Health insurance coverage exclusions and limitations

That's the part I never understand: The Long Game.

In Arizona we have a program called AHCCCS (our Medicaid expansion), the Arizona HealthCare Cost Containment System. The idea seems obvious to me: Treat what we can early, and avoid the ongoing, ballooning costs of chronic illness. At least in theory.

I personally met a patient for whom AHCCCS covered (for six months?) the infamous $84,000-per-dose Harvoni in order to cure his Hep C. I met him (where else?) in the hospital, behind a turkey sandwich, when he was admitted for his most recent CHF exacerbation. He proudly proclaimed his AHCCCS tab was somewhere in the neighborhood of $4 million. Did patching this single (often sub-clinical) diagnosis save the taxpayers any money? Nope. Cost them a helluva lot.

Now, I'm not to say this patient shouldn't have his illness treated. I'm pleased he's Hep-C-free! But when does "preventative, cost-saving care" become "We'll happily cover that, but definitely not that"? You say

gonna come back to bite them in the ass

But I wonder if any particular coverage provider will ever pay. Seems they'll just charge the patient incredible amounts for "uncovered services," call it "uncollectible debt," and then send it to an outside agency. Rinse, repeat.

I personally see insurance as horribly broken. There must be a better way for the receivers of medical expertise to compensate the providers of it. Hopefully someone smarter than I can come up with something.

/r/medicine Thread Parent