Category: Insurance

Waivers Of Covid Costs

Check this out. What you will see is an interesting discussion of the financial actions that insurers have taken in response to the COVID pandemic. The most visible of these is the waiving of cost sharing payments (copays) in an attempt to make sure that expense does not keep patients from receiving treatment. Additionally, some insurers have been making loans, in many cases substantial ones, to hospitals to keep them afloat during challenging times.  

An interesting sidebar here is that many insurance companies have actually had offsetting benefits from patients refraining from getting elective care during the pandemic. As we have previously discussed, how long patient reticence to venture into medical facilities for fear of getting infected remains unclear.  

Many companies are extending the length of time that the copay waivers will be granted. We will all recall that when the pandemic initially erupted, lots of us thought it would pass in weeks or at worst, months. The fact that we are dealing with a far more chronic set of circumstances calls into question how long these voluntary waivers will continue to be granted.  

Bottom Line. As we have discussed previously, the impact of the pandemic on the economics of physicians and hospitals has been significant. To that impact, we can now add the effect that COVID has had on insurance companies. Put that all together and we realize the truly pervasive impact on our healthcare system’s finances overall. What will the long-term effects of this be?  

Death By Patient Satisfaction

Check this out. What you will see is a great, tongue in cheek piece by an ER doctor who is obviously “up to here” with “customer satisfaction” applied to U.S. healthcare. The strategy of business optimization through “CSAT,” as she points out, was readily grasped by various medical institutions in the U.S. that were trying to be profitable, or at least to survive. Adding fuel to that fire, along came Obama and the Feds who took away substantial hunks of reimbursement $$$ from institutions where surveys did not indicate that patients were not, you guessed it, satisfied.  

The result? Absurdity! But most poignantly, a major force behind the opioid crisis. A patient that wants pain killers gets them, right? Otherwise he won’t be “satisfied.”

Bottom Line. And so it goes. The goofiness of gauging the quality of medical care by the level of resultant patient satisfaction seems to me to be sufficiently obvious that eliminating these stupid metrics from the U.S. healthcare scene shouldn’t even require a second thought. But it obviously does. AND. My partner in psychological crime at ThinkGen, Dr. Neale Martin, regularly cites research that indicates that even in non-medical areas, like consumer packaged goods, CSAT predicts neither repurchase behavior nor virtually anything else of any importance.  

Will anybody ever wake up to the craziness of what is going on in CSAT-based medical care?

Stay tuned!

The Folly of Self-Referral

Check this out. What you will see is an interesting little riff by The Country Doctor on the topic of self-referral. In it, he points out that many people, including yours truly, tend to favor a system that allows patients to make their own appointments with specialists without going through a primary care physician for a referral. My penchant for avoiding being “gate kept” has always been a major reason why I avoid anything that looks like an HMO like the plague. BUT. He goes on to make a reasonable point, questioning whether patients have the ability to figure out which specialty they should be consulting, let alone which subspecialist might be best for a particular problem. Where do you go for chronic pain in the stomach? Surgeon? Gastroenterologist? Psychiatrist?

I think he has a point. While still not being too keen on the idea of having to be clutching a referral slip when I enter a specialist’s office, I greatly value the ability of my concierge Internist to direct me to the right place. She not only sorts out for my wife and I the appropriate specialty to consult, but also which specific doctor in that specialty would be best suited for our presenting medical issue. Example. Our physician diagnosed my wife several years ago as having thyroid cancer. Living on Hilton Head Island, SC, with a “medical community” ranging from our little island to Savannah to the South and Charleston to the North (including Medical University of South Carolina, with its thousands of doctors), who should she go see? Based on her experience and expertise, our doctor sent us to Dr. Denise Caneiro-Pla at MUSC. She just happens to be flat out the best Endocrine Surgeon (I never even knew there was such a thing!) south of the Mason-Dixon Line. Probably in the U.S. The outcome? Excellent medical care and a cure, thanks to Denise.

Bottom Line. I think that this issue needs some reconsideration and repositioning. While I still object to being subjected to patent cost saving moves by HMO’s requiring of a referral for a specialty consultation, especially for “out of network” care, I have very much come to value my Internist’s guidance on the matter. It would indeed be “folly” for me to sidestep this expertise.

gofundme for Medical Bills

Check this out. What you will see is a piece that notes that, with increasing frequency, people are turning to crowd sourcing to help cover their medical bills.  In the 8 years since its inception, GFM has collected more than $5 BILLION in donated funds. At the present time, 1 in 3 requests is medically related.

Why? Patients without medical insurance. Rising deductibles. Costs like hotel bills, gas and lost salaries that insurance doesn’t cover.

As usual, I am of two minds on this one. One part of me thinks just how wonderful it is that the money raised by GFM has come from over 50 million donations, large and small. You can read a few of the heart-warming stories of patients who benefitted from this assistance.

The other part of me ponders the desperation and hopelessness that drive patients to this source of funding, and the comment that all of this makes on the state of health insurance in the U.S.  

OH. And then there is the cynic in me that ponders such cases as the high profile GFM started by a couple purportedly to collect money for a homeless man that  gave no money to the nominal beneficiary. Instead, the couple bought luxury cars and vacations for themselves.  

Bottom Line. Whatever the underlying social issues and opportunities for abuse, I thank God that for the generous people who are willing to step forward to help people with their medical bills.  

Need medical $ yourself or know someone who does? Go here to learn how to go about getting it through GFM. 

Insurance Companies That Can Kill

Check this out. What you will see is the story of a lawsuit against AETNA for denying coverage for a potentially lifesaving therapy for the woman pictured above. The outcomes? She died. AND. The insurance company was ordered to pay her family $25 Million.

We have talked many times before about the deleterious impact that insurance company “prior-auths,” denials, and other interventions can have on patients’ health. But here we get some new insight. Like the medical directors admission that they had spent more time preparing for the litigation than they had making the denial decision.  

Bottom Line. Read the story yourself. I am guessing that you will get as angry as I did! But think about the context in which this story is written. And answer the question in the headline. Will the “mega-merger” of AETNA and CVS make this kind of travesty even more likely?

My guess? Yup!

Insurance Denial

A week or so ago we talked about the “joys” of insurance companies requiring “preauthorization” for the use of medications. At the proverbial Bottom Line, we pondered the impact that delays and other short circuits could have on the quality of the medical care delivered. Here we go again. This blog post by a “whistle blowing” physician considers this issue from the extreme case to the day-to-day. More specifically, it begins with the report of a jury awarding $25 Million to the family of a cancer patient that was denied access to a medication and later died. At a more prosaic level, the article goes on to describe a “step therapy requirement,” that is not an absolute denial but rather will authorize a more expensive medication only if less expensive alternatives have failed. Got me to thinking. In virtually every study we do at ThinkGen, we hear physician reports of this requirement and the impact that it has on their practices. What impact? Oh, little things. Like hours of paperwork and the delay of the care which the doctor believes to be optimal. In this latter regard, check out the blogging physician’s tongue in cheek speech that he would recommend that a doctor faced with this set of circumstances might give to the patient: “I prescribed a medication to you that my training and experience informs me is the best choice for you. Instead, let’s spend the next few months giving you some different medicines, just for fun. I don’t think this medicine really makes sense in your case; that’s why I didn’t prescribe it. Your insurance company, who always has your health and welfare as its highest priority, want us to wander off course for a while. Who knows?  Miracles happen. Maybe the stuff might work by accident. No need to fret too much.  Eventually they will give in and you will ultimately get the right stuff covered. And think of all the quality time the two of us will enjoy on our journey together!” Right on!  Also, not to be ignored in his post are the blogger’s musings as to whether or not the real purpose of the step therapy requirement is to make doctors and patients give up and go away. Interesting and bothersome notion. Bottom Line. Like we said at the conclusion of our last blog post on this topic, the unintended (and intended?) consequences of preauthorization and step therapy requirements are profound. Give them some thought, and figure out what you would do about all of this if you were a physician who was “Czar of all of Russia?” Or, the CEO of a medical insurance company that considers every dollar it spends on patient care to be a ding in their profitability?

Death By Prior Authorization

Huh? Check this out. What you will see is a very disturbing blog post. In it, you will see reportage of a case in which a patient died due to an insurance company’s inability/unwillingness to authorize a life-saving anti-seizure medication on a timely basis. So, who gets slapped with the anticipated wrongful death suit? The insurance company? Nope! The physician and pharmacy, both of which seem to have done their jobs. Yikes! But there is a more general point here than litigation. This blog post got me to wondering as to what is the actual impact of this whole “prior auth” circus on healthcare in the United States. I am currently conducting two Habit Engineering SM studies in two different treatment areas with three different specialties. In virtually every single interview, I hear the respondent grouse about the amount of time it takes him or her to get preauthorization. Worse, I hear them complain that trying to pick a drug that will be covered by a patient’s drug plan without preauthorization is like shooting darts blindfolded. Much worse, I hear them tell me that they often don’t learn of a “miss” in this game for four or five days, when an aggravated patient calls to inform the doctor that there is no prescription to be picked up because coverage has been denied. Bottom Line. Think of the things we talk about here. The doctor shortage, physician burnout, poor patient compliance. Then think about the negative impact that health insurance companies’ policies and procedures are having on all of these issues.  Folks, there has got to be a better way to do all of this!

Back To The Future

I present for your consideration a very interesting, make that sort of shocking, blog post. Here, you will see a physician very understandably and vociferously complaining about two related thorns in her side, i.e., Prior Authorization requirements by insurance companies and drug prices. We haven’t talked much about PA. But when I stop to think about it, making a patient wait 48-72 hours to get authorization for a medically necessary drug is sort of unconscionable. Decades ago, when I was the father of a 6-month old who would regularly pierce the night with screams from ear infections, I would have gone ballistic if an insurance company had made us wait for three days to get the drug that my son (and my wife and I!!!) needed. But such is the reality of pediatric practice in 2018. This problem is exacerbated by the out-of-pocket price that patients have to pay at pharmacy for drugs if they choose to circumvent PA. For many patients and for many drugs, especially those requiring PA, the prices at retail are literally unaffordable. So, what has this doctor decided to do to make this all good? She has started buying generics online and selling them to her patients at cost. Her state, as do many, allows physicians to dispense medications directly  to patients, a practice that was relatively common well into the 1960’s. The medicines are immediately available, and the price savings are huge. Bottom Line. And there you have it. A pair of goofy aspects of medicine in 2018, PA and skyrocketing drug prices, both dealt with by this doctor simply by returning to the way things used to work. All of which leaves me wondering how many other current “problems” could be eradicated in a similar manner!!!

Co-pay Clawback???

CVS I’m thinking that it is no wonder that patients are getting increasingly confused, and ticked off, about drug pricing. We talked recently about a patient who got quite befuddled as to why his insurance company would cover the cost of a branded product, but not the much lower cost of generic equivalents. Recall that the reason for this weird state of affairs was a rebate deal that had been struck between the pharmacy and the drug company. Today is a variation on the same theme. With a twist. Some California customers have discovered that their co-pay for some drugs was higher than the cash price of the medicine. And where did the extra money wind up? It allegedly got clawed back, according to lawsuits filed against CVS and other chain pharmacies, into an unholy profitability collaboration between the drug stores and PBM’s. And this is not about nickels and dimes. In one case, the patient was charge a co-pay of $166 for a drug that could have been purchased for only $92 in cash. Bottom Line. Want to get in the way of patient adherence with their drug therapies? Here is what you do. You get patients so confused and angry about drug pricing that they never want to show their face at a prescription counter again. Yup, that’ll do it!

Immediate Gratification

Screen Shot 2017-08-10 at 6.58.09 PMYup. This sort of makes sense. Check out this piece. What you will find is that as healthcare costs have gone up over recent years, employers have significantly reallocated their percentage of spending on employee benefits. Whereas the majority of their spend used to go to funding employees’ retirement, two-thirds of their investment in their work force is now going to current health insurance premiums. Reportedly, that focus on immediate gratification rather than long term planning is keeping the employers happy with a healthy work force, and the employees happy with reduced monthly premiums. Bottom Line. YEAH, BUT. Given the minimal amounts that many Americans have put away for retirement on their own, this trend seems like one that will eventually bite us all in the rear end.  Stay tuned!