Last Valentine’s Day, the FDA issued press releases about having found milk in a lot of dark chocolate samples that they tested, including some that claimed to be dairy-free or vegan as well as in a lot that claimed to only have traces or a risk of milk from shared equipment. I submitted a FOIA request to ask for details, and last spring the FDA put up a lot more details at:
http://www.fda.gov/Food/IngredientsPackagingLabeling/FoodAllergens/ucm446646.htm
However, this didn’t include the actual brands and manufacturers of chocolate that they tested. It just included internally-assigned ID codes. After some pushing they sent me the list of codes for the report they put online. I’m not sure this has been publicly released before now.
A few of the FDA’s results stand out to me, as a concerned consumer. I was sad to see that “Ghirardelli SemiSweet Baking Bar” and “Ghirardelli 60% Bittersweet Baking Bar” both had more milk than two of the chocolate bars that listed milk as an actual ingredient, but better safe than sorry. “Rescue Chocolate 66% Dark Chocolate” claimed to be vegan on the packaging, showed no warning about milk, and contained milk. “Ethereal Confections; 66% Cacao, Strawberries, Rose Petals, Pink Peppercorns” and “Oskri Almond Dark Chocolate Bar” claimed to be dairy-free or lactose-free on the packaging, showed no warning about milk, but contained milk. And most of the chocolate bars tested that had warnings about shared equipment or possibly containing traces of milk, while not listing milk as an actual ingredient, in fact did have milk in them. Some of them had more milk than chocolate bars that listed milk as an actual ingredient.
Here you go, world:
Related to http://www.fda.gov/Food/IngredientsPackagingLabeling/FoodAllergens/ucm446646.htm
Tuesday, October 27, 2015
Milk in dark chocolate, brands tested by the FDA
Saturday, October 24, 2015
Jump on in
There’s a poster up at my synagogue which reads:
GET SCREENED!
YOUR GENES MATTER...
1 in 4 Jews is a carrier for at least
1 of 19 Jewish genetic diseases
Jewish genetic diseases are preventable. All it takes
is a simple blood test to find out if you are a carrier.
Yup. They’re also preventable by widening the gene pool. You know what does that? Being welcoming towards interfaith families.
To the thought leaders of the Conservative movement, intermarriage violates Jewish law. But life and health are more important than observing Jewish law, which is why we are required to violate the Sabbath to save a life, why we are not supposed to fast on Yom Kippur if it will make us ill, etc. Why is this different? Jewish genetic diseases are a solvable problem, which over half of Jews getting married today are already solving by marrying someone with different genetics. This should be celebrated!
So here’s my new poster text:
GET SCREENED!
YOUR GENES MATTER...
1 in 4 Jews is a carrier for at least
1 of 19 Jewish genetic diseases
Jewish genetic diseases are preventable. All it takes
is a larger gene pool, so let’s welcome interfaith families.
All fixed.
Friday, October 23, 2015
I paid for this back seat driver, so I want my money’s worth
Have you ever had some electronic equipment get bogged down over time? It happened to our Garmin, which after some years of use started to get slower and slower at giving directions. It started to tell us to turn after we had passed turns, instead of before the turn.
It’s mildly annoying when it happens to a Garmin, which you can replace. It’s more worrisome when it happens to your Subaru’s Eyesight system, which is a suite of safety software built into the car. One of the features is a lane departure warning, which beeps when it notices you cross a lane marker without having your turn signal on. Over the course of 10,000 miles, the Eyesight system gradually stopped noticing so often that we were crossing lane markers, and it wasn’t because we had suddenly become more precise drivers.
Around that time, Subaru posted a recall for the Eyesight system for an unrelated bug, and our Eyesight system got reinitialized. Hey, look, the lane departure warnings are back! This seems like good confirmation that the system had stopped working correctly over time.
But Subaru doesn’t seem to have any standardized testing approach for the lane departure system, so they have no way to verify with any precision what was happening. The dealer’s mechanic took it out for a test drive, and he got it to beep, so it must be fine. That’s not exactly comforting when you think about how complex the code must be for this system. And other parts of the suite of safety software are actually intended to change the speed of the car autonomously to avoid accidents, so it would be nice to both trust the software and verify that it’s working.
Someone needs to take a Subaru with Eyesight at 0 miles driven and compare its responsiveness to a Subaru with Eyesight at 20,000 miles driven since the last software reinstall or reinitialization. Try crossing a variety of stripes at different levels of wear or fade with both cars, and see whether both cars alert equally. We don’t expect the system to be perfect, but we do expect it to keep working the way it worked when it was new. And I hope that Subaru would not just expect the same, but would test that the system met their and our expectations. Self-driving cars will be a lot less fun if they only work correctly for a year or two.
Friday, October 2, 2015
Silence = EpiPen
As David’s parents, we need to communicate with other people about his life-threatening allergies. We need to tell people what his allergies are, and what the best steps are to keep him safe. We need to do this when people come to our house or when David goes to someone else’s house, when we leave David in someone else’s care, when we sit down at a restaurant, when we plan to share a meal with someone, and when David goes to school. Any failure on our part to do that is a risk to David’s life and health.
Yesterday the preschool director tried to tell us not to do that. She apparently feels she has the right to stop us from communicating with other parents about our son’s life-threatening allergies. That is wrong.
She can offer to help. She can provide us with contact info for other parents in the classroom. She can offer her advice and expertise as someone who regularly deals with the parents of 100 preschoolers about how best to communicate the necessary information. She can reinforce our message, and she can add her voice. She can offer to lend her voice of authority, and she can offer to substitute her voice of authority to better convey the needed message. Offer, not demand.
But she cannot try to silence us.
Leave aside her duty of care to the children in her preschool. Leave aside the fact that it is widespread practice for preschools themselves to communicate with parents about classroom allergies, and that she refuses to do that. That’s a separate failure.
When she tries to stop us from communicating with other parents about David’s life-threatening allergies, she raises the risks to David. She also makes us more reluctant to speak up about his allergies, which is the opposite of what every pediatrician and allergist and child psychologist recommends. That in turn makes it harder for us to teach David to speak up about his allergies himself, which every pediatrician and allergist and child psychologist will tell you is what David needs to learn to do in order to keep himself safe.
When other parents come to her with questions or doubts about David’s allergies, she has an obligation to either forcefully agree with our message or to ask those parents to talk with us directly (which is actually part of our message). If she contradicts our message, she is crossing the line from irresponsible to dangerous. She did not tell us how she actually responded to those parents, but her willingness to try to silence us does not inspire confidence.
I won’t be silenced when David’s life and health are at stake.
Lisa thinks we might have educated this preschool director, that she might have learned something from us. I hope that’s true. Because if it’s not true, I need to spend far too much time trying to find a new preschool for David and trying to find a new director for this preschool.
Thursday, October 1, 2015
Not a good start to the second year of preschool
At the start of the school year, we spent hours crafting a letter from us to David’s classmates’ parents asking them to please be careful about tree nuts and mango at preschool to help keep David safe. (He is 3, and is unable to fully advocate for himself or keep himself safe.) We included all of our contact info, and we asked the preschool director for email addresses for the other parents so we could send it to them. She refused, and insisted on emailing it out herself. She didn’t send it out before the first full day of school, so we printed it out and asked the teacher to send it home with all the kids. Even if it had gone out by email, it seemed like a good idea to do it on paper as well, since email isn’t perfectly reliable.
The director finally emailed our letter to all of the parents after the second day of school had started, after we told her that we would have to remove David from the school until we knew the other parents had actually been contacted. She included our cover note asking her to send this out on our behalf.
Not a single other parent contacted us. No questions, no complaints, no reassurances, nothing.
Today the director told us that she had multiple other parents complain to her about our letter. The director was angry with us that we had sent a note to other parents without having her review it (the same note that she had reviewed and agreed to 2 weeks ago). She was also angry that “we” had put stickers about David’s name and allergies on various pieces of paper outside his classroom. Those were stickers we offered to the teacher in case she needed to label David’s possessions, the same stickers that we used on his possessions all of last year at this preschool, and that the teacher decided to plaster all over the place 2 weeks ago. The director, who prides herself on knowing everything that happens at the 7-classroom preschool, hadn’t noticed for 2 weeks, and had decided incorrectly that it must have been us doing it yesterday.
Back up a little. On the visit day before the first day of preschool, we heard the teacher tell other parents that there were no kids in the classroom with allergies. We had to vocally correct her, but many of the other parents had already left and we don’t know if the teacher had told them the same thing.
This was the same visit day where they refused to put David’s classroom EpiPen in the classroom with him that day. (Their broken protocol is to put it in the classroom after the visit day, before the first full day.)
When we asked the teacher in the first week of school for details about how they handled food in the classroom, the teacher responded by telling us to trust her.
When we asked the teacher on a different day about checking the lunches of the kids sitting next to David, she told us that she doesn’t have to because she knows that every parent was told about David’s allergies, and besides the school is peanut-free. (Peanut is not one of David’s allergies, so that doesn’t actually convince me that she even knows what his allergies are.) And she repeated that I was supposed to just trust her instead of asking any questions.
Yesterday, as part of a 2.5-hour appointment with the doctor who heads the Boston Children’s Hospital food allergy program, we reviewed with that doctor what we guessed were the necessary classroom protocols to keep David safe (hand-washing, checking lunches of adjacent kids, etc.). He added some things we hadn’t ever thought of, and we typed it all up and gave it to the director this morning. She blew a fuse, telling us that she didn’t trust the list because it wasn’t signed by the doctor, that the school did everything required by the state, that she couldn’t possibly do everything on the list, and finally decided that they already did everything on the list. She listened as we tried to explain that we can’t know what they do or don’t do on that list if they don’t tell us, that the teacher had been substituting demands of “trust me” for actually telling us what they do in the classroom, and that the teacher had specifically said that they were not doing some of the things on the list. She then dragged the teacher into the office to have the teacher reassure us about what they actually do in the classroom, and the teacher was very concerned that we had not simply trusted her.
It’s the same director as last year, when the school seemed to have perfectly good protocols and good communication and well-trained teachers. Every school year is different, apparently. And while I’m sure we finally have the director and the teacher paying attention, it now appears we have classroom parents who are deeply offended by someone else having life-threatening allergies. As if this is something we chose.
There are a huge number of people who complain bitterly about their child being deprived of the right to eat whatever they want wherever they want, just because of some other child’s silly life-threatening allergy. It's an astonishing level of self-absorption and self-centeredness. It’s disturbing that we have some of those people as fellow parents in David’s very small class, but we’re unlikely to fully escape them anywhere we go. We were just lucky last year.
Do we start over at a new preschool, pulling David away from all his friends, hoping that a new preschool will behave better and have more civilized fellow parents? A new preschool will have more parents, none of whom know David or us, and an entirely new set of communication challenges. And it will take us a long time to learn whether it’s actually a good fit for David socially and intellectually, which this preschool was last year.
This is all exhausting. It should have been one conversation at the start of the school year, with the school then communicating with the other parents and the teacher telling us exactly what protocols they follow around food. Instead it’s been an endless struggle, and that’s baffling.
Thursday, September 17, 2015
Possible foods for kiddush
Here are the rules: No nuts, no mango, all kosher. This list should grow over time.
Kosher brands to buy
Food Should Taste Good (Whole Foods, Costco): no nuts, all kosherhttp://www.foodshouldtastegood.com/about-fstg/faq/view-all-faq/products
Treasure Mills School Safe (Whole Foods): no nuts, all kosher
http://www.treasuremills.com/about-us/plant-certifications/
Kosher brands to avoid
Entenmann’s: nut cross-contamination known in all productsAllergies and trust
Friday, August 28, 2015
Dear Abby, my playground is a wreck!
Playstead Park is today in the condition that Cummings Park was in six years ago: graffiti, vandalism, broken equipment, trash everywhere. The discussion about it on Facebook is heartbreaking. Many people want the playgrounds maintained, want the damage fixed, and want the vandals caught and punished. None of those people work for the City of Medford.
The police department is responsible for preventing the vandalism and catching the vandals. They refuse to patrol the parks, refuse to install video cameras, refuse to send officers when they are told that vandalism is occurring, and refuse to investigate. Whose fault is that? It’s the fault of the individual officers who refuse to do their jobs, the police administration who refuses to exercise any control over the police department, the mayor who oversees the police department and sets the city budget, and the city council who approves the city budget. If you want this to change, show up at community police meetings on the first Wednesday evening of every month at the police academy and say that you want the police to start doing their jobs. If you want this to change, take photos of the damage and show up at City Hall, demand to speak to the mayor, and tell him that you demand he instruct the police to start taking care of the parks.
The parks department is responsible for repairing the damage and maintaining the parks. The head of the parks department is Mike Nestor. The parks department is part of the Department of Public Works (DPW), and they all report to the mayor. The parks department does not repair most damage and does not maintain the parks. Whose fault is that? It’s the fault of the mayor and the city council, who jointly control the city budget. Many DPW employees are well-intentioned and hard-working, but the department is understaffed, underfunded, and has been given other priorities. If you want this to change, call DPW every day with complaints about specific damage at specific locations in the parks. If you want this to change, take photos of the damage and show up at City Hall, demand to speak to the mayor, and tell him that you demand the parks department start taking care of the parks. If you want this to change, do not vote for any incumbents on the City Council.
What can you do today? Voice your displeasure to City Hall. Call the mayor, call DPW, call the police, call every member of the City Council. Be clear, firm, and specific about what you want them to do. Keep calling until you get what you want.
What can you do on Tuesday? Vote, and do not vote for any incumbents for City Council. The current City Council is fully aware that the parks are not maintained and they are comfortable with that. We need a new City Council.
What can you do in the longer term? Keep voting, and do not vote for anyone who has held public office in Medford recently. Encourage new people to keep running for office, and pray that we get someone new to run for mayor in 2017, since 2015 is just a race between a current member of the City Council and a former member of the City Council. Support an override to increase the city budget to invest in our city. Support a change in the city charter so we do not leave all of the power in the hands of the mayor with no power in the hands of the residents.
DPW can repair equipment, can clean the parks, and can also hire contractors to do both of those tasks. The mayor can ask the county sherriff’s graffiti removal unit to come remove graffiti. (There’s no charge for that, and it baffles me that the mayor refuses to use their service and instead leaves our city covered in graffiti.) The police can patrol the parks, can remove people at night when the parks are closed, and can arrest people they catch vandalizing the parks. These things are all possible, but they will not happen routinely until the city government changes.
I’ve done everything a resident can do. I’ve called the fire department when items in the park were set on fire at night, which used to happen with surprising frequency. I’ve called a homeless services agency when a homeless person started staying in the playground. I’ve called DPW and the parks department, I’ve emailed DPW and the parks department, and I’ve shown up at DPW in person. I’ve gotten a mix of rude answers and polite brush-offs, and occasional action when I’ve emailed Mike Nestor. I’ve shown up at police community meetings, spoken with individual police officers and police administration, and called the police when I’ve seen vandalism occurring. I’ve gotten a mix of rude answers and polite brush-offs, and occasional promises of increased patrols that rarely actually happen. I’ve been cursed at by police officers on the phone and threatened by police officers in person. I’ve gone to a Parks Commission meeting, which was utterly useless for action on playgrounds. I’ve contacted the county sherriff’s graffiti removal unit directly, obtained the form for requesting their services, filled it out and given it to City Hall to act on. That last action embarrassed the city into actually removing some graffiti themselves. Once.
My one real success was around six years ago. After over a decade of complete neglect of Cummings Park by the city, which was in at least as bad shape as Playstead Park is today, I went to City Hall. I brought some large color photos of the damage, and demanded a meeting with the mayor. He called in the head of DPW and the police chief, and we all sat around a table while I laid out their decade of neglect, showed them the results in color, and told them that it was simply unacceptable. They acted surprised and appalled, and within a week at the order of the mayor, DPW repaired and replaced the broken equipment and broken structures, and the county sherriff’s graffiti removal unit came in and removed the graffiti. The police actually responded to a few phone calls in a professional manner for the first time in over a decade, and explained to a number of teenagers that the playground was no longer an acceptable place to drink and do drugs at night and that tearing apart the park equipment was no longer an acceptable activity. That turned out to be enough to turn things around. Within the next couple of weeks, little children started using Cummings Park in far greater numbers. (It used to be largely abandoned during the day, and with good reason.) Parents started contributing toys and play structures to the playground. (This had not happened in over a decade, but it started then and has continued for the past six years.)
The cost is that we have to keep volunteering our time. We have to call the police, clean up garbage, call DPW for continued maintenance, report damage and graffiti and vandalism, throw out toys that are broken beyond usefulness, and trim weed trees. We have to put up with frequently unprofessional and hostile responses from the police and DPW, and put up with complaints and threats from the minority of neighborhood residents who would prefer to see the park go back to falling apart. But we’ve seen how bad it can get, and we’ve seen how much better it can be, and we made our choice. Any parent in Medford knows (or should know) Miss Andrea at Medford Family Network. She runs playgroups that go around to all of the city parks, and if you ask her, she will tell you that all of the parks need that sort of care and attention from neighbors.
A functional city government would not rely so heavily on us to do their jobs. But that’s not the city government we have, and it won’t be until more Medford residents wake up, realize that the deplorable condition of much of our city is not inevitable, realize that the unprofessional and hostile way that city agencies interact with residents is not inevitable, and demand both a change in attitude and increased investment in our city.
The city could make Playstead Park look ten times better tomorrow (and will if you scream at the mayor loudly enough), but until enough neighbors take on enough responsibility themselves and/or the city government changes, it will all be torn apart again in a matter of weeks or months.
Thursday, August 20, 2015
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.
Sunday, August 2, 2015
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?
Wednesday, July 22, 2015
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.
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.
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
Wednesday, May 27, 2015
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?
Wednesday, May 20, 2015
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?
Sunday, May 10, 2015
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.
Friday, May 8, 2015
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/
