Child dying? Call your insurance company, first!

The Pediatric Insider

© 2015 Roy Benaroch, MD

The action steps, in any health emergency, are: ABC. Airway, Breathing, Circulation. The airway has to be open, the patient has to be making an effort to breathe, and the heart has to pump blood. In any emergency, health care people are trained to address these, one by one, in order. Fix what you can before moving on, and concentrate on what’s going to kill the child first. Then, arrange transport for definitive care. That’s the core of life support, and how health care people are trained to respond to an emergency.

But in today’s enlightened times, health care isn’t run by people trained in health care. It’s run by bean-counting administrative flunkies who care only about saving costs.

Here’s this week’s true story: A child presented to my office in severe respiratory distress. He was not breathing well. In fact, he was barely breathing at all. We gave oxygen and supportive care, but he still needed more help—so we called an ambulance to transport him to the hospital. There, he was admitted to the ICU and received expert, life-saving care. He’s now doing fine.

Except his family now has to deal with a second nightmare. To get an ambulance to transport him, we called 911, and the county 911 service did what 911 services are supposed to do–they sent an ambulance over right away, with oxygen and trained people to get him quickly where he needed to be. But that specific ambulance company was “out-of-network”—that’s not the ambulance company that the family’s health insurance company wanted him to use. So the ambulance trip goes to “out-of-network” benefits, at a lower coverage rate with a separate deductible. And the family owes $1900 they can’t afford.

Bean-counting administrative flunky: Hello, sorry for the 30 minute wait, can I help you?

Mom: My child is blue and dying. Which ambulance company should I call for in-network benefits? Money is tight.

Bean-counting administrative flunky: Please enter your 15 digit member ID number, or say the numbers out loud.

(Etc, etc. After another 45 minutes Mom gets a straight answer to call Bob’s Ambulance Company. Bob and ambulance arrive 30 minutes later. The child is dead.)

Seriously: even if mom knew the name of the ambulance company that was “in-network”, she doesn’t get to choose what ambulance comes when she calls 911. They send whoever’s closest, whoever can help—that’s what a health provider is supposed to do. Help the patient. Unlike, obviously, the insurance company.

Bean-counting administrative flunky: Hello, sorry for the 30 minute wait, can I help you?

Mom: My child is dead. Which mortuary should I call for in-network benefits?

Bean-counting administrative flunky: Please enter your 15 digit member ID number, or say the numbers out loud.

The Affordable Care Act has helped many more people get health insurance. But the insurers are still in the business of making money, not in the business of providing health care or paying for health care. They don’t make their money by paying bills. They make their money by doing whatever they can not to pay the bills. If you want to get them to actually pay for your health care, you’ve got to know the ins and outs of the contract, and you’ve got to steer services to “in-network” providers– that includes hospitals, docs, pharmacies, and even ambulance companies.

Child dying? Forget the ABCs of airway, breathing, and circulation—your first call, now, is to your insurance company*. Do a crossword while waiting on hold. And maybe give your child a little oxygen, while he waits—just don’t expect the insurance company to pay for it.

*Though this post was 100% true, the advice in the last paragraph was “snark”, for comedic effect and narrative impact. If your child is very sick and you need an ambulance, call 911 right away. Do not call your insurance company. Later, you may have to straighten out some bills—but take care of your child, first, always.

Insurance provider lists are full of lies

The Pediatric Insider

© 2014 Roy Benaroch, MD

A goal that’s become The Major Talking Point about health care reform is to get more people into health insurance plans. There are XX million uninsured, they say, and this new scheme will help provide insurance to XX people. But just having insurance won’t make anyone healthier. Insurance has to allow access to health care providers in a timely manner.

Unfortunately, that isn’t always the case. A study just published in JAMA Dermatology demonstrated that many provider lists for health care plans are outrageously inaccurate, and greatly overstate the number of providers in health networks.

Researchers in California collected the currently-published physician directories for all of the Medicare Advantage plans available in their state. They looked at one specialty, dermatology, finding a total of 4754 total physician listings. About half of these were duplicate entries, with the same physician appearing multiple times in the same directory. They called every single one of the 2591 actual unique providers, and found that only half of those could be reached, were accepting patients in the plan, and could offer an appointment. For one of California’s Medicare Advantage plans, not a single dermatologist was available. Net for all plans, about 25% of the “listed dermatologists” in the plans could actually see you as a patient – and even then, the average wait time was 45 days.

Having health insurance is important, but it’s not the same as having health. Patients need to be able to see doctors; they also need to be able to get prescription drugs or ride an ambulance if necessary. And they need the cash to meet ever-growing deductibles. Cheap health insurance isn’t really very useful if you can’t use it. While this study doesn’t speculate on why the insurance booklets are so inaccurate, it’s obvious that if the insurance companies wanted accurate provider directories, they could make them. After all, in one quick phone call I can find out if a patient’s insurance covers a visit with me. Their computers know. But if you’re a health insurer, it’s better for you to misrepresent and obfuscate and over-state your networks. Their listings say 4754 dermatologists are in-network; but less than 1500 are really available to see you.

The goal of the insurance companies (and government-funded health care coverage bureaucracies) hasn’t changed. They want to spend as little as possible on your health care. Since they can’t exclude pre-existing conditions any more, they’ve come up with new ways to keep your premiums to make big profits. Tiny, limited networks are one trick. They make it very difficult to get an appointment, and care delayed is care they may not end up paying for. Even better for them: sometimes people become so frustrated that they see an out-of-network provider, paying with their own cash. You pay—you lose; you pay—they win.

EDIT: After I wrote this, a study was published looking at Medicaid — and found that about half of the providers on the lists were retired, dead, or not seeing Medicaid patients. Half is better than 25%, but both figures are terrible. Both private and public health insurers are way overstating their provider numbers.

Games insurance companies play

The Pediatric Insider

© 2014 Roy Benaroch, MD

Here I am, on my “day off,” trying to get an insurance company to pay for something for one of my patients. Or not pay for something—honestly, they’ll do whatever they’re going to do, they don’t care what I say—but I need to at least make it look like it’s not my fault. That’s the game, see. Confused? Let me explain.

Bob has been in speech therapy for a year, and has been doing well and making good strides. Though they had been paying for the therapy, now the insurance company is balking—their letter to mom says that they don’t feel that the therapy is “medically necessary” any more. (I suppose it’s not medically necessary to talk. Maybe they’ll give him a little chalk board to tie around his neck instead.)

So mom, understandably, contacts the insurance company. They tell her their decision is based on information they got from me. Me! They didn’t ask me for any information, and I haven’t heard a word about this. Anyway: Insco tells mom that they’ll have to start a peer-to-peer review, alleging that one of their doctors will speak with me. Mom calls me to pass along their phone number. I’m supposed to call them. That very phrase gives me chills. You’ll see why.

By the way, this is one of the biggest insurance companies in Georgia. I suppose I can’t say directly who they are, but their name rhymes with “Goo Moss/Goo Field”, if you catch my drift.

Anyway: I call “Rue Toss”, and find out that they’ll only accept phone calls between 9-12 and 2-5. When I’m most busy with, you know, scheduled patients. The sick kids I trained to take care of. These phone calls should take priority over patient time, if you ask “Moo Floss”.

I finally did get a chance to call them, this morning, of course on my day off (that’s pretty much the only time I could possibly be free during those hours.) And I listened to a 5 minute message—which ended with a recording for me to leave my name and number. I had to call at a specific time just to leave a message that could have been left at 2 AM! They promise to call me back within 48 hours.

And I guarantee they’ll call me right when I’m seeing actual patients. Or they won’t call me at all, though they’ll tell mom they tried to. Golly, your doctor just won’t speak with us!

The saddest part: they’ve already decided that they’re not paying for this service. I know this. In all of my years, these phone calls and appeals for things like speech therapy have never worked. This whole game has been created by the insurance company to make mom think that this is all my fault. Oh, says the insurance company, we decided this based on what your doctor told us. If he’ll just call us, we’ll reconsider. That’s a load of shit. They’ll waste my time, hope I give up, and do anything they can to make doctors look like the bad guys.

Man up, insurance. If you won’t pay, just tell your “members” that it’s not a covered service, and leave me out of it. You obviously don’t care what I recommend, so stop pretending that you do.

Insurance tries to make it your doctor’s fault

The Pediatric Insider

© 2014 Roy Benaroch, MD

Little kids don’t like to accept blame. They’ll say “someone else did it,” or “it’s not my fault”, and they’ll look at the ground and shuffle their little feet. In their hearts, maybe they really think that someone else scribbled on the wall with lipstick.

Insurance companies know better. When they’re trying to deflect blame and obfuscate, you can bet that they know exactly what they’re doing.

Just one example: prescription drug “preauthorizations”. Even the word itself, “preauthorize” – what is that, getting permission before you get permission? Did Orwell himself make that up? I have a medical license, so, in the wisdom of the legal system, I can authorize a patient to get a prescription drug from a pharmacist. The “authorization” is the prescription, the piece of paper with cryptic scribbings and abbreviations and my unreadable signature.

Trouble is, just having an “authorization” from a medical doctor sometimes isn’t good enough. Sometimes, especially if the medication is expensive, you need a “pre-authorization,” too. And the insurance company tries to make it seem like that getting a preauth is the doctor’s job, too. If you don’t get a pre-auth, that’s the doctor’s fault. Honestly, Mom, I had nothing to do with the noodles in the clothes dryer.

No, a pre-auth has nothing to do with your doctor’s decisions. My job, my “authorization,” is based on my history and physical, the decision my patient and I made in the exam room. I already did that part, and I gave you the script. Now it’s up to your insurance company to pay for it, at whatever terms are spelled out in your insurance documents. If they don’t want to pay for it, that’s their decision. It is not mine.

Insurance companies have made up a new kind of authorization, the “pre-authorization”, that somehow has also become something your doctor is supposed to do. They’ll make it sound easy—just tell your doctor he has to fill out a form, or tell her she just has to call a “prereview specialist.” Of course, it’s never that easy. I don’t have the form, and it will take days to get it. The form itself may be complicated and many-paged, and will require me to pore over your old chart to see what other medications you’ve taken and on what dates. And a phone call? Please. We wait on hold just like you do. Me and my staff are supposed to be taking care of patients, not spending 45 minutes listening to “Muskrat Love.”

Any even when we do the form, the “pre-authorization” will often be denied. We won’t know it, but there are often “secret rules” that drug X won’t be paid for until the patient has tried drug Y and drug Z for at least 60 days. Documented, in the notes that we have to send and sign. You say those medications were tried by your last doctor, and didn’t work? That’s good enough for the doctor. It’s not good enough for the pre-authorization clerk or lackey with his red rubber stamp.

After all that, the patient gets a letter, which continues to blame the doctor: “Your request has been denied, based on the information supplied by your physician.” Needless to say, your doctor can appeal this, by spending a few more hours beating his head against a tree or contacting your insurance appeals department (those are approximately the same thing.) That won’t work either, but it will further reinforce the point of this entire adventure: it’s not your insurance company’s fault. Really. We’d love to pay for your medicine. It’s just that, between you and me, your doctor just isn’t very bright. He can’t fill out a simple form. We’d do it, sure, if only that doctor would get a preauth like he’s supposed to.

No. I’m not “supposed to.” Getting pre-auths was not part of my medical education, and it’s a huge waste of time. It’s a transparent way to make it difficult for people to get medications that they need, so the insurance company can spend less on your medical care.

That letter, the one that politely refused the preauth and blamed your doctor, it’s got one other truly Orwellian component. The letter will also tell you that the insurance company isn’t dictating treatment decisions. After all, they don’t have a medical degree. They can’t decide medical things. That’s up to the doctor. Yes sir. You can have any medicine you want. We’re just not going to pay for it. And we’ll do our best to make sure you think that’s your doctor’s fault, too. And so is the lipstick on your wall.

A win for grey hairs! Experienced docs save money

The Pediatric Insider

© 2012 Roy Benaroch, MD

One thing’s clear: we’re spending gobs of money on health care, and we can’t afford to keep doing it.

A provocative RAND Corp study published this month looked at Massachusetts health care spending from 2004-2005, examining the claims data from 1 million residents and 12,000 doctors. They found that the more experienced the doctor, the less health care dollars were spent to diagnose and treat the same health conditions. The differences became larger as more years of experience accumulated. Overall, physicians with 40 or more years of experience had about 13% less costs than those fresh out of residency.

Costs were not associated with other factors—it didn’t matter, for instance, whether the doctors had had a malpractice claim, or were board certified, or whether they practiced in a large or small group. This study didn’t look at outcomes, so it wasn’t designed to see if the increased costs associated with less experienced physicians could mean that there was better health care overall. But other studies have clearly refuted that. Increased costs do not mean better outcomes or better health.

So why does more experience seem to lead to less spending? The authors have some ideas:

• Younger docs may rely more on the newest, most-expensive technologies. That would be OK, if these devices improved overall health—but there is no evidence that this is true.
• Less-experienced docs may be less confident, so might order more tests and procedures.
• Older docs may have patients who trust them more, who might then not push for the latest drugs and tests.

Is 13% a big difference? Considering overall health care expenditures of $2.5 trillion per year in the USA, that 13% is about 325 billion dollars. That could certainly buy a few bottles of Grecian Formula or Clairol for those experienced docs who’ve learned to spend less and still provide good care. And also provide health care for just about every uninsured American – with about 200 billion left over for a tablet computer for every single human on the planet.

(You think I’m kidding? This November, 2012 study puts the cost of healthcare for uninsured Americans at $125 billion per year, leaving 200 billion to spare from the overall 13% cost savings. There are about 6 billion people on the planet, so that 200 billion works out to $30 per person. There are inexpensive computers in development for $25-50 each. The costs of health care are truly staggering, and it’s easy to lose perspective on just how much money we are wasting. Ironically, it’s not even our money—it’s the money our children and grandchildren haven’t even earned yet. Ha ha, suckers, that’s why we don’t let you vote!)

More about health care costs:

Where is the money going?

Who’s wasting the most $?

Bizarro inflated prescription drug expenses

Defensive medicine adds costs for everyone

“Patient satisfaction” may increase costs, and make you less healthy

Counting more beans is sure to help

Wasting your healthcare dollars

The Pediatric Insider

© 2012 Roy Benaroch, MD

As I’ve said before, the biggest problem with health care delivery in the USis cost, which seems to have taken a back seat to other issues meant to be addressed by health care reform. We spend about $2.5 trillion dollars a year on health care—that’s over eight thousand dollars a year for every man, woman, and child. What’s that getting you? Accord to the government, about 30% goes to hospitals; 20% goes to doctors & other clinicians, 10% goes for prescriptions, and the other 40% or so goes for “other spending,” mostly administrative costs and haircuts for insurance executives. But it’s probably even worse than that: according to a recent JAMA study, about 20% of total healthcare expenditures are wasted dollars.

20% of 2.5 trillion dollars, by the way, is 500 billion dollars. Each year. The JAMA article (which, ironically, will cost you 30 clams to see in its entirety) breaks down the waste into several categories:

Failure of care coordination ($25 to $45 billion wasted): I see examples of this all the time. Docs and hospitals don’t talk to each other, and patients don’t bring records—so tests get repeated, or (even worse), medicines are added on top of other (unknown) medicines, creating costly havoc. The patients suffer. Why does this happen? Docs (like me!) get paid to see patients, not to read charts and chase down forms. In fact, HIPAA “privacy” laws have made care coordination even more time-consuming and frustrating for everyone.

Failure of care delivery ($102 to $154 billion): I’m not really sure exactly what that means. I imagine they mean waste created by not treating medical conditions early, when they’re less expensive to address.

Overtreatment ($158 to $226 billion): In part, this is defensive medicine—docs do whatever they think they need to do to they don’t get sued. Show up in the ER with a headache? You get a $1600 CAT scan! Those tests not only cost money themselves, but they lead to more tests and procedures and costs that really aren’t making anyone healthier. (Except the medical-malpractice industry. They’re doing real well.) Overtreatment also includes steps taken by lazy doctors who find it quicker—and better for business—to just order the tests and treatments the patients expect, rather than doing what’s medically appropriate.

Unnecessary administrative complexity ($107 and $389 billion): We love filling out forms, and we love hiring staff to wait on hold for administrative pygmies at the insurance agency to approve Grandma’s catheters. Yup, that’s why we went to med school.

Noncompetitive pricing ($84 and $178 billion): “Noncompetitive”, I think, must be a euphemism for “batshit crazy”. Ever see a doctor or hospital’s price sheet? They’re locked up, guarded by poisonous lizards deep in an underground bunker. Prices have to be super-inflated so the insurance companies can negotiate them down to what they’ve already decided they’ll pay (when they get around to it, which is after they’ve paid for the VP’s executive jets and haircuts.) People who don’t have insurance, of course, get hosed.

Fraud and abuse ($82 to $272 billion). With this much money sloshing around, scumbag frausters (including some with MD degrees) crawl out and starting grabbing what they can. For every jerk the government finds and prosecutes, there’s a handful of other cockroaches to take their place. Though there’s certainly insurance fraud in the private market, there is far more abuse designed to extract money from government health programs. Insurance companies do what they can to guard against fraud, which could hurt their profits or drive them out of business. Government agencies just don’t seem as driven to control costs. I guess they figure we can always borrow more money from our grandchildren.

I have no idea if that 20% estimate of wasted dollars is accurate—the researchers claim to have used the lowest, most conservative numbers. It wouldn’t surprise me if the percentage were actually quite a bit higher. I don’t know if these figures even include the huge amount of waste that occurs when people seek health care through emergency rooms inappropriately. Whatever the exact number, it’s certainly true that after waste, fraud, and the huge expense of our enormous, multilayered government and private insurance industries, it’s unlikely that even half of the money spent on health care does anything that plausibly improves anyone’s health. The system itself is obviously bloated and unhealthy, staggering under its own weight. Do we have the guts to fix it?

Inscos want to own your health care provider

The Pediatric Insider

© 2011 Roy Benaroch, MD

 We cut out the middleman to SAVE YOU MONEY!

It works with jewelers, car dealerships, discount chains—cut out that greedy middleman, and the buyer gets the goods, cheap!

Will it work for health care?

Here’s a new trend: insurance companies owning their own retail-based clinics. I’ve raised some red flags about retail clinics in drug stores and big box outlets before. One objection I have is the conflict-of-interest: if the drugstore will also make a profit when it sells you the drug, could it be that their salaried employee will want to prescribe the medicine that makes the most money for the drug store?

Take it one step further—what if the insurance company itself actually employs the health care provider? Every dollar spent on you is one less dollar of profit for the company. Do you think their provider is likely to order the best medicine, or the cheapest medicine? How about those blood tests or x-rays–you’d like to be sure that the person deciding whether to order them cares only for your well-being. What if the person who decides whether to order the test works for the company that has to pay for it?

Drug-store owned clinics are a huge conflict of interest, but at least the impact of their decisions is really limited only to medication choices. With insurance company-owned clinics, decisions aren’t just about who makes profit on the medicines. It’s about everything: how many specialist referrals there are, whether you’re told to go to the ER, whether you get an MRI on a knee or your brain. Every decision to offer anything past rudimentary, inexpensive care is less profit. Who do you want making these decisions?

The way health care is financed, “the middleman” is your doctor. Physicians are not beholden to the insurance company—we can pretty much order what we think is appropriate, without affecting how we’re paid for the encounter. (There are ill-defined “bonuses” to reward what’s considered “good care,” but those payments are minimal and unpredictable. And sometimes we have to jump through hoops to expensive things pre-approved, but whether they’re “approved” or not, we doctors still get paid.) Furthermore, I don’t actually make money on the stuff I order. You go get your MRI somewhere else, you go buy your medicine down the street. I decide what you need based on what I know about you and my best medical judgment. That’s the kind of middleman you need: a person squarely in your corner, looking out for only your interests.

Insurance companies are there to make money for their shareholders. Period. Who do you think will win when they alone decide what services you get?

A smooch for the trial lawyers

The Pediatric Insider

© 2009 Roy Benaroch, MD

In case you were wondering what’s included in the 1900 page behemoth that is the current health care reform bill, here’s one provision:

Section 2531, entitled “Medical Liability Alternatives,” establishes an incentive program for states to adopt and implement alternatives to medical liability litigation. [But]…… a state is not eligible for the incentive payments if that state puts a law on the books that limits attorneys’ fees or imposes caps on damages.

 So: we’re going to encourage states to reform the medical liability mess—but not if in any way it might affect the incomes of the trial lawyers. More details here.

For those of you who may have naively thought that comprehensive health care reform would address the huge cost of defensive medicine and malpractice litigation, the intentions of Nancy Pelosi’s House Bill couldn’t be more clear. The bill discourages any meaningful reform. As for what’s in the other 1898 pages, a PDF version has been posted online—but honestly, there’s so much legal gobbledygook, I doubt anyone could possibly understand it, and I doubt anyone has read the whole thing. As I feared, it’s getting ugly. Put on your galoshes, America: you’re about to get hosed.

The government pokes me in the eye. Again.

Remember HIPAA? That’s the “Health Insurance Portability And Accountability Act” of 1996, a fabulously convoluted and incomprehensible pile of stink that was supposed to make health information more private, while at the same time allowing individuals to more easily change health insurance plans. After numerous revisions, clarifications, and doodling in the margins, we’ve got a system in place that:

• Costs billions
• Prevents doctors, hospitals, and labs from communicating
• and creates (1.5 million links!) a Byzantine, sprawling industry of consultants, lawyers, and bureaucrats to monitor enforcement and create new rules. None of this improves health care in any way.

From the patient’s perspective, the only tangible impact of this monster is a steady stream of unreadable, paper-wasting lawyer-scribble in the form of “privacy notices.” Oh, and you get to sign a few more forms when you go to the doctor.

From my perspective, HIPAA is  a hugely expensive waste of time squatting uninvited between me and my patients, a hideous, stinking uninvited guest that only gets bigger and more stinking every year. (As an example—the current Economic Recovery Act includes tweaks that requires providers to track every disclosure of health information that’s been used for any purpose—for three years. See, that will help with the economic recovery by employing even more administrative pygmies and consultant-weasels. Not that I am bitter.)

But get this: HIPAA might just have been a preview for a whole new set of rules and regulations being foisted on the healthcare industry by the nameless rule-makers. You haven’t heard much about this—yet—but get ready for the “Identity Theft Red Flags Rule.” Since it lacks a snappy abbreviation like HIPAA, let’s call it the “Screwing Physicians and Empowering Weasels” Act, or SPEW for short.

The rule was announced in 2007 by the Federal Trade Commission (FTC) as a way to protect consumers against identity theft when dealing with financial institutions and creditors. Fair enough, those businesses handle zillions of dollars in increasingly complex transactions, and identity theft is a genuine threat. But after the rule was announced, and the period of public comment ended, the FTC told physician groups that it was going to consider the term “creditor” in a very broad sense, including any business that defers payment. That’s right—since doctors will allow you to leave without paying, while we wait for payment from your insurance company, that makes us a creditor. No matter that we don’t charge interest, or that we’re only extending “credit” to cover a medical bill for  a few weeks. We get the same rules and oversight and paperwork as the megabanks, though of course no bail-out money to pay for all of the consultants, employees, and time its going to take to do this. Since no one guessed that SPEW would apply to physicians and hospitals, we had no chance to review the rules or suggest any modifications to make them work in our industry.

The SPEW rules are so vague that no one knows what we are really supposed to do—a boon to the consultants and lawyers who leaped so happily into HIPAA-chummed waters a few years back, and are salivating over a new opportunity to make sure that even less of your health care dollar is actually spent on health care. The rule requires health businesses like mine to develop and conduct an identity risk assessment, followed by implementation of an identity theft program to identify, detect, and respond to potential risks. We’ve got to have a plan in place stating how we’ll respond to alerts of potential misuse of identifying information. What, exactly, does all of this mean? I found one example I could understand: The FTC suggests, among other steps, that to comply with this rule we should check photo ID at every encounter. I hope your baby has a driver’s license.

SPEW, like HIPAA, is a hugely misguided effort by your government run amok. It will add layers of complexity and cost to every medical encounter, further burdening physicians and distracting us from providing medical care. It’s one more completely unnecessary poke in the eye, one more straw on the back, and one more nail in the coffin for the few physicians left who still enjoy practicing medicine.