The Fixer

Her Nationwide guy suggested that she call me. And though I appreciate Mike’s confidence, I also know that his referrals are often people who have somehow fallen through the cracks of our system. This woman epitomized the permanent flaws in this and any system of health care. And more to my frustration than hers, I could not fix her problem.

Much like Eddie Vedder’s The Fixer, I have always been obsessed with making things right, of solving everyone’s problems. That empathy works well in what I do for a living. But I am deeply frustrated when I encounter a situation that can’t be fixed. Here is hers:

The woman, we’ll call her Maria, has group insurance through her employer. The cost of the policy has increased over the years, but the employer is still paying the vast majority of the premium. This year the employer changed the coverage to a High Deductible Healthcare Plan, in other words, a policy that qualifies for an HSA. Maria no longer has an office visit copay. Maria no longer has an Rx card. All of these expenses are applied towards her $4,000 deductible. In theory, this might save her money. In reality, she is screwed. She is on two very expensive medications. One is $885 for a three month supply. The other is $1,400!

Where does she come up with the money for these prescriptions? She makes just enough per month that she won’t qualify for any help from the drug companies. She makes too little to be able to afford the medications she needs to be able to work.

Got an answer? Neither do I?

No system could possibly sustain the cost of paying for everyone’s doctors’ visits, prescriptions, and hospital stays. We must contribute. We must either pay for insurance or be taxed by the government (or both) to fund the system that pays most of the bills. The balance, whether that structure includes copays or deductibles, must be paid by the person receiving treatment. Should we all be responsible for the same amount? Will there be a sliding scale based on income, location, or family size?

No matter the final outcome, most people will be offended when it is their turn to pay. Worse, many people will be forced to pay more than they feel that they can afford. And some will be buried in debt. The other choice is to simply limit the most expensive care based on survivability and efficacy. And that opens another set of worries.

In a recent Forbes article, Richard Grant argues that what we need is less regulation, not more. “Government’s main role has been to serve as the enforcer of a cartel that limits the supply of doctors, of hospitals, of drugs, and of innovative alternatives.” There is truth to all of that. And if we reversed our course and somehow made it to a completely open market, the well-off and educated, like Mr. Grant, might receive better care for less. Unfortunately, the Maria’s of our world would be collateral damage. I’m not sure which regulations Mr. Grant would like to eliminate. Do we want to trust the marketplace to license doctors and approve prescriptions?

The HSA policy is a half-hearted attempt at empowering the patient and controlling costs. It succeeds at neither. Does Maria need to be on these expensive medications? Would more common, less expensive drugs, be almost as good? Since at least one of these drugs is for a mental condition, would she have the needed faith in a new prescription that was purchased not because her doctor thought it was better for her, but because she can’t afford the good one? The experiment is doomed to failure.

And I can’t help her. And there is no moment worse for a Fixer than when he realizes that there is nothing that he can do.

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5 Responses to The Fixer

  1. Susie Sharp says:

    Dave, throughout the years I’ve known a LOT of insurance guys. You, dear sir, are a total gem and a delight to know. You’ve been honest and caring with very single person I’ve sent to you. What makes you different is that you actually, really, truly CARE about these people and go out of your way to explain the pros and cons of each and every option. We’re not dollar signs to you; we are PEOPLE. And you advise us as if we were members of your own family. It’s a real pleasure to deal with someone who remains so passionate about their profession.

    Thanks so very much for all your many kindnesses over the years. Many of them were not necessary, but they most surely were appreciated.

  2. says:

    Thank you, Susie. You normally have to be dead before people say such nice things about you.

  3. says:

    Posted on the blogspot location:

    Apr 13, 2012 01:16 PM
    There are several problems with Maria’s situation. First, HDHPs are for healthy people, at least as far as it was explained to me when I had to make the choice which plan to subscribe to. And yes, I had a choice – I have the HSA but I could have paid more for a premium PPO. It sounds like Maria’s employer didn’t give her a choice, and the insurance they offer is inappropriate for her.

    Second, since the HDHP/HSA combo costs the employer less, it’d be nice of them to throw a little cash into the HSA up front. That would have given Maria a month or so worth of medication while she searched for a compromise – cheaper or fewer drugs. My employer contributes to my HSA every year but it sounds like Maria’s doesn’t. Again, the insurance they are offering is inappropriate for her – in this case for her income level.

    Third, the changes in the employer’s health care offerings should have been made with enough advance warning to allow the employees to make accomodations – in Maria’s case, sock away the $4000 out-of-pocket-maximum. I’ll give her the benefit of the doubt by assuming that she wasn’t given the time or wouldn’t have had the resources – the latter is likely since you don’t begin to save money on lower premiums until you’re actually on the HDHP, by which time it was too late for Maria.

    It’s a tough spot to be in. Managing the health care of a sick person is like being the general contractor of a house that’s being built. Having your employer change your health plan like this is like the city changing the construction codes in mid-build.

  4. says:

    Great analogy. There are lots of workers, few who are capable of building the house, but almost all of them could negatively impact the project.

  5. says:

    From the Lakewood edition of the AOL Patch:

    Patrick Giusto commented on your blog post, The Fixer:

    “Dave, I love your blogs on health care. You keep people thinking about the complexities of an issue that is increasingly black-and-white in our partisan culture. I am not particularly in favor, in total, of the current law; although I feel it’s at least a starting point. What bothers me about the debate on the so-called “Obamacare” law is that we seem to have this “keep-it-or-crush-it” mentality, and totally lost sight of the endgame of fixing a health care system with very real problems for very real people. Also, any time you mention Pearl Jam in the description, I’m gonna read. Might I suggest a “can’t find a betterplan” reference?”

    To respond view the comment on Patch.

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