health insurance


Anorexia: Potentially Deadly, Treatable And Still Not Always Covered By Insurance

(Mary Lock/Flickr)

(Mary Lock/Flickr)

By Drs. Gene Beresin and Steve Schlozman

People die from Anorexia Nervosa.

This is true of other psychiatric syndromes, but with anorexia, the cause of death couldn’t be more straightforward. People with anorexia literally expire from the complications of malnutrition.

They starve and they die.

Your heart cannot beat if you don’t feed it. Your immune system can’t protect you without food. Your bones crumble, your kidneys fail, your liver sputters and your brain wanders, all as a result of inadequate food.

Suicide is common. Without proper nutrition, depression is prominent and thinking is blurred. Coping mechanisms falter. Life can seem unlivable.

So, here’s the really strange thing about anorexia: Despite its awfulness and potentially fatal outcomes, despite a death rate more than 12 times higher than any other psychiatric syndrome, insurers still balk at providing adequate coverage.

In 2008, the Federal Mental Health Parity and Addiction Equity Act put special restrictions on the coverage of the treatment of eating disorders. While the explanations for this exception vary — some have suggested that this is because eating disorders are thought to lack a biological basis — it is clear that getting standard of care treatment for anorexia remains problematic even to this day.

In 2010, the U.S. Court of Appeals for the 9th Circuit found itself facing what was essentially a logic problem. The case of Harwick versus Blue Shield of California noted that while the insurer agreed that the residential treatment requested for a patient with anorexia was medically necessary — thus making it in compliance with existing parity statutes — coverage for residential treatment was not authorized because residential treatment was not part of the health plan. The court ruled in favor of the patient in this case, but the fact that this even ended up in court is shameful. Can you imagine an insurer refusing to pay equally for the medically necessary care of any other disease with such clear risks?

So, while patients, their families and physicians continue to fight for coverage, we know that treatment for this disorder can be life-saving.

In this context, here’s the story of a young woman who recovered.

Nicole (who asked that her last name not be used) is a remarkable 16-year-old. She is academically and socially accomplished and she speaks with wisdom that belies her age. She also faced Anorexia Nervosa head on and here discusses her struggles with humility and insight.

What we can learn from her story?

To begin with, we can acknowledge that her bout with anorexia has not been easy. She suffered significant depression and even suicidal ideation as she muscled through the course of the illness. This aspect of her history is perhaps the most important take-home message. The work towards recovery from an eating disorder is never straightforward. Each patient finds a unique way to work with his or her treatment team and family to progress towards health. We can also note that Anorexia is a typically insidious and largely unconscious development. As you can hear from Nicole, the syndrome essentially snuck up on her and her family. Continue reading

Mass. Defines ‘Affordable’ Health Insurance

What’s affordable when it comes to health insurance?

Any figure that comes to mind right now is probably less than you actually pay every month.

The federal government says Americans should be able to spend 8.05 percent of their income on health coverage this year. Massachusetts cuts low-income residents some slack.

Here’s the new affordability rate for individuals. The Health Connector board also approved affordablity rates for couples and families today.
Connector Affordability individuals copy

The 2016 rates for individuals, couples and families were set today too.

But there’s some tension the Connector will have to resolve in future years. It boils down to, well, what the definition of “affordable” is.

“Do we define affordability as a constant percent of income or do we define affordability as burden sharing between people and the government?” asks MIT economist and Connector board member Jon Gruber.

There’s a difference because health care costs are rising much faster than your income or mine, and future affordability rates will factor in health care costs.

As he speaks, Gruber looks across the board table at Harvard School of Public Health professor Nancy Turnbull. She looks troubled. The state hasn’t adjusted the affordable rate since 2012. The numbers approved today will hurt people who have little, if any, disposable income.

“We’re saying to somebody, ‘your income has not changed, you’re very low income, and yet we think you can afford a 5.4 percent increase at a time when inflation is virutally nothing,” Turnbull says.

The two have a rolling, mostly friendly, duel on this topic. It may heat up well before the debate on 2017 rates, because Massachusetts will spend tens of millions of dollars (looking for the exact number) this year to keep those affordability rates below 8.05 percent for low income residents. And with a tight budget, some folks on Beacon Hill are asking: “Can we afford to do this?”

If Gov. Charlie Baker or the Legislature decide that the additional subsidies are not affordable for the state, you’ll hear some health care reform champions withdraw their support for the individual mandate. A retreat from the individual mandate in the first state to use it would trigger some interesting political waves.

2/13 Update: Does Massachusetts offer more generous health insurance for low income residents? Take a look at this comparison of Massachusetts and Connecticut, prepared by Bob Carey at RLCarey Consulting (click to enlarge):

Mass./Conn. comparison

Health Connector Site Handles Last-Minute Signee Load

Massachusetts residents signing up for health plans endured hour-long waits over the phone ahead of Wednesday’s midnight deadline.

But online, the state’s website handled the last-minute load.

The revamped Health Connector website did not suffer the same outages and delays as last year. Thousands of people without insurance through their employers were able to sign up for health plans during the day. To ease the demand on the call center, Connector official Maydad Cohen extended the deadline to pay for those plans.

“Given the heavy interest in signing up for January 1 coverage, we will accept online and paper payments through Sunday, December 28,” he said.

The Health Connector call center will be open on Sunday to help those who did enroll by yesterday’s deadline, but still have to set up payment for their health insurance.


Vermont Gov. Won’t Pursue Single Payer Health Care This Year

Gov. Peter Shumlin earlier this year (Wilson Ring/AP)

Gov. Peter Shumlin earlier this year (Wilson Ring/AP)

Gov. Peter Shumlin of Vermont announced on Wednesday that his state would not pursue single payer health care in this coming legislative session.

Shumlin blamed a sluggish economy for his decision. The taxes required for single payer would prove too burdensome for Vermont, a state that has downgraded its revenues twice this year.

The taxes required to implement single payer would include an 11.5 percent increase in payroll taxes and up to a 9.5 percent increase in income taxes for every Vermonter.

Shumlin added: “Making fundamental changes in our health care system — nearly 20 percent of our economy — is a huge undertaking, and one that must be done with care.”

You can read Shumlin’s prepared remarks here.


Health Care Leaders Call For Closer Scrutiny Of Partners Deal

In an unusual, perhaps unprecedented move, leaders from across the health care industry are calling for closer scrutiny of a deal that would cap prices for Partners HealthCare in the short term but would let the state’s largest hospital network add four more hospitals.

Massachusetts Attorney General Martha Coakley (Steven Senne/AP/File)

Massachusetts Attorney General Martha Coakley (Steven Senne/AP/File)

The deal that is fueling letters, analysis, statements and meetings is between Partners HealthCare and Attorney General Martha Coakley. She says it will limit Partners’ clout and the health care “Goliath’s” (her word) ability to drive up costs. That might be true. But no one has seen any details. The only thing made public is a press release. The public deserves to have more information about such a significant health care industry transaction, says Health Care for All director Amy Whitcomb Slemmer.

“There are a number of unknowns that have a direct impact on the care that will be delivered in Massachusetts and on costs, particularly, the impact to people’s pocketbooks,” Whitcomb Slemmer said.

Coakley has said that the details would be available when the agreement is filed in court. That was supposed to be next week. But Health Care for All, the Massachusetts Association of Health Plans, the National Federation of Independent Businesses/Massachusetts, the Retailers Association of Massachusetts and the state’s largest employer group, Associated Industries of Massachusetts, are all calling for a delay that would allow time for a public review.

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Know Your Mental Health Coverage Rights? Probably Not, Study Finds

Former Congressman Patrick Kennedy testifies at a Massachusetts hearing on mental health parity. (Courtesy of Scott Bryson)

Former Congressman Patrick Kennedy testifies at a Massachusetts hearing on mental health parity in 2013. (Courtesy of Scott Bryson)

No one could ever blame for you failing to grasp all the Byzantine ins and outs of your health insurance plan. But here’s a simple concept that everyone should know, and that most of us don’t: Under federal and state law, your health insurer must treat mental health on a par with physical health, covering care for mental illness and addiction no less than they cover physical care.

How do I know that most of us don’t know this? From a survey of more than 1,000 adults just released by the American Psychological Association (which, yes, may have a vested interest in spreading the word that therapy should often be covered.) It found that only 4 percent knew about the 2008 law that guarantees mental health coverage “parity” with physical health, no higher than in 2010. From the press release:

“More access to mental health care is the rallying cry, but the simple fact is many people may already have coverage and not know it or not understand how to use it,” said Katherine C. Nordal PhD, APA’s executive director for professional practice. “The mental health parity law, together with the Affordable Care Act, has expanded mental health treatment opportunities to many Americans in need who may otherwise have gone untreated. But laws don’t have the intended effect when people don’t know that they exist. Continue reading

Mass. To Drop Contractor Behind Flawed Health Insurance Website

Massachusetts is negotiating an end to its contract with CGI, the Canadian vendor that built the state’s flawed health insurance website.

The site was supposed to be up last October, offering one-stop health insurance shopping for anyone in Massachusetts. But six months later, only a few functions work but have glitches, and a few are not usable at all.

Sarah Iselin, a special assistant to Gov. Deval Patrick hired to oversee the fixing of the website, has been working with a team of outside contractors from Optum to determine if the CGI project can be fixed.

“That assessment made clear that based on past performance and our current needs, parting ways with CGI is the right course for the commonwealth moving forward,” Iselin said Monday.

In a statement, CGI said it will “work with the Commonwealth to ensure a smooth transition to the next phase of exchange deployment, allowing for the best use of system capabilities already in place.”

Iselin and her team told the Health Connector board they are reviewing two possible remedies: hiring a new vendor to build on working parts of the current site or buying website elements from other insurance exchange sites. Iselin cautions that buying elements will be difficult because Massachusetts has many unique insurance rules, including 263 different factors that determine who is eligible for what type of coverage.

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Lesson Of The $446 Ear Rinse: Medical Bills That Make You Say ‘What?!’

(Photo: Robin Lubbock/WBUR)

(Photo: Robin Lubbock/WBUR)


Get your attention, all those upper-case, bold-face letters? They certainly got mine, when they came in the mail recently. It was a virginity-losing moment: My first debt-collection letter in more than a half century of financial clean living.

And of course, it was a medical bill that did it — just as it’s medical care that causes more American personal bankruptcies than any other bills.

My health bills for preventive care had all seemed reasonable until now — or at least, they were bountifully paid by insurance. Mammograms, children’s check-ups, all were fully covered. But I’d shifted recently to an insurance plan with a $500 personal deductible, and I’d made a naive mistake: When my doctor kindly offered to clean my waxy ears during my annual check-up last April, I said, “Okay…”

Well, really, how was I to suspect that three or four minutes of whooshing ear-rinse could add up to $446 out of my pocket? (Correction: $446 upon first billing, but knocked down to $338.03 after several long and tortured phone calls, and a medical re-coding. It still struck me as insane, but I paid it to get the collection agency off my back.)

Doctor, if we’re going to cross the line from preventive to billable, I’d like you to let me know.

It’s an ever-more-common American rite of passage: That shocking moment when you unfold the bill, look at the total that is unpaid by your health insurance, and expostulate, “Are you (expletive) kidding me?!?”

Readers, do you have an eye-popping bill and back-story you’d like to share? We’re hoping to make this a series — “Medical Bills That Make You Go ‘What??!'” You can send in your story — and, if you’d like, scans of your bills that will protect your privacy — by clicking on the “Get In Touch” button at the bottom of this page. Goodness knows, you have few other outlets for your frustration.

In my own case, I’m asking you to brave the numbing tedium of any billing tale because there’s a clear object lesson here: Yes, preventive care, including check-ups, must be fully covered by insurance plans under Obamacare. But that doesn’t mean that everything that’s done during a check-up has to be covered.

And therein lies the rub. The line between “preventive” and “diagnostic” or “procedural” can creep up on you, as WBUR’s Martha Bebinger has reported: When Is Preventive Care Free And When Do You Pay? Her report included this valuable lesson: As one Massachusetts woman was horrified to discover, it’s possible to go in for a free — because it’s preventive — colonoscopy, but then, while you’re still on the table, if the doctor finds polyps and removes them, that transforms it into a non-preventive — and thus potentially billable to you — “surgical procedure.”

I’d read that story but clearly I didn’t take its lesson enough to heart. I also take full blame for my longtime practice of getting routine primary care at an expensive top Boston hospital: You can see in the upper right corner of the image above that the initial charge to my insurer for my check-up — which involved no lab tests and nothing higher-tech than a blood pressure cuff — was nearly $1,192.

Still, in hopes that my own financial pain might help others, I asked Blue Cross/Blue Shield of Massachusetts, the biggest health insurer in the state and the one that happens to cover me, for useful pointers. I spoke with Debra Wilson, a senior manager in the Member Service Division. Our conversation, lightly edited:

DW: I think it’s great that you’re highlighting this for people. Folks go in and have preventative visits, and things will invariably come up. The patient is there and having their physical, but they’re also addressing problems. These problems could be longstanding. So it’s important that when something does come up and present itself, that the patient ask questions.

It’s very important that all of us are educated in our health care decisions, and part of that is that we not be afraid to ask, ‘What does that entail and what might the cost be?’

Ask questions beforehand so you’re fully aware of what’s going to be involved, not only with the procedure but the cost. It can generate a liability to the patient, and no one likes an unplanned bill. We’ve also asked our network management team, the folks in the field working with physicians’ offices, if they could also educate the patient at the time — usually after the fact, but let them know, if they were in for a visit and also had a procedure or additional service, that they could receive a balance bill.

We don’t want to discourage these conversations with physicians because it’s probably something they do need to have addressed, and it’s being done all in one trip, so it’s efficient. We just want everyone to be aware of what could happen in terms of cost liability, that that could change depending on services rendered.

The tricky part for the patient is that it can be hard to know whether something is considered preventative or diagnostic or a procedure. For example, at that same checkup of mine, my doctor found that my blood pressure was a bit elevated, so we discussed ways to lower it. Conceivably, that could be billed as not preventive but diagnostic, or an education procedure?

That’s discretionary, based on that particular provider’s office and their billing practices. Certainly, that could be within the preventative visit, but again, I think it’s important not to be afraid to ask those questions.

Would it be reasonable to go into a preventive appointment and say, ‘Doctor, if we’re going to cross the line from preventive to billable, I’d like you to let me know’? Would that be weird? Continue reading

Put Back The Teeth? Why We Separate Dental And Medical Care

Some patients are concerned by a lack of communication between their dentist and primary care physician. (Herry Lawford/Flickr Creative Commons)

Some patients are concerned by a lack of communication between their dentist and primary care physician. (Herry Lawford/Flickr)

My colleague Stef Kotsonis stops me in the hall at work every few weeks with a new pearl of health care wisdom. Last week, it began with the story of three teeth that had to come out.

“I’m getting implants put in, dental implants,” Kotsonis explains, an index finger pulling back his lower lip. “Two down here, bottom left, and one up here.”

He pauses to grin.

“So when they tell you to chew on the other side, it’s a much more subtle dance than that.” Kotsonis is giggling now. “There’s a foxtrot going on at meal time.”

Paying to fix the problem is no laughing matter.

“Our dental plans are awful compared to our health plans,” Kotsonis says. “I’m paying thousands of dollars for these [implants]. It’s, boy, it’s breaking the family bank.”

Should dental health be treated separately from the rest of the body? (US Army Africa/Flickr Creative Commons)

Should dental health be treated separately from the rest of the body? (U.S. Army Africa/Flickr)

Kotsonis is also worried about the lack of coordination between his primary care physician and dentist.

“My own doctor has no idea what’s going on in my dentist’s office,” Kotsonis says. “She doesn’t know if I’m having implants, she doesn’t know if I’m being given these antibiotics, she doesn’t know if these antibiotics clash with anything else she’s doing. And it just seems to me that this is exactly the sort of thing, in this information age, that should be shared.”

How did this happen, this decision to treat the teeth and gums separate from the rest of the body? There is lots of proof that poor oral health is tied to heart disease, diabetes, HIV and can lead to death. So why, in this era of integrated medicine, do we continue to carve out the teeth? And is anyone trying to put them back?

Continue reading

Health Insurance Limbo: The Latest On Mass. ‘Connector’ Sign-Up

Screenshot of Mass. Health Connector website

Screenshot of Mass. Health Connector website

More than 44,000 Massachusetts residents (as of Dec. 24) who have applied for coverage through the Massachusetts Health Connector are in limbo. The vast majority have applied for subsidized insurance and are waiting to find out:

• If they qualify for free or subsidized coverage
• If they are eligible for a subsidized plan, what are their options?
• If they don’t qualify for government help, do they have to start all over again?

Many people submitted applications months ago. The Connector, the Massachusetts health insurance exchange, has had a lot of problems with its website — to the point that the state is reviewing its legal options against the contractor. Here, we address some of the most common questions from Massachusetts residents who’ve applied for insurance assistance. Connector spokesman Jason Lefferts helped us with the answers:

1) I submitted an application for subsidized coverage. When will I find out if I qualify?

The state expects to send most of the more than 44,000 outstanding applicants a letter by January 1st. The letter will say either:

a) You are approved for a subsidy or
b) the Connector hasn’t processed your application yet and is putting you, temporarily, into a MassHealth (Medicaid) plan.

The Connector is giving priority to applicants who may qualify for an insurance subsidy and aren’t already enrolled in Commonwealth Care. Health plans for everyone who is already in Commonwealth Care have been extended through March.

2) If I qualify for subsidized coverage, how do I choose a health plan? Continue reading