Killing for Profit

This is going to be an adventure, so buckle up.

2018 will go down in Amburn family lore as the Year of the Deductible. I know that doesn’t sound very exciting, and it was not meant to be. The fact is that we satisfied three different yearly deductibles as a result of the mind-bogglingly stupid employer-based medical insurance that this country employs.

Yes, I know there are other options for acquiring health insurance, particularly since the ACA took effect. But, for affordable and comprehensive(ish) health coverage, most Americans look to their employers for the plans that will cover their families.

WTF 2018?

We began the year on a High Deductible Health Plan (HDHP) offered by my wife Lauren’s company. I was still working my own business and some side jobs while looking for some more long-term work. In April, I began working for the City of Madison. Not my dream job, to be sure, but a good bridge job with the great benefits that come with a government union job. I mean, seriously good benefits, with amazing health coverage. Zero premium, very low deductible, and 100% covered after deductible.

The new health plan did not go into effect until June 1, so naturally 1 month before that we had an emergency room episode which took care of that outgoing high deductible. Bad timing, to be sure, but not a terrible thing to happen. We would be rolling forward with some great coverage from there on out. Or at least the rest of the year.

A New Opportunity

In late June, I received a job offer from a company that I had been pursuing for several months. I was so excited about it and knew that I was going to take it, even though it meant losing the great health coverage I enjoyed at the city.

My city-sponsored health coverage was good through the end of July, so we had a decision to make. Do we go back to the health coverage from Lauren’s company? Or start up with my new company’s coverage, which we could start, effective August 1?

The first order of business was to call up Lauren’s company’s healthcare coordinator and ask if the deductible that we satisfied earlier in the year would carry over to the plan if we signed up again. Want to guess what they said? Anyone? Anyone? If you said that the deductible would not remain satisfied, you win! And, you are probably an astute observer of the power that corporations wield in this country.

For-Profit Health Care

Let’s take a moment to unravel this. The point of a deductible is to annually force a client to meet a certain threshold before they will start paying for the care. By all measures, we had met the criteria. This is the same health plan, same people covered, and same year. Yes, there were three months where we did not pay the premium for this plan, but we were also not covered by it and would not have been able to submit any claims during that period.

So, why do they return the deductible to zero in this case? For the same reason that the cable company might charge a re-activation fee if you drop their service for a few months. Or the reason that a concert venue might charge you for re-entry if you have to leave. Because they can and it helps their bottom line: profit. There may be a deterrence factor for those other examples, too. But what is the need for deterrence in the health care example? Are people jumping back and forth from health care plan to health care plan? Only when outside issues force it, like a job change.

This brings me to my main gripe. Profit motivation is driving health care decisions. These decisions are life and death situations, unlike the cable company and concert venue examples. This has been talked and written about for decades, but it still has not sunk in for many Americans how bizarre this is. This will rear its ugly head later in our story.

Our Health Scare Nightmare

Back to our 2018 adventure: After careful consideration of the plans, we decided to get back on Lauren’s plan. It made the most sense financially. Her plan started back up on August 1, and in true 2018 fashion, we were back at urgent care a few days later. This time, we were dealing with a very scary situation when Lauren found blood in her urine. A couple days later, she went in for the first of what would turn into FOUR ultrasounds. The brand spanking new deductible would be met very quickly. Oh, and the same day that her ultrasound results came back showing that they found something concerning and would need to do more testing, Lauren found out that she had lost her job.

So, here we were. Scared to death about Lauren’s health. And on top of that we had to worry about how our health insurance was going to cover the care she was going to need. Again, we weighed our options. Lauren’s insurance would cover us through the end of August.

That’s when things got really complicated.

Do You Want the Bad Choice or the Worse Choice?

Lauren was going to have surgery. Of this we were pretty confident. And we were not going to be able to get it done before the end of August. Our first obvious option was to buy COBRA coverage and continue with her existing coverage, but as anyone who has ever bought it knows, it’s really expensive. (So convenient when you just LOST a means of income.) Or we could move to my insurance at the beginning of September. That would make sense financially, but it would also mean starting over with a brand new deductible.

Complicating matters was my company’s plan year. Instead of the normal November open enrollment period with plans starting January 1, we had open enrollment in September with the plan taking effect October 1. This meant that if we did not choose to go immediately to my plan, we would have to decide in September to join it starting in October. If we decided not to join at that time, we would not have another opportunity until October of 2020.

We decided that my son and I would sign up for the plan through my company and Lauren would get COBRA for the month of September. Then the difficult decision came up about whether she should join us on my plan during open enrollment. If we chose to continue COBRA for her, she would not be able to join my plan until the following October. So what does that mean? Paying almost $700 a month for her coverage for more than a year. Even though we were not able to schedule her surgery during September, we decided to move to my company’s plan, knowing full well that we would be satisfying yet another deductible during 2018 when she did have her surgery.

Surgery Options

Lauren had a growth on her kidney. We did not and could not know whether it was malignant. Her doctor told her she would need surgery and they will remove the kidney with the growth. You can live with one kidney, they say! Yes, of course. Who needs two kidneys? Just wait, folks. Well, Lauren was not satisfied with this, so she sought a second opinion. She was referred to a doctor who performs a robotic surgery that can analyze the growth in the middle of the surgery to determine whether the growth is dangerous or not. Then, while the patient is still under, they can decide whether they need to remove the growth or even the whole kidney.

As this seemed like a better option, Lauren decided to go forward with the robotic surgery. We scheduled it for November 9 and prepared ourselves for the possibility that she was having a cancerous tumor addressed in her surgery. The surgery was extremely successful and went even better than expected. The surgeon was able to determine that the growths were benign and posed no risk to her kidney. They cleaned up what they could and that was that.

As it turns out, the condition was an extremely rare one, with only 200 recorded cases in history. But no threat remained.

Intentional Incompetence?

Following the surgery, Anthem started messing around with our claims. First, they somehow had Lauren’s birthday wrong in their system, so they immediately rejected the first claims from the surgery. It took an incomprehensibly long time to fix this error, with our representative needing to call Anthem over and over to get it rectified. Then, once they finally fixed that issue, Anthem decided to reject the large claims because Lauren had other insurance, something that was not only untrue but we had already explained it to them quite clearly. They continued this charade for the next three months. All this time, they approved claims left and right for Lauren, but not these large claims. Sound fishy to you? Yeah, me too.

Anthem is a publicly traded for-profit managed health care company. Its primary responsibility is to make money for its shareholders. So, when they finally accepted that Lauren did not have other insurance, they moved on to another tactic. Last week, we found out that they had rejected our claim because they determined that Lauren’s surgery was not medically necessary. Yes, you read that right. Anthem would only cover this surgery if the patient had only one kidney or was not medically fit enough for the kidney-removal surgery.

Yes, they are not going to cover any of her successful surgery, in which she was able to keep both kidneys, because she did not choose to just have her kidney removed. Anthem now refuses to cover a $26,000 bill from the surgery. They did cover the anesthesia for the surgery that they rejected. They covered other expenses, just not the surgery itself.

Grievance

We will be filing a grievance against Anthem, and any help that anyone can provide as far as advice or suggestions is welcomed and appreciated.

We need to get the profit motive out of health care. There is no reason that companies trying to please their shareholders should make these coverage decisions, without regard to actually serving people who need help. Furthermore, the complicated nature of these plans and claims make it incredibly stressful on people, many of whom are already stressed out about their health situation. It’s insanity to expect them to be aware enough to make an informed decision.