Friday, June 20, 2014

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.

Wednesday, June 18, 2014


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.

Saturday, June 14, 2014

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?