Monday, February 16, 2009

A Kaiser Foundation Misstep on Employer-Based Coverage for Cancer Care

How unfair. But it works.

Want to attack any process with a track record that is pretty good, considering the circumstances and alternatives? Look for individual instances of shortcomings and vaguely generalize them, making it appear that things are far worse than they really are. Given the complexity of insurance benefit designs and cancer coverage, the topic is perfect for this type of gamesmanship. And this is exactly what the Kaiser Family Foundation and the American Cancer Society (ACS) did here. By lining up 20 cancer victims who got tangled up in insurance benefit designs, the unsuspecting reader would conclude that when it comes to cancer, commercial insurance companies are either hopelessly broken (‘individuals may not be protected from high out-of-pocket costs’) or evil (force patients to ‘incur debt in order to pay for care…. or forgo or delay lifesaving treatment’).

The Disease Management Care Blog is not saying that each breakdown isn’t heart breaking or an opportunity to learn from mistakes. While this makes for a good narrative, this is not how to make good policy about the interlocking roles of deductables, cost sharing, out of network tiering, annual limits, lifetime limits and minimal coverage designs in the evolution of healthcare reform.

The truth is that faced with unrestrained medical costs, the vast majority of employers are successfully coming up with creative and functional health insurance designs. Without such creativity, there is either no health insurance for their employees or no staying in business for their customers. While the insurance may thin out, the fact is that for every example described in this Kaiser Foundation report, there are many other unseen examples of individuals who were able to use perfectly adequate insurance to access cancer screening and treatment. That piece of good news went decidedly unmentioned.

Instead, Kaiser and the ACS used anecdotes in combinations of highly unusual and lethal diseases requiring highly unusual treatments under highly unusual insurance designs. Toss in overpriced screening tests, docs cancelling their insurance contracts and rare employer stupidity, and you have biased report tilted away from locally controlled State-regulated or HIPAA protected employer-based insurance. That’s not necessarily bad, says the DMCB, but us citizens can’t rely on biased reports like this one to make an informed decision about the alternatives of a) greater State or Federal regulation, b) developing a tax-payer supported Federal insurance plan with first dollar coverage, no deductables, no coinsurance and no lifetime limits or c) a single payer system.

A rare Kaiser Foundation misstep.

Well, the DMCB to the rescue. It suggests you read the report, but keep in mind the inconvenient truths that follow below. You’ll be closer to getting your head wrapped around the high cost of cancer and how to insure against it.

Pre-existing condition exclusions cause treatment postponement. Many patients with pre-existing conditions preferentially seek insurance after the fact. Forcing coverage under such circumstances would drive up the cost of the premium, forcing even more individuals to forgo insurance.

The individual market screws patients by refusing coverage to persons with a cancer diagnosis. If the individual market were forced to cover individuals with a past history of cancer, all persons buying insurance in the individual market would be forced into higher premiums to pool that added risk.

Out of network doctors lead to medical debt: Many doctors choose to be out of network because they refuse to accept the insurers’ fee schedules, putting patients in the middle.

Annual benefit limits lead to debt: Benefit limits of $2500 to $20,000 to $100,000 are the exception and not the rule. $1 million is common, but when it is exceeded, what is the right limit that Americans are willing to pay for?

Patients need to continue working while getting chemo: In the example provided, the patient’s employer worked with the patient to maintain her employee status. Most do.

Separate deductables lead to debt: Deductables are a standard approach to making insurance affordable. What’s more, in the example provided, the patient was contesting a PET scan’s medical necessity, not the deductable.

COBRA sucks: COBRA was conceived, written and passed by the U.S. government and insurers are following the regulations. To the letter. Which is why the Feds have stepped in with another fix. Whether we can count on government over the long run to continue its support is a question mark because of the next item.

High Risk Pools suck: As the DMCB reads it, it’s the government that is underfunding them, which should make one wonder about the government's ability to manage any of this over the long run.


AlanHP said...

This is a political issue, and the way for advocates to make their point is to make their point, forcefully. Another dry white paper won't do it. Abd dragging victims out and parading them has a long and glorious history in Washington. No health hearing can occur without "victims' panels".

I am surprised in your comments. The problems that these are having occur specifically because of the fragmentation of the system, with the almost unlimited, but uncontrolled, unsupervised, and unevaluated experiments run by thousands of employers in combination with hundreds of health plans and carve outs.

I am a cancer patient who has nothing but good things to say about the care I received, the options I had, the providers I dealt with, even the health plan I was covered by. However, my satisfaction with the plan is only in retrospect as I had to spend many frustrating hours with the plan and providers trying to unravel payments, deductibles, copayments, etc. And of course, the crackerjack disease management nurse who called to see if I needed help...when I was within one week of finishing chemotherapy (8 months after my surgery).

Fortunately I am not dealing with any health or financial problems stemming from my cancer. But, I am dealing with individual coverage issues for my daughter, who is an out-of-work college graduate with pre-existing conditions. She can't get decent coverage because she received care for some serious problems when she did have coverage. Isn't there something wrong with that?

Jaan Sidorov said...

Well said, AlanHP! I agree that I need to keep these white papers in perspective. Pass the antacid.

My comment is that these select 20 are the uncommon exceptions in a largely market-based system that is arguably offering up a variety of insurance options. I believe that the vast majority of them serve cancer patients very well.

That being said, you have a good point about the paper work. As you can tell, I'm no fan of the electronic health record as currently conceived. However, I hope that one day the system will be able to adjudicate the physicians' bill against the benefit the right time everytime.

It's not just persons with a history of cancer that are being denied insurance coverage on the basis of pre-existing conditions. In my mind, this may be the biggest reason to have a) an insurance coverage mandate (play or pay) and b) limitations on underwriting (even though it may drive some smaller insurers out of business). Neither require a one size fits all guv'mint program.

And finally... good point. Disease management for cancer is one of those success stories that many persons don't know about.