Get Sick In One State...Move To Another

If you live in Illinois, then you are lucky.  It's not because of the Cubs. However, if your child has Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS) and Pediatric Autoimmune Neuropsychiatric (PAN), then you are indeed very lucky.

That's because Illinois passed "Charlie's Law" in July of 2017.  This made it mandatory for all insurance companies in the state to provide coverage for IVIg infusion therapy for PANDAS/PANS patients.  Without insurance coverage, IVIg can costs families $1000's per month.

Now, using IVIg to treat these conditions is considered "off-label".  That means that it's an FDA approved treat for other illnesses.  But it is not approved for this particular type of use.

And yet, it works...very well.

So what are you to do if you live in Texas or any other state?  Where it is up to the insurance companies to decide if IVIg is an approved treatment or not?  Clinical evidence supports it.  But the FDA still has not approved it as such.

Even within a state, one company may agree to IVIg coverage while another might not.

So are you supposed to use up your life savings to give your child the treatment that works?  Or are you expected to pick up, leave your home, and move to Illinois?

Neither seems like a fair option.  A key element of insurance reform has to be creating uniform standards for coverage of efficacious treatments.

$7000 CAT Scan (What would Einstein and Franklin do about it?)

"It is the first responsibility of every citizen to question authority"  (Benjamin Franklin)

"The important thing is to never stop questioning.  (Albert Einstein)

This month I received a bill for an ER visit to my local hospital.  The billed charges for the facility (not doctor fees) were $14,876.59 and the amount that I owed was $2082.72! Though I never received an EOB ("explanation of benefits") from Anthem for this, it certainly looked like the insurance company had paid down this bill somehow leaving me with only a measly $2000+ co-insurance amount due.

(Spoiler Alert:  the actual amount that I owed end up being $0.00!)

After recovering from the sticker shock and shot of scotch, I started to think a bit more clearly. Here's what I did:

1)  I called the hospital's billing department and requested a detailed, itemized list of all the charges.  I had to see how a two-hour ER visit ended up costing over $14k considering the fact that we left without needing any treatment or medicine.   

2)  After receiving the itemized bill, I verified that all of the services were actually rendered.  I also noticed that they charged $7000 for a CAT scan (which costs only $550 at our local radiology facility).  They also charged $900 to administer an EKG which took about only 1 minute.  The basic charge for simply stepping into the ER was $2352.  I actually don't find that charge to be so unreasonable. 

3)  Next, I went online to Anthem to find the EOB and see how Anthem had processed this claim since I suspected that something was amiss.  I couldn't find the EOB which is unusual. Anthem's patient portal is pretty good (albeit very, very slow) and it's usually easy to find an EOB. 

4)  So, I called Anthem figuring that maybe the EOB got stuck somewhere and they could look it up.  Guess what?  They couldn't find a claim submitted by the hospital for this DOS at all.    "OK, Anthem, I'll call the billing department at the hospital and see what's what." 

5)  I asked the billing department to explain to me how the $14,876 was paid and reduced so that my co-insurance became $2000.  "I see here that your insurance company is xxxxxx.  Is that right?"  "Huh?  I've heard of that company. My insurance is with Anthem." 

The hospital had never even submitted this claim to Anthem.  Further, it is a complete mystery how the hospital had the correct insurance information to process the doctor's fees but complete bungled their facility bill.  It's also a mystery as to how this unknown insurance company could have discounted or paid anything towards these charges.

I gave them my Anthem information and they will submit the claim.   Once they do, the claim will be paid at 100% because my wife had already reached her annual out of pocket (OOP) maximum before this ER visit.

This means that the $2082.72 bill is going to go down to... $0.00.  Yeah!

Key Takeaways:

1.  Never trust that the amount that a provider says you owe is actually the amount you really owe.  Always read and question every bill.  (See the above quotes from Einstein and Franklin.)

2.  Always read your EOB.  If you don't have it, get it.  Then read it.  If you don't understand it, make your insurance explain it clearly or find someone who can.

3.   Realize that billing mistakes occur every day.  Perhaps your bill is accurate.  But chances are good that a bill that seems too high has mistakes in it.  If it walks like a duck...

P.S. - I am not certain what would have been the amount I owed if my wife had not met her OOP maximum.   I estimate that it would have been about $1000 which is still a sizable savings from the original billed amount.

The Costs of Not Going to the Gym ($500 Billion)

Most of us know that we should be eating healthier and exercising more.  It's not a complicated formula.  And yet, the statistics on preventable illnesses are staggering.  Here's just a small sampling:

• Nearly 10% of the US population has diabetes (~30million)
• Approximately 1.4 million new cases of diabetes reported annually
• 30% of all Americans are obese
• Obesity related illnesses account for ~$200b per year in health costs
• 17% of all Americans over 18 are tobacco smokers
• Another 16 million Americans live with a smoker.
• Smoking causes $300b a year in health costs and lost productivity
• Cigarette smoking is responsible for 480,000 deaths per year and is the leading source of preventable deaths

(sources:  American Diabetes Association and CDC) 

The statistics on exercising are not very good either:

• 191 million Americans (60%) don't get the recommended amount of weekly exercise
• 25% don't exercise at all (79 million people)
• # of gyms in the U.S.:  30,500
• # of Americans with gym memberships:  58million
• % that don't use their memberships:  67%

(sources:  CDC and StatisticBrain) 

The average cost of a gym membership is about $60 per month.  That's $720 per year.  Many diabetes medicines cost far more than this.

So let's generously assume that there are ~85million people in the U.S. (27%) with a preventable illness.  If the government spent $720 per person on a gym membership for each of them, the cost would be $61billion per year.  

So the big question is:  could this $61b reduce health care spending by more than that amount?  If ~$500b is being spent on preventable illnesses, that means that it would have to result in 12.2% savings.

I haven't found any conclusive studies one way or the other.  But, personally speaking, I prefer the idea of spending $61b on gym memberships as opposed to the same amount on diabetes medicine.  

Of course, the big problem is how to encourage (or require) that people use their gym memberships?  Any solution would certainly be very controversial (just ask any ACA opponent about the mandate).

The Golden Triangle of Health Care

I am a big fan of inspirational quotes.  I even have a few of my own; some of them are even original.  One of them (and I don't think I invented it) is:  

"If money can solve it, it's not a problem."  

 [My Mom has a great variation that she swears that I did create:  "If there is a solution, then it's not a problem."  I think she just misquoted me.  But I like her version better than mine.  So, I'll claim ownership.]  

In the health care system, a lot of people and a lot of companies are spending a lot of money to solve its problems. It's not working.

Why?  It's the "Golden Triangle".  It looks like this:

Simply put, the Golden Triangle consists of three options:  Good, Fast, and Cheap.  You get to pick any two.  It often refers to the world of design.  But it can be applied to practically any service being rendered ranging from car repair to restaurants.  Of course, it's not unusual to want all three corners of this triangle. Sometimes you can actually get it.  Usually, not.  More often you get what you paid for.

The major difference between applying the Golden Triangle to health care as opposed to graphic design is that  picking only two corners can end up with undesirable, and sometimes, deadly results.  Fast and inexpensive care would certainly not substitute for getting proper treatment. Nor would excellent care that you could afford but had to wait weeks to receive it.    And yet, when we are sick, we want to receive quality care in a reasonable amount of time and not worry about losing one's savings (or worse) in the process.  These are not unreasonable expectations in my opinion.

Most of the time, patients are more concerned with good and fast.  That is, work on the health issue as quickly and as effectively as possible. Inevitably, that leads to sticker shock when the bill arrives.

Unfortunately, too often, we are only getting one corner of this triangle.  And sometimes, patients get none of the corners.  The latter is often true for challenged populations such as uninsured and low-income patients.  

If you were only allowed two corners of the Golden Triangle for your health care, which ones would you choose?  This certainly will vary from person to person.  And that's why it has been so difficult to make systemic improvements in the health care system.  

Can we solve all three issues at once?  Perhaps not.  So, which corner(s) would you address?  And how would you justify ignoring the other corner(s)?  This is a very difficult decision which providers are wrestling with every day.  

Please let me know your preferred corner.

Don't Cry For Me Aetna (and UnitedCare and Anthem)!

(Update:  Aetna may have pulled out of these states because they didn't get Federal approval for their merger with Humana.  See Aetna's DOJ Letter)


Waaah!  Health insurers are crying.  They are losing money and can't carry on insuring all of the new ACA enrollees.  Aetna just announced that it was pulling out of 11 states where it offers ACA plans to individuals due to fabulous losses it incurred: $430million last year.  (CNN)  Other insurers have claimed similar or greater losses.  It kind of makes you feel sad for their financial burden. (Note: Aetna pulled out of California, my home state, after 2014 leaving me high and dry.)

I guess that's why Aetna's CEO saw a paltry pay raise of only $2.2m last year ($15.1m in 2014 to $17.3m in 2015 -  WJS).  UnitedHealth's CEO really suffered when he earned $66m in 2014, a belt-tightening increase of $42m from 2013 - FierceHealthCare).

It's true that a lot of insurers got slammed with a lot of new enrollees incurring more health services than expected.  Perhaps the most controversial part of the ACA was the mandate provision forcing people to buy health insurance.  The reasoning was simple.  How could insurers afford to get rid of all of those fancy restrictions on benefits (e.g., life time caps, pre-existing conditions, etc.) if they only had sick clients.  They needed healthy clients to pay premiums to make up the difference.  

As it turns out, many of the new ACA enrollees are not as healthy as anticipated.  They wound up (heaven forbid) actually using their health insurance policies for (wait for it)...health care. And now insurers want to stop offering individual policies because they claim that they are bleeding money.

A cursory examination of their woe-is-me claims shows that a loss in the individual health policy business is not actually making much of a dent in the overall profitability of major insurers:

• UnitedHealth's 2015 net profit: $5.8B (up from $5.62B)  
• Aetna's 2015 net profit:  $2.4B (up from $2B)
• Cigna's 2015 net profit: $2.09B (down from $2.1B 2014)
• Humana's 2015 net profit:  $2.4B (up from $2.2B)

(Note:  all figures taken from the company's own annual financial statements)

Remember, these figures have already accounted for the losses from ACA policies.  So not one of these companies showed a loss due to their ACA business.  They simply made less profit.  Aetna's profit actually increased despite their ACA losses.  

So if the individual policy business is tanking, then where is this profit coming from.  Turns out that most of these profits are coming from you, the taxpayer. Half, or even more, of these profits derive from Medicare, Medicaid and other government related policies. In other words, these companies are profiting from your tax dollars while making it harder for individuals to become insured by them under the ACA exchanges.

That's like paying the mechanic to fix your car and then someone else get's to drive it.  It's not right.

(Stay tuned...Are the insurers really spending more on patients?)