Health Plan Consumer

By Jan Greene

Just came out of a session at Health 2.0 about websites that help consumers with their medical bills and health insurance. Here are the highlights:

Change:healthcare is my current favorite among these types of sites. It addresses the same issue as this blog talks about: The yawning gap between what consumers are now expected to know about managing their healthcare dollars and their practical ability to do so. It has detailed information about medical bills and is regularly adding tips on how to handle specific difficult situations, such as negotiating with a provider before you get a medical service.

Another one, bwell-informed, is useful for choosing the right health insurance plan for you. There are a number of websites that allow you to buy health insurance online, but this one has a nifty tool that will let you compare plans and predict your out-of-pocket costs given your typical use of healthcare services.

Getinsured.com is another website that helps people buy health insurance. The interesting thing about this was the company CEO's comments about the difficulty of many of his customers to afford health insurance. He thinks the marketplace will in the next year or two offer many more low-cost catastrophic insurance plans for people who can't afford $200 or more to insure themselves and their families. He also noted that some of these kinds of products, such as discount cards, being marketed today aren't worth the money. This is a problem we'll address here soon.

Medicaresaver is a handy site for people looking for Medicare Part D insurance, which can be a bewildering search because of the complexity of prescription drug plan choices for the elderly and others who use Medicare.

More later!

By Jan Greene

This may be a foolish thing to do, but I'm going to publicly discuss my lower back problems. This is dangerous because I buy my health insurance on the individual market, which means that anything that places me in a category of undesirable risk could make me uninsurable in the future. But what's happening to me is not uncommon and raises interesting questions for consumers.

I've been buying my own health insurance for the past five years or so. My premiums have doubled in that time; to some extent it's because of my age — I'm 47, a time of life when medical expenses tend to creep up. But premiums for everyone have also been rising at the same time.

Like an increasing number of Americans, I have a high-deductible health insurance plan. I pay $2,500 before the 70 percent coverage for most things kicks in. There are exceptions for many prescription drugs and a certain number of doctor appointments. But for both of the past two years I've spent that deductible and more because of what seemed like relatively routine medical tests that turned out to be really expensive even after the insurance paid its part.

So I sought out help from an insurance broker to see if I could get a better deal. I'm healthy, except for some chronic low-back pain that I deal with on my own with exercise and stretching. The broker, though, said I could not qualify for a lower deductible/higher premium plan because I've had a diagnosis of degenerative disk disease. This sounds rather dire until you realize that the medical world views this dwindling of the pads between the vertebrae as "a natural process of aging" that affects the majority of people over age 50.

But to insurance companies, the chance that a person with low back pain will seek out expensive surgery or long-term physical therapy appears to be such a terrible risk that they don't want to give insurance to people with that diagnosis, or at least not without a big spike in premiums. A friend of mine went through a similar process, seeking to buy better coverage from her existing insurer, and was turned down because she once sought very short-term treatment for insomnia.

So the message seems to be that if you want to stay insured you should never use your insurance. I've certainly avoided asking my insurer to help me pay for physical therapy appointments for my back, which I use every so often, or consultations with mental health professionals when my emotions need a tweak, such as after my mom died a couple of years ago. Why put red flags on my record for a measly $30 payment, which covers barely a third of the cost of the appointment?

Theoretically, though, even if I pay for those kinds of things myself, my insurer expects to know about it and take it into account if I ever apply for a better plan or ask a different company to insure me. It would be nice if they could take into account the fact that I'm only going to make claims for the bigger things I can't afford and that they can negotiate good rates for, given their clout in the marketplace. But these are large corporate entities that don't flex well to account for individuals and their problems.

I'm interested in hearing from other people about whether you carry out stealth healthcare, paying out of pocket even though you're insured, so you don't make waves with the insurer. In California this has become a big issue because several of the big insurers have been accused by state officials of finding flimsy excuses to cancel the coverage of people who make substantial claims (because they're particularly sick). It's scary out here, and getting more so. As a journalist I don't like to advocate one way or another, but I do get chills when I hear free-market supporters talk about how the marketplace is the best way to provide health security. I have my doubts.

By Jan Greene

I had the opportunity to meet a family that's been through hell and back, but managed to remain smart and informed consumers of healthcare even as their toddler son endured a long and difficult fight with liver cancer.

The Clarks, Richard and Diane, realized their son Dillon was sick during a visit to the pediatrician when he was 18 months old. His belly was distended, and it turned out that his liver was enlarged with tumors. He was started on chemotherapy to reduce the tumors that had also migrated to his lungs, while doctors decided whether they could remove the cancer from his liver surgically. When that appeared to be impossible, the next step was a liver transplant. But they wouldn't put him on the transplant list until the lung nodules were taken care of. Through all this the boy went through multiple surgeries and round after round of chemotherapy, plus regular CT scans for which he had to be restrained. Anyone who's had a toddler can imagine how difficult this was for everyone.

The family hit a crisis point when the doctors decided there was still too much cancer in his body for a transplant (organs, in short supply, are saved for those with the best chance of surviving). Richard Clark, as it turns out, has been a business guy with some biotech companies, and he knew his way around a medical journal article. He challenged the doctors every time they doubted further care would be useful, and understood that just because one doctor's judgment was that treatment wasn't worthwhile, another might give it a go. The family sought second opinions and, with a key medical journal article in hand, convinced another surgical team to take a closer look at Dillon. That turned the tide…a fresh CT revealed the liver could be resected and the original surgeons did the work. After a couple more surgeries to remove the last of the cancer from Dillon's lungs, the boy has been cancer free for two years. He turns five in October, and is as bouncy and lively as any child his age.

The Clarks also faced financial hurdles — when they went out of state for the second opinion their insurer wouldn't pay, so they put the $50,000 on a credit card and got ready to use the equity in their house. The insurer later reimbursed them for much of that. They also struggled to maintain health insurance through the ordeal, using expensive COBRA and high-risk pool plans when the parents couldn't work because their child's medical care took all their time.

Now that their ordeal is over and they are enjoying Dillon, his younger brother and older half-siblings, Richard Clark helps other families facing hepatoblastoma. He's met families who can't quit work or rely on home equity to get through a tough spot. He met one father working construction in California's central valley would finish his shift, drive two hours to Stanford to be with his young child, and leave the hospital in the middle of the night to drive back to work.

The Clarks were fortunate and they were informed, and they are passing their wisdom on to others. In a healthcare system that is complex and often requires patients to take on much of the decisionmaking and coordinating themselves, people like the Clarks are invaluable. They share their knowledge with other families online through websites such as caringbridge.com. It's unfortunate that consumers have to carry so much of the financial, emotional and decisionmaking weight themselves, but the Clarks' experience shows how online communities can spread the burden a bit.

By Jan Greene

Wasn't that some culture's curse — may you live in interesting times? Well, in healthcare we're smack in the middle of interesting times, and they don't want to let up.

I've been busy with work (a good thing for a freelance writer! A bad thing for a blogger!) so I've been remiss in posting. Meanwhile, lots of action to be noted:

–AHIP, the trade association for health plans, is meeting just across the bay from me this coming weekend, and proponents of single payer (government-sponsored) health coverage will be outside promoting their cause. That should be interesting…a little street theater at San Francisco's Moscone Center usually jazzes up a slow summer news day. And maybe that's the kind of energy it will take to get some kind of reform happening somewhere, somehow.

–Yet another Commonwealth Fund report following the experiences of the underinsured finds that their ranks have grown from 16 million to 25 million since 2003 — a 60 percent increase! This is interesting because people with inadequate health insurance tend to get ignored in policy discussions focused on covering more people with no insurance at all. But these folks are often employed, maybe work for themselves, are paying an insurer for "coverage" and yet face big out-of-pocket expenses anyway. The Commonwealth Fund found that 45 percent of these people have an outstanding medical debt and 53 percent of them went without needed care because of costs.

The other interesting piece of this study is its mention of the various ways that health plans are being winnowed away and not just with high deductibles (the dollars you pay before coverage kicks in). Health plan designers are finding creative ways to cut costs, and in ways that the average consumer might not notice until she trips on them — limiting the total amount the plan will pay for medical care, limiting the number of physician visits.

–The wordplay around "consumer-directed" continues to be an interesting topic of discussion. It's the flavor of the month in the healthcare industry but some consumer advocates believe the term is a palatable-sounding shield for making individuals pay more out of pocket for their care. Writing on the Health Affairs blog, Ron Cunningham, an editor at the journal, makes the the point nicely:

But the policy community understands, and pardons with an ironic wink,
the gamesmanship involved in labeling as “consumer-directed health
care” those recent insurance benefit redesigns that increase
deductibles and patient cost sharing. When did consumers ever stand up
and demand that they be allowed to pay more when they are sick?

Meanwhile, back at the ranch (we'll see how many of you young'uns catch that reference), I'm checking out a redesigned medical price information service provided by an outfit called change:healthcare. Its Medstimate is supposed to be new and improved and based on a wide variety of sources. We'll see if it measures up and I'll report back next time.

By Jan Greene

There's a really interesting column in the Wall Street Journal this week by Dr. Benjamin Brewer, who writes regularly about his experiences in the American health system. He talks about taking his daughter to an emergency room for stitches and getting a surprisingly high bill. His comments address what this blog is all about:

Nobody I know would be willing to buy gas at an unknown price, only to
find out the damage when the tab comes a month and a half later. But
between the mind-numbing complexity of health-care charges and the
reluctance of many in the health system to reveal their prices up
front, you don't have much of a choice.

Yeah, exactly. He goes on to talk about being on the other side of the billing process:

Some patients with big deductibles or health savings accounts try to
negotiate fees with me. I'm not offended, but as a family doctor in
Illinois my margins aren't that high to start with. A $65 to $85 office
call carries $45 to $50 in overhead.

This is instructive because it goes to one of my main pieces of advice: Know which medical services have a high profit margin and negotiate harder on those. It's pretty well known that primary care doctors such as family physicians aren't making a lot of money on office visits, so there's not much point in dickering their prices down much (though it's always worth asking). I'll be devoting future posts to the profitability of other common medical services.

There's an interesting string of comments after Dr. Brewer's column in the WSJ that get into a debate about how much medical services cost and what should be done about it. If you have a subscription to the WSJ you can read all about it (though someday soon the journal is rumored to become free of charge).

Some of the comments were from consumers who had tried to get pricing information before they had a medical service and were told that information is confidential. That's ridiculous. We should all ask and keep asking until hospitals, doctors' offices, labs, imaging centers and all the other parts of the system get the message that they need to evolve with the times just like consumers, whether we like it or not. It's ludicrous to think that consumers have to take the brunt of paying for more of their care without giving them the information and skills to do so. That's what we'll try to remedy, in some small way, on this blog.