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Thursday, June 5, 2014

Adventures in caring and acting affordable

I'm back. I'm recovering right now from trauma related to the Affordable Care Act. I'm OK, but probably a few months until fully recovered.

Some would think that since I no longer accept money from insurance companies, the Affordable Care Act would have less of an effect on me. Those folks may be right in how it directly impacts my practice (since I don't know the actual impact on other doctors, it's not easy to compare), but there has been a significant impact. I've got plenty of ACA stories.

But that's not what I am going to discuss in this post.

My personal adventures with this law are far more interesting from the other side of the insurance card: the health care consumer (AKA patient). It has been quite a ride, one that has not yet reached its destination.

Chapter 1: Dec. 9, 2013
Being the adventurous guy I am, I thought I'd give the Healthcare.gov website a whirl. Expecting the worst, I set aside a lot of time for the experience. It was actually quite a bit easier than advertised. My family is as follows:
• Me - Age 51, healthy
• Wife - Around my age, but actual age disclosed only for legal reasons.
• Child 1: Son, 21 years. College grad but living at home for now.
• Child 2: Daughter, 20 years. In college
• Child 3: Son, 18 years at time of application. In college. Birthday later in December.
• Child 4: Daughter, 14 years.

I submitted the information about whether any of us smoke (no), any of us are pregnant (no), and how much money we earn (not much, as I am starting a new business). I immediately got the following eligibility notice:
• Me, Wife, and Kids 1 and 2 were eligible for insurance with a tax credit that would lower our cost to about $100/month. Nice!
• Child 4 was potentially eligible for "Peachcare," the state run insurance for those with low income, that's not low enough to qualify for Medicaid.
• Child 3 had the following next to his name: "Based on your application, you don't qualify to purchase health coverage through the Marketplace. In addition, you don't qualify for a tax credit, cost-sharing reductions, COMPASS, or Georgia PeachCare for Kids. You still might be able to get health care at a lower cost. The health care law has expanded funding to community health centers, which provide primary care for millions of Americans. These centers provide services on a sliding scale based on your income. Learn more about getting care at a community health center on HealthCare.gov."

This made no sense. I immediately assumed I had made some error in information input on Child 3 (like that he was pregnant or he owned some property in Utah), so I deleted this application and repeated the information.

Same result. So what do they have against my kid?

Chapter 2: later in December
A few days later I found the number on the website for Healthcare.gov phone assistance and gave it a ring. My expectation of chaos and stressed-out government phone gnomes was proven wrong when I got a very nice and helpful worker on the phone. This, in fact, was my experience each time I called the healthcare.gov phone system (an experience, it turns out, that does not extend to the state level … more on that later).

The woman on the line looked at my information and listened to my explanation of what happened, ending up with a similar opinion about the result: confusion. She agreed with my guess that child 3 was booted from eligibility for regular insurance because he was 18 at the time of application, and booted from the Peachcare queue because he was 19 when the insurance kicked in. It's the only thing that made sense to either of us. So, she did what all good workers do when faced with a difficult process: she booted it to her superior, telling me that I'd hear from someone "soon" regarding this.

A week or so later, after not hearing from anyone, supervisory or otherwise, I called back the healthcare.gov hotline. I was again greeted with another helpful person, who again listened to my tale and looked at my info. She saw nothing to indicate I was getting attention from supervisors, telling me to try resubmitting after my son's birthday. Mildly frustrated, I agreed to do that.

Nope. That didn't work either. My application form my family had been submitted and had reached a "point of no return" status, and could only be changed by someone with the proper credentials, I was told by another very pleasant person on the hotline. I asked how I could reach a person with such credentialing, and was forwarded to a supervisor. I spent nearly an hour on the line with the supervisor, who really seemed to be trying to resolve my problem. I was very happy with the time and attention my problem was given.

Here's the final conclusion of this phone call:

1. I should go ahead and get insurance for me, wife, and children 1 and 2

2. I should go to the state website and get stuff submitted so I can get insurance on child 4.

3. Child 3 should be also submitted to the state, but will be rejected. Then I could re-apply for regular insurance and be accepted.

That's what I did.

Chapter 3: January and February 2014
The state website gave me some vague timeline about when I would be contacted regarding the application, along with a case number with which to check the status online. I did that regularly, and it was always "in process." We never were contacted during that period.

I tried to call the state agency to check on the status, but was met with eternal repetition of Kenny G, which (as they clearly realize) cannot be tolerated for more than 15 minutes in 1 sitting without significant trauma.

We did receive insurance cards for me, and my 2 older children. Oddly, my wife's card wasn't in the mix (despite the fact that she was on the list of insured on the initial eligibility notice). I figured she misplaced it.

Silly me.

We continued to be worried about the fact that 2 in our family were potentially uninsured, so I kept the mega-expensive policy we had prior to January, just in case.

Chapter 4: March 2014
At the beginning of March we received a mysterious message on our voicemail saying that we were getting a notice saying that healthcare.gov had determined our eligibility and that we were getting a notice and should disregard it. Huh?

But then the message said that no further action was required on our part, and I was happy. I am highly skilled at "no further action." That's exactly what I did (or didn't) do.

A week or so later we got the following notice in the mail:

Huh?

We were never contacted by anyone regarding an interview. Now we were denied? I tried to call the number on the letter, but again got eternal Kenny G music and was eventually disconnected (it seemed a mercy at the time). I tried to contact people online, but again was met with silence.

I eventually toughed out the Kenny G marathon, and after over an hour of waiting was actually able to talk to a human ... well ... someone who was "mostly human," or "human-like in qualities." She was all that I initially expected from healthcare.gov and more. She was grumpy, non-sympathetic to my Kenny G-induced brain injury, and not interested in helping me. According to her, I had only one thing I could do: fill out another application, which she would mail to me, and then I'd have to wait 4 to 6 weeks to get a reply. When I asked how I'd know if they received it and what the status of the plan was, she said I should call (I fought to suppress vomiting) or go online. When I pointed out that I'd tried to do that in January and February, she was unbending.

Chapter 5: April and May 2014
We never got an application. What a shock. My stomach convulsed at the thought of going online and reenacting the fun of the previous application. My head, still reeling with echoes of Kenny G, prevented my fingers from dialing the number. Procrastination seemed like the best approach.

Then I got a text from my wife:

She doesn't generally respond to statements like the last one.

So our response was well-rehearsed: Huh? No insurance for her? What's up with that?

Our confusion was increased when a few days later, something appeared in the mail: Three Medicaid cards: one for my daughter, one for my wife, and one for me.

Huh? Huh??

What about my son? I still don't know. What about our earlier rejection letter? I'm not willing to call the state (risking brain injury) to find out. I did earn a pathetically low amount of money last year (the joy of starting a business), but I didn't expect to get Medicaid. If I qualify, then why am I paying Humana? We are now contemplating how to manage this.

Lessons learned
Here are some take-home lessons from this ongoing adventure:

1. Healthcare.gov seemed to work as advertised. The website did what it was supposed to, in general.

2. The people who they hired are very nice. I'm not sure how they manage it. Maybe they all live in Colorado. They were quite good to work with and seemed to take my problems seriously.

3. The majority of our problems came at the state level. The people are confused, unhelpful, and only moderately human. Perhaps passing some laws like those in Colorado would help.

4. Communication between state and federal government needs a little work still.

5. My son is still not insured and I've got two insurances. I would like to give him one of mine, but I doubt that's possible.

6. Kenny G brain trauma takes several weeks of recovery (and strong drinks).

That's all for now. I'll keep you all updated on the adventures. I do intend on posting about the adventures I've had as a doctor, if only that stupid song wouldn't keep echoing in my head.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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