A Deadly Conundrum

Here's the (gruesome) headline:

"California dad charged with insurance fraud after he drove off cliff, killing autistic sons"

Now, we've discussed before the fact that one may not profit from a crime:

"In this story ... we learn about Joaquin Shadow Rams, who seems to have a habit of buying, and then collecting on, life insurance policies for his intended victims, including (allegedly) his mother and his girlfriend."

And of course there have been others. In all of the related posts I can find, though, all save one have been about straightforward and underwritten (term, whole or universal life) plans. But this one's different, and I'd like to talk about that difference.

"Regular" (aka "ordinary") life plans like term and whole life are generally underwritten (although there are guaranteed issue versions which impose waiting periods). But "accidental death" plans pay out only if the death is due to an non-purposeful injury (well, almost always). And the key to these plans is that they are generally not underwritten.

[ed: As an aside, one wonders if there was a cultural motive involved here in addition to the financial one]

In the case at hand, the facts seem pretty straightforward as to what happened. What's interesting to me is why the father chose an Accident Only plan instead of a term or even "Jumping Juvenile" one. And it seems to me that the answer is fairly obvious: the lack of underwriting makes it an easier "buy," and the fact that it's Accident only makes it a lot cheaper.

It's also worth noting this little tidbit:

"[T]wo years and 12 days earlier, Elmezayen bought the last of his insurance policies, which were purchased to cover his family in the event any of them accidentally died."

One presumes that this was to avoid triggering the "Contestability Clause," but I'm not seeing where that would apply to an Accident Only plan. After all, that clause is to protect the carrier from misstatements of health, age or sex; I'm not aware of any app that asks "Are you planning to murder your spouse/children any time soon?"

This is obviously a very sad case, but also a very strange one.

Cost transparency: I'll drink to that!

Shot:

"Health care is a service like any other. We ought to expect price transparency for medical goods and services to make informed choices that maximize value."

I, too, have been chasing this wild goose for many, many years. And I still believe that it's a noble goal.

But as long as government and insurance - in other words, 3rd party payers - are in the mix, it's not a viable one.

Chaser:

Are you a Dr. who agrees with this article? Please help us show patients/media/govt that this article is true. Post your cash fees on https://t.co/KruMnPRA4H. Help be the proof-source that affordable medical care is abundant and not limited to a few DPCs and @SurgeryCenterOK

— Alisa LeSueur (@Alisa_LeSueur) November 12, 2018

And why would any physician agree to this? And perhaps more critically, how would they?

Which brings me back to my first point (above): so long as the government (through Medicare and Medicaid reimbursement levels) and insurance (trough multiple provider contracts) distort the price (that is, that which the consumer/patient/insured pays), then there's no practical way for this to occur.

Which of course brings to mind Direct Care (whether Primary or other): when one pays the piper oneself, then it's reasonable (and viable) to pre-determine the cost of various services beforehand [ed: up to a point - what if the knee surgery uncovers something more serious?]. Of course, there's still an affordability challenge (and, often, an accessibility one), which means we still have a long way go.

Which is still another reason I'd love to see true cat plans re-legalized.

Tuesday Potpourri

■ So this past August we posted on the most recent "shiny new thing," Association Health Plans, which allows otherwise disparate groups of folks (employers and individuals) to band together to create larger insurance "pools." Our friends at HAFA (Health Agents for America), tip us that some carriers are beginning to roll out actual plans:

"Land O'Lakes, several Nevada chambers of commerce, and the National Restaurant Association have formed association plans this year ... the Land O'Lakes association plan “will offer another really good choice for individuals who either don't receive a subsidy and cannot afford coverage on the exchange or for some reason prefer not to purchase that coverage.”

Interesting. And we're seeing a lot of activity lately in the group self-funded space. So perhaps the market itself is killing ObamaCare with 1,000 cuts?

We'll see.

■ Thanks to FoIB Dabz, we're treated to this very interesting piece on creative (and viable) ways to deal with the (over-hyped) pre-existing conditions issue. For example:

"... the option of buying coverage at some point in the future—insurance against developing a health condition that makes one uninsurable."

This is not new; a decade ago we noted that (now-defunct) American Community Mutual rolled out "Community Flex," it starts out as an accident policy (major claims are only paid for injury, not illness), with some coverage for doc visits, preventive care, and a drug discount card ...  if you want more coverage, such is available through a "Gold Plan" buy-up."

And of course, "Dave's Plan" takes a similar approach:

"The capper, though, is that the plan has a rider that allows the insured, at their discretion (and with with no additional underwriting) to convert it to a major medical plan."

Which is to say, Chris Jacobs at The Federalist is spot on.

■ As we've long noted (most recently here), The VA is a hot mess. And if you still harbor any doubts, well:

Veterans Day: By the time I saw my VA doctor, he said it was too late...#veterans#healthcare#lessismorehttps://t.co/0BgNyaj8AP pic.twitter.com/dCi4bEsTvd

— Dutch Rojas (@DutchRojas) November 13, 2018

Wonderful Veteran's Day.

Dutch Doc in Dutch

We've written before about Holland's fascination with euthanasia:

"The number of Dutch people killed by medical euthanasia has more than doubled in the 10 years since legislation was changed to permit it, rising 13 per cent last year to 4,188."

And that was a little over 5 years ago. In the meantime, seems that the situation has deteriorated even further:

GOOD. This case was utterly disgusting. "Hold down the old lady while I shoot her up with death drugs."

Dutch doctor faces first euthanasia prosecution https://t.co/PHuwQXPyLg via @YahooNews

— I'm a woman, and I'm mad as Hell (@nowhere_nh) November 9, 2018

Thing is, it's not really clear to me why this doc has been singled out: it's not as if the underlying culture of enforced expiration is new, or somehow a secret.

Perhaps it's because, according to the linked article, this particular case was "assisted suicide" in much the same way as The Soprano family offered free swimming lessons. So the *true* message is ... a more subtle, refined ... approach.

It will be interesting to see how the case is ultimately resolved. Perhaps it, too, will (not so quietly) "go away."

Stupid, Self-Defeating Carrier Tricks

So, have a (long-time) client that needs a short term medical plan. Decided on one from United Healthcare (don't judge). After choosing deductible and co-insurance options, we started the "Broker Assisted Application" process (which basically means that I fill in his name and date of birth, etc, and checking account info). Once that's done, I press a button that sends him a link, he completes that link with his last name and date of birth, then hits continue to send it back to me for finalization.

Well, that's the way it's supposed to work, anyway.

What happened this morning - repeatedly - was that he would get the link, enter the info, press the magic button, and be told:

"Application not found."

Really, then how the $@()*^ did you know to send him the link in the first place, dummies?

After repeating this another time, with different browsers and same results, I called the ever-helpful people at Home Office. They advised me that he needs to complete this process from Google Chrome. I responded, well then, maybe we'll just use the "via text" option, and was assured that this process will not work for the application portion.

Then why offer it, you dolts??

This person wants to give you money and you're making it difficult for him to to do so?

Wow, just wow.

From the P&C Files: Ooops!

Rx and Profits: A Contrary Perspective

There's no question that the cost of prescription medication is a significant driver of health insurance costs. And there's decent enough evidence that "Big Pharma" plays by ... ummm ... perhaps different rules than most industries, racking up fairly decent profits (NTTAWWT). And we hear from the "health care press" on a daily basis how bad this is for consumers and patients.

But maybe there's a good reason for this: after all, in a (nominally) free enterprise system, greater risk should justify greater return.

Okay, Henry, what the heck are you babbling on about?

Well, this:

"the United States generates more new medicines annually than the rest of the world combined. Specifically, it produces 57 percent of all new drugs each year. Switzerland is second with 13 percent;" https://t.co/QLE2W9hBeo

— Bob Tufts (@TuftsB) November 6, 2018

Keep in mind that it may cost millions of dollars and decades of research to come up with even one new med, which then has to undergo the (presumably) stringent FDA approval process. And, of course, some non-trivial number of these new efforts fail to pay off.

Maybe there's some room for debate here, after all.

Mixing religion and health

I'm not really sure that I find what I'm about to share credible, but it is intriguing, and who knows, maybe there's something to it. In any event, it's something very different.

 Let's start with the Jewish practice of "laying t'fillin:"

The practice comes to us from several sources. The Torah (Jewish Bible) tells us in Deuteronomy and in Exodus to "bind them as a sign upon your hand, and they shall be for frontlets between your eyes." Observant Jews (and Jewish tradition) has interpreted that to mean wrapping one's left arm (near the heart) and one's head with special leather straps (at proscribed times and using a specific ritual and prayers).

But  what the heck does this have to do with insurance or health care, Henry?

Well, FoIB Holly R sent us this rather interesting article connecting them:

"A pilot study led by researchers at the University of Cincinnati (UC) College of Medicine suggests Jewish men who practice wearing tefillin ... may receive cardiovascular health benefits."

To be fair, this is a very limited study, including but a score of Jewish men, some of whom regularly engage in this practice, and some who do not (control group).  And of course, correlation ≠ causation, but still, intriguing findings:

"We found people who wear tefillin in either the short or long term, recorded a measureable positive effect on their blood flow. That has been associated with better outcomes in heart disease."

Hunh.

Tuesday Linkfest

■ For once, the term "shoddy insurance" doesn't apply to an ObamaPlan. Our friend Jeff M tips us to this item:

"Federal authorities have shut down a network of Florida companies that they say used aggressive, deceptive tactics to sell skimpy health insurance products that skirt requirements of the Affordable Care Act and left tens of thousands of people around the country with unpaid medical bills."

And no, these aren't Short Term Medical plans (or at least, not legit ones). First, these rocket surgeons (allegedly) used the logos of actual carriers to lure folks in, then sold them mini-med and discount plans as if they were "comprehensive" CA-sompliant policies.

And, of course, the numbskull "reporter" calls them "short term health insurance plans like those promoted by President Trump as an alternative to the Affordable Care Act."

Y'know, Bob, a simple call to a real agent could've helped you avoid embarrassing yourself.

(Aww, who am I kidding - these "journos" have no shame)

■ We're generally pro-DPC (Direct Primary care), although we've been known to call out some of its more ... enthusiastic ... proponents. Mark Aubry (of Impact Capitalists) alerts us to "The 8 Problems with Direct Care Medicine:"

"[W]e’ve been involved in the direct care “movement” for about 6 years now.  Sometimes we’ve stood on the periphery at events and conferences and sometimes we’ve run direct care clinics ... there is a real difference between hiding prices and using prices as a competitive advantage."

There's more and, while it's not exactly devastating, it does point out some areas of legitimate concern.

■ We've long written about the Much Vaunted National Health Service©'s war on children. Here, for example:

"[I]n this case it's actually cost the MVNHS© more money to fight his being flown elsewhere for treatment at his parents' expense."

And so one might be justified in thinking they'd hit rock bottom.

Justified, but wrong:

Children's operations cancelled by NHS up 58 per cent since austerity began, new figures show @Independent https://t.co/IGOtjbF7zh pic.twitter.com/aliOiyUhfo

— Sally Pipes (@sallypipes) October 29, 2018

But hey, free!

CanuckCare© Gone Private

Regular readers know that Canada's "free" health care system has, well, issues. Some years ago, we noted:

"A group in British Columbia has offered medical waiting-list insurance to members whose government treatment is on hold."

And, of course, it's well-documented that this is a problem for a lot of our Neighbors to the North:

"My father’s first oncologist appointment was scheduled for after he died."

Well, better late than ... Oh.

A half dozen years ago, Bob posted on the Surgery Center of Oklahoma, which "operates on a cash only basis. They do not accept health insurance, Medicare or Medicaid funds."

Turns out, our Neighbors to the North also have their own version:

"Check out Timely Medical Alternatives in Canada, which specializes in helping Canadians find affordable care (for cash payment) instead of waiting in the queue."

And indeed, when one visits the (aptly named) "Timely Medical Alternatives" site, one is greeted with an informative banner that touts their 14 years of experience, 20 facilities in Canada and the US, and (like their Sooner State colleagues) significant discounts. Best of all, they touch on two IB "hot buttons:" speed and transparency.

Speed:

"Recent evidence suggests that Canadians who require surgeries wait on average for approximately 20 weeks to receive the treatment they deserve, more than twice as long as national averages from when data first was collected a little more than 20 years ago"

But hey, free, right?

And transparency: one has only to select from the menu of services provided, and with a click of the mouse receive a free, no obligation quote.

Nice.

[Hat Tip: Twila  Brase]

On Open Enrollment v6.0: Perspective

So as Open Enrollment '19 kicked off yesterday, lots of folks checking out the new plans and (of course) higher rates. Our friend Rich Weinstein offers this helpful factoid that may give us a hint of things to come this time 'round:

Has anyone noticed there's only abt 10m enrolled in exchanges & the (2013) baseline estimate is about triple that?

I know 8m were to be screwed out of ESI & sent to HIX via Cadillac Tax. But that still leaves an additional 10m shortfall.

Obamacare's an epic failure. pic.twitter.com/2Y7NcUllJl

— Rich Weinstein (@phillyrich1) October 31, 2018

More on CMS (Moron CMS?)

In case you were under any illusion that The DC Rocket Surgeons© have gained a single clue lo these past 6 years, well let's just disabuse ourselves of that notion.

Readers may recall that I did my annual Marketplace re-certification a few weeks ago, at which time I received a certificate (suitable for framing!) so attesting. You may imagine my surprise - my dismay - to then receive this in email this morning:

"Our records show you have not completed Marketplace registration and training for plan year 2019. To avoid losing your Marketplace access for Open Enrollment beginning on November 1, you must complete plan year 2019 registration by October 31."

What???

After a frantic phone call to the Exchange folks, including a 30+ minute time on hold, I was assured that this was an error on their part, and the nice man could only confirm that a blast-email with this misinformation was generated last evening.

Thankfully, I received this helpful update a few minutes ago:

"You may have recently received a message entitled “One Day Left Before You Lose Your Marketplace Access,” which stated that you had not completed Marketplace registration and training for plan year 2019. This message was sent in error." [emphasis in original]

One wonders, though, how many senior agents are still recovering from heart attacks caused by the message "sent in error."

ObamaCare Auto-Reminder

Heads' up, courtesy of the CMS in email this morning:

"If your clients do not update their Marketplace application and enroll in a plan November 1-December 15, they may be automatically enrolled in a 2019 plan."

If you're okay with that, then no need to take action. On the other hand, if you'd like to see what's "new and improved" out on the market [Spoiler Alert: pretty much zilch], then starting tomorrow you can get a quote for a new plan, preferably through the services of a local, professional, independent agent.

Oh, and if you don't, and you'd like to keep your plan as-is? Well, that may not be possible:

"Individuals currently enrolled in plans through issuers that will not be participating in the Marketplace for 2019. These consumers will be matched with an alternate plan from a different issuer."

Seems like there was some kind of explicit promise made, back in the day.

Oh, yeah.

Quite Novel Medical Tourism Idea

Wow:

A Utah insurer is offering plane tickets to San Diego, transportation to Tijuana, and a $500 cash payout to patients who need certain pricey drugs for multiple sclerosis, cancer, and autoimmune disorders. https://t.co/oAZtKWsYtX

— Rebecca Robbins (@RebeccaDRobbins) October 29, 2018

CanuckCare© FTW

Surprise!

This woman spent 47 hours waiting for surgery in the Sunnybrook ER, with shattered wrists, a broken elbow, cracked ribs and internal bleeding. An investigation into the overcrowding of Toronto ERs..https://t.co/by2dxBLjLO pic.twitter.com/5m0oyaDELC

— Dutch Rojas (@DutchRojas) October 28, 2018

Money quote:

"There was a curtain, but no switch to turn off the lights at night. That location would be Yerxa’s home for the next 19 hours—and her predicament would get worse from there."

But hey: Free!

MyChoice: Part 2

Last Friday, we posted on a new product being rolled out by Blue Cross/Blue Shield of North Carolina (BX):

"MyChoice is a less expensive option for families and small businesses who may not be able to afford other, higher-priced ACA plans"

The product's "hook" is that, instead of paying negotiated rates (as in PPO and HMO models), the plan reimburses "up to" 140% of what Medicare would pay. So, for example, if the doctor charges $100, and Medicare would have paid $60, MyChoice would reimburse $84 (leaving $16 as a potential balance to be billed). Now it's possible, given the "up to" wording, that the carrier may, in fact, send a check for (substantially?) less than this.

But it gets even more interesting: I had at first taken this to be a plan for small employers, but BX is also offering it on the individual market for 2019. Note, though, that even though it's ACA-compliant, it's not going to be offered on the Exchange, and therefore it's not subsidy-eligible (which makes sense, given it's already bare-bones pricing). On the other hand, it does include ACA-required EHB's and no exclusions for pre-existing conditions. And, of course, no extra charge for folks with those conditions.

So Henry, you may ask, how can they offer ObamaPlans with premiums discounted by up to 30%?

Well therein lies a rather interesting tale: while pretty much all carriers are now moving to narrower networks and abandoning PPO-style plans, MyChoice eschews the network model altogether, and, in fact tosses out UCR (usual, customary and reasonable), as well. Instead, you go to any doc you choose, and the plan will pay up to that pre-arranged number. And this is the case with both the individual and group models.

Patrick and I have some questions about this, and have reached out to the carrier for clarification (which we'll share in a future post providing they reply). But in the meantime here's my takeaway:

On those individual plans, the anti-choicers went ballistic over the new, expended Short Term Medical plan rules; one can only imagine the paroxysms they'll have on these.

And what about employers: will they be able to explain the potential balance billing nightmares to their employees? The carrier provides at least a partial answer:

"Blue Cross NC encourages myChoice customers to talk with their provider before any appointment or procedure to make sure they will accept the benefit payments that are provided, or find providers who will."

Now again, this touches on the Holy Grail of transparency, but as I alluded to in the previous post, who shops for the cheapest brain surgeon?

Patrick was concerned about how prescriptions would be handled in these plans, and now we know:

"The plan has a contracted network of pharmacies with agreed-to prices. There is no balance billing if a member goes to an in-network pharmacy."

And they're also HSA-compliant, which may help mitigate some of the balance billing concerns (or no).

Patrick also noted that these plans aren't available state-wide:

"BCBSNC is only offering the product in counties where they couldn't leverage providers."

Which makes sense, in a macabre way. Again, this is ripe for balance billing.

Will be interesting to see how this fares.

Looking forward to reporting on BX's answers.

Something old, something new [UPDATED]

[Scroll down for Update]

So back in April, we blogged on a medical insurance reimbursement model called reference-based pricing:

"Briefly, this is where an employer enters directly into a contract with a hospital (or other health care provider, one supposes, including DPC) ... but can carry additional risks, as well, namely balance billing"

In that post, I really defined the concept way too narrowly, because it doesn't have to be contractual with the provider. Indeed, as FoB Jeff M alerts us, it can be in relationship with one's insurance company:

"MyChoice is a less expensive option for families and small businesses who may not be able to afford other, higher-priced ACA plans ... This isn't a reduced-coverage plan, however. The cost savings are achieved through reference-based pricing. The plan reimburses customers directly for medical procedures at rates that are up to 40 percent higher than what the doctor or hospital would receive for providing the exact same services to a patient on Medicare."

Which seems fair, and also touches the sacred Price Transparency button. The challenge, of course, is two-fold (at least):

As noted in our April post, this opens up the very real possibility of balance-billing; that is, it's not a network issue, so the provider is free to charge more than the reimbursement value. Which leads to the second, related issue: sure, this may be great for non-emergency services, but who's shopping for the cheapest ER when having chest pains?

And the balance billing issue on this could be huge. remember last month's post on the $100,000 heart attack? A key passage notes:

"His insurance did what it was supposed to do, it made a fair and reasonable offer for the care received."

Kinda like 140% of Medicare pricing?

And how did that work out?

"St. David's stuck to their guns and refused to budge."

So, is this the future?

UPDATE: Co-blogger Patrick explains how this will work in practice:

"Essentially the member gets reimbursed for the cost of the service at 140% of the Medicare rate, so if a doctor charges $100 the member pays $100. If Medicare contract says the provider gets $40 then BCBSNC will reimburse the member at $56 (140% of $40).

If that isn't enough reimbursement for the doctor then they can balance bill the difference [ed: as noted]. Think about how much of a nightmare this will be for members: Every code has a different charge and reimbursement. If you have ten codes from your ER visit then you could be balance billed for each line item. Aspirin at $8 Medicare pays $0.20. 140% of $0.20 is $0.28. Does the hospital balance bill the difference of $7.72 or do they eat it? How ticked is the member if they have to pay $7.72 for an aspirin?"

Indeed. Thanks, Patrick!

Careful What You Wish For Dept: VA edition

A bit of foreshadowing for all those folks out there clamoring for Medicare4All (aka socialized health "care"):

This is enraging. A veteran who had spinal fusion surgery was in great pain, oozing blood, and his leg went numb. But he needed Department of Veterans Affairs’ approval to call an ambulance. 😡 God bless Jimmy John’s. https://t.co/WYm5vgiBnE

— Allison Reynolds (@chim0m) October 24, 2018

(Great sammiches, BTW)

Interesting HSA Marketing

So this shows up on my Facebook feed:

[click to embiggen]

I reached out to the vendor to confirm that these are, in fact, legit HSA expenses, and was assured that they were:

"Yes, they are. All of them are available for HSA purchase."

But you know me, ever skeptical, so I also reached out to our Gurus of HSA, FlexBank, for confirmation, which they happily provided:

[click to embiggen]

Hunh.

So there you have it: a unique and potentially life-saving use for your HSA.

Cool.

Let's Talk Scope

We've talked before about the true number of folks who, prior to ObamaCare, were medically ineligible for individual health insurance, most recently here:

"ObamaCare has failed patients with pre-existing conditions ... Estimates suggest that less than one percent of all people covered by private insurance have medically uninsurable conditions that would make them ineligible for medically underwritten coverage."

But that was then, and this is now, and we have this helpful video:

About how many Americans faced barriers to health insurance coverage due to a pre-existing condition before the Affordable Care Act? Keep watching. You might be surprised by the answer. https://t.co/zK7dIl3f4B #healthcare #IWhc #PreExistingConditions pic.twitter.com/TCLOPOyxTw

— IWV (@IWV) October 22, 2018

(I couldn't find a version on YouTube)

[Hat Tip: @spongeworthy2]