To the phones

One last push, two more weeks, thirteen more calls to make to protect that ACA and our vision of a just society.

Right now Cassidy-Graham is chugging along with the hope that the need to do SOMETHING means that the last bill standing is SOMETHING.

We can do something about it.

Call your Senators today. If you are from North Carolina, Florida or the Upper Midwest, tell your Senators that you don’t want your state to get whacked to reward Texas’ intransigence. If you are not from those states, ask your Senators to vote for Alexander-Murray as the only health care bill.

Call your Governors as they would be handed an incredible mess.

Call…








Kids these days

I have incredible respect for those students. If I was 19 and standing there, I would have punched someone. The discipline and the courage to bear witness and hold onto their values without allowing themselves to respond to clear and constant provocations is incredible.

The kids are alright.



Bring out your problems: Medicare edition

From last week’s post on common problems that we all have with the health insurance system, it seems that Medicare is a major source of concern. I want to highlight a couple of questions and responses and then fill in as needed. After that, raise your new concerns in comments and we’ll figure things out as we go.

Let’s start with a common string of questions on Medicare supplemental plans using Peej01 as our jumping off point:

I’m not 65 yet, but I’m thinking that I should get a Medicare supplemental insurance plan when I go on Medicare. Can you explain the costs/benefits of those policies?

Barbara, an actual expert, replies:

For starters, go to Medicare.gov. There is a handbook that you probably already received but its on-line alternative can be easier to navigate. There is also a health plan comparison tool that allows you to plug in your exact drugs in order to personalize the comparison. It is my experience that most Medicare beneficiaries ask a threshold question of whether their doctor is in the network. For that, you might need to just ask your doctor. The comparison tool allows you to order results by premium, maximum out of pocket, etc.

MA versus Med. Supp. or some other kind of wrap around: The general perception is that if your employer is paying for an option, it usually ends up being a better deal, but you should do your homework. And no, I wouldn’t waive anything.

One thing to remember: for Medicare Supp, you are not underwritten when you are first eligible so if you think you want Supp, the best time to try it is when you are first eligible, because if you first enroll later, you will end up paying more.

The key point is that Medicare does not cover everything.

The biggest weakness with traditional Medicare and prescription drug coverage (Part D) is that there is no out of pocket maximum. This can be dealt with in four ways. The first is to be rich enough to self-insure. That works for millionaires who can pay the 20% coinsurance out of cash. The second is to never get sick or at least die very quickly. The two most common methods are to get a Medicare Advantage plan (Part C) or a Medicare supplement.

Supplemental plans are a buy-up. They limit out of pocket expenses for people. The richest plans move Medicare from an 84% AV plan to a 99% AV plan. The least expensive plans put in a fairly reasonable out of pocket maximum and a few other benefits. At the linked guide book, you should look at page 7 and 11.

The important thing with a Medicare Supplement is that you only need it if you go the traditional Medicare route. I worked for a company that sold Medicare Advantage plans and in Pittsburgh that was a popular choice. Medicare Supplemental plans are worth considering if you think you will choose traditional Medicare.

Next from Stibbert:

Awhile back (when you were Richard), you had a friend FP about end-stage home hospice care.
Can you post a link to that thread?

Sure thing!

And if Cactus Prescott wants to write some more, I want to read and learn some more from him!

May 14, 2016 Hospice
May 21, 2016 Death the Final Frontier
End of Life Doulas

A good point from Mr Snub:

My wife had thyroid cancer (easily treated, in remission).

Part of the treatment required 2 injections which cost $1700.
Her endocrinologist office submitted the claim as medical and we would have been stuck with most of the cost.
My wife’s hospital job is in insurance so she told the endocrinologist to check the prescription benefit and we were able to get it for $100

So: why does the endocrinologist, who does this all day, every day, submit for the wrong coverage, or not submit for all coverages?

The short answer is that they don’t know. I’m working on a project right now that looks at the cost differentials of infusion instead of oral treatment pathways and there are some significant cost variances. But docs in most systems don’t know. More importantly, most of the docs have historically been told that their job is to get the patient better and not to worry about how the payment stream is categorized. This is a symptom of an underlying problem.

I don’t think there is anything nefarious going on; they will get paid $1,700 from either stream, it just matters if they are getting a big check from you or a small check from you plus a big fund transfer from the insurance company. If anything, they should prefer billing the pharmacy benefit as it gets them their money faster and more reliably in most cases.

Insurance benefit design is a mess. I spent a significant chunk of my working life in insurance and I get confused as to why a certain code is cross-walked into a certain benefit category. There are good operational reasons as to why this is the case but it creates massive complexity with only one insurance company much less the dozen or more insurers a typical practice could be dealing with.

That is what I have for this week… so tell us about your problems with insurance in comments and we’ll try to solve at least a few for next week.



Bring out your problems

Good morning.

We have big challenges but we’re not going to focus on those in this post. Instead we’re going to focus on smaller, more solvable challenges in this series of posts.

Do you need to know if your deductible applies to a preventative visit?

Are you getting a ton of mail about Medicare Advantage plans?

What does redetermination mean for Medicaid?

Or any of the 1,001 other confusing things about health insurance that we have to deal with every day no matter what happens in Washington.

Let’s be a helping community for each other. Put your questions and situations in comments. We’ll try to solve them and I’ll recap a few at the end of the week.



Keep up the pressure

Local media is covering the impact of the Senate Bill. Here in North Carolina is an extraordinarily detailed and humane look at the care that medically frail kids needs. It is a lot.

Among those who could be deprived of medical services are nearly 2,400 “medically fragile” children in North Carolina whose ventilators, oxygen tanks, feeding tubes, catheters and round-the-clock nurses are covered by a little-known Medicaid program available to middle-class families with private health insurance.

The program pays for services that private insurance doesn’t cover, allowing parents to work and the children to attend school….
Caring for one seriously ill child in the program costs an average of $80,000 a year in North Carolina, compared with $4,700 for a typical Medicaid beneficiary in the state. That could make the program an easy target for cost reductions, parents fear, because the amount of money required to treat one “medically fragile” child can be used to provide health care for 17 kids on Medicaid.

“Our kids aren’t cheap,” said Jenny Hobbs, a Pfafftown mom near Winston-Salem who works as an HR manager. Three of her four children are “medically fragile.”

Madison, 7, Meredith, 12, and Michael, 14, all have mitochondrial disease, a progressive disorder that can cause muscle weakness and pain, seizures, vision loss and hearing loss, learning disabilities and organ failure, among other complications. The condition has no cure. Last year, Madison was also diagnosed with melanoma. All three use feeding tubes for medications and supplemental feedings. Meredith and Michael need ventilators to help them breathe, while Madison requires an oxygen tank. All three have their own designated private duty nurse who accompanies them to school and cares for them overnight.

A block grant program creates a very strong incentive for states to minimize the amount of money that they spend on the highest cost cases. That means providing minimal or inadequate care to the kids who need the most help.

The local press is doing a good job of highlighting locally relevant stories.

Use these stories when you call your Senator this week.



What’s next

First thing, tonight, enjoy it.

If you like to partake in a recreational, legal intoxicant, enjoy one in moderation.

And then tomorrow get back on the phone and get back to pressuring the Senate.

The current Republican plan is to see what Senate Majority Leader can do to make the bill worse while giving non-Tea Party Republican hold-outs visible media wins with carve out cash and plus-ups for visible priorities. The plan is for him to release $20 billion dollars to opioid treatment so Senators Moore and Portman can claim a victory. He’ll authorize a plus-up for Medicaid reimbursement for Alaska and Montana and Idaho for $5 billion dollars. It will be the saddest show of an old man making it rain to buy attention for himself.

And then they’ll try to jam the bill through once they get back from the 4th of July recess.

So keep on calling tomorrow.



Call the Senate

Continue to call the Senate:

The ask is simple — no bill that leads to coverage losses.