Roger Moore downblog made an excellent point that I hope I would have eventually bumped into over the next ten to fifteen thousand words:
It seems to me that the current insurance situation creates the worst of both worlds for consumers: there are enough choices to be confusing, but many of the choices are essentially meaningless, so the complication doesn’t really benefit the consumer. Stripping away meaningless choices bares the essential ones so you can focus on the decisions that matter. It doesn’t guarantee that you’ll be happy with the available options, but it reduces the chances that you’ll get something wrong by mistake.
A good communication system should clearly distinguish options and those different options should be practically and meaningfully different. Right now, in the non-actively managed market states, which is Healthcare.gov and several of the state exchanges, meaningful difference is a hyper technical term that is easily gamed. Insurers are able to flood the market with isomorphs where the distinguishing characteristic is confusion.
There is some order in that the metal bands provide one relevant comparison anchor, namely the actuarial value. That anchor is only truly reliable for people making more than 200% of the Federal Poverty Line. Below that, Silver is better than Gold or Silver is better than both Gold and Platinum. That is not intuitive. So even the one decent anchor on the open competition is not reliable.
Covered California and other active purchaser exchanges reduce the choice set. They basically force companies to compete on a single entry in each level and that entry has to have a uniform benefit package. Here the comparisons are effectively on price, plan design, network, reputation and customer service. The cognitive load is much lower as people don’t need to process the benefit configuration choices. And browsing around in a couple of major urban zip codes, I am seeing no more than two entries per insurer, usually an HMO and PPO offering.
Covered California is offering meaningful difference but to get there, they are significantly restricting choice space especially on the network side. If an insurer is only allowed one or two entries into a single metal band, if they are choosing to be cost competitive they need to narrow their network. If an individual is chronically ill and has a set of relationships that has been effective in managing their care for several years and has an ability and willingness to pay, restricting networks is not in that person’s best interest.
I don’t know where the balancing point is between clear communication, decision simplicity and option space frontiers should be. I don’t think that anyone in the insurance industry is at an absolute or even a desirable local maxima.
Health insurance isn’t a normal consumer item. It’s like selling fire insurance in a world where every building catches fire.
And this is where we are now. The spousal unit and the eldest offspring are both type-1 diabetics. We have been lucky that the Endos they use have been in the relatively broad network that my employer’s chosen insurance company. We’re a 1-50 employee and I reviewed and approved the plan when the decision was made.
The area where insurance company cost-control has bitten us has been in prescriptions — both family members have been on the same basal insulin brand and same bolus insulin brand for years (there are no generics.) When evaluating the plan, it was a 3-plus Tier prescription plan (Generics, preferred Brand, non-preferred Brand and specialty,) and ours was on the Tier 3 (non-preferred Brand.) My assumption in evaluating that is that we would pay more out-of-pocket, but that it would still be covered. And that was true for 5 months –then we got a notice that they would no longer cover any of the cost of either of the insulins (the information provided by our Endos “did not meet medical necessity …” and that the drugs would only continue to be covered if we could document a “contraindication to, intolerance to, allergy to, or a documented failure of an adequate trial one (1) month of the preferred alternative …”. We were now required to risk changing from two known-to-work medications to two untried medications or pay retail.
So reviewing my decision and all of the fine print I’ve come to the conclusion that people with chronic diseases using long-term medications that they like should treat non-preferred medications as functionally uncovered for the purpose of evaluating plans.
@WereBear: And where some fires never really go out, and where the insured building can change insurance companies covering the costs.
Health care should rightly be infrastructure that a civilized country provides to its people. It is in a lot of countries, and it would be in the US if our national religion weren’t The Church of the Invisible Hand Fairy (the spousal unit is a tithing congregant and MBA.)
@Pseudonymous Bosch: Oh gosh. This is where we were and part of why I was yelling in the comments in Richard’s last post.
Some years ago (less than ten but not many,) a prescription allergy medicine that I was taking went from non-preferred to completely uncovered. There were many hoops to jump through to attempt to get the medication covered again. The insurance wanted documentation from the allergist that I tried every over the counter allergy medication that did not even touch my allergies for two weeks each. We tried. Our documentation was never sufficient, or they would come back with one more to try. There are three OTC allergy medications: Allegra (does nothing), Claritin (works in arid climates without many grasses and molds), and Zyrtec (works but causes a fogginess that makes it hard to do math.)
There were two prescription medications at the time. Clarinex and Zyxal. I am worried that this type of policy is going to discourage people from developing new medication.
The only other option left was to take the shots. Some people cannot do this because they have anaphylactic reactions before they reach therapeutic doses. I take shots now. In spring and summer, the therapeutic dose causes big local reactions due to all of the pollen in the environment so I have to back off and have my dose cut and attempt to use a combination of the over-the-counter medicine and the shot to control allergies.
I was so so sick during the time when my medication was gone and before I was able to ramp up to therapeutic shot level (this takes about a year.)
This is why it was absolutely horrifying when the main epinephrine injector that my insurance covers (Auvi-Q) was withdrawn from the market. We called the doctor and requested a new prescription for a medication that our insurance does not cover ($300-$500/per thingy.) We called the insurance company, and they said that the doctor needed to call them. The doctor’s office said “We got this.” Yesterday, my husband called the pharmacy that said they did not have whatever they needed from the doctor’s office. Then my husband called the doctor’s office that was all “Who did you talk to?” and my husband had not written this down so the receptionist was useless. I called them back and talked to a nurse that I know who said they needed some paper from the pharmacy saying that the insurance company refused to cover it before they could begin their appeal. Then we called the pharmacy again, and they said they sent the paper to the allergist’s office. Now we have to call the allergist’s office to see if they got whatever they needed from the pharmacy. If the allergist’s office does not have it, we will have to call the pharmacy again and ask them how they sent it (postal mail, fax, email?) and babysit a process that we know nothing about.
I really hope this works out, but I am not optimistic.
In this case that the medicine that they covered has been withdrawn from the market due to manufacturing defect, the insurance should be issuing some blanket exception, but I don’t know if they are doing that so we are suffering.
But since this medicine is not something that we will likely ever use, we can be more cool-headed about jumping through all of the hoops.
Ok, so if anyone has made it this far, @Pseudonymous Bosch, document every damn interaction with everyone and when it happened and when your people start or discontinue any medication, every side effect, etc. Pharmacy, insurance, doctors, write all the shit with dates and names and everything. I will cross my fingers for you.
The average American doesn’t have the math background to understand risk, expected value, and so forth in quantitative terms, and yet they’re betting their lives and livelihoods on their choices.
I would not be surprised if both of you have gotten caught up in the huge rise in prescription drug prices that’s been happening under the radar. I became aware of it when the cream I use for my rosacea went from $100 a tube to over $1,000 a tube for no reason at all, other than that the company decided to raise the price. And my example is not life-threatening, only annoying.
And our allergist’s office called and said that the insurance is refusing to cover the epi-pen. Can I burn down a prescription drug plan to the ground, please?
The epi-pens are injectors that allergic people keep on hand in case they are dying due to allergies. You are to shoot yourself in the leg and get to emergency room. I have never had to use one, but they are kept on hand in case of emergencies.
And my husband called the insurance company again. They escalated the issue and took care of it. Fun times.
This process was to get Epi-Pens approved so we could replace the injectors that have to be at school for a preschooler in my household. I have not started the process for my own Epi-Pen.
Is there enough booze in the world?
The Raven on the Hill
“they’re betting their lives and livelihoods on their choices”
They are mandated to bet their lives and livelihoods.
Thank you, Obama.
This make me livid. These decisions get made for financial reasons, not medical ones. And given the hidden information nature of the pricing (the retail price being ridiculously inflated) make it so that you almost have to use the negotiated brand.
And as you obviously know, always follow up by phone. This is not something we should have to do. The spouse is certain that these barriers to service are put up in hopes that we will just give up and do what they want.
The information is too hidden, the system too byzantine. Getting healthcare should not be a fulltime job. FSM help any who are not as persistent as we are.
I will keep my fingers crossedd for you & yours as well.
I am sure this is true. The drug companies have been squeezed on those meds where people have more than a few options, so they have been Shkreli-ing people who have fewer options. And where there are a few options, the insurance companies have been playing them off against each other. Sanofi-Aventis gives Aetna a better price if they don’t cover Novo-Nordisk’s product.
I hate all of that BS.
Reminds me of my boss’ favorite saying when I worked at the car dealership he owned… “In confusion there is profit.” That was many years ago, but it’s just as true today as it ever was.
Epi-Pens? They’re refusing to cover Epi-Pens? Thar’s insane. I carried one for years because I’d been stung by a bee once and had a mild reaction. Despite being 51 years old, I’ve still never gotten that second sting.
When I had a severe anaphylactic reaction to an antibiotic I was damned glad I had the thing (although it took me a while to locate it). We were living in Mazatlan at the time and I knew that as far as we were from the nearest hospital, I’d be dead before 066 got there. It worked, I’m still around, and you bet I carry that thing with me everywhere now.
So what – having an allergic reaction is now a lifestyle choice that shouldn’t be covered?