Adam texted me yesterday about a problem he was having with getting his COVID-19 booster. I’m transcribing a portion of the text-chain with his permission as it highlights administrative burdens:
“INSURANCE will not cover the new covid booster”
RAGE FACE
“The system has not processed the new code for the new booster”
“Yet”
“So I’m going to pay for it and then submit for reimbursement once it is added to the insurance company system….”
There were a couple of other things, including the mechanics of generating new CPT-4 codes and then implementing the benefit structure to activate payment for a new code, but I want to focus on administrative burden.
Adam (and many tens of thousands of others) has to do a lot to get a “free” shot. Everyone has to make the normal time and attention carve out an appointment. Normally, there is no transaction at the point of service. There might be a paper or a screen to sign/initial and then the insurer pays the bill.
Even in this fairly smooth system, my colleagues and I found substantial variation in the uptake of no cost-sharing preventive services by both actuarial metal level (higher implies more care seeking or risk averse behaviors) and income as lower income individuals with high CSR Silver plans had different uptake.
But it was not a smooth process for Adam and others. Instead they now have to figure out where to send a claim, get the right set of forms, fill them out, find a stamp and then get it in the mail. These steps are substantial burdens. Things fall through both known and unknown cracks. In the context of the ACA, we found that the process of setting up a payment account to pay a $1 or $2 monthly premium instead of nothing makes people lose about a month of insurance coverage on average per year. I would assume that over the long run, many people who have to get reimbursed will get reimbursed.
However, the cost of burdens are not evenly distributed. Kyle and Frakt found substantial gender, education and income disparities on burden. More marginalized populations faced higher costs and higher likelihoods of foregoing care. A little bit less concretely, I would speculate/hypothesize that the existence of these burdens likely acts as a deterrent from individuals seeking care as they know that they don’t have the time/ability/willingness to deal with this shit.
And that is bad. Especially when we’re dealing with infectious diseases.
mvr
I just became medicare eligible and since I still work opted for only part A (hospitalization) coverage with the remainder of my coverage through work. I was told that the rule is that if you are still covered through work (with the right sort of insurance) you can hold off on part B without penalty. Even so CVS needed my medicare number which I thought I had misplaced (it was in my wallet as it turned out). They told me they have been told to bill medicare and not my regular insurance.
It made no sense to me but I did get it and my flu shot for free on Saturday.
My spouse is now having trouble getting an appointment. Not sure what is up with that. For a while there were no appointments available online but they would not make them over the phone. She can get one in a couple of weeks. So she is going to try to walk in today.
HinTN
I received notification from my insurance company that I should get the new COVID vaccine along with my flu shot and that both would be no cost to me. I haven’t tested the billing because my pharmacy doesn’t yet have the latest vaccine.
p.a.
Feature, or bug? Cynicism is always the proper default when analyzing the insurance industry, whether health or property. Best case is the difficulties are caused by simple bureaucratic inertia- in the government and/or the industry.
Scout211
This seems to be a problem for many people. Link
The pharmacies are pointing to the private insurance companies as the problem. Those of us with Medicare are not having the same problem.
Bedraggled and Bedazzled
It was tedious yesterday with a CVS appointment. The pharmacist herself (genius woman and determined!) Worked nearly 30 minutes to figure out how to even submit our situation for the no-pay copay…2 retirees with Medicare but group insurance from my state plan and hubby’s university plan was primary for this. And the code was a medical code rather than another kind of code they had been using. It was very very strange—we are fortunate for this coverage (hubby is a kidney transplant) and had equated good coverage with less friction in accessing pharmacy services like this. First time we used pharmacy appointments—did not happen like this at the last immunizations at doc office and group clinic.
Yarrow
At least people can get the vaccine instead of being told they don’t qualify, even though it’s well over six months since their last vaccine. So they get Covid instead. (Still bitter)
They should be able to fax the claim. Medical related places still use faxing. Not sure that’s any better for the youngs, but it should be an option.
Dorothy A. Winsor
Here’s another example of how the ridiculously complicated US health care system wastes money and provides a lower standard of care.
Another Scott
Even complicated systems can work quickly when there’s an incentive to do so.
I’m reminded of the history of the federal Juneteenth holiday. The final vote and signing was about 2 days (+/-) before June 19th, and the work was completed by OPM and all the rest to make sure that federal employees got the holiday on June 19, 2021, even with that tiny time window.
Insurance companies have known the new vaccine was coming for months and months. They could have been ready. If they are not, it’s because they choose to be that way (because it helps their bottom line – friction always helps their bottom line). Grr…
Good luck, everyone. Stay safe.
Thanks, Mayhew.
Cheers,
Scott.
taumaturgo
If one ask anyone living outside the guarded private walls of the suburbs, they will say the system is working as intended, denied services increases profits. We live or die by this rule. Literally.
mvr
@mvr: I was determined to get the shot so when I was not sure where to find my medicare card I asked how much it would be to pay it myself. I was told $140.
I wonder whether this is going to come back on me given that I in fact have no coverage other than part A (which I told them) and that there seemed to be no way to bill my work insurance which is both for stuff like this and primary.
bbleh
It’s increasingly beyond me how anyone without a PhD and a lot of spare time can navigate the American healthcare system without substantial degradation in health and/or financial loss. From first to last it’s profit-seeking and/or obstruction. Doctors and medical systems, their appointments people, and their billing people. Hospitals ditto. Insurance companies. Pharmacies and pharmaceutical suppliers. Pretty much every step of the way somebody is saying no or something has gone wrong and it’s on you to fix it, and pretty much everyone you talk with — assuming you’re lucky enough to actually talk with a human — is ignorant or unhelpful or both.
It’s no wonder we pay so much more per person and yet have so much poorer health outcomes than any other similar industrialized country.
Lobo
Thank you. This is why who pays for admin burden is so important. If the rule was insurance pays no matter what and they had to deal with the paperwork it might be different. That’s why with any programs assuming eligibility rather than proving need works much better. See free lunch programs. Almost less expensive to provide free food for all than the paperwork associated with proving who qualifies.
Burnspbesq
Got mine yesterday at Walgreen. Gave them my Medicare and UHC Medicare Advantage cards. Zero out of pocket.
No reaction worth worrying about, just a little soreness at the injection site this morning.
Layer8Problem
You folks are about to be burdened with a screed.
I was told late last week by the young man behind the CVS pharmacy counter that yes CVS was taking walk-ins for the vaccination, yes it’s the new Covid vaccine they have and not some substandard old-school Covid vaccine, and yes drop in whenever the pharmacy is open except for the lunch break. I walked in confidently with my partner on Sunday and we were told sorry, no can do, pharmacy manager does the shots and no, not in today, try back tomorrow.
This is kinda important to us since we have a nice overseas trip planned for next week, our first international travel post-Covid, and boosted vaccination might be nice, you know?
Partner in a lather arranges an appointment on the Walgreens site for late Monday. I confidently figure ok, an appointment’s a good thing, it’s all locked down. We drive over to the Walgreens and are told “sorry, the vaccine didn’t come in, we’ve been calling everybody.” No, no they hadn’t called everybody, even with both of our cell numbers given for the appointment.
Partner in a heavy froth now, convinced we’re condemned to finally getting Covid. I drive us back to the original CVS to see if we can do their walk-in before the pharmacy closes. The person behind the desk says my insurance isn’t covering it and Partner’s Medicare Part D won’t either. Partner says Medicare Part B damned well does cover it and afterward confirms this online. The CVS pharmacy person says the insurance companies don’t have their codes for this yet, so their hands are tied. End of visit. We know the person at the desk is repeating whatever the folks further inside the CVS bureaucracy told her and it’s not her fault.
Arrive back at home, pour some wine because stressed, and proceed to call my insurance, who after fifteen minutes or so on hold presumably because they’re doing the in-depth research come back with a magic code which will for sure allow CVS to give me my free Covid shot. Whether it works or not I am prepared to pay for the shot and get reimbursed. Partner wails that I’ll pay full freight and only be reimbursed for the insurer’s wholesale cost. I say I don’t care because it’s just goddamn money and mumble “Bridge Access program”.
We’re both trying again today. “Finest health care in the world”. Burdens for sure, Mr. Anderson, and thank you for all your work on this. My partner and I are relatively smart people, partner actually worked in health insurance for a while, and enjoy intellectual puzzles like navigating an insurance company’s phone tree. How in god’s name do poor single parents with extra jobs deal with this shit?
Ohio Mom
The last time I went to my CVS to pick something up — must have been a couple of weeks ago — I asked when the new Covid boosters would be available and the pharmacist sighed and said, “We don’t know yet.” I took the sigh to mean, “If one more customer asks me this I will have a meltdown.”
Now that I see it’s available, I will mosey on over and make an appointment. My CVS is inside a Target and there is almost always something I can’t live without in the store (really, there isn’t, it’s just the spell Target casts).
ETA: Ohio Dad and I are on traditional Medicare so I am not expecting any snags.
Paul in KY
If you are a Vet, you should be able to get it for free via VA Healthcare System. You probably will have to go to a VA hospital to get it.
Matt McIrvin
Well, I just managed to sign my whole family up for an appointment on Sunday at the CVS inside the local Target store (which is not our regular CVS but is just up the road from it).
We’ll see how it goes. Our prescription plan is through CVS Caremark so you’d think that if CVS is giving out these shots they should have their act together, but you never know.
Burrowing Owl
Three days ago we went to a CVS a few towns away because they said they had gotten the new Covid vaccine early and available for walk-ins. We waited in line, and then the pharmacist let us know that our insurance kept rejecting coverage for it (they tried three times to run it). We called insurance and eventually were told that it doesn’t cover -that- CVS but would do Walgreens, and Walmart, and the CVS closer to home, and no, they didn’t understand why not the CVS where we were. We could have paid out of pocket about $200, but we weren’t hopeful that it would be reimbursed.
So we are still not boosted. It feels much more difficult this time around. I will try again, but this time will call insurance first to see where we are allowed to go. Definitely finding administrative burden here!
Matt McIrvin
I guess the lack of government emergency coverage means that a lot of us aren’t going to be able to get these shots even if we want to. It sounds like a disaster in the making.
StringOnAStick
Not able to even make an appointment here in the frontier of central Oregon, no one knows when the vaccine will arrive. Soon, I hope.
StringOnAStick
@Matt McIrvin: Just the R’s wanted when they refused to extend any funds for the Covid programs. Working as planned, it seems.
VFX Lurker
Los Angeles County here. The 2023-2024 Pfizer/Moderna had limited availability at CVS last week and widespread availability at CVS/Walgreens starting this Monday.
I have “good” Blue Shield coverage.
I used CVS’ online appointment system last week to make group flu/Moderna appointments for last Saturday. I could not make a group appointment while signed in to CVS, so I had to log out of my CVS account to make the appointment. I was able to enter all of my insurance and health information during the online sign-up. I used the same email/phone for everyone in the group.
My husband and I showed up about eight minutes late for our appointment. I was able to check in online for my husband, but not for myself. We walked straight to the pharmacy section as instructed. I “checked in” by telling the pharmacist I had arrived for my appointment. I was told I would have to fill out forms by the CVS pharmacy, but I never did. We got our flu/COVID shots, walked around the store for 15 minutes, then went home.
The 2023-2024 Moderna shots shipped in their own prepackaged syringes this time, not in vials Both the “regular” flu and Moderna shots shipped as boxes of syringes, each box labeled differently, and with different syringe shapes.The 2023-2024 “regular” flu shot has a long and thin syringe. The 2023-2024 Moderna shot has a short and squat syringe. The pharmacist just had to affix a needle to each syringe and “get rid of the bubble” to prepare each shot.
Anecdote from Spring 2022: my age 50+ husband tried to walk into a Rite Aid for his second booster and was told “we don’t have any vaccine — appointment only.” We made an online appointment that night for a next-day appointment at Walgreens, because the Rite Aid site couldn’t handle appointments for folks who initially received a single Johnson & Johnson vaccination. The Walgreens pharmacist told us then that there was a “shortage” of vaccines. Online appointments determined where vials got shipped, and each pharmacy got just enough to handle scheduled appointments. Walk-ins got served only if the pharmacy had any leftover doses.
It’s possible this Spring 2022 “shortage” was limited to retail pharmacy chains with a “just-in-time” approach to keeping vaccines in stock. However, since then I have always scheduled appointments for COVID/flu shots online.
Sister Golden Bear
Since my “insurance” company routinely denies any claim and forces me to fight for approval — I’m still trying a get a prescription that was prescribed 3 months ago — I’m sure they’re gonna fuck around on the Covid booster as well.
Especially scamming because it’s through my contract agency, and most workers are on 6-month contracts making it near-impossible to meet their high deductible anyway. But hey, they promote how they save money — for employees. Even more enraging, they don’t even provide the insurance themselves, it’s actually through a well-known insurer, they’re just an unnecessary middleman.
JeanneT
Not directly vaccine related, but Dr. Glaucomflecken has been running a series of videos (30 Days of US Healthcare) about how health care insurance works against patient interests in the US. Not his funniest series, but very biting…. It’d be interesting to know how accurate you think his portrayals are, David.
Mousebumples
I work for a PBM and for the first time, Covid boosters didn’t hit our pricing file (eg how much will we be paying pharmacies) until after CDC/ACIP approval.
We have manual processes in place (ugh, manual), but the vaccines should be in our system by tomorrow.
Not ideal (and we had a similar issue with the recent generic Vyvanse launch earlier this month), but I’m hopeful that these problems will resolve sooner vs later.
I’m having issues finding my kiddos (1 & 4) places to get the vaccine, which is frustrating, too.
JDM
I can offer a different experience it seems. Over the last couple years I’ve been off and on in BC, Canada dealing with an estate, and the timing has meant I’ve gotten covid boosters there. I’m not a resident, so I had to call first and set up a BC health number, then good to go. When it’s time for a booster, they email and give me a link to set up an appointment at my choice of pharmacies. Which vaccines are available where is also listed there and you can choose. No charge.
Canadian healthcare has problems, but compared to virtually everything I hear about US healthcare, it’s superior. The vaccine experience there is what the US should have available, at a very minimum.
JaneE
Kaiser SoCal is saying they plan to have vaccines by Sept. 28th, and will cover them based on your plan’s provisions on routine vaccinations. I expect that will be free or nearly so for most members. No indication they will offer vaccines to non-members at all, as they did with the previous Covid-19 vaccines.
I would expect an email telling us they have the vaccines, and possibly the same online scheduling that they did before. If there is a fee you will need to check in, per usual instead of going straight to the vaccination area.
UncleEbeneezer
@Matt McIrvin: My wife checked on the CVS Caremark website (we have a Sat appointment) and it looks like the boosters are covered. Of course, things can always go sideways with this stuff, but that makes us feel pretty confident in this case.
David Anderson
@JeanneT: Regarding Dr. G. I think he is hilarious when he is talking about the different specialties…. Texaco Mike and Rural Medicine are side-splitting while Cardiology vs. Nephrology is dramatic.
But on payment policy, the wish is “just let us do whatever, and don’t worry about money….” That system does not work too well either.
Origuy
I made an appointment last week at Walgreens. Today I got in line and my insurance (Anthem Blue Cross) paid for the Covid and flu shot. They wanted a $75 co-pay for the RSV vaccine so I decided to hold off until I can ask my PCP about it. Got the shots and came back to work.
sab
@JDM: Doesn’t Canadian healthcare vary a lot depending on the province you are in, and big city v very rural?
JDM
@sab: it can to some degree, but no more so than in the USA, plus the costs are far better. ie., I’d rather be needing healthcare in smalltown rural Alberta, for instance, than in Riverton, Wy.
Ruckus
@Layer8Problem:
I used to own a company, in the last century and we provided HC insurance. Fully paid. No hassle. And I used to deal with this stuff, 2 jobs ago. 90 person company, good health insurance coverage. Was in the office of the lady that did all the hassling for the insurance at the time the insurance industry decided to screw every human in the US. We had very good insurance – right up until that moment, at which no insurance company would sell insurance that covered what we had prior to that moment at any price. It was a scam by the insurance industry to screw every human in the US – for profit of course. This woman called around and not one company would budge, not for money or threat of their lives. Profit over health, over life, over everything else in the world. I really, really hope there is a hell, even if I have to go, just so I can see every damned insurance company executive burning in it. I didn’t serve in the US military so that insurance companies could fuck over an entire population. It was supposed to be for a better country. This shit isn’t better.
Betsy
I was in the post office of the day. A young man came in. A member of a racial minority that generally speaking of course, faces massive structural life obstacles in this region. He was wearing work clothes for a very physical job, and was in a hurry, as if he were short on time off — it was about lunch time. He was there to mail a letter. He had an envelope and a form to put in it. He needed to buy a stamp. He asked the postal clerk where to write the address and stamp on the envelope. He said, “I don’t have to use the mail very much and it’s been a long time since I sent a letter.”
David, I think you make great points about the administrative burden. And how it falls disproportionately on certain groups and people. I am sure that most people who write laws and enact laws and prepare administrative regulations take for granted that everyone knows how to address an envelope and mail a form, but as I was reminded the other day, it’s not a universal skill.