Uncollaborative Insurance

For those accustomed to data-driven posts, I apologize.  This post is 99% personal experience.  It represents my ongoing battle with Harvard Pilgrim Health Care to obtain coverage that I need at a price that I can afford.

This episode began when I received a notice dated 2/11/09 notifying me that the cost of my family coverage plan would increase from $1785.96 to $1929.68 per month, an 8% increase that would push my family’s cost  to over $23,000 annually, considering the $25 copay per visit and the $15/$30/$50 tiered drug copay.  As a solopreneur with two kids in college and predictable expenses with unpredictable cashflow, I felt that a win-win negotiation was in order.  I printed information from a variety of Harvard Pilgrim policies on the Commonwealth Connector and called Harvard Pilgrim last Thursday to discuss my options.

I mentioned (see Gotcha: A surgeon dissects patient-centered care) my frustration with insurance company micromanagement of physical therapy (PT).  I explained that a limit of 60 consecutive days of physical therapy did not work for me because a seizure sustained as a complication of chemotherapy for lymphoma in 1981 resulted in compression fractures of my spine, chronic pain, and limitation of motion.  Knowing that I would have to pay full price for PT after 2 months despite paying out nearly $23,000 in premiums did not buy me peace of mind.  I stressed that nobody in my family smokes cigarettes, has high blood pressure, or is obese.  Other than my spine issues, we have no chronic conditions.

I asked, “What can we do to reach a mutually beneficial outcome?”  You would have thought that I was asking for permission to desecrate the American flag.

“We can’t change PT coverage,” she protested.

“Nonsense,” I replied (I confess that I used a different compound word that had the same number of letters; it just came out in the heat of the moment).  “If a human being can write an arbitrary, capricious rule that has more to do with managing cost than managing care, a human being can promote wellness by changing that arbitrary and capricious rule!  Why aren’t there limits to spine surgery or MRI scans that cost a lot more than PT?”

I continued, “I know that you can’t change the rule, nor do I expect you to.  All that I ask is that you convey my request to the people at the top of your organization that make the rules.  I want you to know that I want to stay with Harvard Pilgrim if we can find a way to accommodate my family’s needs.”

She thanked me for my comments, and we hung up.

The tragedy of the conversation is that (to paraphrase Jerry Maguire) she could have had me at hello.  Perhaps I am naive to think that a mere surgeon/MBA/author-blogger could have a mutual dialogue with a company that reported operating income of $22.6 million on revenue of $2.6 billion for 2008. Net income for 2008 was $48.1 million.  As of December 31, 2008, total membership for Harvard Pilgrim was 1,068,000, an increase of 38,000 members from 2007.

I am not suggesting that Harvard Pilgrim is a bad company.  I know that it is ranked number 1 in New England by a variety of measures.  I learned in business school that the definition of a good customer is someone who keeps a company in touch with the marketplace.  I know from having traveled over 500,000 miles in the last 6 years to over 40 states in the US that many of us in the middle class are feeling squeezed and we’re not gonna take it anymore.

In a memorandum to the heads of all Executive Departments and Agencies dated February 27, 2009, President Obama wrote that government should be transparent, participatory, and collaborative.  Shouldn’t these principles apply to healthcare insurance companies as well?  If we want better healthcare outcomes, we all need to work more interdependently

As I wrote in Facilitating Physician Engagement, it took years of meetings of healthcare professionals at the Pittsburgh Regional Health Initiative before questions shifted from the accusatory, “Why don’t you…?” to a more systems-based reflection, “What if we…?” (“Socioeconomic Issues Affecting Healthcare Collaboration, p.48, in Cohn KH. Collaborate for Success! Breakthrough Strategies for Engaging Physicians, Nurses, and Hospital Executives, Chicago: Health Administration Press, 2006).

What do you think?

  • What would you like to say to your healthcare insurance company
  • How can citizens who are not part of big companies promote a more patient-friendly wellness agenda
  • Is now the right time raise these issues

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn
© 2009, all rights reserved

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10 Responses to Uncollaborative Insurance

  1. talesofacrazypsychmajor March 5, 2009 at 8:55 am #

    I’d like to tell them to make improvements on their lists of providers. It needs to be updated daily and have more information. The mental health part is particularly bad. There’s more to finding a therapists than just their name and phone number. People specialize in specific things. The list should say if they are accepting new patients and allow them to add some kind of paragraph statement on the type of patients they accept. I can’t count how many therapists I’ve called off of that list who’ve refused to meet with me because they’re too busy or because my problems are not what they in. Right now there are a handful of categories about what they treat but the list is far from exhaustive and doesn’t include any of my particular problems.

    Oh and it’d be nice if their “reasonable and customary rate” for out of plan coverage actually was an amount that people really charged

    I have 2 insurances right now, which is ridiculous. And I still have problems getting affordable coverage/finding providers. How’s that happen? All the extra insurance has done is give me lots of paperwork to fill out and deal with them fighting with each other about who will pay for stuff and then finally the bill getting passed onto me.

  2. Kenneth H. Cohn, M.D., MBA March 7, 2009 at 12:04 pm #

    Bill Ives wrote a heartfelt post today on his struggles with healthcare insurance, http://billives.typepad.com/portals_and_km/2009/03/ken-cohns-request-for-more-responsive-health-insurance.html

    He ends by writing, “We have one of the most expensive healthcare systems in the world, but do not get the value out of it.”

    I encourage you to visit Bill’s blog to read his take on healthcare insurance and to benefit from his expertise in knowledge management.

  3. charlie March 16, 2009 at 2:05 pm #

    Dr. Cohn — First of all – thanks for your membership in HPHC, and for your post. Let me offer up four points/observations in response…

    1) I’ve had recent personal experience with our PT benefit myself. I ripped up my ankle in June of 2008 and spent last summer – July and August – receiving superbly provided PT services from Peak Performance, a nearby PT provider. It worked, and it was amazing. I also posted on my experience (The Cost of Non-Compliance on my blog). For me, having 60 days and as many visits as I wanted during that period worked well – although I’m sure that’s not the case for everyone.

    2) I totally get the frustration you feel with a structured benefit. Frankly, we thought we had to choose between managing for medical necessity (which BC/BS of MA and Tufts Health Plan do after 8 visits), or offering up a non-managed benefit with a defined window for services. We thought this was a better route – for practicioners and members.

    3) We are not really positioned to change/negotiate plan designs in mid-stream. We’re expected – by regulators and purchasers – to provide what we sell, nothing more or nothing less – during a plan year. Changing plan designs in the middle of a plan year to meet particular needs of an individual customer – at least in this business – is considered bad policy. I think that’s because people worry about plan design changes in mid-year that work against members, not for them – and no one could figure out how to separate one from the other.

    4) We are reviewing all of our PT & OT plan designs to see if we can come up with a wider service window, without getting too heavily into managing visits – which we’ve tried to stay away from. This should open up some new options for next year. Let me know if you’d like to discuss your experience with the people working on the re-design.

    You should also know that we do have a prior approval process in place for all non-emergency high end radiology procedures (like MRI), and services like spine surgery require a number of sign-offs before they can move forward as well.

    Again, we do appreciate your business.

  4. Paul Mark April 15, 2009 at 11:25 am #

    Amazing site, by the way. I just came across it today. Your videos are unique.

    I can understand your frustration with the insurance company, but when you look at it from the perspective of an actuary, then it makes sense.

    You appear in excellent health and I would look into health deductible/savings accounts with high deductible plan and spend your yearly premium on that.

    And if you have back issues, I strongly recommend walking for long periods of time as often as possible. I do that daily with audiobooks – it’s great.

    Regards,
    Paul

  5. Mrs. Little January 2, 2010 at 12:49 pm #

    I recently lost my husband and with him went the company insurance coverage. What would be a good insurance for a woman of 56 years old in good health? Thank you kindly for any recommendations. Even though I’ve checked the best ratings for insurances in the United States, those fall under businesses and not individual. Could use some help here.

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