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ObamaCare Clusterfuck: Covered California's narrow networks threaten to inflict first casualty

Paradise Post:

THURSDAY UPDATE: Medical care refused to terminally ill resident
A 28-year-old Paradise resident is fighting for her life after Stanford Medical Center has not come to a financial agreement with California Health and Wellness's insurance to see her for her disease of Achalasia.

When Tiffany St. Cyr was diagnosed with Achalasia in June of this year, she weighed 143 pounds. Since then, she hasn't been able to eat a solid meal since August and currently weighs 105 pounds.

"Achalasia is a rare disorder that makes it difficult for food and liquid to pass into your stomach," according to the Mayo Clinic website.

To treat such a rare disease, St. Cyr's local GI doctor, Dr. Hack, recommended she go to the specialist at Stanford Medical Center to undergo surgery.

"There (are) no doctors up here that can help me since it is such a rare condition, I have to see a specialist," she said.

Prior to being switched over to California Health and Wellness, she was covered by MediCal. If she still had MediCal, she said that she would have been able to receive treatment at Stanford and she wouldn't have to deal with these problems.

"Stanford told me that if I would have still had MediCal, I would have been down there three weeks ago," she said.

Because of laws that were passed people who were covered by no share cost MediCal were required to have a health care plan. The two options that were offered were Anthem Blue Cross or California Health and Wellness Plan. The choice had to be made by Nov. 1. She chose California Health and Wellness.

She had a consultation scheduled for this Thursday at 2 p.m., but recently discovered if she continues through with the appointment she will have to pay for it herself, because California Health and Wellness could not come to an agreement with Stanford on the payment. The consultation costs $800 for a 15 minute appointment, St. Cyr said.

"I had a feeling that something wasn't right because Stanford never called to confirm," she said, adding that she decided to call Stanford and confirm. "They said, 'No we don't, we couldn't come to a financial agreement. Unless you want to pay the $800, then you do not have an appointment.'"

A representative from California Health and Wellness, Deanne Lane, could not confirm or deny whether the two sides could come to a financial agreement. The only comment she could say was that the "member's consultation is still scheduled."

St. Cyr said that she has not canceled the appointment yet, but will not be able to go because she is not financially able to pay.

It took four weeks to make the appointment for St. Cyr at Stanford, and in that time she lost about 10 pounds.

Now California Health and Wellness is working on making her an appointment at UC Davis Medical Center, St. Cyr said. She later informed The Post that a consultation has been scheduled with UC Davis on Friday at 11 a.m.

"I personally called every hospital from Redding Mercy Medical Center to San Francisco, and nobody at this time is currently dealing with California Health and Wellness," she said.

Now, you can say that St. Cyr should have been a smarter shopper. But what kind of barbaric system forces a critically ill citizen to be a smart shopper -- by taking away an insurance plan that was already working for them?

UPDATE A followup story explains the law and the rules, and yes, ObamaCare was the driving force.

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Submitted by Dromaius on

To be fair, I'm pretty sure this travesty is happening outside of Obamacare. However, it's similar to the travesty that people who are purchasing narrow network Exchange plans will experience.

But yes, "death by spreadsheet" is alive, well, and thriving in good "liberal" states and has been nurtured under Obamacare, while insurance companies have now been given in, aren't we nice? We take the premium dollars from people with pre-existing conditions...we just don't treat them. And oopsie, it's because their docs are out of network, sorry.

As a side point, I'm hard pressed to believe that any doctor is worth $800 for 15 minutes. Do they really have that much to add that can't be found via having a decent and reasonably priced doctor read research literature? I don't know.

Alexa's picture
Submitted by Alexa on

forcing us to remain in a "domicile" which we're normally not residing in for more than a couple months (if that long).

Both instances, however, occurred AFTER the ink was dry on the ACA. In the first instance, literally had to delay care until April of 2012, because of provider hospital that our internist is out of, still had not reached agreement. I was told this by our Group Health Insurance Plan Administrator. Luckily, although very serious, no one's life was hanging in the balance.

Regarding "Medicare"--don't claim to be an expert (for sure), but have read enough of the ACA to know that some of these more expansive networks may soon be a thing of the past.

There are ongoing pilot programs experimenting with various "managed care" models.

Also, "capitated care." Which may eventually create a managed care type of system, instead of a fee-for-service system.

Don't like the sound of the following:

Definition of CAPITATED [from Merriam-Webster]:

Of, relating to, participating in, or being a health-care system in which a medical provider is given a set fee per patient (as by an HMO) regardless of treatment required.

From some of my reading, I suspect that we won't recognize Medicare in a few years.

And Medigap has been offered up by Dems on the sacrificial chopping block (and I believe will be accepted by Repubs before this Presidential term is up)--which will result in more out-of-pocket costs for many seniors (who carry Medigap insurance).

One of the most harmful Medigap proposals is that offered by Alan Simpson and Erskine Bowles, co-chairs of the National Commission on Fiscal Responsibility and Reform.

Under this plan, one in five beneficiaries would experience significant cost increases, with the average increase amounting to $806 per year.

A proposal offered by the Obama Administration would add a Part B premium surcharge equivalent to 15% of the average Medigap plan premium for those who choose Medigap plans with low cost-sharing requirements
Like the Bowles-Simpson idea, this plan saves dollars merely by forcing beneficiaries to pay more.

Even with the present Medicare program (non-managed care), Fidelity says couple need a quarter million dollars (rounded up a bit) for "medical expenses in retirement" (in the US).

With any luck at all, we hope to be able to circumvent going on the rolls of the ACA or Medicare, by relocating to SA. It really is not an exaggeration to say that (in some instances) medical procedures and surgeries are a fraction of the cost, compared to the US. And many of the medical centers and US-trained physicians are top-notch.

[The surgery we need is one-quarter to one-fifth the cost in several SA countries.]

Alexa's picture
Submitted by Alexa on

distinguishing features--or maybe not.

Yeah, pretty much, I think they've just renamed the much hated "HMO" (in some quarters, anyway) from the 1990's.

Just goggled--ACO's usually have a slightly different payment system--"bundled payments," maybe?

If we are approved for a surgery out-of -the-country--we've asked the insurer to consider Singapore, Ecuador and Uruguay--I hope to either live blog it, or keep a diary and post a several-part post, after the fact.

(Unless the entire procedure and experience is extremely boring, LOL! And that's a possibility, I suppose. If they don't make a decision by the first half of next year, we'll just wait until we relocate. As high as the dual two-track deductibles have gotten now--it won't even matter, much longer.)

Submitted by hipparchia on

kip sullivan is one of my favorite health policy wonks, and the person who is most responsible for my learning about the idiocy of the dartmouth atlas "researchers" (the people who "invented" the aco).

here is some of his writing on ACOs:

he's done some other great writing too:

Submitted by lambert on

I've gotten sucked into the Kaiser world. I should be in the PNHP world.

The Dartmouth stuff is not alive yet in the press, i.e. not deployed, I'm convinced, because the powers that be aren't ready to pull the trigger on it.

I need to understand the entire system better instead of playing whack-a-mole, but it seems to me that if the hospitals run all care, doctors are serfs, and everything including the patient is coded, then treatment plans are pretty much a straight algorithmic readout of driven by profit, with the Dartmouth study providing the ideological justification for a race to the bottom on costs (and by ideological justification I don't mean anything like the truth).

Basically, think of, oh, the life cycle of a typical (hah) farm animal.

Submitted by hipparchia on

then treatment plans are pretty much a straight algorithmic readout of driven by profit

you have nooooo idea...

in no particular order:

notes: 1. jack wennberg founded the dartmouth atlas. 2. david wennberg is his son.

Alexa's picture
Submitted by Alexa on

if consumers (yes--hate the term, too) or patients refused to incur such exorbitant fees.

And that is whether or not a patient is participating in a public health care plan (tax-payer supported plan), an employer-sponsored group health plan, in a Marketplace Plan, or in a plan purchased in the private, individual market.

I, too, am doubtful that a one-quarter hour talk (consultation), not even a service like surgery or anesthesia, could be worth $800!

beowulf's picture
Submitted by beowulf on

The narrow network problem is one of the many side effects of the failure to enact a single payer system. To note the counterfactual, over 90% of US doctors and virtually every hospital accept Medicare assignment, making Medicare the broadest (fattest?) provider network in the country.

Alexa's picture
Submitted by Alexa on

not redistribution" tends to make be totally skeptical that the PtB of any of the two legacy parties will sign on to MFA.

I'm "guessing" that this is the underlying reason that we couldn't get MFA, even with Dems in charge.

Considering the Medicare cuts that are already in place, and being further looked, it appears that greater and greater costs are being passed on to the Medicare beneficiary.

And Democrats seem to be taking the same tack that Mr A's group plan has--after several years of huge premium increases (double-digit), the plan switched to jacking up every out-of-pocket expenses, with smaller premiums increases--maybe 7-8-10%.

In the end, though, by far the most prohibitive measures they've taken ARE the OOP costs. They are almost endless--particularly if one MUST GO out-of-network for care.

Capitated (managed care) is "frightening" to us.

What incentive would a provider have to give you care, if they receive a set amount annually--whether or not they furnish any care?

I had "balance billing" imposed on my (and didn't even realize it, at the time) with one of my broken bones. Yes, our group insurance provider agreed to 80% instead of 60% for our only orthopedic surgeon group--which would not take our insurance from a major insurance carrier, because they did not like the reimbursement rate--but, of course, since the orthopedic group had not signed a contract with them as at in-network costs--we were billed the difference.

And as Dromaius often drives home--the ACA has not changed this practice, in many instances.

It seems to me that anyone who stays under the American medical system, will be "scr**wed," if you'll pardon my French. ;-)

Submitted by hipparchia on

so they went to texas, which has a shortage of doctors, basically (#41 out of the 50 states in 2007 in doctors per 100,000 residents), and then used the results of a survey that had only a 4% response rate (and self-selected, at that) to "represent" texas physicians as a whole.

here's a copy of the results of that survey - medicare patients are luckier than a lot of others according to this table (from page 2):

File attachments: 

beowulf's picture
Submitted by beowulf on

Excuse me, if you think that was a misleading statement you should take it up with CMS.

"More than nine in 10 (91%) -based physicians report that they accept new Medicare patients, as do almost all (98%) surgical specialists. And as of September 2013, less than 1% of all physicians in clinical practice have “opted out” of Medicare entirely, according to new, unpublished data from the Center for Medicare and Medicaid Services."

Submitted by Dromaius on

The same CMS that told us Obamacare would be up and running on October 1 is an organization that lies.

CMS has an agenda. They want Medicare reimbursements to be cut. That is why they come out with these generalities that don't bear out when people go out and try to find adoctor.

What I know is of the articles I've read for YEARS about people having serious trouble finding doctors who accept Medicare. I also have personal experience with the same.

Submitted by Dromaius on

If we believed what the government tells us all the time, we'd still be thinking that the problems with were about healthy demand for "care".

We'd think Katrina was no big deal and Brownie did a heckuva job.

We'd speculate that the NSA was spying on us, but we wouldn't know for sure.

And maybe we'd believe that the rate of doctors taking Medicare patients is increasing.

Our government is not a trustworthy source of information. The only true information we have comes from little stories, anecdotes, opposition research. These are sucky sources, but in reality, they are ultimately where the truth comes from.

Anyway, just expanding with examples of how our government deliberately lies, and the only way to get the truth is through other media sources.

Submitted by hipparchia on

CMS has an agenda. They want Medicare reimbursements to be cut.

yes. and you might want to take that up with your congresscritter and senators. they're the ones who pass the laws that tell medicare what to do.

Medicare Payment Advisory Commission (MedPAC)

The Comptroller General of the United States is responsible for appointing individuals to serve as members of the Medicare Payment Advisory Commission (MedPAC). MedPAC is an an agency of Congress whose mandate is to analyze access to care, quality of care, and other issues affecting Medicare and to advise Congress on payments to health plans participating in the Medicare Advantage program and providers in Medicare’s traditional fee-for-service program. MedPAC was established by the Balanced Budget Act of 1997 1997 (42 U.S.C. 1395b-6 (2008)).

Submitted by hipparchia on

The problem was actually created by Congress itself, back in 1997, through a flawed formula called the Sustainable Growth Rate, or SGR. And every year since 2002, when the formula first began calling for cuts, the SGR has created political and fiscal fits for lawmakers.

"The SGR has threatened to make draconian cuts to physician payments — cuts that could cause seniors to lose access to their doctors," said Senate Finance Committee Chairman Max Baucus, D-Mont. "And every year, Congress has had to spend more time and money to pass temporary fixes."

the article doesn't go into much detail, but the fix sounds awful:

The current patch cancels a scheduled 24 percent cut in doctor pay — at a cost of around $7 billion. And that's just for three months. But that's because this Congress that's now famous for doing almost nothing is poised to do something significant. It appears ready to repeal the flawed payment formula and replace it with a whole new system — one that pays doctors according to the quality of results they produce rather than the quantity of services they provide.

so now, after a decade of trying to pay doctors less money to give you more care, congress wants to pay doctors more money to give you less care. that should fix the problem.

Submitted by lambert on

CMS spokespeople seem to me to suffer from cognitive regulatory capture in a big way; they speak of insurance companies partners, for example.

It would sure be nice to have corroboration from another source. From anecdotes in the great state of Maine, it's not so easy up here -- aging population and aging doctors.

It would be nice to have a Medicare doctors by county map. Plenty of finders by zip but oddly, or not, no way I can find to get an over view.

Submitted by hipparchia on

here's where you can find the downloadable physician database (and the data dictionary)

on cursory inspection it looks to me like you could map them by either city and state or by zip cde, but i didn't see county names in there (i didn't look very hard though). also note that physicians with multiple offices are listed multiple times.

knock yourself out.

Submitted by lambert on

... doping out the data and building the map. Hard to believe nobody else has thought of using this , too -- though maybe everybody has the use case of typing in the zip and nobody has the use case of a map with everything on it.

Submitted by lambert on

There's no concept that a consumer, as opposed to a citizen, would want to do anything but look out for themselves. Hence, type a zip in the box, query the database, instead of making a map that put all the data out there by zip.

It might need a separate database, but I find it hard to believe my server couldn't handle it.

The real issue is data transformation and representation. Drupal wants each dot on a map to be represented by a node; that also allows filtering. That's difficult to do in bulk because (a) the Drupal tools for doing that suck and (b) that could be a ton of nodes. We have ~40K nodes as it is, and I'm not sure I want to double that in a stroke, especially since I'd be automagically importing them. It might make more sense to have a separate site. But all in all, three days or do so of work.

The alternative to doing what Drupal wants is to write a one-off and that's a terrible use of my time and not my skill.

Submitted by hipparchia on

if you choose an individual state, instead of national, in the dropdown menu, you can see county-level numbers for various types of healthcare professionals

The alternative to doing what Drupal wants is to write a one-off

or, if you're not averse to using google earth / google maps, here's a kml file of all the zip codes

and how one guy used that file to make a cost of living map

maybe you could adapt his code?

The real issue is data transformation and representation.

yep! there's an entire huge industry devoted to this. ;)