Monday, May 2, 2016

Sorry To Bother You



Mayfield Heights-20160502-00743

Quick Personal Update – Thanks for asking. I’m feeling stronger everyday. Already spending too much time at the office.

Frank (name changed) knew exactly what he wanted. Frank wanted the kind of policy he used to have twenty years ago when he worked in the family business. He wanted a small deductible, office copays, and an Rx card. A throwback. The policy needed to cover him and his twenty year old son. He wanted Platinum in a Silver or Bronze environment. Frank was insistent.

There was a way. I could put Frank and his son into the Government Exchange. Medical Mutual of Ohio was still offering a Gold Level policy through the Exchange, and even though he didn’t qualify for a tax credit subsidy, we could access this contract for them. I DIDN’T WANT TO DO IT. I warned Frank that accessing the Exchange needlessly simply multiplied our chances for failure. But Frank was insistent.

I can’t tell you how many hours I have invested in this disaster. It is difficult to even explain how healthcare.gov messed this up. But they did. The original mistake isn’t the interesting part. It is all of the subsequent steps that leave us today, May 2, 2016, with Frank and his son uninsured.

Let’s skip ahead to April 9, 2016. Frank sat in my office for almost two hours that day. We were on hold for over 40 minutes before we got to talk to anyone. We were lucky. The woman we worked with seemed both knowledgeable and caring. Here is what she told us:
  • I can see where we corrected the initial problem and got Mr. Frank and his son covered as of March 1, 2016
  • I can see where we corrected that mistake and got Mr. Frank and his son correctly covered as of February 1, 2016
  • I can see that the policy then automatically cancelled itself out on March 1, 2016 through no fault of the insured
  • I can see that this was supposed to be expedited
  • I can see that it was never expedited
She promised to get this into the right hands and assured us that there was no reason for this problem to persist. We actually felt pretty good about the process when we finally hung up with her.

Don’t get too comfortable

The rejection letter came three weeks later. The government had decided that he didn’t deserve to have his policy reinstated. The letter helpfully included the marketplace appeal hotline 855.231.1751. Frank came in today.

By the way, this isn’t a specific problem of the Patient Protection and Affordable Care Act (Obamacare). This is a bureaucracy issue. This is a regulatory issue. This is a full-fledged screw up.

Frank sat in my office as I called the hotline. Working through the automated system I finally hit the button to file an appeal. WE WERE IMMEDIATELY DISCONNECTED.

Second call. This time, to the surprise of a Ms. Shannon, I managed to get to a human being. She had no interest in hearing why we were calling. The process demanded that we must first go to healthcare.gov, file an appeal, and then, and only then, will anyone talk with us. Maybe. I tried. She wouldn’t budge.

We went to healthcare.gov with her on the line. She made sure to point out the next to the last section, Choose an Authorized Representative. Frank had the right to name me as his contact, someone who could easily answer their questions and make sense of this. We got off the phone and completed the appeal form.

And once the appeal form had been completed we hit the link to the special authorization form. The picture at the top is where the link takes you. We’re so screwed…

 
DAVE

Sunday, April 24, 2016

Shedding Pounds By Shedding Organs



back home

My new weight loss program

Standing by the hospital bed, the two nurses discussed the patient’s status. They reviewed recent ultrasounds, CT Scans, and the importance of “you have to go before you can go”. At some point I just looked up at the two of them and said, “I am being transformed from a 61 year old man to a 29 year old in the Maternity wing.”

Welcome to a very special Health Insurance Issues With Dave. It must now be obvious that some of the posts of the last year dealing with doctor interaction and cancer treatment were, in fact, about me. I apologize for being less than 100% transparent. I kept waiting for my Emily Litella moment. It just never came. (By the way, the links are footnotes that attempt to make these posts more informational and entertaining. Take a moment to enjoy Gilda Radner).

This post will discuss my last two weeks in stark detail. The picture above was taken Thursday, after I got home. Yeah, Happy Ending. Still, my story is still evolving and so is yours. And though less than pleasant, this is very relevant to you.

My annual physical has always included bloodwork. My PSA started to climb a few years ago. Nothing shocking. Not too high. No spikes. I didn’t have ANY problems, but I could hear my prostate calling. I finally had a biopsy last fall. The news wasn’t good. I had a Gleason Score of 7.

In some countries an otherwise healthy, asymptomatic man in his early 60’s would be monitored. Prostate Cancer moves slowly. In the US we aggressively tackle Prostate Cancer now, while the patient has the best opportunity to not only withstand the process of surgery or radiation, but to lead a long, normal life post-treatment. I opted for a combination of hormonal and radiation treatments. This was detailed in my last post.

I was invited to participate in a clinical study. Part of the protocol was another CT Scan. My last was just outside the timeframe. OK. One more test. The test results were fine, except that there was a shadow on my left kidney. The subsequent ultrasound was not determinant, but it wasn’t good. The next CT Scan was focused on my kidneys. I had a mass, approximately 10 cm wide, on the base of my left kidney. It didn’t matter if it was benign or malignant (probably), it had to come out. The radiation was put on hold for a couple of months so that this could be resolved.

before

This picture is of me walking into University Hospital Wednesday morning, April 13th. I had to accept that this was to be the first day of my process. It might be a year before I felt this good again.

The goal was to remove the mass and a small part of my left kidney. The surgeon would attempt to utilize minimally invasive techniques. But if he didn’t like what he saw, I had been warned that he wouldn’t hesitate to open me up and take the entire kidney. I should be able to leave the hospital Friday or Saturday. Sunday was my worst case scenario.

The surgeon removed the mass and part of my kidney. The doctors were concerned about my post-surgical bleeding. They took me back in, briefly, early that afternoon. Ten hours later we came close to ending my life as we ended the day. I was bleeding to death. You aren’t supposed to remember these incidents. I recall the room in vivid detail. At some point I attempted, with my left hand, to authorize another complete surgery while keeping my blood-soaked gown away from the form.

Let us at this point finally end the irrelevant notion of patient controlled cost containment. The patient, a 61 year old man who had never had any previous medical issues and was not on any medications, needed a major operation. He had done his part. Do We Save His Life? That is a YES or NO question. What if he had been 71? 81? 91? This is a question that we, as a society, must answer.

So, we all agreed to save my life. Yeah! Now, who’s paying? We have several ways to pay for medical services:
  • Government
  • Private Business (Insurance)
  • Some combination of government and insurance
Self-pay is not an option. Who but a very few could guarantee the availability of liquid assets when needed most? What society would turn away most of the truly ill? And how could the medical industry depend upon us to meet our obligations?

And just as important, who decides how much the medical providers (doctors, pharmaceutical companies, hospitals, labs, etc.…) get to charge for their goods and services?
  • Government
  • Private Business (Insurance)
  • Some combination of government and insurance
  • Or are the medical providers allowed to charge whatever the market will bear?
They rushed me into surgery in the early morning hours of Thursday, April 14th. The surgeons removed the balance of my left kidney and my spleen.

Each patient is connected to an impressive array of computers. Each machine has its own set of bells, horns, and alarms. Sleep and silence have been disrupted by an alarm. Every minute of an alarm feels like an hour. Alone in the darkness you first need to determine if it is your alarm. Why is it ringing? Am I Ok? And if it isn’t you, you relax for a moment before you wonder how that other guy is doing.

I awoke in the intensive care unit. Sally and Jennifer had been through the entire previous 30 hour adventure and were visibly relieved. They were allowed to dab my lips with a wet sponge. I was moved within a few hours to a surgical step-down unit. They gathered my stuff and put a long stainless steel cylinder next to me on the bed. “What’s that”, I asked. “That’s what’s keeping you alive”. I tried to move over and give them room for two.

I had been told that there was an almost sadistic nature to the way nurses and techs woke you up all night to draw blood and take tests. I greeting my nurses, nurse’s aides, and tech by name. Their presence proved that I was still alive. And I was only going to be able to leave the hospital with their help.

I had a great team. I recall these names: Nurses Becky, Sue, Lauren, Jen, Katarina, and Megan. Assistants Dave, Marie, and Debra. The surgeons resolve a problem. The nurses heal the patient.

Mark was one of my nurses in the step-down unit. Mark is in total control of his little corner of the world. Lucky for me, I got to spend about twelve hours there. He was the one to track down XL sized hospital socks, reassure Jen and Sally, and remove the catheter. Mark decided that I had to get out of the bed and take a wheelchair to my room on the 5th floor. There was push back. Didn’t matter. Mark was my first step towards recovery.

Nurses tell the truth. It is sometimes the patient’s responsibility to ask the right questions, but the nurses are your advocates. I was fortunate to have Tom for a couple of days in a row. He answered every question. He helped me to mentally prepare for my recovery.

I got home the afternoon of Wednesday, April 20th. I’m OK. Really. I’m almost fine. I’ve very tired and it will take a while to be back to 100%. I will share the bills with you as they come through. I’m curious as to what this all cost. I bet it would be cheaper and easier to drop a few pounds by going to Weightwatchers.

Thursday, April 7, 2016

$34,228.50


Big Bucks

Consumer Directed Health Plan. One of the biggest jokes in the health insurance industry is the illusion of control. We pretend that you, the consumer, can control your medical expenses. We created products that, by law, have high deductibles, no office visit copays, and no Rx card. We know that you will shop for the best deals in primary care doctors and cardiologists. We are counting on you to force the doctors to justify every blood test, CT scan, and procedure. You know that you are a great shopper. Here’s your chance to prove it.

Can you shop for a deal when they are wheeling you in to the hospital with a blocked artery? “Hold up Mr. EMT. I just got a text alert that Hillcrest is having a sale on bypasses this week.”

But of course, none of this is real. There is no way to know the real cost of medical services in advance. And who amongst us wants health care by the lowest bidder? Plus, do we know anyone who is prepared to say to his doctor, “Another surgery? Gosh I don’t think we should spend so much just to save my life.”

The client is in the early stages of his treatment for prostate cancer. He and his doctors discussed the various ways to remove his prostate, external beam radiation, and even radiation seeds that can be implanted. The patient chose external beam radiation. The doctors then suggested that he also have hormone therapy.

Hormone therapy almost appeared to be an afterthought. By taking pills or getting shots the patient would inhibit testosterone production, shrink the prostate, and slow the growth of cancer. What shot? Which pill? The patient was told that the nurse practitioner would tell him when they met.

The client had a shot and got a bill a few weeks later. Ready? The shot cost $34,228.50. Surprise. The Anthem Blue Cross negotiated price for the shot was $18,932.99. The client’s deductible was $5,500. He blew past that. The client maxed out his share and Anthem paid the rest.

I looked at the bill and the first question I had was, “Did they buy you dinner?” I mean for this price he should have received a gift card for The Cabin. Sadly, all he got was an off switch for his libido. My second question was, “Is this some new miracle drug?” No, he was given Lupron which has been in use for over 30 years. The good news that it was a double shot, good for 6 full months.

$34,228.50 for one shot. Who knew? That’s easy. Everyone but the patient.

We have no control. Remember our friend the next time you wonder why your insurance premiums are going through the roof. I wouldn’t have done anything differently. You would have been just as surprised as he was. This shot is just one more example of a broken system in search of a solution.

Dave

www.cunixinsurance.com

Thursday, March 10, 2016

Platinum, Gold, Silver, Bronze, Lead



Rebranding

 

The Metal Tiers were a key component of the Patient Protection and Affordable Care Act (Obamacare). The idea was to force all policies (square pegs) into four levels of coverage (round holes). The metal tier would allow you to purchase a policy that would fit your needs. Each described the percentage the policy would pay of your overall healthcare claims.

Platinum – 90%
Gold – 80%
Silver – 70%
Bronze – 60%

PLUS PREMIUMS

Are these percentages accurate? Do they really represent 90%? 60%? Who knows? If you ask 5 people you will surely get 7 answers. Part of the problem is that everyone, and I do mean everyone, is engaged in the constant struggle to recreate reality. The pricing, the policies, the benefits, the covered doctors and hospitals, and even the insurers change annually. There can’t be an apples to apples comparison when 2014’s apples were replaced by kumquats in 2015 which were replaced this year by frozen pizzas.

The PPACA included an annual cap for out-of-pocket covered expenses. That cap has increased each year. In 2016 it is $6,850 for an individual and $13,700 for a family. This number includes the most you, the consumer, can spend on the deductible, copayments, and co-insurance during the calendar year. It does not include the premiums you pay.

The 2017 maximum out-of-pocket will be $7,150 for an individual and $14,300 for a family. Those numbers apply to Platinum, Gold, Silver, and Bronze policies. But if you have a family, especially a family that has ongoing health issues, the possibility of facing $14,300 of exposure (plus premiums) doesn’t feel like Platinum, Gold, Silver, or Bronze. It feels like lead. And many of these policies will be as valuable as lead pipes in Flint.

The health insurance market is changing rapidly. I can’t find a Platinum level policy in Cuyahoga County. There are only a few available in all of Ohio. Gold level policies are disappearing, too. At some point the metal tiers will need to be redefined or a couple of new ones will have to be added. Or, we will change to letters, such as Tier A, Tier B, Tier C, etc…

Because when all else fails we can always fall back on rebranding.

Dave

www.cunixinsurance.com

Thursday, March 3, 2016

Notes On Napkins



Trump health plan

 

It was a warm spring evening. Warm enough for the guys to sit on the whiskey bar’s patio. The group, a restaurateur, an insurance agent, a physical therapist, a scrap metals guy, and an attorney (isn’t there always an attorney?) were solving the world’s problems over adult beverages, mostly Scotch, and good cigars. But their real focus that evening was Korea. The insurance agent took notes on a couple of napkins as the group formulated a simple, common sense solution to Kim Jong-un and his nuclear paranoia. The only thing these five guys knew about Korea was a good place to get kimchi, but that didn’t deter them.

Last week’s post noted the ignorance of Donald Trump, specifically when it came to the Patient Protection and Affordable Care Act (Obamacare). I was not the only person to notice. Mr. Trump’s opponents, especially Senator Rubio, focused on the emptiness of his rhetoric at last Thursday’s Republican Debate. Even Mr. Trump’s most ardent supporters had to admit that he looked clueless and unprepared. And thus the Healthcare Reform To Make America Great Again plan was created. (That is a real link to the Trump plan)

This blog has reviewed each of the Republican alternatives as they have been released. The Bart Simpson Award for Spectacular Underachievement was presented to Scott Walker last summer for his fifteen page term paper. We have our first entry for 2016.

I want you to imagine Mr. Trump, his shadow Chris Christie, and a few advisors sitting on the patio in Palm Beach. The glasses are full of orange juice and unsellable bottles of Trump Vodka. The ideas are coming fast and furious.

Scotland! We love their health care.

No Americans dying in the streets.

We have to get rid of the artificial lines around the states.

Mandates! OK, maybe not.

No one had time to get a laptop or even a notepad. A junior staffer stopped refilling the glasses and started to take notes on some napkins. And that is how we got the Healthcare Reform To Make America Great Again, two and a half pages of napkin fodder.

The opening paragraphs were borrowed from all of the previous Republican offerings. Obamacare is blamed for all of humanities ills. Words like economic burden, higher premiums, and partisan litter the preamble with the promise that a complete repeal would bring the exact opposite. Obamacare would be blamed for global warming if the Republicans accepted climate change. The opening paragraphs also beg for help from Congress, the first time Mr. Trump has acknowledged that he isn’t officially running to be our dictator.

Here are the seven reforms that the Trump Administration wants Congress prepared to pass on the first day he is in office:
  1. Completely repeal Obamacare and eliminate the individual mandate. “No person should be required to buy insurance unless he or she wants to.”
  2. Allow the sale of health insurance across state lines as long as the plan purchased complies with state requirements.
  3. Allow everyone to deduct their health insurance premiums. Suggest to the various states what they should do about Medicaid and coverage for the poor.
  4. Legalize Health Savings Accounts (HSA)
  5. Require price transparency.
  6. Send the states money for Medicaid (Block Grants)
  7. Allow foreign companies easier access to sell prescriptions in the U.S.
“The reforms outlined above will lower healthcare for all Americans.”

That’s it. I know that you are more surprised by what is missing than what little is there. There is no mention of preexisting conditions. None. What do we do with the people who are now covered who wouldn’t be if the insurers had a choice? Your guess is as good as mine. How could any of this change happen? Don’t ask Donald. He ran out of napkins.

Unfortunately, I don’t have the luxury of running a fact-free presidential campaign. Neither do our friends at Forbes or at the home offices of the major insurers. My clients are already calling and asking how they would be affected by the Trump plan. The quick answer is that they wouldn’t be impacted at all. The seven bullet points simply prove that the candidate doesn’t care about their issue.

We’ve discussed points one and two. Deducting health insurance premium (point 3) is really important to people who want to pay less taxes. It is meaningless to people who want help in paying for their premiums. Donald and his team appear to be confused about the difference between the FSA, Flexible Spending Account, and the HSA, Health Savings Account. You should know that BEFORE you release your paper to make America Great Again. And if we send the states Medicaid Block Grants, we will condemn millions of Americans to substandard care as the money is misdirected elsewhere.

There are times in politics when being attacked from the Left and from the Right means that you really are in a good place. The Healthcare Reform To Make America Great Again appears to be nothing more than random thoughts on a cocktail napkin. And Donald came up empty.

www.cunixinsurance.com

 

 

 

Monday, February 22, 2016

Ignorance Is Bliss



Trumped

The United States is a true super power. We have wealth, power, and almost unlimited resources. What we lack, what we desperately need, is more intellectual honesty. There is no reason to believe that that is going to change anytime soon.

The debate that led up to the passage of the Patient Protection and Affordable Care Act (PPACA or Obamacare) in 2009 and 2010 was filled with undeliverable promises and sugar-coated fantasies. This blog called out several Democrats by name. And a lack of intellectual honesty seemed pretty bad until we got the debates of 2011, 2012, 2013, 2014, 2015, and now 2016. We have replaced blather with cynicism.

The cynic knows what he is attacking is safely out of reach and what he is proposing wouldn’t really work. It doesn’t matter. It is the House of Representatives voting to repeal Obamacare 60+ times. It is our nation’s most cynical politician, Senator Ted Cruz, shutting down the government in effort to call more attention to himself.

The cynic understands the issue. The ignorant does not. We have devolved to ignorance, an entirely fact-free discussion of an important issue such as our health care and 20% of our economy. This is far more dangerous. And for that we must thank super salesman Donald J. Trump.

We may all have our own opinions about whether Mr. Trump knows what he is talking about when he tackles immigration, national defense, or taxation. But I feel compelled to speak up when he invades my territory, the delivery of paid access to our health care system.

Anderson Cooper conducted town hall meetings with all six Republican candidates on CNN last week. When asked about the PPACA and health care, Mr. Trump agreed to the need for mandates before he moved to his usual self-aggrandizing answer about his large crowds and standing ovations. I was impressed simply because the word mandate means something and his acceptance meant that he might be paying attention to this issue. That impression was short-lived.

Donald Trump appeared on CNN again on Sunday. Jake Tapper interviewed Mr. Trump on The State of The Union. Here is the entire interview. Mr. Trump, fresh off his South Carolina victory, quickly backtracked on mandates. He must have been briefed on the official talking points. Though he kept on detouring to how great his plan will be and that he will make sure that sick Americans aren’t dying in our streets (a real concern), he decided that he really doesn’t like mandates and he wants to eliminate state lines. Watch the interview. Words matter and it was clear that he had no idea what any of the terms meant.

Republicans cite the Tenth Amendment almost as often as the Second. But States’ rights seem to be unimportant when it comes to insurance regulations. Eliminating state lines and having insurers sell wherever they’d like might have some eventual benefit, might, but certainly nothing in the short run.

This blog has discussed the individual mandate numerous times. We all understand that people won’t purchase car insurance unless required. Health insurance is no different. If we want to have guaranteed issue and cover preexisting conditions, we need to have everyone participating. Even the GOP 1993 plan incorporated mandates, mostly because it was a real plan.

So what was Mr. Trump talking about? Nothing! What is the Trump plan? There is none. His gut instincts might have him embracing the core values of Obamacare or its ancestor, the Republican’s 1993 plan, but he hasn’t bothered to learn the details. This isn’t a lack of intellectual honesty. This isn’t cynicism. This is simply ignorance. He doesn’t know anything about Obamacare. One can only hope that a President Trump will.

He may appear angry, but Donald Trump is a really happy guy. Damn near blissful.

DAVE

www.cunixinsurance.com

Thursday, February 4, 2016

Time For A Little Firesign Theater



IMG-20160204-00656

The real name for this post would have been How Can You Be in Two Places at Once When You're Not Anywhere at All. The link to the 1969 Firesign Theater album will let you listen to the album while you continue to read this post. Of course, if you are of a certain age, I’ve already lost you…

How can you be two places at once? How can you appear to advocate for something while you spend all of your time and energies undermining that very same thing? This being Health Insurance Issues With Dave, smart money says that this is probably about health insurance and the companies that sell it.

The major insurers want you to know that they are here for you. Ask them. They’ll tell you. The major insurers litter their public pronouncements and email communications to their agents with words like commitment and partnership. Companies such as Aetna, Cigna, Anthem and UnitedHealth Care want you, the American public, to know that they are committed to their partnership with the American people and are ready to deliver their product through the federal exchange, the state exchanges and whatever platform available to them. You can hear the Battle Hymn of the Republic playing in the background as you read the emails, the fruit of the labors of their overworked PR departments.

And this would be wonderful if it were true. But, of course, it isn’t. There would be a huge uproar if the largest insurers abandoned the exchanges. Terrible publicity. Government officials and the heads of the exchanges would all blast the insurers as bad corporate citizens and incompetents. Plus, drop out of the market and they can’t get back in for five years. So the insurers needed to find a backdoor.

The solution is to stop paying the agents. Anthem, Aetna, Cigna, UnitedHealth Care all hope that by not paying the agents during the Special Enrollment Period we will place our business with those companies who will. Sure that may push all of the clients to one or two companies from February till December, but it won’t be them. And what would happen if all of the companies stop paying the agents, so that none of us can afford to spend the hours of time necessary to match Americans to the appropriate policy and insurer? NOTHING! No one with any authority would ever notice that thousands of Americans were even more unhappy than usual with their health insurance.

The insurers are losing millions of dollars on policies written on the exchanges. The Special Enrollment Periods are being abused. The federal exchange is not enforcing the rules. Fixing the problem is an option. It would take a lot of work and require the building of trust between the exchanges and the insurers. Removing the incentive to do our jobs is easier but terribly cynical. But Congress attempted to repeal the Patient Protection and Affordable Care Act (PPACA or Obamacare) for the 60+ time last week. What is more cynical than that? So who is going to notice one more act of self-serving cynicism?

The insurers will continue to say one thing publicly and do the exact opposite privately. But like Nick Danger, we are lost on the wrong side of the album and you really can’t be two places at once.

 
DAVE
 
www.cunixinsurance.com