: outside of maybe an emergency room. Doctors have to get
Speaker 3: prior approval from private health insurers to cover part of
Speaker 3: a medical.
Speaker 2: Cost because they're the ones paying for it, right.
Speaker 4: Sure, and who, by the way, are not themselves medical professionals,
Speaker 4: and who are making assessments based on dollars and cents,
Speaker 4: not necessarily you know, the well being of the patient.
Speaker 2: We're going to talk about that because that's why one
Speaker 2: of the value adds of one of the corporations we're
Speaker 2: going to be talking about is we use doctors, and
Speaker 2: we have doctors because doctors have to make those decisions.
Speaker 4: Oh right.
Speaker 3: This leads us to the story k Dog that you
Speaker 3: suggested not too long ago, back in October of twenty
Speaker 3: twenty four. This is the tale of evycore not evil.
Speaker 4: Nobody not noticed or like let them know that this
Speaker 4: is one letter away from being evil core, which sounds
Speaker 4: like an incredible genre of that high parody.
Speaker 3: Account on Twitter.
Speaker 2: I think it's evicre e core.
Speaker 3: Well, you know what will give them the measure of
Speaker 3: respect they deserve. Here are the facts. Let's okay for
Speaker 3: anybody unaware, guys, could we explain what prior approval is.
Speaker 3: What does it mean.
Speaker 2: It's authorization by a medical professional that says, hey, this procedure,
Speaker 2: this medication, this, whatever it is, is medically necessary for
Speaker 2: this patient. That's what a prior authorization is. Before the
Speaker 2: surgery happens, before the MRI test, before the certain exam.
Speaker 2: Name it that an oncologist would perform, before your heart
Speaker 2: gets checked out, or you get a catheter in there
Speaker 2: to make.
Speaker 3: Sure you get medication.
Speaker 2: Yes, any of that. It's a group of people saying, yes,
Speaker 2: this is necessary before anybody takes on any further costs.
Speaker 3: Yeah. And additionally to this important note, this is evaluated.
Speaker 3: Part of this is not just whether it's medically necessary,
Speaker 3: but whether it is specifically covered by whatever hierarchy of
Speaker 3: plan you have. So even if you definitely need that
Speaker 3: kidney and you don't have the right plan, you may
Speaker 3: not get approved, meaning that you would be theoretically responsible
Speaker 3: for the entirety of that bill.
Speaker 4: It's another reason too that it's really really difficult to
Speaker 4: get certain experimental treatments covered. And you always hear about,
Speaker 4: you know, people that have cancer and that maybe there's
Speaker 4: this you know, cutting edge treatment that's being used. That's
Speaker 4: the kind of stuff or to get the top person,
Speaker 4: that's the kind of stuff that almost always has to
Speaker 4: be paid out of pocket and can bankrupt people at
Speaker 4: the very least cause them to carry massive, massive debt.
Speaker 2: I agree. I think one of the things we have
Speaker 2: to address at the top here is that most medical plans,
Speaker 2: no matter who's providing them, will state somewhere within the
Speaker 2: massive documentation you have to sign that medically necessary things
Speaker 2: will They won't be fully paid for, but depending on
Speaker 2: your whatever your contract says, they will be paid for
Speaker 2: with a certain percentage, right.
Speaker 3: Sure, after a certain threshold of payments.
Speaker 2: Well, yeah, there's like all these different things. Well it
Speaker 2: just depends. There's all these different things that can go
Speaker 2: into it. And but ultimately, almost every single one of
Speaker 2: the healthcare plans that I have seen say within that
Speaker 2: writing that they will cover medically necessary things, which is
Speaker 2: why that term, that phrase becomes so important.
Speaker 3: Yeah, yeah, and also such a such a foundational stone
Speaker 3: in the controversy and indeed conspiracy we're discussing here. You know,
Speaker 3: in theory, the idea of prior approval is used by
Speaker 3: insurance companies and their health plans and physicians to make
Speaker 3: sure things are cost effective, that the service is necessary,
Speaker 3: it's covered. That makes sense. However, we could argue the
Speaker 3: solution to the second part of covered by your plan
Speaker 3: could be solved very easily by just getting everyone on
Speaker 3: the same plan, like so many other developed countries. Story
Speaker 3: for another day does need to be mentioned. But in theory,
Speaker 3: prior approval does mean that drugs and services are going
Speaker 3: to people who need them.
Speaker 4: And which I guess you know, was sort of the
Speaker 4: point of the Affordable Healthcare Act. But even that in
Speaker 4: and of itself was like a little not great because
Speaker 4: it still required, you know, connecting with these private insurance
Speaker 4: companies that were just in this new network, right yeah,
Speaker 4: the marketplace, that's the market the marketplace. So it's still
Speaker 4: not even close to resembling what other countries have and
Speaker 4: have had for many, many years. And it's also something
Speaker 4: that is for whatever reason and very controversial and seems
Speaker 4: to be in the process of being shut down, or
Speaker 4: at least attempted to be.
Speaker 3: Yeah, it goes back and forth just because there is
Speaker 3: so much money here. We have it later in the episode.
Speaker 3: But maybe one of the things you have to consider
Speaker 3: now when you're playing along at home, folks, is that
Speaker 3: as an industry in the United States, healthcare is by
Speaker 3: far the number one employer, and that that is as
Speaker 3: of March twenty twenty five. Went back and forth between
Speaker 3: that and retail or even I guess the Pentagon is
Speaker 3: technically the largest single entity employer, but not anymore well
Speaker 3: healthcare industry, Yeah, it's all the other companies. Oh no, yeah, God,
Speaker 3: I haven't even thought about all the stuff that's gonna
Speaker 3: happen rip to the stock market. By the way, I
Speaker 3: guess there's no prior approval on whatever surgery was needed
Speaker 3: for that one.
Speaker 4: Ah, the patient's just stuffering for a minute and then
Speaker 4: it's going to heal. I mean to be fine, but
Speaker 4: to be fair, y'all, we've seen corrections before. We've seen
Speaker 4: you know, recessions before. I'm not trying to diminish what's
Speaker 4: going on, but also I really trying not to be
Speaker 4: utterly doom and doom about it.
Speaker 2: Cool, that's good.
Speaker 4: I stuck the mental health thing, guys, I'll go on
Speaker 4: to call it, call it willful self decepsion if you must.
Speaker 4: But this is where I land.
Speaker 3: I had a I had one of those moments where
Speaker 3: I said, you know what, I'm just not going to
Speaker 3: look at anything like a four four A one K
Speaker 3: until twenty twenty nine. Get yeah, exactly.
Speaker 2: So let's let's also just state here most of what
Speaker 2: we're talking about, if not everything we're talking about right now,
Speaker 2: have to do with insurance companies. So all the patients
Speaker 2: to the provider to the insurance company. The insurance company
Speaker 2: is the most important thing. These are private entities that
Speaker 2: are for profit entities. Right There are other medical plans
Speaker 2: that you may find yourself getting if let's say you
Speaker 2: were you were formerly a member of the military, if
Speaker 2: you don't reach a certain level of income on a
Speaker 2: yearly basis, you could be a part of a federal
Speaker 2: or a state like medicare system, et cetera. That they
Speaker 2: function very differently than the ways we're talking about this
Speaker 2: whole system. They're still attempting to cost cut right and
Speaker 2: sure and save get some savings wherever they can, but
Speaker 2: those systems are much less likely to have this type
Speaker 2: of system in play with the denials we're going to
Speaker 2: be talking about today.
Speaker 3: Right right, especially the rate of attrition here, which is
Speaker 3: going to be key.
Speaker 4: Now.
Speaker 3: We gave the the theoretical defenses, right and god knows,
Speaker 3: nobody wants an innocent person to die because somehow the
Speaker 3: medicine that they should have gotten has been, you know,
Speaker 3: funneled off to someone who doesn't need it. Everybody agrees
Speaker 3: on that point, but it is is it not an
Speaker 3: argument of convenience because practice prior approval gets super dicey.
Speaker 3: We'll talk about the rules and criteria, and before we
Speaker 3: do that, we have to establish this is a hodgepodge
Speaker 3: of incongruous, sometimes conflicting bureaucratic regimes. States have their own
Speaker 3: different laws regulating the process and what indeed should even
Speaker 3: be reported about the process. And the most important thing.
Speaker 3: I feel like we get lost in the banality of
Speaker 3: evil here, But the most important thing to remember when
Speaker 3: folks are navigating this arcane system is that there is
Speaker 3: often a ticking clock involved not getting a medicine, not
Speaker 3: getting a procedure or treatment can lead to disaster. It
Speaker 3: is not as if your failing kidney is going to
Speaker 3: wait on your insurance company's paperwork. You know what I mean.
Speaker 3: You can't tell a bodily function or an organ of
Speaker 3: yours that you didn't fill out form XYZ correctly. The
Speaker 3: heart's not going to go now. Yeah, okay, well I'll
Speaker 3: keep taking along for ninety days.
Speaker 2: That is a great point, Ben, because it is human
Speaker 2: beings that are potentially on the brink of death or
Speaker 2: you know, extreme extreme illness or pain. Yes, right, And
Speaker 2: as we found out last year, sometimes that denied back
Speaker 2: surgery could lead to a homicide.
Speaker 3: So you know, we're learning, Luigi Mangio.
Speaker 2: We're learning that this is the stakes couldn't be.
Speaker 3: Higher here, And I really appreciate that because that foreshadowing
Speaker 3: is one of the crucial mission critical larger contexts that
Speaker 3: want us to get to at the end, because this
Speaker 3: occurs in situ with this stuff in media arrests. What
Speaker 3: is medically necessary quote unquote If you ask most insurance
Speaker 3: companies or insurance company adjacent things, they will say medically
Speaker 3: necessary means that when a doctor tells us or puts
Speaker 3: in a request for insurance to cover this thing private insurance.
Speaker 3: Then we have to know for sure that the recommended
Speaker 3: treatment from the physician is proven to be the best
Speaker 3: current approach based on the most current verified research.
Speaker 2: Again, that's also that there's not a cheaper alternative that
Speaker 2: will have quote the same outcome.
Speaker 3: Right. They want to make sure something's not getting duplicated,
Speaker 3: and that can happen if you're seeing multiple specialists, right,
Speaker 3: One one specialist request an X ray, another one request
Speaker 3: an X ray, So an insurance company will say, hey,
Speaker 3: we've already got an X ray. The economical option, or
Speaker 3: what we'll call lowballing, it occurs when just simply put,
Speaker 3: there are two or there are a couple of drugs
Speaker 3: that could treat a condition or a specific aspect of
Speaker 3: a condition, your doctor, for one reason or another, recommends
Speaker 3: one that is more expensive. The insurance company you will
Speaker 3: then ask your physician, why can't you just go with
Speaker 3: the less expensive version. That's not an automatic denial, but
Speaker 3: that does mean your doctor, who's already very busy, has
Speaker 3: to justify why the more expensive option is better. Right,
Speaker 3: Is it because the pharmacy far is it because the
Speaker 3: pharmaceutical reps bribe them?
Speaker 2: Which which is a potential thing. But then you create
Speaker 2: a situation where that physician has to spend hours on
Speaker 2: the computer typing up the reasoning behind something right that
Speaker 2: they just as the physician and as a care provider,
Speaker 2: said hey, this is what needs to happen.
Speaker 3: Right, and you can appeal these denials. You can resubmit paperwork.
Speaker 3: A lot of times, it's the bureaucracy that gets people.
Speaker 3: You might have some kind of other quite innocuous error.
Speaker 3: So if you ever get denied for one of these
Speaker 3: prior approval requests, the first move you and your physics
Speaker 3: team are going to make is to try again. And
Speaker 3: there are cases where someone got denied for something twice thrice,
Speaker 3: only to get approved the third or the fourth time.
Speaker 3: It for a long time, a huge issue with this
Speaker 3: was that these just like how the laws go state
Speaker 3: by state, each private insurance company in the United States
Speaker 3: had their own different systems, their own kind of formatting
Speaker 3: for things, their own kind of reasoning behind how we
Speaker 3: evaluate medical necessity. So what flew with like your I'm
Speaker 3: just making stuff up, but like what flew with you know,
Speaker 3: casadea United might not fly with shoe feed incorporated.
Speaker 4: Well, and it's just I don't know. It's just kind
Speaker 4: of mind boggling that it's not more standardized, and it
Speaker 4: just really points to the problem of how having all
Speaker 4: of these separate entities kind of making their own rules
Speaker 4: without much cohesion between them, really is tough when it
Speaker 4: comes to like human health and human life and well
Speaker 4: being and being treated humanely, because so much of it
Speaker 4: feels like a crap shoot. The idea of getting approved
Speaker 4: the third or fourth time.
Speaker 2: Why well, we'll get into it. But I think the
Speaker 2: real problem is that each of these entities is looking
Speaker 2: at the bottom line, and each of these entities, especially
Speaker 2: at the very top of the private insurers, are trying
Speaker 2: to make sure the total revenues for that year or
Speaker 2: that quarter are higher than the ones that they were before.
Speaker 3: Yeah, you could also argue that their primary patients are
Speaker 3: the shareholders. Is just wild.
Speaker 4: I'm sorry. I mean, I don't understund naive. It's just
Speaker 4: I know this is how capitalism works. But when you
Speaker 4: have such a capitalist, you know, philosophy behind something as
Speaker 4: important as like saving human lives, it's just yeah, it's wild.
Speaker 2: It makes you wonder what the American Medical Association, it's
Speaker 2: four Besides lobbying, I guess or the.
Speaker 3: Many other related medical associations. I love what you were saying.
Speaker 3: There no the idea of this massive discrepancy, these competing,
Speaker 3: sometimes contradictory systems. There's a solution, Dylan, if we could
Speaker 3: get some fanfare perfect set about large scale automation courtesy
Speaker 3: of companies like Core.
Speaker 4: Right right.
Speaker 3: The idea is uniformizing the approval process. Supporters will say, look,
Speaker 3: this saves cost, it cuts confusion overall. While imperfect, it
Speaker 3: is a better system. However, critics will say this system
Speaker 3: is purposely, brutally designed to deny as much coverage as possible,
Speaker 3: accelerating profits while you know, endangering or even ending human lives.
Speaker 4: And we'll get into more about how that happens after
Speaker 4: a quick word from our sponsor.
Speaker 3: Where it gets crazy. All right, evil Core, Evcore, Evycore.
Speaker 2: However you they say, eviCore our corporate video.
Speaker 3: All right, Well, we've given them the respect they're due.
Speaker 3: So evil Core is founded in the early nineteen nineties.
Speaker 3: It's a medical imaging company, you know the kind of
Speaker 3: folks who work with cat scans and X rays and stuff.
Speaker 3: This is nineteen ninety two, and it goes through several
Speaker 3: different headquarters like back and forth from South Carolina and Florida,
Speaker 3: et cetera. It goes through acquisitions. There's a merger in
Speaker 3: twenty fourteen, and the product of the merger is ultimately
Speaker 3: acquired by the gigantic company Signa in twenty eighteen. And
Speaker 3: so now this is unnecessarily complicated, right, This company operates
Speaker 3: through eviCore operates under Signa with relative autonomy because they
Speaker 3: operate under a another subsidiary of Signa called ever North.
Speaker 3: So yes, it's Petroshka Dolls, right, that's partially to help
Speaker 3: out with accounting, to be quite honest with.
Speaker 2: You, Yeah, it's really fun to go through those companies
Speaker 2: and then just see what all the mission statements are
Speaker 2: for the companies. As you imagine going down and parsing
Speaker 2: the mission into a sharper thing. I guess as you get,
Speaker 2: you know, through ever North, through Signa to ever North,
Speaker 2: to to eviCore.
Speaker 3: Which is dance of euphemisms.
Speaker 2: Oh yeah, which is now in Franklin, Tennessee. Everybody head quartered.
Speaker 3: Tell them we said hi. So Evicore's best known thing
Speaker 3: the platform we're talking about tonight, along with thirty eight
Speaker 3: other huge clients of theirs is something called in telepath.
Speaker 3: In telepath, which sounds like a weirdly specific superhero power,
Speaker 3: I'm not a telepath, I'm an intell past that's funny.
Speaker 4: I only read smart people's minds.
Speaker 3: We got there. But the idea is that this proprietary
Speaker 3: platform can get things approved faster, can at least get
Speaker 3: decisions made faster, reducing the burnout of doctors. Overall, their
Speaker 3: argument is this makes things more efficient and less stressful
Speaker 3: for everybody, including patients on the ground who already pay
Speaker 3: these insurance companies a ton of money.
Speaker 4: Well, you could certainly argue or see the merit in
Speaker 4: something like this. It all just depends on the rubric
Speaker 4: that it's using, you know, and then which sign it
Speaker 4: favor and which ultimate outcome is prioritized for the folks
Speaker 4: programming the platform or the very least nudging it in
Speaker 4: whichever direction.
Speaker 3: What's the dial?
Speaker 2: Oh, we're going to learn about the day dial. But
Speaker 2: if you want to put yourself in maybe you're not
Speaker 2: a medical provider or a physician, but if you want
Speaker 2: to put yourself in the shoes of somebody, let's say
Speaker 2: you're a doctor that you go and see on a
Speaker 2: regular basis, Evicre on their website has a nice little
Speaker 2: author pre authorization or they call it prior authorization checklist
Speaker 2: where you can see just all the things you need
Speaker 2: to do as a provider to provide to this thing
Speaker 2: that we're talking about, this automated service, and then all
Speaker 2: of the different steps you need to take as that
Speaker 2: physician just to get a single prior authorization done.
Speaker 3: And it is.
Speaker 2: From my eyes, it's infuriate, infuriating the amount of busy
Speaker 2: work that somebody has to do to make one surgery happen.
Speaker 3: Which is why there are entire small armies of support
Speaker 3: staff who has who have to walk through this stuff.
Speaker 3: You know, and keep in mind again we are make
Speaker 3: no mistake, we are talking about potentially life saving services. Now.
Speaker 3: Evicor can't get in too much, too much trouble for
Speaker 3: this as an insurer because it is not itself a
Speaker 3: direct insurer. It is a third party. Your insurance companies
Speaker 3: are outsourcing these approval decisions to companies like Evicre or
Speaker 3: evil Core, and these clients. It might sound small when
Speaker 3: you hear these folks say, hey, we started with like
Speaker 3: three clients and now we have thirty eight. But those
Speaker 3: clients each one. They comprise some of the biggest insurance
Speaker 3: companies in the United States. So as a result, the
Speaker 3: partially automated approval decisions from this company, this outsourced third party,
Speaker 3: they affect around one hundred million people in this country
Speaker 3: as of last year. That is about one and three
Speaker 3: Americans with insurance.
Speaker 4: Yep.
Speaker 2: So if you've got oh, I don't know, Blue Cross,
Speaker 2: Blue Shield, Etna, United Healthcare, you were, or even some
Speaker 2: Medicare or some Medicaid groups use this service.
Speaker 3: Yeah, I mean, and this is Look, this did not
Speaker 3: come out of someone's fever dream one night. This is
Speaker 3: the culmination of a massive decade long, multi decades long
Speaker 3: campaign by existing insurance companies because they looked around and
Speaker 3: they saw some studies that are again sort of convenient,
Speaker 3: and they said, all these healthcare costs are exploding, all
Speaker 3: these people getting over treatment. That's the euphemism over treatment.
Speaker 2: That's not healthcare costs for you and me and us
Speaker 2: and the human beings. That's healthcare costs for healthcare corporations.
Speaker 4: And again, though I mean, like this centralized platform that
Speaker 4: we're talking about, it would if used kind of more humanly,
Speaker 4: I guess be the thing we were saying maybe needed
Speaker 4: to happen some sort of standardization between these companies. But
Speaker 4: what it's trying to do is just not that's exactly
Speaker 4: the opposite of what we want, right.
Speaker 3: It's so weird because the idea is that this company, like, okay,
Speaker 3: you're an insurance company, you outsource, you sign one of
Speaker 3: two types of contracts with this company, and as a result,
Speaker 3: they will somewhat automate the decisions or they'll they'll offload
Speaker 3: the decision making process from your company. They specialize, ever
Speaker 3: Acorse specializes in expensive or niche procedures and recommendations, so oncology,
Speaker 3: gastro entrology, sleep problems, a Baker's dozen of other specialized
Speaker 3: fields like cardiology, course, and the idea is kind of
Speaker 3: what you were describing there. Know that this proprietary platform
Speaker 3: in Telepath streamlines everything in a single application. It manages requests,
Speaker 3: clinical surveys, and it gives you real time decisions. That
Speaker 3: real time decision aspect is a game changer, especially when
Speaker 3: we're talking about time sensitive stuff, especially if those requests
Speaker 3: get approved. And that's the problem we can't thank again,
Speaker 3: k Dog and our pals at pro Publica and Capital Forum,
Speaker 3: we can't thank them enough for the fantastic work they
Speaker 3: published in October of last year. It's a long breed,
Speaker 3: but everyone should check it out.
Speaker 2: It's huge, Yes, but dang is it intense. You can Yeah,
Speaker 2: you can find it everywhere. I think CNN even reposted
Speaker 2: it when it's like word for word, Yeah, exactly, a
Speaker 2: couple other places that our big publications put it out
Speaker 2: because it is that important.
Speaker 3: Yeah, and they're saying they're saying what we've been sort
Speaker 3: of saying here at the top. Their investigation indicates that
Speaker 3: this company and companies like it's there are more than
Speaker 3: one in the game. They may be incentivized by more
Speaker 3: than just efficiency. They may be pursuing profits for clients
Speaker 3: by increasing rates of denial and doing so knowingly. And
Speaker 3: they don't even call it denials. They call it inappropriate
Speaker 3: care intermentrop say.
Speaker 2: Guys, we talked about overtreatment, but ben, I think we
Speaker 2: skipped over the actual stats there of what is stated
Speaker 2: by the health insurers in like why they're looking for
Speaker 2: this service. Can we just hit those real quick?
Speaker 3: Yeah, they said something the overtreatment rationalization right from the
Speaker 3: insurance companies are a handful of studies that if you
Speaker 3: read them are a little bit dodgy. We're not experts,
Speaker 3: but they're a little dodgy. They're claiming that twenty to
Speaker 3: forty five percent of certain medical treatments are ineffective, wasteful,
Speaker 3: or unnecessary. Forty five percent is a really high number,
Speaker 3: especially considering that the people making these requests have gone
Speaker 3: to medical school forever.
Speaker 2: Dude, Yeah, well, and just this concept that, oh, well,
Speaker 2: we checked out patient a's heart because patient A was
Speaker 2: complaining of you know, heart issues. These are symptoms that
Speaker 2: someone who might have a heart attack soon would have,
Speaker 2: so we checked out his heart. Is that wasteful? Is
Speaker 2: that unnecessary? Because he wasn't actively having a heart attack? Right.
Speaker 3: We talked about that too, you know, like, how do
Speaker 3: you That's such a devilish thing how one defines necessity? Right,
Speaker 3: someone's blood work comes back right, indicative of a possibly
Speaker 3: serious symptom. It's the sort of thing that as a
Speaker 3: physician you are ethically required to look into. It is
Speaker 3: your job to do that, and instead they're insured comes
Speaker 3: to you and says, well, this is going to be unnecessary.
Speaker 3: Or a few years ago, people did these blood tests,
Speaker 3: and this percentage of people did not in fact have
Speaker 3: that dangerous condition. So roll the dice, you know, pick
Speaker 3: a card. Yeah, because it's probably not going to be
Speaker 3: the dangerous one. Request denied stamp, like denied stamp.
Speaker 2: Sound already you can see how it feels like betting
Speaker 2: on human lives already. And we haven't even gotten to
Speaker 2: the details yet.
Speaker 3: No, we've got to. We've got to talk about the dial,
Speaker 3: all right. This is the partially AI powered algorithm that
Speaker 3: makes the initial call your doctor. You know, someone comes
Speaker 3: in and they say, I'm having shortness of breath. I'm
Speaker 3: having you know, maybe like fugue states something like that,
Speaker 3: or heart palpitations, and you put in a request for
Speaker 3: some stuff. This AI powered algorithm is not a set
Speaker 3: in stone system the thing that replies. It's referred to
Speaker 3: the dial because it can be adjusted. I want to
Speaker 3: be careful how we say this. It can be adjusted
Speaker 3: in a way that in practice raises rates of denial.
Speaker 2: Yeah, yes, yes, and and and specifically that has to
Speaker 2: do with the type of contract EVI Core ends up
Speaker 2: signing with whatever insure other entity, right, because Ben, you
Speaker 2: mentioned there's at least two types of contracts. One of
Speaker 2: them is like the general we're gonna we are going
Speaker 2: to handle your prior authorizations through our system. Then we'll
Speaker 2: just do the whole thing of back and forth if
Speaker 2: we need to appeal the other one that you talked about.
Speaker 2: There's a great example within that Pro Publica article of Uh, well,
Speaker 2: I'll just I'll read directly from the article. Uh, you
Speaker 2: can check it out if you want. The title of
Speaker 2: it is not medically necessary. You can just look that
Speaker 2: up probably and find it Pro Publica.
Speaker 4: You'll find it.
Speaker 3: Oh and is it? Is it okay if I shout
Speaker 3: out the authors there?
Speaker 2: Oh?
Speaker 3: Yeah, this is several Yeah, because they're there. This is
Speaker 3: like a posse track. So we're talking about t Christian
Speaker 3: Miller from Pro Publica, Patrick Rucker from Capital Forum, and
Speaker 3: David Armstrong also of Pro public journitists exactly.
Speaker 2: So this is a direct quote from that. They're talking
Speaker 2: about these known risk contracts, which is a separate type
Speaker 2: of contract. They say, as an example, say an insure
Speaker 2: spends around ten million dollars a year on MRIs if
Speaker 2: eviCore keeps costs below ten million dollars per year on MRIs.
Speaker 2: eviCore as a corporation, as an entity, pockets the difference
Speaker 2: in how like basically how much money that insurance company
Speaker 2: saved on MRIs that year according to that contract, or
Speaker 2: it might split those profits like fifty to fifty sixty
Speaker 2: forty something like that, depending on the contract with the
Speaker 2: health insurance company.
Speaker 4: So isn't that like a kickback?
Speaker 3: Yes, it's it's loosely called a risk contract.
Speaker 4: Yes.
Speaker 3: Former employees speaking under anonymity, called it.
Speaker 4: Betting on future or something.
Speaker 3: It's very much so, I mean that's the that's the
Speaker 3: other thing.
Speaker 4: Right.
Speaker 3: So the argument that there may be incentivization that moves
Speaker 3: you beyond just efficiency. It goes to look the contracts
Speaker 3: that have been verified by the investigation. They do indicate
Speaker 3: company profits can be tied, like you were saying, Matt,
Speaker 3: directly to the amount of cuts made and expenditures. Now,
Speaker 3: the insurance companies have agency in this. The contracts that
Speaker 3: they sign can direct can direct this company and others
Speaker 3: like it toward focusing on certain not just outcomes, but
Speaker 3: certain conditions, certain medical conditions like now you're going to
Speaker 3: be our oncology approval gang. Right, And so some folks
Speaker 3: may argue, hey, this is just a matter of perception,
Speaker 3: because companies that are baking in this relationship between denials
Speaker 3: and profits. They might just be trying to get stuff
Speaker 3: up and running that's better than their own older approval methods.
Speaker 3: Those may have had a lot of room for error,
Speaker 3: you know, and a lot of people were working with
Speaker 3: antiquated paper based systems.
Speaker 2: Oh yeah, absolutely, But to really dial down on it,
Speaker 2: Oh god, sorry, I'm so sorry that this dial thing
Speaker 2: that is referenced a ton throughout that investigation, which is direct,
Speaker 2: which is essentially the algorithm that we're talking about here,
Speaker 2: it can be, according to a lot of those insiders,
Speaker 2: really turned right. So you could say the insurance company
Speaker 2: actually needs to save x more percentage on those MRIs
Speaker 2: or something, and you could adjust how it looks at
Speaker 2: these prior approval documentation, the documentation for each individual one.
Speaker 2: And it's talking about how it can deny claims that
Speaker 2: have like a ninety five percent necessary rating or something.
Speaker 3: Ninety five percent or less likelihood of approval. Yeah, yeah, yeah,
Speaker 3: And this is before we get to that. I got
Speaker 3: to I gotta say, I want us to put the
Speaker 3: claims of evicre in in context with the claims of
Speaker 3: critics and the claims of investigators. So you've got it, folks.
Speaker 3: While you're on the internet. There is a webinar from
Speaker 3: eviCore because yes they have a YouTube channel. Check out
Speaker 3: ours as well, Conspiracy Stuff show. So in this video
Speaker 3: there's a spokesperson for evicre who says, yeah who who
Speaker 3: portrays client profits as not the primary goal, but as
Speaker 3: kind of a Bob Ros Style happy accident. And we
Speaker 3: love to love to play a clip here, Dilan if
Speaker 3: we could.
Speaker 5: Not being exposed to things that they don't need to
Speaker 5: be exposed to unnecessarily. So we are improving the quality
Speaker 5: of health care, the safety of health care, and by
Speaker 5: a very happy coincidence, we're also decreasing a significant amount
Speaker 5: of unnecessary cost.
Speaker 3: The line he says, I think is really important is,
Speaker 3: by very happy coincidence, we're also decreasing a significant amount
Speaker 3: of unnecessary cost. Woops, says the guy flying the plane.
Speaker 3: As a side effect of this plane, it turns out
Speaker 3: it flies, and of course, if you want to if
Speaker 3: you want to see that. Specifically, we're big fans of
Speaker 3: the titles and the Evicore's or Evcore or evil Core,
Speaker 3: because I'm not going to give them too much respect.
Speaker 3: We're a big fan of the titles and their webinars
Speaker 3: that comes to us from retain and grow your self
Speaker 3: funded business with effective utilization management three years ago.
Speaker 2: Yeah. You can also find an update too that they
Speaker 2: put out pretty recently on their YouTube that has the
Speaker 2: same kind of language, not quite exactly the same, but
Speaker 2: search understanding Evicore's approach to patient centered care.
Speaker 3: So is this really a happy accident? If you go
Speaker 3: to back to pro Publicans and related investigations, you'll say,
Speaker 3: you'll see that what representatives of this company are saying
Speaker 3: internally does not match what they're saying externally. I'd love
Speaker 3: for us to go to a quote from pro Publica directly.
Speaker 4: eviCore markets itself to insurance companies by promising a three
Speaker 4: to one return on investment that is, for every one
Speaker 4: dollar spent on eviCore the system, the insurer would pay
Speaker 4: out three dollars less on medical care and other costs.
Speaker 4: Of of course, salespeople have boasted of a fifteen percent increase
Speaker 4: in denials, according to the investigation, which is based on
Speaker 4: internal documents, corporate data, and dozens of interviews with former employees, doctors,
Speaker 4: industry experts, healthcare regulators, and insurance executives. I mean, y'all
Speaker 4: if you took the first part of this lift from
Speaker 4: this quote from the article eviCore market it self to
Speaker 4: insurance companies by promising a three to one return investment.
Speaker 4: It sounds like the kind of thing that they would
Speaker 4: do as a sales pitch, you know what I mean, Like.
Speaker 3: Yeah, it is yeah, one hundred so one hundred percent
Speaker 3: that yeah, And we know that because former salespeople, I
Speaker 3: guess legally I can't say they're former salespeople. Former employees
Speaker 3: confirmed this in some very high level ones. We also
Speaker 3: know some disturbing stats because again, remember how we're saying earlier,
Speaker 3: state by state laws change. Some states require denial rates
Speaker 3: to be a matter of public record. It is crazy
Speaker 3: that not every state requires that. But with that, armed
Speaker 3: with that information, we can give you another stat here,
Speaker 3: pulling from evicuor's own self produced data, they fully or
Speaker 3: partially turned down around twenty percent of all request for
Speaker 3: medical care in Arkansas, So twenty percent, so one out
Speaker 3: of five of every request. And for comparison, people in
Speaker 3: that same state who were in Medicare advantage, about seven
Speaker 3: percent of their claims would be rejected. So this shows
Speaker 3: us a big discrepancy between the business as usual and
Speaker 3: whatever innovations we could call them evicres bringing to the table.
Speaker 3: So to understand what's going on, we have to go
Speaker 3: back to the dial. Dial it back to the dial
Speaker 3: and maybe take a break for a word from our
Speaker 3: sponsors and walk through this claim process step by step.
Speaker 3: What do you guys say?
Speaker 2: Oh, but yes, we should do it.
Speaker 4: Sorry I sounded too excited. Let's do it.
Speaker 3: And we returned the dial of denial. Not proud of it,
Speaker 3: but it's there.
Speaker 4: That's worse than the dial of destiny, imaginarently, but it
Speaker 4: is a dial of it's true.
Speaker 3: Really good point, Yeah, it really is. So Okay, you're
Speaker 3: a doctor. What's a good name for a doctor?
Speaker 4: Oh?
Speaker 3: Doctor? Spashuman doctor? Oh yeah, yes, yes, uh all right,
Speaker 3: so submit some paperwork, right, and this goes to the system.
Speaker 3: This goes to the dial, and the dial which is
Speaker 3: it's an informal name. By the way.
Speaker 2: Uh.
Speaker 3: The dial can automatically approve a request or it can
Speaker 3: flag it for further review. I think one thing a
Speaker 3: lot of people need to keep front of mind. Here
Speaker 3: is the dial, the AI power powered algorithm itself. It
Speaker 3: cannot as of yet, automatically deny a claim. It can
Speaker 3: only pop a flag and send it to a human.
Speaker 4: Yep.
Speaker 2: You will hear that as like rhetoric coming out from
Speaker 2: people that you know rightly see major issues with this
Speaker 2: and talk about how things are getting automatically denied by
Speaker 2: this algorithm. But you're absolutely one hundred percent right. It
Speaker 2: says that over and over in the investigation.
Speaker 3: Yeah, it look where it is an important note because
Speaker 3: we do have to be fair. Anything it flags as
Speaker 3: not entirely kosher gets sent to an internal team of
Speaker 3: evicre nurses and doctors, some full time, some consultants. Only
Speaker 3: the doctors can issue that actual final denial, but all
Speaker 3: along the way, depending on the nature of the contract,
Speaker 3: the conversations with execs and shareholders, people in EVICORPS can
Speaker 3: adjust the settings on the system. They can dial up
Speaker 3: or down what rates as an automatic approval.
Speaker 4: Yep.
Speaker 2: Oh, and just to have Evicor's back a little bit here, guys,
Speaker 2: according to their videos that they put out, they let
Speaker 2: everybody know they only hire doctors for these purposes who
Speaker 2: are going to be doing the denials or approvals, who
Speaker 2: have had medical experience, like actually worked in a hospital
Speaker 2: or some similar practice.
Speaker 3: Oh no, somebody like ethics degree. Isn't going to let
Speaker 3: me get in there, you know, underwater basket underwater basket
Speaker 3: weaving PhD.
Speaker 4: Is it going to work for this ethics degree? All right?
Speaker 4: That sounds I wish more people had one of.
Speaker 2: Those philosophy major doctor exactly.
Speaker 3: Oh god, there's so many airplay jokes that could make.
Speaker 3: But anyway, okay, just one.
Speaker 5: All right.
Speaker 3: So somebody's having a heart attack there on the plane
Speaker 3: and the you know, the flight attendant says, is there
Speaker 3: a doctor in the house?
Speaker 4: Anyway? It goes, no, I'm not a doctor. I just
Speaker 4: play one on TV. There it is.
Speaker 3: Uh So, this algorithm gets that paperwork, it analyzes it,
Speaker 3: it assigns it what we could loosely call a likelihood
Speaker 3: of approval, knowing what we know in the past, based
Speaker 3: on the guidelines that we have generated internally, how likely
Speaker 3: is this thing to be a yes? One request could
Speaker 3: get rated at sixty or seventy percent, and depending upon
Speaker 3: where the algorithm is set, maybe if it meets seventy percent,
Speaker 3: it gets automatically approved. Because now there's the argument would
Speaker 3: be fighting for that thirty thirty percent possibility of being denied.
Speaker 3: It's not worth our time it's not cost effective. But
Speaker 3: if the company wants more denials for a certain contractual relationship,
Speaker 3: they can dial that threshold up, like you were saying, Matt,
Speaker 3: to something around ninety to ninety five percent. So when
Speaker 3: you think under that likelihood gets flagged for review and
Speaker 3: it goes to those internal employees, and the more reviews,
Speaker 3: the higher the chance of denial due to the nature
Speaker 3: of the internal guidelines.
Speaker 2: This is just it's so infuriating, and you have you know,
Speaker 2: if you look at the outward statements for anyone who
Speaker 2: you know is going to be talking about this that
Speaker 2: has their job on the line, let's say it works
Speaker 2: for eviCore in any capacity or is is in that
Speaker 2: chain anywhere from the healthcare company down to the physician.
Speaker 2: You you can imagine that nobody is going to come
Speaker 2: out and say, well, I'm incentivized to deny the things
Speaker 2: that are even at ninety percent ninety five percent approval,
Speaker 2: I am incentivized as a physician working for Evicre to
Speaker 2: stop that from happening, because if I stop that from happening,
Speaker 2: I'm you know, I'm going to keep my job. The
Speaker 2: company's going to make more profit. The healthcare insurance insurance
Speaker 2: company is going to make more profit, and then somebody
Speaker 2: might have a big, big problem, you know, with their health.
Speaker 4: It's one of those things too, where it's just they
Speaker 4: kind of tweak it just enough, it would seem where
Speaker 4: it's not like you could trace doctors getting paid off
Speaker 4: or like an incentive of you know, a bonus of
Speaker 4: some kind of four denials. But in a roundabout way,
Speaker 4: what it amounts to is more or less that in
Speaker 4: terms of like systematically the way this organization operates.
Speaker 3: Yeah, because you can always say it's just for review, right,
Speaker 3: We're not immediately saying no, And then well we should
Speaker 3: get into the controversy about the guidelines. But yeah, that's
Speaker 3: the thing. When this stuff goes to review, the chances
Speaker 3: of it being denied are much higher. And then also
Speaker 3: you could argue they're foisting a bureaucratic burden upon the
Speaker 3: actual on the ground physician, upon the patient, anybody involved.
Speaker 3: They've et acre evil Core has always said the system
Speaker 3: is built on continually updated guidelines, always based on the latest,
Speaker 3: most accurate research. And then they also say they go
Speaker 3: a step further, they say, look, these guidelines are sacked
Speaker 3: or sank to us, they're part of the system. They're
Speaker 3: state agnostic. The same stuff gets applied for all states,
Speaker 3: all clients. Someone requesting an MRI in Vermont gets treated
Speaker 3: the way someone the same way someone requesting an MRI
Speaker 3: in Georgia would be treated. In short, they deny any
Speaker 3: and all claims. Get it of willful misconduct.
Speaker 2: Hey, they deny all the claims, deny the Yeah, yeah, yeah.
Speaker 2: Just another quick quote from that investigation about those guidelines.
Speaker 2: And this comes from as you as we were saying,
Speaker 2: there are people inside the system speaking out talking about
Speaker 2: what they've experienced. This comes from they had to kind
Speaker 2: of mask it a little bit.
Speaker 4: Uh.
Speaker 2: This comes from an eviCore employee involved in the radiation
Speaker 2: oncology program. And the quote says company executives quote would say,
Speaker 2: keep a closer eye on the guidelines for reviews for
Speaker 2: aarticular company because we're not showing savings unquote for that
Speaker 2: particular company that they have a contract with.
Speaker 3: And again, you know, the argument from that perspective is
Speaker 3: due diligence, right, But that's a big umbrella, and you
Speaker 3: can put a lot of villainy under that umbrella. And
Speaker 3: if we I've also want to point out the other
Speaker 3: the another issue that does not to be fair does
Speaker 3: not come from Evicors. But you know, we said evicre
Speaker 3: is kind of the Coca Cola. There are other brands
Speaker 3: in the game. One we could call the PEPSI would
Speaker 3: be under Elevance Health, a subsidiary called Caroline Medical Benefits Management.
Speaker 3: They had to settle a lawsuit in twenty twenty two
Speaker 3: to the tune of thirteen million dollars because the courts
Speaker 3: investigated claims about claims concerning tactics they would use to
Speaker 3: deny approval requests. And one of the most villainous and
Speaker 3: petty like supervillain level of petty we found was this
Speaker 3: company has provably in the past set its fax machines
Speaker 3: to only receive five to ten pages at once, and
Speaker 3: it did not tell the customers. It did not tell
Speaker 3: the physicians. What it would do is deny requests that
Speaker 3: were longer than the page count and say you didn't
Speaker 3: give us all the information, and someone at the doctor's
Speaker 3: office refaxes the thing, and then they get the same
Speaker 3: message back and get back on the phone and maybe
Speaker 3: eventually with some digging, they say, why is your fax
Speaker 3: machine like this?
Speaker 4: Yeah.
Speaker 2: In a quick note on that little company, from the
Speaker 2: investigation and just from general knowledge that we've learned on
Speaker 2: this show over the years. Elevant's Health used to have
Speaker 2: a different name. What do we know about companies that
Speaker 2: have to change their name of times? Once, twice, three times.
Speaker 4: Come up with a joke about that earlier and I could.
Speaker 4: That's good, Matt, you did it. You got there.
Speaker 2: They were anthem back.
Speaker 3: And they were anthem. Yeah. Yeah, companies who look on
Speaker 3: this show. We always respect the preferred names and pronouns
Speaker 3: of individual people. But if you're a sketchy company, sorry, man,
Speaker 3: that first name is the scarlet letter. You earned it.
Speaker 4: Pomecast guys, hey, it's been a weird channel.
Speaker 3: Yeah, every all of them, you know, I know, I
Speaker 3: hope we should keep it on.
Speaker 4: I think you're probably right.
Speaker 2: Yah yeah, no, I mean for real, because the biggest
Speaker 2: one we talked about was back in the day, remember
Speaker 2: that contractor business, Yeah, changed your name at least three times,
Speaker 2: Xie academic. H Why did they change their name? Is
Speaker 2: just a rebrand right? Oh?
Speaker 4: Wait?
Speaker 2: No? Oh wait, no, there is think called WikiLeaks showed
Speaker 2: horrific videos of their contractors doing things.
Speaker 3: So I need to continue today, yep, So just.
Speaker 2: Remind yourself every time you see that rebranding thing, just
Speaker 2: what does it really mean?
Speaker 3: Yeah, you don't have to automatically deny the potential goodness
Speaker 3: of that corporation, but you should flag it for personal
Speaker 3: review and see what their likelihood of approval is.
Speaker 2: On your end, I'm seeing the seventy percent chance.
Speaker 3: Sits for chicanery. There are Look, there are a ton
Speaker 3: of critics for this. It's pretty clear. You know, you
Speaker 3: mentioned multiple medical organizations they say the guidelines are kind
Speaker 3: of malarchy. And that's not just lobbying groups are all
Speaker 3: familiar with, but it's things like the American College of Cardiology,
Speaker 3: the Society for Vascular Surgery, the one I didn't know,
Speaker 3: but I think we'll all love this. When the American
Speaker 3: Society for Radiation Oncology or ASTRO. I think ASTRO is cool,
Speaker 3: pretty cool. But the one thing these organizations all have
Speaker 3: in common is that they are experts in the in
Speaker 3: the conditions that this company approves or disapproves treatment for.
Speaker 3: These are the boffins. These are the eggheads and the experts,
Speaker 3: and they're the ones saying that the guidelines are crap. Yeah,
Speaker 3: I just want to point that out. You know, it's like,
Speaker 3: it's different from it's like if if the three of
Speaker 3: us actually built cyber trucks, are actually built pickup trucks
Speaker 3: and said we didn't like cyber trucks. That's way different
Speaker 3: from us seeing one on the street in Austin and
Speaker 3: going uh huh, that's goofy.
Speaker 2: That is it's very different. These are the people that
Speaker 2: actually know what they're talking about.
Speaker 4: Have you guys seen a video of people using cyber
Speaker 4: trucks as skateboard ramps. It's kind of the perfect perfectly sometime.
Speaker 4: And also have we talked about the fact that they've
Speaker 4: recalled literally I think all of them beca because of
Speaker 4: this really dangerous metal strip that's just got glued on
Speaker 4: and that will just fly off randomly. Yes.
Speaker 3: Yeah, if you're trying to save cost and per unit manufacturing,
Speaker 3: you can use the wrong adhesive and just have a
Speaker 3: no refunds policy. But luckily the US still has something
Speaker 3: like recall wawls.
Speaker 4: Hopefully Healthcare doesn't deny your claim when that metal shrapnel
Speaker 4: flies off in traffic and slices your arm off or something.
Speaker 3: Oh man, yeah, no kidding. Uh, there's another let's talk
Speaker 3: about the contracts too. There's another thing we have to mention.
Speaker 3: So in some of these deals there will be an
Speaker 3: agreement where we said evicor will guarantee a certain threshold
Speaker 3: of rise and denials right or rise and deficient or
Speaker 3: efficiency or whatever they call it. They'll also do a
Speaker 3: little bit of glad handing and they'll say, hey, if
Speaker 3: there are claims that are not denied, then we will
Speaker 3: pay them. We the company, will pay the cost of
Speaker 3: those in exchange forgetting to keep any savings that we
Speaker 3: get beyond your standard expenses. This is part of the
Speaker 3: This is part of the tricky and ethically fraught thing,
Speaker 3: the risk contract. They have a flat rate contract, they
Speaker 3: have a risk contract. It looks like it makes the
Speaker 3: system not as objective as it would appear to be.
Speaker 3: And that's not us saying it. That's folks like the
Speaker 3: former California Insurance Commissioner Dave Jones, who has spoken about
Speaker 3: this multiple times. Not just a pro public that's right.
Speaker 4: Apparently doctors will sometimes be a bit more hesitant to
Speaker 4: send a request in the first place if they know
Speaker 4: the system is involved, the ev core system or core
Speaker 4: E of courses, the claim will get denied no matter
Speaker 4: what in this case, and Evicre internally refers to this
Speaker 4: as sentinel as facts or sentinel syndrome. Yeah, it sounds
Speaker 4: like something of X men.
Speaker 2: Well, because you don't want to as the phys position
Speaker 2: or you know, that care provider. You don't want to
Speaker 2: get singled out and say, this person keeps pushing through
Speaker 2: all these things, we keep denying Where why are they
Speaker 2: being a problem?
Speaker 3: Yeah, exactly, real drip. And then there's the other side,
Speaker 3: the way this company will portray it because they use
Speaker 3: the phrase sentinel effect as well. They'll say, think of
Speaker 3: it like how a sheriff comes to town, you know,
Speaker 3: and now people are a little more on their p's
Speaker 3: and ques. That's their argument. Again, your perspective may differ here,
Speaker 3: but this is the quick skinning. The US healthcare industry
Speaker 3: is a leviathan by any means, and it's we mentioned
Speaker 3: as the biggest employer in the country statistically. That means,
Speaker 3: you guys, that a lot of us in the audience
Speaker 3: tonight tuning in are employed by this industry in one
Speaker 3: way or another, And that means it touches everyone in
Speaker 3: this country. Even if you have never filed a claim,
Speaker 3: even if you are in perfect health, this will somehow
Speaker 3: reach you and your loved ones. So it's important for
Speaker 3: us all to ask, is this, knowing what we know now,
Speaker 3: is this genuinely a matter of reducing waste and making
Speaker 3: things more efficient or did these, perhaps once noble intentions,
Speaker 3: lead to a vast conspiratorial industry that is built to
Speaker 3: purposely prevent people from getting the care that, by the
Speaker 3: way they pay for, they're paying for us.
Speaker 4: It's the most vexing part of all of it when
Speaker 4: you start like, even with these wildfires and things like
Speaker 4: I think we all have friends and colleagues of course
Speaker 4: that lost things in those and lost homes or were displaced,
Speaker 4: and just the attitude it would seem of the insurance
Speaker 4: company to do everything humanly possible to deny claims, especially
Speaker 4: after you've paid in all of this money, you know,
Speaker 4: for so so very long, and then you don't even
Speaker 4: get the thing that you've been paying towards. It's really
Speaker 4: really disappointing.
Speaker 2: It's baffling to see from Evercore's own website, in their
Speaker 2: own statements, from officials and board members and people who
Speaker 2: say things they give you the value add right, anytime
Speaker 2: anyone's going to pay for a product or service, what
Speaker 2: is the value that this product or service has for me.
Speaker 2: The person who's buying it right in this case is
Speaker 2: the health insurance companies, and they're also you know, essentially
Speaker 2: giving a value add to the physicians and the care providers, saying, hey,
Speaker 2: we're gonna remove a lot of that junk you have
Speaker 2: to do all your busy work when you're getting these
Speaker 2: prior authorizations. But ultimately, to me, it's trying to fix
Speaker 2: a problem that's created by this insane system that we've built.
Speaker 2: And every time we make these little changes to the
Speaker 2: American healthcare system, the private healthcare system, it is like
Speaker 2: putting band aids on leaking pipes, right, or pipes that
Speaker 2: have a gaping hole in them. We're trying so hard
Speaker 2: to fix something, but it just seems like, I don't know, guys,
Speaker 2: we've talked about before, it seems like the only way
Speaker 2: forward really is to dismantle the thing. But if you
Speaker 2: dismantle the thing, as we said at the top of this,
Speaker 2: you're dismantling the largest like what employer base essentially that
Speaker 2: exists out there.
Speaker 3: Yeah, yeah, and it is. It is a pickle. I
Speaker 3: always think it's best to think in terms of analogy
Speaker 3: to the point about whether the system itself is inherently
Speaker 3: beyond repair right as the car totaled. Think of it
Speaker 3: this way, Private insurance companies in this situation, just objectively,
Speaker 3: it is as though somebody owns a shoe store and
Speaker 3: they go to another company and they say, guys, these
Speaker 3: people who buy shoes too many of them are walking
Speaker 3: out with the shoes they bought. Is there a way
Speaker 3: that we could, you know, make sure like fifteen to
Speaker 3: twenty percent of them don't leave with those shoes.
Speaker 2: That's evil. That yeah, that's that's evil to the core.
Speaker 2: And let's also, hey, let's quickly point out here SIGNA
Speaker 2: Group on their website they boast about how they have
Speaker 2: one hundred and eighty point five billion total revenues at
Speaker 2: last time they checked.
Speaker 4: Uh.
Speaker 2: SIGNA Group. That's the people that own what's ever North
Speaker 2: that then runs this holostism we've been talking about the
Speaker 2: whole episode.
Speaker 3: And SIGNA is using revenues in the plural correctly, because
Speaker 3: they're adding up the revenue from every arm of their.
Speaker 2: Octopus exactly because they are the SIGNA Group, not just
Speaker 2: SIGNA Healthcare, which is a you know, international situation. But
Speaker 2: just think about that money that exists there, that money involved,
Speaker 2: and in the end, what is it for.
Speaker 3: I thought you were going to go, Oh gosh, I
Speaker 3: thought you were going to do the song.
Speaker 2: I almost did. It's just oh, it's given. I don't
Speaker 2: know I put it. It's given MANGIONI core to me,
Speaker 2: It's given core vibes. And you can just see, you
Speaker 2: can see.
Speaker 4: Why have we mentioned that they're seeking the death penalty
Speaker 4: with old Luig.
Speaker 3: That's yeah, that's how we're gonna wrap up. So it's like, yes,
Speaker 3: the these two companies we mentioned, they did get in
Speaker 3: trouble recently, just about two weeks ago, well over two
Speaker 3: weeks ago, as we record, on Friday, April fourth, and
Speaker 3: Anthem and Signat got in trouble with the Virginia State
Speaker 3: Corporations Commission. They had to pay back hundreds of people,
Speaker 3: but they had to pay back peanut fees. And this
Speaker 3: further brings us to the context of Mangionics. Like you
Speaker 3: were saying, Noel, the Attorney General Pam Bondi, just a
Speaker 3: few days ago, just like this Tuesday, ordered federal prosecutors
Speaker 3: to seek the death penalty for Luigi Mangio, who, as
Speaker 3: we know, is the man I currently not convicted of
Speaker 3: gunning down United Healthcare CEO Brian Thompson in New York
Speaker 3: City last year. He's twenty six, he's in jail. The
Speaker 3: population of the US overall versus the power structure of
Speaker 3: the US overall are deeply divided on this case.
Speaker 4: I think we could the very least argue that he
Speaker 4: is sure as hell being made an example of.
Speaker 2: Yeah, and he's also got an insane amount of support
Speaker 2: in the news. Also this, I think it was this
Speaker 2: past week, maybe the week before you're hearing this. Two
Speaker 2: weeks he put out a statement asking people to stop
Speaker 2: sending in so many photographs.
Speaker 3: Yes, yeah, because Snell even talked about it.
Speaker 4: Yes, And none of a support violence, none of a
Speaker 4: support you know, this kind of thing. But it's interesting,
Speaker 4: it's an interesting bellweather as to how so many people
Speaker 4: feel about the healthcare system and how clearly broken it is.
Speaker 4: It's just really kind of kickstarted again the whole conversation
Speaker 4: around it.
Speaker 3: Yeah, please check out our series on Luigi. We explore
Speaker 3: the motivations for his actions, which are related to the
Speaker 3: idea of denying healthcare. During the research for this episode here,
Speaker 3: I think we were all unsurprised, but still moved to
Speaker 3: find how deeply these stories tie together. We may be
Speaker 3: looking at a sea change. You know, the Manngione case
Speaker 3: has exposed this great divide that always existed between the
Speaker 3: average American and those in power. And as we're recording now,
Speaker 3: you know, we should also mention that he's got federal
Speaker 3: and state charges. So if state prosecutors bring their case first,
Speaker 3: he hasn't been federally indicted, then he could be imprisoned
Speaker 3: for life without parole or something to that nature. So
Speaker 3: that's still very much an evolving case, and in some case,
Speaker 3: some points it does seem like people would rather it
Speaker 3: be forgotten. I don't know, maybe that's where we end.
Speaker 3: What do you guys think what's going to happen next?
Speaker 2: I think this kind of thing only gets worse because
Speaker 2: again we're talking about trying to fix leaky pipes, but
Speaker 2: you've got whole sections of this thing that just don't
Speaker 2: even have any pipes, and there's just water filling up
Speaker 2: the submarine or whatever however you want to talk about it.
Speaker 2: It's just it's messed up.
Speaker 4: I think we should only talk about it in nautical metaphors.
Speaker 4: I'm sorry, I'm joking. It's a really good one, Matt.
Speaker 4: I'm visualizing it, and you're absolutely right.
Speaker 2: It's a sinking ship that is only serving the people
Speaker 2: who have life boats, you know.
Speaker 4: See.
Speaker 2: So continuing with I want to talk about something that
Speaker 2: a friend of the show, Charlie, brought up to me,
Speaker 2: which was that in a lot of states, if you
Speaker 2: don't make enough money, you can get on that state
Speaker 2: run medicare program. But if you all of a sudden
Speaker 2: cross that threshold because you got a new job and
Speaker 2: now you're making a little more money, now you're required
Speaker 2: to get healthcare through you know the what is it
Speaker 2: whether the marketplace? You have to get healthcare there, which
Speaker 2: then those costs are in the hundreds of dollars. Before
Speaker 2: you weren't paying any money for your healthcare if you're
Speaker 2: on a state program or you know, the federal program,
Speaker 2: Now you have to pay, which means you're actually going
Speaker 2: to be making a lot less money on a month
Speaker 2: a month basis because you have to now pay into
Speaker 2: the private system. Like, how is that an okay thing?
Speaker 2: And how does that incentivize people to not get a
Speaker 2: better job?
Speaker 4: Right?
Speaker 2: And something we've talked about before, like this concept that's
Speaker 2: very popular in governmental speak, is a human being living
Speaker 2: off the system or something like that. Right, But we've
Speaker 2: designed a system that is going to punish people who
Speaker 2: aren't rich enough, right, or it's going to incentivize people
Speaker 2: to make sure they don't get too rich.
Speaker 4: I don't know. It's just weird. It is weird. That's yeah.
Speaker 4: It's an interesting way of looking at it. That I mean,
Speaker 4: is it's how it is.
Speaker 3: Yeah, something we had discussed previously, as as you mentioned.
Speaker 3: One thing that I think it's lost in a lot
Speaker 3: of the tribalization or politicization of things like that was
Speaker 3: calling the ACA Obamacare as a means of vilified it
Speaker 3: for people who didn't like that administration, when in fact
Speaker 3: it was generated by Mitt Romney very much as a
Speaker 3: conservative solution to the existing healthcare problems. Folks, this is
Speaker 3: where we're going to call it. Thank you so much,
Speaker 3: as always for tuning in. I think it's always important
Speaker 3: for us to note obviously we cannot thank journalists like
Speaker 3: the good folks at Pro Publica enough for this fantastic,
Speaker 3: truly disturbing work. We also know that a lot of
Speaker 3: us listening tonight work in the healthcare industry aren't villains.
Speaker 3: It's the system. It's like stick said, it's deeper than skin.
Speaker 3: It's the system that they're keeping us in. Stick Man
Speaker 3: from Dead Press of course. Anyway, that's our group. Whuitous
Speaker 3: hip hop reference. Gonna We're gonna call it an evening
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Speaker 3: how this episode goes.
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