Posts Tagged The New York Times

In the June 30 edition of The New York Times, Reed Abelson wrote an article entitled Insured, but Bankrupted by Health Crises. The article focused on the story of an individual forced into bankruptcy based on costs that were not reimbursed under his “limited benefit” policy.

As someone who lives daily on the precipice of medical bankruptcy, I know very well that “limited benefit” policies are just one example of the problem. Healthcare is personal to all of us, of course, and I know that everyone has at least one compelling example of how the healthcare system, broadly defined, has failed them.

In my case, my oldest child has Duchenne Muscular Dystrophy (DMD), the most severe form of the many muscular dystrophies. In most cases, DMD is an inherited condition, with the mother as a carrier of the genetic mutation. Boys have a 50-50% chance of inheriting the gene, and girls have a 50-50% chance of becoming a carrier.

DMD is terminal, with an average life expectancy of 19 or 20. To date, there is no cure, and the general progression results in boys being confined to a wheelchair by age 12 or 13. While the boys are “up”, as we refer to it, the only therapies are physical therapy and a steroid regimen to maintain muscle strength as long as possible. Once the boys are “down”, they are relegated to a wheelchair for the rest of their lives. Ultimately, they succumb to the atrophy of the heart or the lung.

You might think that the rarity of the condition would be accounted for in the actuarial tables, and that standard health insurance policies, as opposed to “limited benefit” policies, would cover DMD. Sadly, that is not the case. As a result, I live daily with the words of the Keith Urban song, “But for the grace of God go I”.

Since we learned of our son’s condition, we have been covered under five separate insurance plans: once by United, three times by Blue Cross Blue Shield plans, and once by HealthSpring. Of those five plans, none paid more than $2,500 toward an electric wheelchair, the list (i.e. chargemaster) price for which is north of $50,000. Of those five plans, one did not pay for any physical therapy, while the other four capped the number of visits between 20-24 per year. Of the four plans that provided physical therapy, all of them paid the provider a percentage of charges. Our provider charged $400 per hour. Since we have an HSA, we used our deductible very quickly.

So, why value and not just quality? For many things in healthcare, quality is a given, while for other things, it is “the only thing”. For us, physical therapy consisted of stretches and limited physical activity, my favorite example of which was Wii bowling. Is quality is a key factor to evaluate in playing the Wii? Is It Worth It® to pay $400 an hour to have your child play a Wii?

For you, maybe the relevant example is a blood draw, or an ankle x-ray, or a throat swab for strep – quality should be, and usually is, assumed in those examples. In such a case, the other elements of value, such as price, efficiency, convenience, access, and experience, should be the determining factors in choice. On the other hand, if you need brain surgery, quality is probably the dominant factor in your decision, and price, if you have insurance, the least.

The issue for America at this point in history is that there are relatively few brain surgeries and an abundance of blood draws and ankle x-rays and throat swabs. We can afford to pay premium prices for premium services, but we cannot and should not pay premium prices for commodities. Our goal is to help people figure out the difference between commodities and premium services, and everything in between.