Posted tagged ‘insurance reform’

Child dying? Call your insurance company, first!

January 5, 2015

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

December 18, 2014

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.