First, the drug companies have a competitor, Four Thieves Vinegar Collective. They teach groups how to make their versions of the same drugs that big pharma makes. For example, there is a drug that costs $1000 per pill that cures Hep-C. Doesn't treat, cures. But it takes 84 pills. So insurance never pays for it, they pay for the much cheaper pill that treats Hep-C making it so one can live with the disease forever. Obviously, I think most would rather it be cured—the cost of the cure for the collective to make, 80 cents a pill.
Four Thieves Vinegar Collective has made DIY medicine cheaper and more accessible to the masses.
www.404media.co
Another drug they work with is Daraprim. Now this one was $13.50 a pill until a hedge fund startup bought the rights and it went to $750. So this is different than above, this isn't a company recouping investment costs, this is profiteering. So they make Daraprim available. It is mentioned in the story above, here is a story about it being bought and the price jacked up:
Now switching to insurance. By law, insurance denials are to be looked at by doctors and signed off on. One would think that is to safeguard the consumer. In CIGNA they are signing off on denials at an incredible rate, one former employee-doctor said it takes 10 seconds to sign off on 50 denials. One doctor rejected 121,000 claims in his first 2 months. How much time is he spending looking at a file and considering?
This hit home after a buddy had a claim rejected. I've known him since high school, he was diagnosed with a degenerative lung condition and his quality of like greatly eroded. It came to the point he could no longer work though he was desperate to work until 67, so he was facing going on social security disability. Just before that point, he was sent to a new specialist. The specialist said he was misdiagnosed. his issue was in the pulmonary artery and there was a very effective treatment in a pill. Of course the pill cost maybe $1000 per pill, but it was available. This is someone who could barely sit up for 2 hours any longer. Of course his insurance denied it. He won on appeal, but it was 3 months. It seems the insurance company has an incentive to deny. The worst that happens, they save 3 months of the treatment. If they are lucky, he accepts their decision and they never pay.
So it turns out, Aetna is doing almost the same thing as CIGNA. Claims are denied in bulk without being reviewed.
It seems coverage mandated by state law are often turned down:
States have passed hundreds of laws to protect people from wrongful insurance denials. Yet from emergency services to fertility preservation, insurers still say no.
www.propublica.org
Mistakes happen, we all know that. But it seems that insurers aren't particularly concerned about reducing mistakes that benefit them. And as that last article notes, the fines are often a very small percentage of their profits, so not exactly a great deterrent. If enough big bills are held back for a month or three on appeals, that can be a lot of interest gained.