Thursday, November 12, 2015


Seriously, I wanted to begin this post with the most vulgar language I could muster but that's not going to get me anywhere. Besides, I have two things to do next week in somewhat professional settings and I really don't want people looking at this blog to see that.

Here's the problem and as of this moment, there is no solution. Correction. No acceptable solution or affordable solution. Let's back up a minute.

I was insured by Health Republic. I had an individual policy for a family member and one for a small group where I was insured. In September, I was notified the individual policies would all be cancelled on December 31, 2015. Around the same time, I received notification of the premium increase for the small group policy. Yes, it was substantial and yes, I expected it. I'm not a moron and I don't live under a rock. I read and I knew this was coming our way.

Suck it up. Figure it out. It's the running theme of my life. Figure.It.Out. and it seems I'm always figuring shit out myself. The problems could involve a number of different people in my life, but even when they cause the problem, somehow, it gets dumped squarely in my lap to, yes, figure it out.

I'm tired of figuring it out. I'm irritated by the whole concept. I just want to skate along ignorant and happy. My dad always believed I should be ignorant and happy. That I should be protected from things that others should be doing or not doing. I'm not ignorant and I'm not happy either. And, at this point, I'm so irritated, I'm not making much sense.

I was staring down December 31st knowing I had until December 15th to put coverage into place so there will be no lapse in health insurance. Then, on October 31st, which was a Saturday, Health Republic was backed into a corner and told to cease operations by November 30th. All operations-individual and small group. This was the first inkling I had that I wouldn't be able to renew my group, even with stupid numbers in premium increases.

I received the notification on Tuesday, November 3rd. Now, I'm staring at a November 13th deadline for coverage to be effective on December 1st. I need an individual policy with very specific coverage and I need a group policy that is not going to break the back of the small business. Based upon what has been going on for the past week, it would appear this insurance nonsense is ALL on the backs of the small business owners. Keep pushing them down and watch how quickly the trickle down effect of that is going to be. Take those employment numbers that were just rolled out and just watch. This country is being held up by all of the small businesses whose success puts food on many tables and keeps a roof over many heads. Let's mess with the small businesses some more and then, let's mess with those who can purchase off exchange individual policies, too.

And now let's add in a twist. I am a cancer patient. Yes, I'm NED but I am followed by my doctors at Sloan Kettering which is how I would prefer things remain. And yet, it appears I will be seeking care at NYU Langone or NYP/Columbia. By right, I should be finding coverage at NYP. After all, I do scroll across their landing page.

Medivizor, and yes, I'm a huge fan of what they are doing, has a partnership with NY Presbyterian. Apropos of nothing, I'm in their scroll. And for the record, I don't sell myself. I follow what I believe. I've believed in Medivizor since I first learned of the service. So, I'm in the scroll. Wanna see?
Personalized Health Information. I want to scream right now, or pull my hair out. How about some personalized health insurance?

I have been on the phone with my insurance broker every day. He called me on Saturday to see if we could figure it out. On Wednesday, Thursday and Friday, each and every conversation was interrupted no less than five times with updates.

"North Shore LIJ says they can compete with Sloan Kettering. They have a good product. All of their doctors came from Sloan."

I've been in the cancer area of North Shore LIJ and they can't "compete" - they can't even hold a candle to it. The flagship hospital, I've been told, has a bad infection rating. Since I can't be sure the link to the article will work, this was the information regarding infections and fines at the crown jewel in the North Shore LIJ system.

And the snippets continue. They were fined. The worst possible score is a 10. Flagship, "they can compete with Sloan" got an 8.3. That's seriously sucky.
FYI. My dad died in Plainview Hospital (mom, please I hope you aren't reading this). And the scores? I'll be curious to see what happens next month. I'd like to see if they cleaned up their act.
North Shore LIJ just "rebranded" itself and they have their own insurance company. They have also purchased damn near every hospital on Long Island and so far have gotten into three of the five boroughs of NYC, including Manhattan. Lenox Hill was, at one time, a fine hospital. Now, you can see for yourself. Not so much.

That is my affordable option. Buying health insurance from the same company that owns the hospitals. I know this model may be working in other parts of the country, however, I don't buy it. It feels like it should be against the law. It feels like a monopoly. It feels like the fox is guarding the hen house. It feels wrong. Plus, this is the same f'ing health care system that scooped up the hospital where I had a horrific experience in the ICU. That was last October. It was quite a long blog post.

Option one is completely off the table. No WAY am I being stuck inside that hospital system by purchasing their insurance. What options are left?

For my issues, I went on the Sloan Kettering website. They have a list, an up to date list of insurance companies where they are in network.  Armed with the information, my broker and I went down the list of every single carrier. Only large groups, only through your employer, only with a referral (that was pissing me off, but I was willing to finally give in on the referral thing), and at the end of the day it came down to one company. The premium for the platinum plan was somewhere in the 900/month range. Within the hour, the broker called again. From the seminar. "Forget the 900/month option. Didn't you say something about one of your medications?"

And we did the calculation. They found a way to keep people on maintenance medications that are costly off their plans by coming up with this drug nonsense. 30/60/800. HUH? EIGHT HUNDRED???  Eight hundred what?

I am on two brand drugs. One is a cancer medication. I started on brand and I know that it's not a good idea to switch to generic when something is working. I also know that when synthroid went generic, the thyroid specialist at MSKCC who treats my dear friend for her very rare thyroid cancer told her every patient's dose had to be adjusted. Generics are great, but the fillers can be different and they are not the same. Had I started on letrozole, I would have been fine but I didn't. I started on brand, Femara and that is how I intend to finish out my estrogen suppressant treatment for my early stage cancer.

To deal with some of the side effects of the lack of estrogen, I am on another medication. That went generic at some point and I switched to the generic version. When I was lethargic and then completely non-functional, it took me about a month to put two and two together. I called the doctor, switched back to brand and all was well in my world. There's a back story to that as there was a known issue with that medication and patient groups were fighting over the medication. They got an independent lab to prove that the time release was breaking down too fast and after about four years, the FDA pulled the generic off the market. They may have straightened that out, but I'm unwilling to be a guinea pig with medications that did not work. I'm not going off brand. I tried it. It didn't work and I'm not doing it again.

So, the only MSKCC participating network that I am eligible to get will cost me about $2000.00 per month. That would be the premium plus the two prescriptions. There is no max out of pocket with the drugs, either so I'm guaranteed 24K per year plus co pays for all of my doctor visits, blood draws and the occasional visit to the medi-center for an antibiotic when I get the dreaded UTI or if I should develop flu like symptoms or something. Forget about what should happen if I need an emergency room.

What is affordable about that? Limiting access to drugs is one way to negotiate with pharma? Limiting access to drugs that patients really need, patients should appeal and most likely, they will win? Thanks to Marjorie Gallece for sharing this with me on Facebook. This piece is specifically about HIV/AIDS patients and mid priced plans purchased on the exchange. I was looking to buy the best possible plan, off the exchange and I have the same problem. And for what it's worth, MSKCC takes no exchange plans. Period. And for whatever else it's worth, there is a product out there that makes plenty of sense.

It's called Oscar. They use the Magna Care network. MSKCC is in the Magna Care Network. However, Oscar doesn't write small groups (yet????) and MSKCC only accepts Magna Care plans purchased under a group plan. No individual plans accepted.

I vowed to never get political in this blog space but I'm breaking my own rule. The Affordable Care Act? I was never a fan. I saw this coming from miles away. And now, it's in my face. Yes, I abhor Obamacare and I'm tired of hearing about the insurance companies pulling this stunt to force the pharmaceutical companies to do something about their pricing.

There are too many "fail first" rules in place by the health insurers. Doctors don't get to make the decision regarding the drug they feel is best for any given patient. First, you must fail. My health is on the line. My doctor knows me. I know me even better and some clerk at a desk gets to say which medication can be prescribed? A clerk reading like a robot from a script referencing a drug formulary guide that can be manipulated to suit the insurance company. Never mind evidence based or standard of care or my body doesn't work with that drug.

It's all a bunch of bullshit. And pharma is not our enemy. Before you vilify an entire industry, dig into the regulatory issues they deal with. I was sitting with someone earlier this week who was discussing the issues with a clinical trial drug. No, she didn't have to pay for the drug but she did have to fight with the insurance company for routine scans and blood work because her husband wasn't on an approved drug. Pharma would have stepped in and paid for those tests but they are NOT ALLOWED to do so because of the regulatory issues. Her story ended with a huge fight that she had to wage after her husband's death. She had to hire someone to do the fighting. Ultimately, the insurance company paid. There are many villains here. The system is broken. And if we don't all get to the same table, STAT, we are all going to be in big trouble.

As for me, I'll be speaking to Oscar tomorrow. The sad thing about Oscar? They had contracts with NY Presbyterian and Columbia and those were pulled within the last 5 days. To Oscar's credit, they had a banner on their website the moment they knew. Oscar was backed by Google to the tune of 32M. Tom Insel, former director of the National Institute of Mental Health, someone I had the pleasure of meeting just left the NIMH for the greener Google pastures

He believes in Google, Google believes in Oscar and that's enough for me to know I'll be on the red carpet accepting an Oscar policy. Tomorrow. With the help of my broker even though the folks at Oscar reached out to me on twitter which yes, was quite impressive and quite quick. 

As for MSKCC, what's the deal? Why won't you negotiate contracts within a network where you already participate for individual policyholders? Or, in the case of another company, why only large groups and not small groups? It's illogical and it's wrong and I want to say it's discriminatory but I'm sure everyone's legal teams made damn sure there's not a hint of "legal" discrimination in anything. Do morals count for anything? Guess not.

Seems to me like everyone has found a loophole and they are all using those loops to create a noose that just keeps tightening around the necks of those of us who need continuity of care. Shame on the insurance companies and shame on the cancer hospitals that are not providing small businesses or individuals options for care by negotiating reasonable contracts for the rest of us.

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  1. This is absolutely insane. I don't even know what to say about it. At least you are compos mentis and can research this. What about folks who don't have the wherewithal to deal with all this?

    Grrrrr. And hugs. Kathi

    1. And that's exactly why I'm making the noise I'm making. Yes, I've made it very personal but I hope my personal mess will spark something that makes this a more fair situation. This truly is about the haves and the have nots. If you have a job with a large company, it's possible to continue care (except I have no clue how much those employees are cost sharing premiums or how good the plans are....). What we have here is a giant mess and I swear, it's squarely on the shoulders of the insurance monsters. I don't place even one bit of blame on the pharmaceuticals. I've had too many opportunities to speak to people at three different pharma companies over the past two weeks (before this shit hit the fan) and their hands are truly strangled by regulatory and compliance. THIS was a conscious choice to find a great loophole to "self select" on the part of the insurance companies. Rant over. Not really. THIS rant is over. Somehow, I suspect there will be many more over until I see appropriate resolution. Love ya, Kathi!


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