Commentary: Adventures In Modern Insuring

Even With Coverage Access Can Be Labrynthine

\ Jan 10, 2019

8 min read

Here’s the picture: This is the news section of an ascendant progressive publication. We’ve reported on all sorts of notably newsworthy phenomena in the past couple of years, since we decided to jump back into this news thing wholeheartedly.

Because of that directionality—wherein we reach out to the community as a source of information and ideas—all sorts of folks send us information and ideas. These are called leads.

Some of the leads we’ve received recently have to do with affordable healthcare, with the rising cost of healthcare. That may be because we’ve covered the subject recently, urging readers to sign up for insurance through the Affordable Care Act, to consider proposals to bring Medicaid to the masses or to create a new not-for-profit network for citizens of this state. Ultimately we believe that there is an urgent need for healthcare reform in this state and in the nation, too.

But anyway, back to the leads. Two in particular stand out.

One reader wrote to me about his wife’s battle with cancer. There were mixed results—he had written by hand—but she was still alive and vital. The only problem with that: they had just received notice in the mail. The letter from their insurance company informed them that the drug she depended on would no longer be on their formulary come next year, that she should seek out sound medical advice and look into alternatives instead. What had been a medicine with high co-payment ($500 per month) had become a possible cause of financial ruin at a price of just over $8,000 per month.

Another reader called my office phone directly. That line is usually forwarded to my cell phone. A couple of rings rattled out of the new contraption (thanks Ms. Addison!) before I clicked on the unfamiliar Android icon that made mutual transmission possible.

A man who turned out to be local, Hispanic and in his middle years revealed his plight. He had suffered from rheumatoid arthritis for years. It had gotten worse and his doctors had tried all sorts of different treatments. Finally when his condition had worsened into dangerous (his vasculitis showed signs of coming back, many of his joints were very swollen, etc.) his doctors stumbled upon a medicine that changed everything. A year after this treatment with a biologic drug began, he was still symptom-free and as healthy as he had been in his youth.

But this citizen had also received the letter from True Health New Mexico, a subsidiary of Virginia based corporation Evolent Health. In case you want to know, the CEO of Evolent, Frank Williams, received $3,160,800 in compensation for his work at Evolent last year. Here in New Mexico, True Health New Mexico CEO Dr. Martin Hickey pulled down a $450,000 per year base salary when he was the head of New Mexico Health Connections. The subsidiary True Health was the result of Hickey’s company selling much of its assets to Evolent in 2017.

Anyway, the mass-produced missive said the drug my source had been taking for 18 months had been moved from “Tier 5” to “Tier 6” by a panel of expert doctors and pharmacists. This essentially meant that the man’s insurance company would no longer pay for the drug, which without insurance cost $4,000 per month—half as much as William’s average daily compensation and about as much as Hickey made in one week running the precursor to True Health.

In the cases of both writers, I made contact and asked if they had followed up with their insurance company and each one proceeded to tell me a familiar story about how difficult it was to get a definitive answer, how hard it was to communicate their needs with the humans and AI agents that staffed their customer service line. Mostly they felt resigned about a situation that could determine how one lives and how one dies.

So I decided to do some following up of my own. First I found it very difficult to contact the insurance company in question—without going through a customer portal that is as anonymous as it is labyrinthine.

By the time I finally got a patient care representative on the line who would talk to a nonmember and divulge the number of the local corporate office, my steaming hot coffee had grown cold. I returned the cup to the microondas, set it for two minutes and dialed the local number.

Of course they put me through to their media person, a very friendly and efficient individual named Lydia T. Ashanin, the Senior Director of Marketing and Communications at True Health New Mexico. She was decent and professional but seemed to grow defensive at first, especially when I asked about the “panel of expert doctors and pharmacists” who made the potentially life changing decisions related to consumer medicine options. She ended up confirming that the identities of the panel was “proprietary information,” and, sensing my exasperation at such an answer, we both moved on.

She had a lot to tell me about the process that changes a rarely used but very important prescription from something comforting and semi-affordable to a substance that is dangerously absent, an unobtainium of sorts.

And this is what she said:

“August, I really appreciate the opportunity to respond to your questions about changes in health plan pharmacy tiers. Here is a statement for you:

“Health insurers may change their health plan benefits annually to adjust to changes in available services and medications, including making changes to the pharmacy formulary to address overall costs borne by the populations served. The letter that your readers received in October is the letter we send out to let members know well ahead of time when a change is being made to their pharmacy benefits. The intention is to give them time to work with their doctor to make any changes that are specific to their healthcare situation. Within the health insurance industry, drugs may change tiers for various reasons, including availability of less expensive or more clinically appropriate options. This may be the situation for your readers.

“First and foremost, we want to ensure that any True Health New Mexico members are getting the appropriate care. Our goal is to keep you in your optimal state of health, and every person’s health situation is unique. We strongly encourage our members to get in touch with us directly to address their specific and unique needs. Go to our website to find contact information truehealthnewmexico.com.

“Again, I really appreciate the opportunity to provide context on this issue. In this particular situation, if your two readers who contacted you would be willing to call our case management phone number, 1-844-691-9984, our medical management staff can look more deeply into their care plan and provide confidential input. It is really hard to help members without being able to look at the specifics of their care management plan, and we’d really like to be able to ensure that they are getting the most appropriate care.” Maybe the case management phone number is a place to start. Maybe.

Also, in both cases, I’m told that those who wrote in about this phenomena—call it the case of the expensive, lifesaving medication whose withdrawal from lifesaving missions was prompted by an admittedly anonymous corporate board in an organization where the folks in charge literally make millions—have already spent hours on hold and in virtual queues that seem to uniformly end in uncertainty and more complications.

Clearly the need for healthcare reform is an urgent task that must not be left to multibillion dollar corporations where the decision-makers live lives that are markedly different (based on salary) from those they purportedly serve.

In the meantime, there’s much more to this story. For instance, how did certain drugs for certain medical conditions become so expensive? And how does the salary of healthcare CEOs figure into that and the pricing that reaches the consumer?

Did the insurance company make a diligent effort to reach out to, interface with and offer solutions to at-risk patients or is the letter sent (a form letter sent to about five patients, according to Ms. Ashanin) all there is? According to Ashanin, “we count on members to talk to their doctors about the changes and call our case managers/customer service if there is some reason for concern. When that happens, our medical management team will talk through options with the member or their doctor to make sure they are getting the best care for their health situation.”

Most importantly we wonder who is on that board and why they are making decisions for at-risk patients—instead of actual providers—without actually meeting with and evaluating them. That should be a doctor’s duty that is carried out—efficiently and proactively—by the insurer. The inverse of that seems odd and may even be cruel, given the promises and objectives of the Affordable Care Act.