Gold-plated PT

I’ve had the good fortune of doing several months of physical therapy for my knee at three different locations over the past 15 months. Each location did 30-minute appointments.

Cigna paid Harvard Vanguard $65 for each visit. I believe that Harvard Vanguard was using billing codes for 15-minute visits, even though it should have been 30 minutes.

Cigna paid Spaulding Rehab $130 for each visit. I believe that Spaulding Rehab was using billing codes for 45-minute visits, even though it should have been 30 minutes.

Cigna paid MGH $315 for each visit. I have no idea how they are billing.

Harvard Vanguard had a single physical therapist, and had no equipment or ice that I could use before or after my appointment. Spaulding had a physical therapist and a PT student who worked as a team, but I don’t believe they’re supposed to bill for the PT student. Spaulding often had me stay with ice (but no people) for 15 minutes after my appointment. MGH has a ton of equipment and ice that I can use before or after my appointment, and after the 30-minute appointment with the physical therapist I sometimes get handed off to a PT assistant to show me a few home exercises, print out notes, and answer questions. But the billing doesn’t seem to vary based on whether there is any time with the PT assistant. So while the relative prices are in the same order as the amenities, they are not proportional in any real sense. For the cost of a single 30-minute MGH visit, I could pay for a 60-minute Harvard Vanguard visit, a month of membership at a fancy gym, a 90-minute massage, and quite possibly a nice dinner out. This seems a little nutty.

D68, Bingo!

Hospitals all around are being inundated with children who come down with a cold or other respiratory virus and wind up with asthma exacerbation. This happens every year to a lot of people. This year it’s happening to a lot more people than in a typical year. We’ve tested a few of those cases, and we’ve determined that Human Enterovirus D68 is responsible for some of those cases.

There are lots of enteroviruses and rhinoviruses. D68 is primarily unusual in that the cold symptoms are quite mild compared to the asthma impact. For people without asthma, D68 seems pretty innocuous. For people with asthma, D68 can land you at the emergency room, admitted to the hospital, or even in intensive care.

I had this exact pattern, with a mild cold that resulted in an urgent care prescription for oral steroids, something I’ve never needed before for my asthma. David just spent three nights hospitalized with the same pattern of a mild cold and serious asthma exacerbation.

A big goal of managing asthma is to prevent hospitalizations, because those are costly and time-consuming and risky. So you make an asthma action plan with the goal of avoiding hospitalizations. If D68 causes a hospitalization, that’s not a failure of the plan. If a non-D68 mild cold causes a hospitalization, that is a failure of the plan. So on a personal level, it would be nice to know if David had D68 or something else.

(Success or failure is a little more complicated than that, of course. The goal of an asthma action plan is to keep the patient as healthy as possible, and to make sure the patient receives the appropriate medical care when needed. Our asthma action plan did not avoid a hospitalization, but it did result in our giving David the appropriate medications at the appropriate times, and getting medical care as soon as it was necessary. In some ways, the plan worked correctly.)

Right now in Massachusetts, D68 can only be tested by sending a sample to the state lab, who then has to send possible positives to the CDC for specific typing. The state lab is only accepting samples from children admitted to an ICU. Nobody else can possibly find out.

Confirmed cases means cases that have been tested positive by the CDC. Suspected cases means cases that fit the pattern, but have not been confirmed. The hospital doesn’t care about the answer for any given patient, because the immediate treatment and precautions during the hospitalization aren’t affected by the answer. The hospitals do care that they are being swamped by cases, and that most of them cannot manage severe cases in-house and have to transfer them to the few and very full hospitals who do have pediatric ICUs. Whether it’s D68 or something else, it’s a resources problem.

But when you read that there are hundreds of suspected cases in Boston, that is the tip of the iceberg. Lots of people are getting D68. Only a subset are children. Only a subset of those children have underlying asthma. Only a subset of those children go to a hospital, and only a subset of those children are admitted, and only a subset of those admitted children land in an ICU, and only that tiny percentage will possibly be tested for D68.

Among the things that health care professionals told me over the past four days in the hospital:

“D68 only infects children.” Children have greater exposures to most viruses because of their large group settings, which is why rhinoviruses and enteroviruses always spread widely when school starts. Children are also less likely to have previously been exposed to any particular virus, and therefore are less likely to have developed an immunity to it. However, we don’t think D68 has spread widely in the past 30 years, and it does appear to be spreading widely right now, so there are plenty of adults right now with exposure and no immunity. And there are plenty of adults with symptoms consistent with D68. We just aren’t testing any adults.

“D68 only infects children with asthma.” This false conclusion is based on children with asthma being the only ones who end up hospitalized from it, and the only ones tested for it.

“D68 in an adult isn’t a problem for that person because we don’t have a shortage of hospital facilities for adults.” Well, speaking for myself, I don’t really like having uncontrolled asthma or the side effects from oral steroids. And if I had to be hospitalized, the fact that I have a greater choice of hospitals doesn’t really make it less of an interruption to my life.

Some things you might like to know: D68 (or any enterovirus) can continue to be shed in stool for weeks, which makes diaper changes an easy route of transmission. Hand sanitizer is ineffective against D68 (or any enterovirus); instead you have to wash your hands with soap and water for at least 20 seconds.

Hospital admissions for kids with a virus causing asthma exacerbation have at least doubled right now because of D68. Other causes haven’t gone away, so any given admission like David’s could easily have been caused by another virus. With shared rooms, shared toys, shared playspaces, a shared kitchen, and naturally imperfect human beings providing health care, putting a dozens kids who each have a 50% chance of having D68 together for a few days is a good way to ensure that they all get D68. But we don’t have oxygen coming out of our wall at home, or continuous O2 sat monitoring at home, or a respiratory therapist coming around every couple of hours at home. So a hospital was the right place for the past several days, even if it gives us an unfortunately higher chance of repeating the experience soon.

A tech support note about a TiVo talking to a Mac

Problem: TiVo Premiere (Series 4) stopped seeing the shows that had been uploaded to a local Mac running System 10.5.7. TiVo Transfer on the Mac could still see the TiVo.

Solution: In System Preferences, hold down the Command key while clicking on TiVo Desktop. This will let you see the Videos tab. Check that the Media Access Key is correct, the TiVo Recordings folder location is correct, and that “Publish my videos” is checked. Then press the Stop button, wait a second, and press the Start button. This refreshed the TiVo’s connection to the Mac in a way that rebooting the Mac did not accomplish.

Who I'm voting for on Tuesday

Governor: Don Berwick (and please don’t vote for Martha Coakley, who is evil)
http://www.berwickforgovernor.com/issue-statement/single-payer-medicare-all

Lt. Governor: Leland Cheung
http://www.bostonglobe.com/opinion/editorials/2014/09/03/democratic-primary-endorsement-leland-cheung-for-lieutenant-governor/XyqxZCdSoiDQ0hkl1iwF1J/story.html

Attorney General: Warren Tolman
http://warrentolman.com/on-the-issues/

Treasurer: Deborah Goldberg
http://www.debgoldberg.com/visions-goals/

Congressional Rep: Katherine Clark

State Rep to replace Carl Sciortino: Christine Barber
http://www.christinebarber.org/health_care

Middlesex District Attorney: Michael Sullivan
http://www.sullivandistrictattorney.com/michaels-plan-for-the-middlesex-county-district-attorneys-office/

Any port in a storm

Since last winter, I’ve been unable to use usps.com to create shipping labels. More precisely, after entering the shipping label info, I get an error message when I try to proceed to the billing info screen: “An unexpected error has occurred. Please try refreshing the page.”

None of the troubleshooting worked, even after talking to someone in the Click-N-Ship Program Office. It wasn’t tied to the particular browser, or the Internet cache, or the particular computer, or even the particular account on usps.com. I thought it was just a problem with Macs and usps.com. After all, I could pay for labels and print them when I logged in elsewhere from a Windows computer.

Today I asked a friend to check whether she could get to the billing screen from her Mac at work, while in my usps.com account. Success, but still no joy here, until I used my phone’s data connection instead of my Verizon FiOS connection.

So something is wrong with the router configuration or Verizon FiOS which is preventing usps.com from working. Is Verizon blocking yet another port? They already screwed up my outgoing email by blocking port 25. Or is it some sort of authentication problem? Is my IP address blocked by usps.com?

I’m not sure how to figure out more about the specific problem, but at least I have a workaround now, other than going back to Comcast.

Syncope

Many years ago, I read that post-surgical recovery is sometimes easier if patients listen to music or relaxation tapes during surgery, even when they are under general anesthesia. For my knee surgery last week under general anesthesia, I put together a playlist of music that puts me in a good mood, and brought my phone and earbuds with me into surgery.

Who’s in charge here? There was the 2-person surgical team, the anesthesia team, the OR nurse(s), the prep nurse(s), and the post-op recovery room nurse(s). Most people said it was up to the anesthesia team, since the anesthesia team needs to monitor me and is up around my head. The universal response, as I asked each person in turn, was that it was ok with them as long as it was ok with other people. In the end, I went under in the OR with the earbuds in place, and woke up in recovery with the earbuds out. I have no idea when the earbuds were removed, or if the earbuds just fell out when I was transferred from the OR to recovery.

What is the objection? The universally stated concern was that the hospital staff did not want to take responsibility for the safety or security of my phone. I told them repeatedly that it’s only a phone, I was not going to hold anyone responsible, it was no big deal if it broke or disappeared, and I was happy to replace it if I needed to.

Did it help? Well, the music was certainly a pleasant distraction during the 90 minutes of waiting around the prep area before surgery. And having the phone meant I could text with Lisa while I was waiting both in prep and in recovery, as well as look up possible side effects of the first anti-nausea med they offered. I don’t know whether it helped block out the sounds or conversation during the procedure, or kept me more relaxed. I have listened to the mix since the surgery, and I’m glad that listening to the music before and (possibly) during the surgery didn’t create any aversions to the music.

Michael’s surgery mix
Sailing, The Blenders
Theme To Grace/Lament, George Winston
Holy Now, Kallet, Epstein, Cicone
Sallé, Lokua Kanza
Toda Sexta Feira, Belô Velloso
Ngwino Rukundo, Samite
I’ve Just Seen a Face, Holly Cole
Tupelo Honey, Cassandra Wilson
Farthest Field, Kallet, Epstein, Cicone
Tshona Malanga, Talisman
Ring On The Sill, Cowboy Junkies
Caramel, Suzanne Vega
Shantyboatin’, Kallet, Epstein, Cicone
Touch, Jezebelle
Hard To Explain, Cowboy Junkies
Channeling Byron, Janet Feld
The 59th Street Bridge Song (Feelin’ Groovy), Simon & Garfunkel

Making up the numbers

I've noticed that when Cigna processes hospital bills, they are now playing an accounting game to inflate the hospital charges. Here’s how that works: The hospital bills $8000 for a short stay across several line items. Cigna intends to pay $4000. What used to happen is that Cigna would list the billed line items and pay some of each line item. What now happens is that Cigna lists the billed line items totaling $8000, pays nothing on those line items, and then adds a new line item under "ancillary charge" for $4000 and pays that. This doesn't change the amount paid, which remains $4000. This just inflates the amount billed, which goes from $8000 to $12,000.

I can think of a few consequences:

• By inflating the billed amount, Cigna makes their discount look better. After all, they just saved us $8000 instead of the $4000 that they actually saved us.
  
• By grouping their entire payment under an invented ancillary charge, Cigna makes it impossible to see how much they are paying on each billed line item. That makes it more difficult for providers or customers to audit or appeal the claims processing.
  
• By inflating the billed amount, Cigna makes it more difficult for anyone to figure out how much health care costs, or at least how much it would cost without Cigna's gracious intervention.

Their slogan is "That was easy"?

The Staples near our house closed last month. The next-closest Staples closed a few years ago. The Staples that I pass by all the time in Watertown closed recently. The Staples in New Hampshire that we drove past on Sunday had recently closed.

Before the Staples near our house closed, they gave me a coupon for $30 off a $60 online purchase. I also had a Staples gift card to use up, so I went on the Staples web site and found a bunch of things I needed. The site was painfully slow. And when I went to check out, the site told me that my coupon wasn’t valid online.

So I called Staples, but their phone line wasn’t open, because nobody wants to order office supplies off hours. When their customer service line opened a couple of hours later, they confirmed that their coupon saying “not valid in stores” was only valid in the store. They offered to take the order over the phone and override the coupon, but the third item couldn’t be ordered over the phone (only on the web site).

Today I went to a third-closest Staples location, which is still open. Two items I wanted were 30% more expensive in the store than on the Staples website. Out of the five items I bought, two rang up at higher prices than the posted non-sale prices.

<sarcasm>I’m not sure why Staples is closing so many stores.</sarcasm> Personally, I use Uline for shipping supplies and Costco for most office supplies.

Legacy sales tactics

We’ve spent quite a lot of time researching cars, trying to figure out what we want, and doing some test drives. We decided on a 2014 Subaru Legacy with Eyesight late in the winter, but discovered that they had closed factory orders for the year before we made our decision. Argh.

But the 2015 Subaru Legacy was going to be new and improved! Just like every year’s new models are new and improved, but this one actually made improvements we cared about: less road noise, better fuel economy, a new color we liked better, and an upgraded Eyesight safety system that no longer required a bunch of features we didn’t need. The reviews this spring were all stellar, and the car started showing up on dealer lots a few weeks ago. On Sunday we finally found time to take a test drive, discovered that the car was comfortable and handled just like we wanted it to, and finalized the list of options we wanted and didn’t want.

So we’re doing a factory order which will arrive in the late fall, whatever that means. Shopping wasn’t bad: we had a price from the dealership where we took the test drive, and on Monday over lunch I emailed six local dealerships to ask them for a price. Almost all of them asked some meaningless question first, but three of them followed up with a price on Monday, one gave a price on Tuesday morning, and the dealer in North Reading insisted (wrongly) that we could only order a more expensive version than we wanted. We already knew the invoice price and we knew that the best we could reasonably expect on a factory order was about 2% under invoice plus a doc fee, so when the low bidder came in just under that I went over to sign the paperwork and gave them a deposit. No headaches, and all rather anticlimactic. Hopefully it will be just as easy when we pick up the car in a few months.

The dealer in Wakefield was horrible when we went there last year: unprofessional, incredibly rude to other customers, unhelpful to us, and overall seeming like an over-the-top parody of a nightmare dealership. We didn’t even consider asking them for a price. The dealer in North Hampton was overall helpful, though they tried briefly to see if we’d respond to high pressure sales tactics, tried the mysterious back office crap, were clearly used to a foursquare sheet, and tried raising the quoted price by $350 a day later. But they did quote us a perfectly fair price, and were straight about answering the few questions we had. In the end we went with the dealer in Belmont, who could not have been a bigger contrast to the dealer in Wakefield. Hard to believe they compete in the same market.

So the hard part was deciding on the car and putting up with the dealership showrooms. The actual price negotiation over email was far more civilized than I feared it might be. And in a few months, we’ll have the first new car I’ve ever owned.

Follow-up on October 5:

25 days ago, I called the dealer to ask what the timeframe looked like. I was told that our car had been built, and was on its way from Indiana to New Jersey. Once they knew when it would travel from New Jersey to Massachusetts, I would get a call letting me know that the car would arrive at the dealer in 7-10 days.

9 days ago, I noticed that a car with our specs was listed on the dealer’s web site as being in their inventory (not in transit). I called the dealer to ask about it, and was told that the web site was wrong, that our car was still on its way to New Jersey, and that I would get a call once it was ready to leave New Jersey letting me know that the car would arrive at the dealer in 7-10 days. They said that our car’s VIN was not available, but that it was not the car listed on the dealer’s web site (which had a VIN). Our best guess is that the route from Indiana to New Jersey now involves sherpas, sled dogs, and Sharknado 3 instead of rail cars or trucks.

Yesterday the dealer called (during Yom Kippur) to let me know that our car had arrived. There had been no call 7-10 days in advance, and our car’s VIN now mysteriously matched the VIN of the car listed on the dealer’s web site 9 days ago. Hmm. Had our car arrived over a week ago and they just lost track of it? Was the web site simply posting advance information? Have they been using our car for test drives for the past week or two, since they had no other cars with the new Eyesight system? Something went wrong en route, since we never got the call 7-10 days in advance. We’ll check the mileage when we pick up the car next week, but we’ll never know most of the answers.

Rainbow cookies

Fairway carries at least 3 bakery brands of lactose-free rainbow cookies: Oberlander, Delancey, and Lilly’s.

Oberlander makes some very good Passover cakes, but their Passover rainbow cookies are disappointing and their Passover black and white cookies are some odd crumbly styrofoam-based play food that bears no actual resemblance to a black and white cookie and tastes like anti-chocolate. The regular Oberlander rainbow cookies had a bland flavor and mediocre texture.

I know Lilly’s from Whole Foods. They make excellent rugelach and very nice black and white cookies (with a blue and white version for Chanukah last fall). Their rainbow cookies came in an unsliced and comically tall loaf, whose primary ingredient seemed to be dryness. There was no flavor at all.

The Delancey rainbow cookies are ok. The chocolate and fruit flavor components are a bit lacking, but the texture is very good. Compared to the other two brands, they’re delicious.

The Fairway bakery case in Stamford had two house-made rainbow cookies, one with a regular chocolate enrobing and one with a white chocolate enrobing. Unfortunately, ingredients were not available for either one. The Fairway bakery counter said that they weren’t required to provide ingredients. Well, I’m not required to buy their cookies.

Interfaith dues

Most American synagogues operate on a dues model of ensuring financial support for the congregation, where the dues are a set amount and some flexibility is available for lower incomes. Most American churches operate on a voluntary donation model of ensuring financial support for the congregation, where different people pledge and/or donate different amounts. It should be noted that both models fail to keep many congregations in decent financial shape.

I’ve long thought about and avoided the dues model for religious organizations. Most of our annual donations over the past decade have been voluntary donations to organizations which have no set expectations of us, and where we can often feel like we’re exceeding those non-existent expectations.

But now we’re joining a synagogue, and the dues are significantly higher than we’re comfortable with, so I’ve been wondering about the dues policy. I’ve also been wondering about the synagogue’s various policies towards interfaith families, and the confluence of those two mental meanderings is the difficult fact that we want to support both the synagogue and Lisa’s church. What is the right total for us, and what is the right balance for us?

When we were just two people, we made sure that our donations to my religious organization and Lisa’s religious organization were (approximately) equal. That felt right. As three people, the balance is actually much more difficult. Lisa is Christian, David and I are Jewish, so should we give 2/3 to the synagogue and 1/3 to the church? All three of us go to synagogue events, and only Lisa goes to church events, so should we give 3/4 to the synagogue and 1/4 to the church? Should we keep track of how often we actually interact with each community, and base our split on that? Or should we respect the fact that the two adults in the household are two different religions, that we respect and support each other’s religious practices, and continue to give 1/2 to the synagogue and 1/2 to the church?

The right way to think about the total is even harder for me to wrap my head around. If we are members at the synagogue, then we should financially support the synagogue in the same way as all the other members of the synagogue. But that means the total religious expenses for interfaith families are much higher than the total religious expenses for same-faith families. When people owe taxes to more than one state, there’s generally some sort of credit given by the states for taxes paid in other states so that the total tax burden is not dramatically higher than it would be if you only owed taxes to the more expensive state. Could a system like that work for a synagogue in a way that respected the obligations of interfaith families to support multiple religious organizations without the synagogue explicitly encouraging donations to a different religion?

Suppose synagogue dues are $2000, and suppose the expectation of an interfaith family is to pay a roughly equal amount to both faiths. It seems punitive to expect the interfaith family to pay $4000 in total while the same-faith family pays $2000. But asking the interfaith family to only pay $1000 towards the synagogue while the same-faith family pays $2000 risks considering the interfaith families as second-tier members within the synagogue. Perhaps a 1:3 reduction in dues for contributions to the other faith, up to a maximum reduction of 1/4 of the dues? If an interfaith family contributes $600 to the other faith, then the synagogue dues are reduced to $1800; a $1500 or greater contribution to the other faith means that synagogue dues are reduced to $1500. The interfaith family is still contributing a higher total to religious organizations and close to the same amount to the synagogue as same-faith families, while there is some recognition of the higher total being a potential burden.

Or does it just end up the same as the intimidating process that anyone with limited income faces when asking for a dues reduction, where some random people within your small religious community stick their noses into your family’s finances and you never quite feel like you’re on par with everyone else within the religious community?

Here’s how I would like to approach the synagogue dues: First, how much would we conribute to the synagogue if there were no set dues? If that voluntary amount is higher than the dues, contribute the higher amount. That was easy. If that voluntary amount is lower than the dues, can we stretch a bit and pay the dues without real hardship? That was ok. If the dues really are a hardship, then there should be a clearly-stated dues reduction policy based on some sensible factors like family size and adjusted gross income. (That’s how many governmental assistance programs work.) And then a step beyond that for families with more difficult circumstances. I just think that part of keruv/outreach to interfaith families should perhaps put a dues reduction in the clearly-stated dues reduction policy rather than in the difficult circumstances step.

Precertifications

A brand new feature of our health plan this year is that everything has to be precertified. They didn’t actually tell us about this change until they started denying claims for not being precertified.

So a doctor wants to do a blood test or order an MRI or perform a procedure or prescribe a drug. First someone from the doctor’s office has to find the right way to request that Cigna approve whatever it is. Then Cigna asks for medical records. Eventually the doctor‘s office provides the medical records, and Cigna ponders them for a week. Then Cigna may approve the medical care, or may deny the medical care. If Cigna approves it, then you can move forward one space. If Cigna denies it, well, that’s because they care.

So what happens is that medical care grinds to a halt while Cigna does nothing useful.

From my perspective as a patient, this creates a number of unsolvable problems. I’m actually the one who cares about me getting medical care, but I cannot do anything in this entire process. I cannot ask Cigna to approve anything. I can ask the doctor’s office to start the precertification process, but I am not allowed to be kept in the loop about that process. I cannot get verifiable answers to whether or when the doctor’s office has requested precertification, whether or when Cigna has asked for medical records, whether or when the doctor’s office has provided those records, or whether or when Cigna has actually approved or denied the medical care. I am not notified at any step by anyone, and I cannot receive any written answer from Cigna about any of this process. Cigna’s answers over the phone about precertifications are erratic/random/untethered to reality/completely at odds with answers they may give five minutes earlier or later.

When I beg Cigna to expedite the process, Cigna replies that the doctor’s office has to do the begging. I’ve noticed that doctor’s offices don’t like to beg. They also don’t like to wait on hold, and I have actually seen surgeons waiting for an hour or longer on hold with Cigna.

Cigna will not provide their standards of care, their criteria for approval, or their reasons for denials. When Cigna substitutes their medical judgment for the medical judgment of my doctor, Cigna will not answer any questions or recommend any alternatives.

I’m supposed to have an MRI on Friday, June 20. We scheduled it last Friday, and the doctor’s office assured me last Friday that they would take care of the precertification in time. This evening Cigna said that they do not intend to decide on the precertification until late next week at the earliest. Under Cigna’s preferred timetable, even if they approve the MRI at that point, the MRI cannot happen until mid-July. If they deny the MRI, well, that’s because they care. At which point we have to start some miserable appeals process, or just go to the emergency room.

I had thought that a major concern of health care reform was trying to shift health care away from emergency rooms. Cigna’s precertification process does not apply to emergency rooms, so it pushes care towards emergency rooms.

Both Cigna and the doctor’s offices are able to speed things up somewhat if they treat them as emergencies, which they can only do if they wait until the last minute. So they wait until the last minute, playing chicken with each other. And doing it at the last minute means that we get to plan for an MRI on Friday (take time off work, arrange child care, cancel our other plans) without knowing until Friday whether there was any point in doing that.

And of course the doctor’s office cannot schedule a phone call with the PA about the MRI results until the MRI is completed. And they cannot schedule a follow-up appointment with the PA until the phone call is completed. And they cannot schedule an appointment to talk to the surgeon until the appointment with the PA is completed. And they cannot schedule surgery until the appointment with the surgeon is completed. Just like the precertifications have to be done last-minute, all of these appointments have to be made last-minute. The doctor’s office is entirely complicit in this refusal to allow patients to make any plans, in this refusal to acknowledge that many things in life are much easier with advance planning, and are painfully difficult without it.

It’s a degrading process, and a horrible way to treat people.

Update with a case study of this particular MRI:

We told the doctor’s office last Friday that they needed to start the precertification process. Cigna says today that no precertification request was made until the following Wednesday, two days before the MRI. We have no way to know whether the doctor’s office actually procrastinated that long.

The doctor’s office told us that they sent over all clinical information yesterday. Cigna told us last night that the doctor’s office had not sent over any clinical information. We have no way to know who is lying.

Precertifications might be handled by Cigna or by Medsolutions. Last night, Cigna said that Cigna was handling this precertification. This morning, Cigna said that Medsolutions was handling this precertification. Later this morning, Cigna said that Cigna was handling this precertification. We have no way to know which is true.

The doctor’s office told us this morning that they spoke to Cigna on the phone this morning. Cigna said later this morning that this would be how Cigna knows to escalate (speed up) the precertification, but that it didn’t happen. Cigna also says that they cannot take an escalation request from the patient or anyone other than the doctor’s office, and that they cannot call the doctor’s office to confirm that the request should be escalated. The doctor’s office refuses to call Cigna again until noon. Because proving that Cigna is a bunch of lying assholes is best accomplished through passive-aggressive hostility directed at the patient who is begging you for help.

The medical guidelines for approving a knee MRI that I could find from another insurance company say to approve it for basically any suspected or known knee injury, knee malfunction, or knee pain, because it’s the best hope for seeing what is going on in the knee. Cigna needs detailed medical records because, wait, no, they is absolutely nothing that could possibly be in anyone’s medical records that would suggest that a first MRI should not be approved.

An appeal for sanity

I’m finding the financial insanity of our health plan hard to look away from. Start from the premise that the health plan covers a $6000 medication, taken every 4 to 8 weeks.

Another provider might have a negotiated price of $3000 or $9000. The providers know their list prices, but not their negotiated prices. The health plan knows the negotiated prices, but that information isn’t available to the patient. So much for the patient being able to choose a less expensive provider.

Some patients find out after a year of pointless treatment that the medication is no longer working. Leaving aside the damage to the patient’s health, the health plan has just wasted $39,000 to $78,000. There’s a test that can show ahead of time that the medication is no longer working, but that test costs $300 and isn’t covered by the health plan, so doctors often don’t order it. From both a fiscal and a medical point of view, it should be done every time the $6000 medication is given. Instead, it’s done rarely.

We can appeal the decision not to cover the test, but Cigna requires a ton of paperwork from us and from the lab and from the doctor’s office, refuses to use any information already on file, and refuses to provide any response in the end. I have a confirmation number to that effect from 6/14/2014 of 3406, which I know from experience will do me just as much good as any random number. We can supposedly ask for preauthorization for the test, but Cigna won’t even acknowledge that request (let alone approve it).

How does any of this make sense?

Defensive refills

Doctor prescribes a $2000 bottle of antibiotics. Patient cost is $10, insurance cost is $2000. (Numbers are rounded for simplicity.)

Insurance company, seeking to save money, demands prior authorization and refuses to fill the prescription until hoops are jumped through. Uncertain whether the hoops will ever be jumped through or when, and having been told that the antibiotics should be started immediately, patient grows increasingly concerned as an entire work week ticks by without authorization. When the insurance company finally approves the prescription, the patient fills the prescription and decides to get a defensive refill as well, just in case it is ever needed in the future, to avoid a risk of further dangerous interference from the insurance company. Final cost to the insurance company: $4000.

How could this cost be lowered? Well, the insurance company could skip the prior authorization, which would leave the patient willing to skip the refill if it isn’t needed. Final cost to the insurance company: $2000.

Any improvement possible over that? Well, the insurance company knows that some people only take these antibiotics for 2 weeks, so they could approve 2 weeks at a time without any prior authorization. Final cost to the insurance company: $1000 if only 2 weeks are needed.

Even if a minority of patients take the approach I described and get the defensive refill, there is still a cost to the insurance company in having the review process. The only way this makes economic sense for the insurance company is if they are denying a substantial percentage of these prescriptions. If a lot of patients get the defensive refill, the insurance company has to be denying well over half of these prescriptions. From a medical interference standpoint, it doesn’t really matter whether the insurance company is denying the prescription or if the insurance company is being such a source of frustration to the doctors that the doctors are deciding in advance to not even try to prescribe the drug that they believe is medically appropriate. Either way the patient does not get the drug their doctor wants them to take.

This is not the right way to run a health care system.

Separate meals at the same table

Feeding our family is a little tricky these days, and is continuing to evolve.

Lisa: no grains or starches of any sort, including wheat, rice, corn, potato, sweet potato, soy, beans, gums. No sweeteners other than honey. No banana, no kiwi. “Gluten-free” products almost always use a substitute that she can’t eat. Diet is basically non-starchy vegetables, fruits, meats, eggs, cheese, nuts, oils, vinegars, spices. Caveats: meat that has been injected is usually unsafe (this happens a lot with poultry), marinated items are usually unsafe, shredded cheese and nuts often have unsafe starches added, and even spices sometimes have unsafe starches added.

Michael: no shellfish, walnuts, pineapple. No dairy (including milk, cream, sour cream, milk powder, whey, nisin, and lactose). No red meat (beef, pork, lamb).

David: no tree nuts (especially cashew and pistachio), no mango, no pink peppercorn. We carry an epi-pen for him. We do not currently avoid items processed in a facility that also processes tree nuts. Peanuts and coconut are ok.

We spend a lot of time reading lists of ingredients, and we rarely go out to eat these days.
 
And here’s the biggest problem: unless you’re used to worrying 24/7 about cross-contamination issues, it’s basically impossible to avoid cross-contamination. You drop crumbs into the (no longer) safe food as you pass a roll across the table. You touch a serving spoon to a plate with unsafe food, and then put it into the (no longer) safe food. You spread mustard on a roll using a knife, and then put the knife back into the (no longer) safe mustard jar. And you won’t even notice it.
 
This is difficult for us, and we don’t want to make it difficult for other people or add to our own stress in worrying about all of this. Unfortunately, good intentions aren’t enough. These aren’t cooties or simple dietary preferences. We’d rather not discuss the gruesome medical details, and trust me that you’d rather not think about them.

We would like to be able to eat with other people. We’ve worked out specific foods that we can eat. If you want us to come over for a meal, please let us bring our own food that we can keep separate. We’d be happy to bring some for you as well if our food appeals to you, and just ask you to keep it separate. We’d like to share your table, enjoy your company, hear your stories, and share some laughs. We just cannot break the same actual bread together.

Donating prepaid cell phone balances

We’re getting rid of our old T-Mobile prepaid cell phones soon, and I wasn’t sure what to do with the balances on them. Turns out there’s a comprehensive list of charitable organizations you can donate to via text message (if I can figure out how to send a text message with an ancient Motorola V195).

http://mobilegiving.org/?page_id=43

Greater Boston Food Bank stands out to me, since we often give to them anyway.