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You've Been Yellow Slipped

Yellow Slipped

So I got this notification in yesterday’s mail. It’s a letter from the Texas Health Insurance Pool (the insurance place of last resort for those of us with pre-existing conditions). It was letting me know what I already know…

1) Implementation of the Affordable Care Act is moving ahead and will be effective January 1, 2014.

2) Early enrollment through the exchange is scheduled to begin October 1, 2013.

…and what I suspected:

The Legislature could decide that Pool coverage will end and Pool policyholders (like me) will be allowed a certain amount of time to transition into the exchange or seek out other insurance coverage.

…and left a lot unsaid, notably…

That our Governor told CMS to pound sand last fall – so unlike the states that are well underway with some kind of implementation of an exchange, Texas appears to be leaving it up to the fine folks in Maryland to figure it out for us. Of course there are rumors of a workgroup cobbling together an alternative – but CMS would still need to approve it. Given the outstanding relationship between the State of Texas and CMS – my money says CMS will use that opportunity to return the favor and tell Texas to pound sand.

Lots of sand pounding. Lots of chest thumping. And I for one, am growing weary.

So for those of us that are left hanging in the balance, you might want to pick up the phone with your representatives and let them know you are concerned.


$600 vs $8

October 1, 2012 — 1 Comment
A photo of doctor orders for Advil

Really? After the $600 MRI co-pay…an $8 Advil treatment is prescribed?

So I go to my orthodpedist for recurring pain along my left tibia. I was thinking: shin splints. Nothing major, but I’m in enough pain that walking and jogging is ouchy and it’s been getting worse for the past few weeks. Doc orders an in-house x-ray. Appropriate -yes?

It proved to be inconclusive (no apparent stress fracture, etc.). Whew!

Doc: “But given your sensitivity Ashley…(when he touches my leg the pain is so intense that I jump)…I’m not sure.”

Doc: “In fact given your history, I have to ask you: when is the last time you had blood work done?”

My history is breast cancer. I’m four years past the diagnosis and treatment but cancer (really any kind of cancer), is always lurking. Remission is not a cure. So of course I interpreted his follow-up question the way so many people in my shoes do: I assumed the worst. Bone cancer maybe?

Next thing you know he is recommending a STAT MRI – apparently the only way to get a clearer view of not only the bone, but the tissues around the bone. I agree. Make the appointment. Get to the MRI facility the next day. Pay the deductible (gulp). And spend an hour enjoying the “bang, bang, bang, bang, bang, bang” of the tunnel. The following day I’m back in my doctor’s office after two consecutive nights of no sleep.


Doc:  “Inconclusive. So I think what we’ll do is start you on some Advil with some PT to strengthen some of the surrounding leg muscles. Then we’ll see how you do for the next few weeks.”

 <A slew of vitriol followed. Edited for clarity (and scrubbed of obscenities) my message was simple, if not loud. Really loud.> 

Me:  “Why would you scare me into an MRI instead of STARTING with the conservative treatment of Advil and physical therapy? Or let me put it another way: Why did I spend north of $600 in co-pays and deductibles, when I could have spent $8 for a bottle of Advil?

To be honest, I don’t remember the rest of the conversation because I was so mad. I was escorted to the check-out window by a PA who was called to help “calm the patient.” And where I paid my bill,I declined to make a PT appointment because I can Google “exercises to strengthen calves/shins/ankles” for free thanks. And I’ll be damned if I’m giving that practice any more of my money.

I rode my broom all the way home in a fog of red, I was so pissed.

Truth is, I’m most angry at myself. I should have questioned the MRI order. I know better. I’ve been working in healthcare for 25 years. I know how this works! I know all about unnecessary testing, etc. I should have asked for alternatives and options. should have asked him what he thought the possible causes were. Shoulda, coulda, woulda.  

Lessons Learned:  1) As patients we share responsibility in controlling healthcare costs. If tests sound excessive – ask questions. 2) If you have a pre-existing condition – don’t allow that as an excuse for a provider to leap-frog over a common-sense conservative approach straight to high-dollar diagnostics.

P.S.  Happy to report that four days later: $8 worth of Advil seemed to work.

Looks like it should taste good.

A red, ripe tomato sitting on a kitchen counter

Supermarket tomatoes look amazing and taste like cardboard. Why? Decades ago farmers began tweaking the tomato’s DNA to look more appealing on the shelf and last longer. However, the same genetic mutation that makes for great color – prevents the production of sugars and carotenoids that make a tomato taste like a tomato. It also, ironically, kills off most of the health benefits.

I think care management has gone the way of the tomato.

Most health insurers have care management programs that look good enough (we provide high-quality low-cost care!). But bite into one and you find that there’s not a lot of care there at all. In fact personal communication and interaction, the hallmarks of care management, have all but disappeared. (Notice how I didn’t use the phrase “customer engagement” which I think has been wildly overused and part of the problem. That’s another blog.)

So let’s take a closer look.

Walk the halls (cube farms?) of any insurer and you might be impressed by the titles on the nameplates: Customer Care Specialist, Senior Care Coordinator, Integrated Care Manager and Provider Relations Specialist. Looks impressive – yes? You might actually think the majority of these folks can solve some problems – right?

Upon closer inspection you’ll find the cubes are filled with the least expensive, least experienced people  – and this is the team that makes the first impression on a customer.  In fairness, the majority of these folks do the best they can with what they’ve got. Sadly, what they have is poorly integrated systems and policy & procedure overkill. The result? Most front line staff would love to help you but they can’t.

This is most evident by the excruciatingly frustrating experience we all have when we call 1-800 Health Plan. If you can successfully make it past the efficient teleprompt menu of 30 dialing options (“Before selecting an option, listen carefully as our menu has changed – and connect with a live person in less than two minutes, you are off to a good start.

Initial hurdle cleared, Joe Member Service Rep welcomes you by stammering through his “Thanks for Calling” script – the delivery of which has all the warmth and authenticity of “Have a nice day!” at the check out line at the grocery store.

You spend the next few minutes spelling your name (at least twice) and reciting you Member ID (all 27 alpha/numeric characters of it). These preliminaries dispensed with, Joe assures you that “your call is important,” before placing you in Muzak on hold while his screen updates. (BTW if you are a glutton for punishment, I dare you to click on the Muzak link – if only to study the option for “Sonic Branding.” I’m not kidding.)

A minute or two of NuJazz is all it takes for Joe to click his way through an online decision grid to see if he’s allowed/authorized to help you. Odds are stacked heavily against Joe.  Okay, he can’t help you, but the good news is Tina the Care Coordinator can. It’s another minute for the “warm” transfer. Don’t assume that means the facts of your call will magically appear on Tina’s screen. Hard to believe given all the tech we have at our disposal, but for whatever reason, healthcare organizations lag far behind everyone else when it comes to integrated customer support systems – but I digress.

Tina introduces herself to you and after dutifully repeating all the information you just gave Joe, you will be asked a new series of Q&A driven by her desktop software. For whatever reason this software/system/computer is always buggy. “I’m sorry. My computer keeps freezing up. Can you repeat that again? You need a referral for…what?” And so it goes.

With any luck, after 15 to 20 minutes into this care management “excellence ” you might get your question answered.  Might. However, if your issue requires the intervention of a licensed professional, the chances of you connecting to one during that first call are slim to none. Unlike the first two levels of care management, RNs and Medical Directors are few and far between. Because they are some of the highest salaried staff, they are saddled with the responsibilities of three people. In fact, most nurse managers and medical directors today spend less time practicing at the top of their license than they ever have. What does this mean to us?

Instead of providing peer-to-peer guidance to our physician (comparing treatment options, evaluating the latest research, getting that authorization for surgery fast-tracked), they are bogged down managing staff, managing casework, managing committees and managing “management.” So consider it a victory if you get a call back from these ultimate decision makers within 48 hours. This whole process is incredibly frustrating for everyone and instead of getting better; it seems to be getting worse.

Back to tomatoes…

Breeding the genetic mutation out of tomatoes, according to researchers, could take years. Once corrected, the tomato might look less appealing, but the taste and nutrition will be back. I think we need to look at care management through the same lens. Time to excise the overly aggressive cost containment gene and reintroduce genuine, hassle-free communication. It could take a while, but once we engineer the care back into care management, I’m willing to bet the cost savings will be there. One might say improvements might show up organically.

More posts on re-designing care management are on the way.

Black & white photo of a young kid sticking his tongue out at the camera.

Innovative: being or producing something like nothing done or experienced or created before

Improved: made more desirable or profitable or valuable; superior to another (of same class or set or kind)

“We launched an innovative outreach campaign that increased enrollment by 20%.” Umm, sending staff to man the booth at health fairs is far from novel. I’m looking at you ACME Health Plan (name changed to protect the guilty). Sure your stats went up, but getting staff off the phones, out of the cubes and out into the community does not innovative make.

“Our platform offers a wide variety of innovative solutions for claims payment.” Really? Then how come the bullets that follow are features that have been industry standard, in some cases, for the last decade? Aaaargh! When I see this opening line, I expect to see patents or other validation of a game-changer in our midst. And I was disappointed. Utterly. For there were no proof points in sight.

“We are known for our innovative problem solving.”  Such as? Don’t tease us. If you really have perfected a way to hi-jack your consulting staff’s neurological pathways and supersized their cognitive abilities; then by all means back this up with details. Perhaps linking to the New England Journal of Medicine’s citation heralding your breakthrough would help bolster your claim?

In all seriousness, it’s getting out of hand. When faced with the temptation to use innovation in any form, try improvement on for size first. It’s probably more accurate. And I would argue that improvement in healthcare these days is just as sexy as innovation.

And more truthful.