Health Care Crap Shoot

In theory, I have health insurance. Being self-employed, I shoulder the entire cost of the monthly premium to Kaiser Permanente, but I’m definitely a Kaiser member, we’re sure of that much. I have a plastic card with a member number, access to the members-only area of their website, and the privilege of scheduling appointments with Kaiser medical professionals.

But does my membership confer any actual benefits? Or am I simply paying $712 every month to a gang of thieves in exchange for a plastic card with a number on it? This is not an easy question to answer.

For the past few months, I’ve had some pain in my left forefinger. This may seem trivial to you, but since I teach cello lessons and play occasional concerts (both of which are money-producing activities), keeping my hands in good working order is a high priority for me.

My Kaiser physician sent me to a Kaiser physical therapist, who gave me some daily exercises. They’ve done no good, but that’s almost beside the point. Maybe the condition is permanent; I don’t demand that a physical therapist be a miracle worker.

At the time of my physical therapy appointment, I shelled out a $45 “co-pay.” I’m okay with that. But a few weeks later, I received a supplemental bill for this same appointment in the amount of $195. The theory advanced on the bill was that the “usual and customary” cost of this appointment, which lasted less than an hour and required no special equipment, was $550. Kaiser then magnanimously covered $310 of that cost under the terms of my insurance policy, leaving me with an unpaid balance of $240. I had already paid $45, so the balance due was $195.

I made a few phone calls. The actual cost of a physical therapy appointment of this sort in the area where I live would be between $100 and $125. In effect, then, Kaiser is charging me twice as much as I would have had to pay if I were uninsured.

I filed a grievance. When it was denied, I filed a complaint with a state agency in Sacramento, which (after a commendably short delay) told me there was nothing they could do. I was told that the state agency doesn’t regulate fees, which leaves me rather in the dark about what sorts of abuses they can rein in, if any.

Having exhausted my administrative remedies, I paid the bill. But now I’m forced to ask myself, why am I paying Kaiser $712 every month? And $800 next year, I’m sure, and $900 the year after that. As a “health maintenance” organization, Kaiser is plainly worse than useless. I can no longer utilize their services for routine issues such as a painful finger. I can save money in dealing with routine problems by choosing a medical professional out of the Yellow Pages. At best, I could expect to gain some benefits from my Kaiser membership if I have a heart attack or a stroke, if I get cancer, or if I’m in a terrible traffic accident.

But even in such dire straits, would Kaiser membership be of any value to me? There’s no easy way to find out. If I needed, let’s say, a week’s stay at a Kaiser hospital for some reason, the “usual and customary” charges that appeared on my bill might be inflated by 500%, as they were with the physical therapy bill. Kaiser could then claim to be covering the lion’s share of the cost, when in fact the amount for which they billed me was more than another hospital would have charged a cash customer. There’s no way to find out ahead of time whether this would happen — and I would have no administrative recourse if it did happen.

I’m pretty sure that if I asked Kaiser for a list of the “usual and customary” costs of a wide variety of common medical procedures, they would balk. They would claim the information was not available. Of course, it would magically become available after I incurred the cost. But even if they were to provide such information, it would be meaningless, for two reasons.

First, they could boost the numbers next month, without notifying anybody. “Oh, we told you an appendectomy would be $5,000, but our Department of Managed Cash Inflow has determined that the usual and customary charges for that procedure are now $8,000. So sorry.” At no point, I want to emphasize, did Kaiser attempt to justify the $550 they claimed was “usual and customary” for a physical therapy session. They certainly didn’t generate the numbers by doing any actual research on the cost of this type of appointment. For all I know, they picked the numbers using an Ouija Board.

Second, they could unilaterally change the terms of my policy, as they did a year ago. Suddenly my yearly deductible went up, and certain things that had been covered before are no longer covered. I was notified, but I was not consulted or asked to approve the changes. If I don’t like the changes, my only option is to drop Kaiser and shop elsewhere for health insurance.

I slipped into Kaiser through a side door. I have a “rollover” policy, which didn’t require a physical exam or the filling out of any forms detailing my medical history. I first got the policy by joining the local Chamber of Commerce, which had a group policy. When the Chamber dropped their coverage, I was offered the opportunity to roll over into individual membership. At the time, it seemed like a wise choice.

Prior to that, I had been turned down by both Kaiser and Blue Shield on the basis of “pre-existing conditions,” which included seasonal asthma and a hernia operation in 1968. Literally — the operation was listed as one of the reasons for a turn-down. I don’t remember which insurer listed it, maybe not Kaiser. But as we all know, health insurers only want to insure people who have never, ever been sick or required any care. (Where do they find these people?)

Eight years down the road, we’d have to add a detached vitreous gel in my right eye to the list. This is not a progressive condition, and not one requiring treatment, but there it is. It’s recent, it’s a medical problem, don’t let the door hit you in the ass on the way out.

So do I continue paying these huge premiums every month in the fondly cherished hope that if I get really sick, I’ll end up saving some money? I’m a musician. I don’t have a lot of money. Maybe I’d be better off putting $700 every month into my savings account. By any rational measure, I’m ridiculously healthy. I’m 61 years old, take no medications, work out twice a week, don’t smoke, am not overweight — heck, I don’t even get colds.

Between now and when I become eligible for Medicare in 3-1/2 years, I’ll pay Kaiser roughly $35,000. That’s about as much as I earn in a year, so they’ll be taking more than 25% of my entire gross income. And for what? What will I be getting for my money?

A pig in a poke, that’s what. That’s a lovely obsolete bit of slang, but very appropriate in this case. What’s in the sack is a pig, but you’ll have to believe me when I tell you that. I’m not going to open the sack and let you look at it, you have to buy it sight unseen.

$35,000 for a pig in a poke. Such a deal.

This entry was posted in society & culture and tagged , . Bookmark the permalink.

2 Responses to Health Care Crap Shoot

  1. Cheryl Fullerton says:

    jim, I absolutely am in the same predicament. I really can’t afford the premium every month, but because I’m scared to stop paying in the event something dire happens to my health, I delve into the little savings I have. If I do need to see a doctor, I usually don’t because I can’t afford the co-pay on top of the exorbitant premium. I feel like insurance is a huge scam. It is for the employed, and the rich. At the moment, I am neither, and it doesn’t look like that will change.

  2. paraxenos says:

    It was a pig in a poke, before they told you about the $500 “usual and customary” cost of the appointment.
    Now you know there’s probably no pig.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s