Tuesday, September 23, 2014

The Game

I have referred to this contest, the seemingly endless series of one-upmanship as the GAME.  Picture, if you will a pendulum that swings not just back and forth but actually between three points.  One point is the medical providers.  Another point is the insurance companies.  And the third point is the government.  Equidistant from each other, power shifts from one to the other smacking us in the ass every time it passes through the middle.  
We address these issues, not with unwarranted cynicism, but with the clear eyes of a realist.  If you don’t understand how the game is played you are destined to lose.  The stakes are high.  Health and money ride on your ability to make good, unemotional decisions.  Are the tests and procedures being ordered necessary for my health or for the practitioner’s bottom line?  Is the politician working to solve a problem or to collect campaign donations?  Does the insurer’s new network of providers give me access to the doctors and facilities I may need to use?  These are just a few of the important questions we need to answer on a regular basis.  But these aren’t the only issues.
Take, for example, Elisabeth Rosenthal’s excellent reporting in the New York Times.  In this article, partially reprinted in the Plain Dealer, Ms. Rosenthal details the way out-of-network physicians and drive by doctors are beating the system and costing the consumers of this country (us!) millions.  Utilizing loopholes that none of us would have ever thought existed, the unscrupulous have figured out a way to over bill the patient for services that were not rendered, did not require a specialist, or were  intentionally provided by someone out-of-network to evade the only cost controls our system allows.
                                                                     We are all at risk.
The main subject of the article, Peter Drier, was the model of diligence.  He carefully verified that his surgeon, hospital, and tests were all covered prior to his neck surgery.  How was he to know that his doctor and hospital would intentionally bring in out of network providers to juice the bill?  The biggest surprise was the assistant surgeon, an out-of-network sharpy named Dr. Harrison T. Mu.  Dr. Mu billed $117,000 for his services!  The negotiated fee for the primary surgeon was $6,200.  But Dr. Mu (probably beyond shaming, but I’m willing to try) was under no obligation to accept anything less than the full billed amount.  Luckily for Mr. Drier, his insurer, Anthem Blue Cross, paid the full amount.  I’m not sure that Anthem had to since the bill was above anything that could have passed as reasonable.
We talk about consumer directed health care as if we, the patients, have the opportunity to make real choices.  We don’t.  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 even if your procedure is not an emergency and you have the time to vet the key providers, there are still hidden deals with labs, technicians, and assistant surgeons.  And that is before we get to fraud and bogus claims.
I recently received a call from an irate client.  She used to receive services from a doctor in his Ashtabula offices.  The price was under $200.  The same services, now performed within a Cuyahoga County medical palace, were over $3,500.  Her insurer, Assurant, allowed the claim to be processed unchallenged and applied the full amount to her $6,000 deductible.  In other words, she paid the whole excessive amount.  But only once.  She is looking for a Cuyahoga County physician willing to accept Ashtabula like payments.  Or she will drive further for a better deal.
I don’t think that The Patient Protection and Affordable Care Act (PPACA) does anything to combat these issues.   There is nothing to force providers to honor the patient’s network or to even pretend to be concerned about cost.  And nothing, absolutely nothing in the law, will stop patients from being abused by doctors like Harrison Mu.  Stopping that is up to us.  We are being forced to play this game.  We have to learn how to win.

Sunday, September 7, 2014

Stuck On The Bus

Garage Door Opener

The bus stopped right in front of my office. I knew this because the driver often blocked the exit from our Chagrin Blvd. building. And there I was, about a dozen years ago, riding the RTA to work. I had already walked a half a block from my Shaker Hts. home to the Rapid and waited in the rain to transfer to the bus. All of this because of my reliance on technology. Our electricity had been knocked out in the storm. My garage door opener, a first generation behemoth, wouldn’t disengage and I couldn’t get my car out of the garage.

I contacted a client, Smooth Door, a week later and replaced the opener. The new garage door openers, built with a better understanding of what the consumer needed, allowed me to manually lift the door when the power failed.

My last post, The Not Ready For Primetime Players, detailed the problems I have had in getting the government to help me insure a newborn. I have exciting news: As previously noted, Senator Brown’s office has been a real asset. I can now report that there are people doing their jobs at both The Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS).

Last Friday. August 29th, an HHS employee left a message on my client’s cellphone. A Special Enrollment had been granted for the client’s baby son and was made retroactive to his birth. My client was told that “The Plan” would contact him early the next week and advise him on the next steps he would need to take to get the baby added on to his policy through the Exchange.

There were no further contacts and the HHS employee, a Mr. Ryan had blocked his number. We could not call him back.

On Friday, September 5th, the client and I called Healthcare.gov. We reached a helpful, professional woman who was able to verify everything that had been left on the client’s voicemail.
  • A Special Enrollment had been granted
  • It was retroactive
  • There were notes detailing the efforts of the Senator’s office and CMS

Success? NOPE!

If the goal was to get the federal government to recognize that a baby had been born in Cleveland in April, we did it. But insuring the child is still beyond our grasp.

The system crashed four times. Our helpful professional became as frustrated as the client. She rebooted, cleared histories, and begged for help from her supervisors.

One hour and forty-five minutes into the call our contact was forced to provide the required statement. I was told the Healthcare.gov will provide “support feedback to Technical Support and that the individual should try again in 72 hours”.

And I was back to where I had been in May.

I have already heard from on CMS employee, thrilled that this is no longer on her desk. “I understand your frustrations with this whole process, but please try to continue to touch base with the Call Center from Marketplace to effectuate the babies (sic) enrollment. We cannot process enrollments. I hope this helps.”

The Technology that was supposed to make the acquisition of health insurance quicker and easier is preventing my client from covering his child. As part of the Patient Protection and Affordable Care Act (PPACA), the government has created these unnecessary, inefficient Exchanges. They are populated by well-meaning workers who are scandalously unprepared and who know nothing about insurance. And, the government has failed to design a way to manually fix the inevitable problems of their glitch ridden computer system.

Our unwarranted faith and over-reliance on technology has again left us stuck on the bus.