Furnace notes

Our basement furnace heats the basement as well as the house. We like it that way, since it keeps the basement at a reasonable temperature.

Part of the way it heats the basement is through a series of 150 micro-vents in the ducts, also known as leaks. Heating contractors want to seal all the leaks and put in a normal vent for the basement, which would certainly give us more control over how much heat we put into the basement if we ever wanted to change that amount. What surprises me is that the heating contractors all claim that this will make our system much more efficient.

I think it’s because they cannot get past viewing the leaks as waste heat, even if the leaks are actually putting the right amount of heat where we want it. If the new vent puts as much heat into the basement as the old leaks, then the furnace will still be using the same amount of energy and the basement will still be receiving the same amount of heat. The system therefore cannot be more efficient.

The furnace itself is currently operating at an unknown efficiency level, which makes it hard to know how much energy we would save by replacing it with a higher efficiency furnace. The current furnace could in theory last another 10 years. The current furnace is no better than 80% efficiency, and we could get one that would be 95% to 97% efficient. That would lead to a 16% to 18% savings on our gas bill, which would have been a $300 savings last winter. Gas prices fluctuate quite a lot, and it’s hard to know what they will do over the next 10 years. Over the past 10 years, it would have meant saving anywhere from $200 to $500 per year. A guess would be saving at least $3000 over the next 10 years? If the furnace is actually 70% efficient (either because it’s older than we can prove or because efficiency drops with age), then the savings would be 60% more: a guess of at least $4800 over the next 10 years.

Sila wants $10,000 to replace the furnace and add a good filter. Papalia wants $6800 to replace the furnace, $1300 to add a great filter, and $3200 to replace all the basement ducts. Online info suggests that replacing the furnace is only supposed to cost $3000 to $4000, so I’m not sure why the quotes are so much higher.

Supporting the shul's college students

After a long time with very few children, our synagogue now has many kids, and is going to start having its first Bar and Bat Mitzvahs in a year or two. (Hold the date for David’s Bar Mitzvah, by the way: 12/14/24.)

Some of those kids may continue with some Hebrew School, but 5 years later they’ll be going off to college, and I’d like to support the kids continuing to practice Judaism at college and keep their families connected to the shul. Some families tend to drop synagogue memberships after the Bar or Bat Mitzvah, and having a sensible program for supporting kids in college might help keep those families connected for longer, particularly when finances get strained by college tuition.

Lots of organizations give scholarships to college kids, so we could look at that idea. It would have to be significantly less than the dues revenue coming in from those families, or funded separately somehow. Should it be tied to taking Jewish Studies classes?

Assistance with going on a birthright trip to Israel?

Gift certificates for Jewish books? Kids still read in college, right? The PJ Library program is great for little kids, and we could create a college version.

Care packages? Shabbat candles and candlesticks (if the college allows candles), Chanukah candles and menorahs, Passover seder kits, mezuzah for the dorm room door, apples and honey — there are lots of possible needs that could be met. Would we ask parents to cover the cost? Should the shul provide or subsidize everything? Some kids will connect with the college Hillel, which will meet most of those needs, but others won’t. Do we focus on items for the student by themselves, or items they can share with fellow students?

By the by(laws)

As part of joining the board of my synagogue, I was given a copy of the bylaws. Some items of interest to me as a Jewish parent with a non-Jewish spouse, jointly raising a Jewish child and both being active in synagogue activities:

Article III, section 1: “Any person of Jewish faith and the spouse or committed partner of such person (whether or not he/she is Jewish), who are at least 18 years of age, and willing to support the principles and objectives of the Conservative movement, are eligible to become a member of the synagogue.”

The phrase “person of Jewish faith” can include people who are not halachically Jewish under the rules of the Conservative movement. I’m happy about that, since it includes any self-identified Jew who is ok with the Conservative movement without worrying about matrilineal vs. patrilineal descent, details of conversion as a child or as an adult, bet din paperwork, etc.

Only adults are members. My child is not a member. I guess I was never a member of my shul growing up, despite having attended services religiously, having led services, having taught and tutored in the Hebrew School, having worked in the shul office, and having participated in the youth group. That seems a little odd. It feels like children should be considered members (at least non-voting members) if they are part of a family membership.

My non-Jewish wife is a member. While that contradicts the Standards for Congregational Practice of The United Synagogue of Conservative Judaism, I’m very happy about it. As the bylaws are written, she could not join on her own without me even though she has a Jewish child. The time where that seems most relevant is if I die and she wants to continue as a member, but then she’s no longer my “spouse or committed partner” and is no longer eligible for membership. Hmph.

Article III, section 1: “Members shall have the right to vote in accordance with these Bylaws.”

Great! I think there could be a reasoned argument in favor of allowing post-B’nai Mitzvah kids to vote as well, which would require acknowledging them as members, but at least my non-Jewish wife can vote.

Article III, section 5: “Only Jewish members in good standing shall be entitled to one vote at membership meetings.”

Um, wait a second. This is not an implementation of section 1. This is a contradiction of section 1.

Article V, section 10: “Only Jewish members in good standing shall be eligible to vote.”

This is just about electing officers and board members, but it’s not consistent with Article III, section 1.

Article XV, section 2: “A two-thirds vote of the members in good standing present and voting at a meeting of the Corporation shall be necessary to amend these Bylaws.”

And under Article III, section 5, that would only be Jewish members.

So Article III, section 1 is apparently meaningless. Non-Jewish members have the right to vote, but not at membership meetings. I’m not satisfied with that. I can understand saying that only Jews can fill certain roles at the synagogue, and perhaps that list could be tweaked, but not being allowed to vote? I protest.

http://www.thejewishweek.com/editorial-opinion/opinion/making-place-non-jews-our-synagogues
http://www.interfaithfamily.com/news_and_opinion/synagogues_and_the_jewish_community/Shuls_Face_Hard_Questions_about_Non-Jews.shtml
http://www.jta.org/2013/11/13/life-religion/conservative-synagogues-wrestle-with-non-jews-in-the-pews

The numbers are all approximately the same

Cigna Carelink is a problematic arrangement between Cigna and Tufts Health Plan. All medical claims go to Cigna. For claims in most states, Cigna uses Cigna’s network and Cigna’s pricing. For claims from Massachusetts providers, Cigna uses Tufts Health Plan’s network and Tufts Health Plan’s pricing. So the claim comes in to Cigna, Cigna sends it to Tufts Health Plan to process and assign a price, and then Cigna gets the relevant info back from Tufts Health Plan and Cigna generates the EOB and sends payment.

As a Cigna Carelink customer, I can only talk to Cigna. I cannot talk to Tufts Health Plan.

Tufts Health Plan has just priced a simple claim for us three times. The billed amount was $156.00 for seeing a doctor. The first two times, Tufts Health Plan priced the claim at $90.59. The third time, Tufts Health Plan priced the claim at $138.54.

When you provide the same input, you should get the same output. This is a single claim, with no change in the patient, health care plan, date of service, location of service, provider ID, procedure code, or diagnosis code. Why are the numbers changing?

This is not the first time I’ve seen erratic pricing and processing by Tufts Health Plan. I called Cigna today and asked why the pricing by Tufts Health Plan seems to be assigning random numbers. The supervisor I spoke with at Cigna said that the pricing from Tufts Health Plan is random. Too bad we weren’t on a recorded line.

Cigna cannot speak directly to Tufts Health Plan about pricing. When Cigna sends a query to Tufts Health Plan pointing out pricing problems or processing problems, the only response they have ever received from Tufts Health Plan has been “the claim processed correctly.” Tufts Health Plan has never admitted a mistake, has never acknowledged a difference in how they are processing identical claims for different dates of service, has never even acknowledged a difference in how they are processing the same claim when they process it a second or third time. The answer is $90.59. The answer is $138.54. The answer is correct, regardless of which answer it is.

Cigna claims they cannot audit the pricing from Tufts Health Plan, because they have no way to see any of the numbers themselves. They simply have to trust that it’s correct, and in turn assure us that it’s correct. Even when it clearly isn’t.

This is separate from how the pricing interacts with our deductible and our out-of-pocket maximum. That part happens after the pricing, as part of deciding how much we pay and how much Cigna pays.

Would you get away with this at your job? Provide an arbitrary answer, change the answer whenever you feel like it, and refuse to answer any questions about it?

Cigna claims that they offer this arrangement because Tufts Health Plan has a wider network in Massachusetts, and because Tufts Health Plan gets better pricing in Massachusetts. We haven’t personally run into any providers who are in-network for Tufts Health Plan and out-of-network for Cigna, and on the rare occasion that Cigna has been willing to look up their own pricing for a claim to compare it to the Tufts Health Plan pricing, the Cigna pricing has been comparable or cheaper. So why are they really doing this?

Contract, contract, who has the contract

A patient goes to the doctor. The doctor has a list price, the doctor agrees to bill the patient’s insurance, the patient agrees to pay whatever portion insurance doesn’t pay, and the doctor (being in network) has a separate agreement with the insurance company to accept the negotiated price as payment in full.

In a normal scenario, the doctor’s list price (full billed amount listed on the chargemaster) is $300, but the negotiated price with the insurance company is $200. The insurance company pays somewhere between $0 and $200, the patient pays the rest to a total of $200, and that’s the end of it.

In a screwy scenario, the doctor’s list price is $300, but the negotiated price with the insurance company is $350. The insurance company pays somewhere between $0 and $350. What does the patient owe?

The doctor can seek payment from the insurance company, and presumably is entitled to collect up to $350 from the insurance company under the terms of the doctor’s contract with the insurance company. But what exactly entitles the doctor to seek more than $300 from the patient, if the insurance company has paid less than $300?

(In a sane world, the insurance company would never agree to pay more than the list price. We don’t live in that world.)

My feeling is that when I provide the doctor with my insurance information, I am allowing him to bill my insurance and keep whatever he collects from my insurance. But the fundamental debt is mine, and the insurance company is simply helping to cover that debt. If I can owe more than the list price simply because the insurance company has negotiated an even higher price, then my relationship with the insurance company is backwards and I’m helping to cover the insurance company’s debt.

I’ve seen this sort of too-cozy relationship with auto body shops and car insurance, where the body shop feels that the insurance company is the customer rather than the car’s owner being the customer.

Suppose that the fundamental debt is mine, and suppose that the doctor cannot seek more than $300 from me, but is allowed to keep $350 from the insurance company if the insurance company decides to pay the bill in full. What if I see the doctor twice with a list price of $300 each time, and the insurance company pays $350 for the first visit and only pays $100 for the second visit? Should the amounts be aggregated? If each visit is treated separately, then I owe $0 for the first visit and I owe $200 for the second visit. If the visits are aggregated, then I only owe $150.

You know what we need? Some sort of clear rules about how all this works. I’m surprised that I’m having so much trouble finding those rules. If we had insurance regulations, those would probably address this sort of question, wouldn’t they?

Cigna refusing to pay for Early Intervention

Summary

When Cigna refuses to pay for Early Intervention services, the taxpayers of Massachusetts get stuck with the bill. This could easily be costing Massachusetts $1 million to $2 million per year or more. We had an employer-provided health insurance plan through Cigna in 2013-2014. Our child received Early Intervention services. Despite our plan documents saying that Early Intervention services were covered, Cigna denied every single claim when it was first submitted. Our experience on more than 40 claims totaling over $8000 was that Cigna consistently lied about our plan coverage in an attempt to make Massachusetts pay instead of Cigna. After more than a year of appeals, we were able to correct our claims, but that only corrects the payments for one child out of the 36,000 who are in Early Intervention. Massachusetts should investigate how many times Cigna has pulled this scam, and stop it from continuing.

What is Early Intervention (EI)?

Early Intervention is a set of developmental services provided to children from birth to their third birthday. It includes evaluations, individual home visits by social workers and developmental specialists, and group services. Each EI agency that provides EI services in Massachusetts covers a specific town or region. You can find a lot of information about EI at http://www.mass.gov/eohhs/gov/departments/dph/programs/family-health/early-intervention/family-info/about-ei.html.

Who pays for Early Intervention in Massachusetts?

Early Intervention services are sometimes covered by health insurance. Massachusetts has a coverage mandate for EI services, but that mandate is not obligatory for self-insured plans. The Massachusetts Department of Public Health pays for any costs not covered by insurance, including co-payments and deductibles. The EI provider submits claims to health insurance when health insurance is available, and then any remaining amounts are submitted to the state for payment.

What happens when an insurer like Cigna wrongly refuses to pay for EI services?

The state gets stuck with the bill instead, while the insurer (or the employer in the case of a self-insured plan) saves money. The EI provider still gets paid, and the families still receive EI services, so the state is the only party that suffers a loss.

DPH makes EI providers report when services are not covered by a commercial plan, but that process assumes that the insurer is being truthful about whether EI services are covered. This assumption that an insurer will be truthful is a huge vulnerability which Cigna is able to take advantage of.

How much money could be involved?

The most expensive month we saw was $1207.01, while other months were typically $800 to $900. From our experience, this could easily mean costs on the order of $10,000 per year for one child. In Fiscal Year 2014, there were over 36,000 children enrolled and receiving EI services. Over 16,000 had commercial insurance. The state paid over $147,000,000 for EI services, which would be on the order of $7000 per year per child on average.

As of a few years ago Cigna covered over 10% of the people in Massachusetts with commercial insurance. That could translate into 1600 children covered by Cigna who are receiving EI services. At $7000 per year per child, if Cigna is wrongly denying even 10% to 20% of those services, that would be $1 million to $2 million per year.

How did Cigna treat Early Intervention claims for your child?

Cigna denied every single Early Intervention claim that was submitted for our child. There were over 40 EI claims over the course of a year, many covering more than one date of service, and Cigna denied every claim. Our Summary Plan Description said that Early Intervention services were covered. Whenever we called Cigna, we were told that Early Intervention services were not covered. The EI provider successfully appealed a few of these denials, but they eventually gave up and started to believe Cigna when Cigna wrongly said that EI services were not covered. After we placed many phone calls appealing these denials, persisting through repeated denials and incorrect statements from Cigna, Cigna eventually reprocessed and paid these claims.

The initial claims processing from Cigna was completely consistent: no EI claim was paid on the first submission.

Was this deliberate fraud on the part of Cigna?

When an insurer shows a pattern of denying every legitimate claim, lies about coverage whenever a customer questions the denials, ignores the statements in the Summary Plan Description, and knows that a third party will end up footing the bill instead, it certainly doesn’t look good.

Was the problem with Cigna or with Tufts?

Our self-insured plan is administered by Cigna, but the claims that Cigna receives within Massachusetts are sent on to Tufts Health Plan for processing. Cigna created the Summary Plan Descriptions, we only interacted with Cigna, and Cigna consistently refused to acknowledge that there was anything wrong with these claim denials, so it looks to me like a problem with Cigna.

(It is clear that the problem was not tied to the employer, who put together a perfectly good insurance plan and chose a major health insurance company to administer the plan.)

How would Massachusetts recover money from Cigna?

1. Identify which EI claims are being submitted to Cigna and are being denied on the basis of services not being covered by the plan. This information should be known by EI providers and by Cigna, and should be collected by DPH.
2. Total up those denied claims per child.
3. Start with the children with the largest total dollar amounts of denied claims in a year. Check the Summary Plan Description or other plan documents for each child’s plan to see which plans are supposed to cover EI services. It should rapidly become apparent how widespread this pattern is, and how much money the state stands to recover from Cigna.

Who should investigate?

The Massachusetts DPH is losing money because of Cigna. The Massachusetts Inspector General might like to save the state some money. The Massachusetts Attorney General might like to put a stop to insurance fraud that directly impacts the state’s budget.

How could state laws or regulations be changed to reduce this problem?

Whenever an insurer denies a claim for EI services, the insurer could be required to provide a copy of the actual plan documents (such as a Summary Plan Description) to DPH. DPH should check the actual plan documents for each child once per year to confirm that the denial is correct.

When an insurer wrongly denies EI claims on a repeated basis, there should be clear and significant penalties assessed. An insurer like Cigna apparently needs a financial incentive to avoid defrauding the state.

Some resources about epi pens in Massachusetts schools

The law:
https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXII/Chapter71/Section54B

DPH regulations:
http://www.mass.gov/eohhs/docs/dph/regs/105cmr210.pdf

State Dept of Education:
http://www.doe.mass.edu/cnp/allergy.pdf

2015 survey for schools about epi pen use:
https://www.surveymonkey.com/s/EpiPen2015

504 plan recommended as a mechanism for ensuring allergy safety in school:
http://www.mass.gov/eohhs/gov/departments/dph/programs/family-health/directions/chap-8/504-plan.html

(And by the way, Mass DPH issues an annual report on EpiPen use in schools which always concludes with recommending that students with allergies have a 504 plan.)

Some overall info about 504 plans from the Office for Civil Rights:
http://www2.ed.gov/about/offices/list/ocr/docs/hq5269.html

How anaphylaxis works on a cellular level:
http://luriechildrens-salubrity.tumblr.com/post/118705177170/the-science-of-anaphylaxis-an-allergic-storm

Non-negotiable points for an allergy plan:
http://foodallergyconsulting.com/top-3-non-negotiables-food-allergy-plans-2/

Not happy with our Samsung refrigerator

We have a Samsung French door refrigerator. We like it. Well, we like some things about it. It’s large, it keeps our food cold, and it turns out that we really like having the freezer on the bottom.

But it’s also a defective piece of shit, and we don’t like that side of it as much.

Nothing interesting. Flames don’t shoot out the doors when you open the fridge. It doesn’t wobble its way across the kitchen and start molesting the microwave. But the glides that let the freezer drawer open broke after a year. Samsung replaced the glides, and the replacement glides stick all the time, making it very difficult to open the freezer all the way. Samsung says it’s supposed to be that way, because who wants to open the freezer?

Oh, and the door and freezer gaskets aren’t really all that strong. And food along the back wall of the refrigerator compartment tends to freeze, so you can’t use the back couple of inches of the refrigerator, but that’s ok because the refrigerator is really deep so there’s a lot of room anyway.

But the truly annoying thing is when you go to close the left refrigerator door, the one that has the little divider flap that seals up the space between the left and right doors, and the divider flap doesn’t flip itself to the right position and your door bounces back open because the divider flap won’t let the fridge door close. Until you put everything down, hold the divider flap in the right place, and carefully close the door, because that’s convenient. Every. Time. You. Use. The. Door.

Why would that happen? Well, Samsung used a crappy little spring to manage the divider flap, and that spring lasts about 16 months before snapping into two pieces. And the plastic sleeve that it goes into also breaks apart after a bit over a year. Next week we’ll be on our third of each in less than four years. So you have to keep replacing these little pieces, and apologizing to your family and friends for your defective refrigerator until the parts arrive, and explaining that no, you really don’t recommend Samsung appliances, but you also don’t feel good about throwing out a $2000 refrigerator after just a few years, so you’re reluctantly living with it.

Samsung’s attitude is telling. A one-year warranty, because most of the refrigerator parts last at least a year. (Yay?) A one-time repair out of warranty, because that gets you in the habit of repairing your refrigerator instead of demanding a refund. And then an insistence that you start giving Samsung more and more money for repairs that don’t even hold up, with the excuse that they’ve already covered repairing their defective appliance out of warranty once, and how could you possibly expect them to keep repairing their defective appliance without bleeding you for more money? I mean, that would clearly be unreasonable, because an appliance company shouldn’t have to pay for five repairs in four years. With no acknowledgment of the fact that an appliance shouldn’t NEED five repairs in four years, and that if it does need five repairs in four years, that’s their fault and they should absolutely be on the hook for repairing it or replacing it.

Not that the city website will bother to tell you

Wondering where to legally dispose of sharps (needles, syringes) in Medford, MA? Since 2012, Massachusetts has not allowed used sharps in household trash, but the state did not set up any consistent plan. Some health care facilities might take them, or perhaps you can find a friendly pharmacy or doctor’s office.

Here’s the official answer: Sharps can be disposed of either at Medford City Hall outside the Board of Health Room 311 or at the police station next to the prescription drug take-back box.

Leaving your used needles on the sidewalk next to the playground is not recommended, though it is an improvement over leaving them in the playground itself. So if you’re one of the people in our neighborhood who has been doing that, now you know.

Problem solved, right?

*Opiate addiction is a serious problem. The Medford Police Department documented 39 non-fatal opiate overdoses between January 2014 and January 2015. Armstrong Ambulance’s first responders used Narcan on 94 patients in Medford in 2014. Apparently the police do documentation about as well as they do anything else. And they still aren’t bothering to carry Narcan themselves, nor is the fire department. If you need help, please seek help. If you seek help, I hope you get it. But if you keep leaving your used needles where toddlers can get to them, I hope someone kicks your fucking teeth in.

As much fun as having your liver eaten by an eagle every day

Prometheus Labs offers some rather expensive laboratory tests, most of which are only available from Prometheus. The blood is drawn anywhere, shipped to Prometheus in California, and the results are sent to the ordering physician.

The pricing is pretty arbitrary. The first time that Prometheus does a remicade trough level for a patient, they bill $2500. After the first time, it’s just $375. There’s absolutely no justification for this sort of price difference.

Prometheus is not in network for most insurance plans. It’s not clear if they are in network for any insurance plans. They do participate in multiplan, which can reduce the bill by 10% if your insurance plan has a deal with multiplan. Prometheus does bill insurance plans, and they file appeals on (some) larger bills, but they don’t generally count on insurance companies paying them.

Our insurance has denied Prometheus claims, saying at various times that they are not medically necessary, not preapproved, or out of network. The denials are arbitrary, and we’ve been able to appeal them to have them processed either as out of network, or even processed as in network based on the lack of an in network provider who can offer these tests. The appeals process is also arbitrary and can take months (the longest so far took close to 2 years). When we tried getting a prior authorization for a Prometheus test, the insurance company waited over 3 months to give a reply, and then denied the prior authorization. In the meantime, they had already approved the actual claim for the Prometheus test. Left hand, right hand, miles apart.

If your insurance does not pay, then Prometheus will offer to reduce the bill to $250, or possibly less if your income is low enough. This can be a great deal on the first remicade trough level if your insurance applies the $2500 (or $2250 with multiplan discount) to your deductible on a high deductible plan, but you only have to pay $250 at most. Even with a $375 bill reduced to $250, you can save a little bit on your deductible. The same logic applies if you’re likely to hit your out of pocket maximum for the year. It can get complicated with in network and out of network cross-accumulations, which are very dependent on your particular insurance plan. We now know ours much better than we used to.

After years of struggling to understand how to navigate all of this, we discovered that Prometheus has a deal with a few of the thousands of third party labs and hospitals that can draw the blood to have the third party do the billing. The third party pays Prometheus and bills your insurance. If the third party is in network, all of a sudden there’s no more arguments with the insurance plan (at least in our experience). And bizarrely, it can be much less expensive than the direct billing from Prometheus, even with the discounts that Prometheus offers for moderate income patients. For one recent test, the options were $270 from insurance to Prometheus, $250 from us to Prometheus, or $100 from us to the third party (with an unknown amount going to Prometheus out of that). Quest, that wondrous nationwide megalab agglomeration, can draw blood and ship it to Prometheus and bill the insurance plan for the test as Quest, but only from some regions of the country. Ours is not such a region.

Why does Prometheus charge $2500 or $375 for the same test at different times? Why does both a $2500 test and a $270 test get reduced to the same $250 for an individual paying the claim? Why does Prometheus accept $100 or less as full payment from a third party lab, while they demand far more from an individual even if the individual offers to pay in advance? And since their prices are completely arbitrary, why not let the patient request a higher bill to the insurance company if that will help the patient?

Depending on the details of your plan and where you are personally in your plan year, you might be better off paying a $100 in-network bill, or you might be better off paying $250 while having your in network or out of network deductible reduced by a higher amount. This isn’t a path towards rational or transparent pricing for health care. It’s not even a path towards giving patients an incentive to choose the lowest price.

Keeping us in the dark (chocolate)

The FDA made a big announcement in February, right before Valentine’s Day, that they had tested 100 different dark chocolate bars which supposedly do not contain milk, and found that many of them actually did contain milk. But the FDA refused to list the specific bars that tested positive or negative for milk.

I’m a little baffled by the FDA’s continued failure to release this information. So I’m trying a FOIA request: “The FDA recently tested dark chocolate bars for the presence of milk, and announced a summary of the results: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm433555.htm. I am requesting the specific results underlying the summary: which bars were tested by the FDA (brand, flavor, and any other identifiers), and the amounts of milk found in each bar tested.”

If I get any actual information by doing this, I’ll share it here.

Sock puppets

Health insurance is all about limits. You can only see a chiropractor 20 times in a year. You can only pick up a 30-day supply of your prescribed medication. You can only see a specialist if you get a referral.

My question today is whether there should be any limits on the health insurance company? I’d like to cap the number of lies they can tell at a reasonable number, and require them to go through a medical review before telling more lies.

This morning’s example: Cigna denied a claim from March 3, 2015, because of a lack of precertification (prior authorization, prior auth, PA, precert, it’s important to keep shifting the terminology). But we had a precertification approved by Cigna last year, valid until April 14, 2015. When asked this morning, Cigna said that the precertification did not exist. Then Cigna said that the precertification had never existed. It took some forceful arguing before they were willing to admit that the precertification actually was on file exactly where it was supposed to be in their system, and that Cigna needed to approve the claim. But nowhere in there did the Cigna rep think there was any problem with her script or training requiring her to lie repeatedly, nor did she think that there was any good reason for me to be aggrieved about being lied to.

I think there’s a way to fix that. Require that all health insurance companies keep records of all communications with customers, including recordings of phone calls, along with all notes made by CSRs. Customers should have full access online, the same way that I can access claims information. (Right now, I theoretically have the right to get copies of those notes, but it requires notarized mailed paperwork, months of waiting, and an incomplete reply on disorganized printouts.) Then establish a Consumer Health Insurance Protection Bureau modeled on the Consumer Financial Protection Bureau, whose complaint system works quite smoothly for simple problems. Along with straightening out simple problems, the CHIPB could have a swear jar with a set penalty for each time the health insurance company lies to a customer in a recording or in their own notes. Maybe $20, with half going to the CHIPB budget and half being given to the customer? And a higher penalty for the health insurance company “losing” recordings or notes.

At the moment, Cigna doesn’t care whether they lie to a customer about a precertification, or about whether a procedure or medication is covered, or about whether a provider is in network, or even about what they themselves have said within the same conversation. Cigna loses nothing for lying, so over time they lie more and more. That needs to change.

If we ever shift to single-payer, we’re going to have a reintegration problem for health insurance company employees. We’ll have to train them not to lie, not to erase records and evade responsibility, not to see the customer and the provider as enemies. Because having thousands of Cigna reps working in Target without a lot of retraining is going to be hell on everyone. What, you want to buy socks? There’s going to be a waiting period for that, you can only buy 1 sock per week, we’ve never sold socks, the socks that your wallet covers are only available in a single store in New Hampshire, you have to prove that you tried stockings and those didn’t work, and the price for the socks will be randomly assigned 3 to 12 weeks after you’ve worn them.

Release your wrath

A friend came over yesterday to talk about one of the most problematic passages in the traditional Passover haggadah where we ask God to pour out His wrath:

Pour out Your wrath against the nations that know You not, and upon the kingdoms that call not upon Your name; for they have consumed Jacob and laid waste his habitation. Pour out Your rage upon them and let Your fury overtake them. Pursue them in anger and destroy them from under the heavens of the Eternal.

After much of the seder, after the festival meal, after much reading and singing and talking, after the third cup of wine, we fill the fourth cup, open the door for Elijah, and let loose with that righteous anger. It’s quite the contrast to when we start telling the Passover story early in the evening and say “All who are hungry, let them come and eat. All who are needy, let them come and celebrate the Passover with us.” But we don’t open the door for that part.

Who is the righteous late-evening anger directed against? Surely we are not asking for vengeance against the non-Jews who are at our seders and in our families, nor our actual non-Jewish neighbors with whom we just shared roof rakes and calcium chloride in the midst of a record-setting winter. But ritual language does not just express what was in the hearts of those who wrote it. It shapes how we see ourselves, every one of us who recites and hears those words. It shapes how others see us. And it shapes how our children come to understand who we wish for them to become.

An unbroken continuation of this anger is not what I wish for my son.

My friend’s haggadah had replaced this passage with a Holocaust remembrance passage before the door is opened for Elijah:

On this Seder night, we recall with anguish and with love our martyred brothers and sisters, the six million Jews of Europe who were destroyed at the hands of a tyrant more fiendish than Pharaoh. Their memory will never be forgotten. Their murderers will never be forgiven.

Trapped in ghettos, caged in death camps, abandoned by an unseeing or uncaring world, Jews gave their lives in acts that sanctified God’s name and the name of His people Israel. Some rebelled against their tormentors, fighting with makeshift weapons, gathering the last remnants of their failing strength in peerless gestures of courage and defiance. Others went to their death with their faith in God miraculously unimpaired.

Unchecked, unchallenged, evil ran rampant and devoured the holy innocents. But the light of the Six Million will never be extinguished. Their glow illumines our path. And we will teach our children and our children’s children to remember them with reverence and with pride.

We invite the souls of all who are missing, the souls of all who were snatched from our midst, to sit with us together at the Seder. This invitation was uttered by Seder celebrants in the Vilna Ghetto in 1942...and we repeat it tonight. For on this night all Jews are united in history and in hope. We were all in Mitzrayim. We were all at Sinai. We were all in the hell that was the Holocaust. And we will all be present at the final redemption.

While I like it as a personal reading, it feels too long for the haggadah. So too does my haggadah’s version of the fifth child, the child of the Holocaust who did not survive to ask a question.

Faith should be stronger than hate, and the impulse for peace should be stronger than the desire for vengeance. That may not be true in the moment, but the haggadah is a durable statement of remembrance and hope. So here’s my new plan for after the third cup of wine, shortening and refocusing the Holocaust reading, and replacing the traditional wrath and fury paragraph:

After the third cup, pour the fourth cup.

On this Seder night, we recall the six million Jews of Europe who were murdered in the Holocaust. Their memory will never be forgotten. We draw inspiration from the strength of Jews who held onto their faith and celebrated Passover in the Vilna and Warsaw ghettos and all over Europe even as their communities were being destroyed.

In their names, we invite the souls of all who are missing to sit with us together at our Seder. For on this night all Jews are united in history and in hope. We were all in Egypt. We were all at Sinai. We were all in the Holocaust. And we will all be present at the final redemption.

Open the door for the prophet Elijah. All rise.

We do not know when the final redemption will come, but we open the door for the prophet Elijah at every Seder with hope. We work to cast aside wrath and fury, longing for Isaiah’s description of the time to come when violence shall no longer be heard in our lands. Never again let us be slaves, and neither let us be the taskmasters to others. Let us strive for peace and justice so that we may hear Elijah announce the coming of the Messiah.

All sing Eliyahu hanavi.

That’s what I want to teach my son. Remembrance and faith, connections through the generations, and hope made real by the work we must continue to do.

Distributing the herd

Because of the spreading Disneyland measles cases, there’s been a lot more national conversation about vaccination, exemptions, and herd immunity.

Vaccinations aren’t 100% effective, and populations aren’t 100% vaccinated. Herd immunity protects the unvaccinated as long as the vaccination rate is high enough overall, because there aren’t enough new people for a sick person to infect for the disease to keep spreading. However, our herd immunity to measles is visibly facing two challenges: declining vaccination rates and clustering of unvaccinated populations. An insufficient herd immunity means that parents who choose not to vaccinate their children are endangering lots of other people in addition to their own children.

We have to allow medical exemptions to vaccination, because of allergies and certain medical conditions that would make the vaccine unsafe for those people. A tiny fraction of people claim a religious objection, but an increasing number of people are claiming a nebulous “personal beliefs” exemption. And because those personal beliefs are spread through personal conversations between parents and local peer pressure, there are clusters of people refusing vaccination for their children.

Requiring that parents consult a (hopefully sane) pediatrician and get the pediatrician’s approval before being allowed to opt out of vaccination is a reasonable step, but it doesn’t go quite far enough. There are pediatricians who are willing to go along with skipping vaccinations, as well as many who are not. We need to limit how many exemptions an individual pediatrician can hand out, and setting that limit to the percentage that would preserve our herd immunity is the only safe approach. If we need 97% of people to be vaccinated against measles in order to preserve our herd immunity, and a pediatrician has 1000 patients, the pediatrician should only be allowed to have a maximum of 30 patients who skip the measles vaccination. If you’re the 31st patient and you really want to skip the measles vaccination, you’ll need to find a different pediatrician.

This approach makes it more difficult for parents who want to skip vaccinations for their children, at least until this anti-vaccine nonsense dies down. Good. It should be difficult to endanger other people. This approach prevents pediatricians who don’t have the courage to stand up for their medical training and their other patients from causing too much damage by handing out obscene numbers of exemptions. More importantly, it forces some distribution of the unvaccinated. And forcing the unvaccinated to step away from each other is an important step to take.

Water, water, everywhere

Yesterday our water heater tank failed, leaking water onto our basement floor. The water and mold damage nearby suggests that some leaking started over a week ago.

Step 1: Turn off the incoming water supply. And eventually turn the water heater control knob to off as well, though we should have done that sooner.

Step 2: Get the water heater replaced. A direct replacement would be a 50 gallon gas water heater with chimney venting. A potentially better replacement for us would be a power-vent (aka direct-vent) version, but that would require adding some PVC vent pipes.

The water heater was still under warranty with Sears, so they were my first phone call. After an hour on the phone, I learned the following: Sears was grudgingly willing to admit that I had a warranty, but I would have to pay Sears $79 to have a technician come out in five days to look at the water heater and deem it in need of replacement. At that point, I would have to pay Sears $280 for installation of the replacement, plus $75 for a permit fee, plus unknown other amounts for other unspecified charges, and then Sears would decide when to install a replacement. Which could be weeks later. Total cost: $434 plus. Total time to new water heater: minimum of 1 week, probably 2-4 weeks.

Our furnace maintenance company was here yesterday morning, so their office told their salesman Jason to give me a call about having them replace the water heater. Jason told the office that he would call immediately, but did not actually call until 25 hours later. He had no pricing. That was ok, because I had told their office late yesterday afternoon to have another salesman actually get in touch with me. That salesman did call yesterday, and quoted me $2300 for a direct replacement or $3100 for a power-vent replacement. They could install next Monday or Tuesday, maybe, but definitely sometime next week.

Home Depot could do same-day installation, according to their web site. They actually could not install until next Tuesday at the earliest. Could not do a power-vent replacement, and would cost about $1400 to install a direct replacement. Since the water heater is only $600 in the store, that’s $800 for installation by their poorly-rated local contractor.

Independent top-rated plumber #1 required photos and time before quoting a price. He estimated $3200 for a power-vent replacement. Getting a quote on a direct replacement took until after 5 pm. The quote was $1325 with a 6-year warranty, with installation on Saturday. It would have been another $250 to bring that to a 10-year warranty, but the plumber said he would not recommend that since he thinks it’s the same water heater with a different label. Fastest turn-around time, and a reasonable price.

Independent top-rated plumber #2 did not answer his phone and never called back.

Lowes could do next-day installation, but their phone rep was fuzzy on numbers and dates and recommended going to the store. So we went to the local Lowes in the late afternoon and ordered an $1100 direct replacement, including the $600 water heater and installation. They’re installing the replacement on Monday morning. It would have been another $250 to do it on the weekend.

Warranties are weird on tank water heaters, especially since they’re all made by a couple of companies and then rebranded to lots of different name brands. From a plumber, you get either a 6-year or 10-year warranty. In a big box store, you get 6, 9, or 12 years. Some places claim the primary difference is in the tank lining or insulation or construction, others claim it’s entirely about the anode rod. One guy said there actually was no difference. But there’s no labor warranty on any of them after the first year, and labor is a huge cost component. We paid an extra $115 to Lowes to get a 12-year labor warranty, so hopefully this is the last expense we have from the water heater for a while. I’m guessing there’s a greater than 25% chance that the water heater will need to be replaced in less than 12 years, in which case the warranty was statistically a good deal for us. And as a purely labor warranty, it’s one of the few cases where the insurance math can work out well for both parties, since I pay retail for labor without the warranty but they pay wholesale for labor with the warranty.

A direct replacement, just for the tank itself, would be $400 to $600. The installed quotes ranged from $1100 to $2300. A power-vent replacement, just for the tank itself, would be $900, and would require about an hour or two of additional labor and $50 of PVC. The installed quotes were $3100 to $3200.

And now we can go back to throwing out the ruined lumber that was stored too close to the water heater.

Update a few days later: Lowes showed up with a water heater that needs a power outlet for no apparent reason. Shouldn’t be a problem since there’s an available outlet right there, except for the installers claiming that it also needs a dedicated circuit. So they left without replacing the water heater.

Meanwhile the condensate pump on our furnace’s humidifier leaked water all over the floor last night, just like the water heater had previously. Hmm. Maybe it was the condensate pump all along. We had asked Central Cooling to check the condensate pump last week, and they had told us that the pump was fine and that the water heater was to blame. But now there’s a new condensate pump in place, this time with a wet switch so it should turn off the humidifier if it overflows, and our old water heater is back in service while we keep an eye on everything and our wet vac at the ready.

I can’t believe that just one malfunctioning device, or possibly two, could make Central Cooling, Sears, and Lowes all look bad. But none of them did what they should have done. Central Cooling didn’t adequately check the condensate pump, and even told us today that they could have changed things around last week really easily so that we wouldn’t have had today’s mess. Sears showed me that their warranty is useless. And Lowes either sold me a water heater that they couldn’t install (and they knew that our previous one didn’t plug in) or sent installers who refused to install a water heater for no good reason. And I’m still throwing out lumber. And carpeting. And a power tool. And some furniture.