All posts by pennygentieu

The Blade Editorial

December 20 Toledo Blade Editorial, Big Pharma buys another win:

http://www.toledoblade.com/Editorials/2017/12/20/Big-Pharma-buys-another-win.html

“It’s a lot of money, but education’s expensive,” said “No On 2” spokesman Dale Butland.

And what did Big Pharma wish to teach Ohioans? In essence: If we can only charge Medicare and Medicaid what we are required to charge the Department of Veteran Affairs, then we will have no choice but to raise our prices for all other insurance providers.

So the case made to Ohioans — at great and disproportional cost — was that if we stood up to the bullies, they would take even more of our lunch money. It’s a good bet that, having let ourselves be bullied again, they will take more of our money anyway.

I’m voting yes

Donatello’s David. David took on Goliath and won! Imagine that!
Ohio has a rare opportunity to lower drug prices this November.

I’m voting Yes on Issue 2, even after seeing all the “No” ads that the drug companies run warning of dire consequences if we dare to demand that we should pay the same for drugs that the Veterans Administration pays.

TV commercial after TV commercial scaring us of excessive legal bills. As if, if the bill passes, the state of Ohio could be bought by PhRMA, since if the law does pass, PhRMA will surely be waging war. As if the voters who passed the law should have no rights in the legal defense of the law. Implying that the state of Ohio will just buckle-in to the big bully’s demands, and the citizens of Ohio dare not have a say-so.

As if drug companies can hold our health hostage and demand outrageous ransoms. As if big PhRMA and big pharma can get away with paying off all of our patient advocacy groups like NAMI, that gets 75% of its funding from pharmaceutical companies, and all of Washington DC. As if pharmaceutical companies can charge ten times more for drugs in the United States than Europeans pay, and Americans aren’t allowed to negotiate. If that is truly so, then only the richest people will ultimately be able to pay, and the rest of us will be out of luck. We aren’t really going let that happen, are we?

Regardless of all that pressure from drug companies and deceptive TV ads that bleed money – confusing ads that indoctrinate us to hate and fill our hearts with prejudice, dread and fear, keeping us down like spineless little mice – an industry that pollutes our communities with their opioids and got Congress to pass a law to ease up on the DEA investigations of how they do it — I’m still voting yes, because voting yes is the only way to get them to stop killing us.

With money to burn, drug companies dominate our nightly dinnertime news hour with ads for very expensive drugs that hardly anyone needs and few can afford. As if we don’t have doctors. Since when do drug companies prescribe the drugs? 

Having to pay multiple times the price people pay in Europe for the same prescription drugs is a shameful social travesty and a betrayal of public trust. Yet we’ve been standing aside while they make huge profits and waste our healthcare dollars. 

I’m voting Yes on Issue 2, to start the revolution. Taxpayers can save an estimated $400 million per year on state-bought drugs alone. The state of Ohio is a huge pharmaceutical buyer and we deserve the same lower price that the Veterans Administration pays.

If Issue 2 wins, then other states will follow suit, insurers will demand the same price, and we will be shaving billions of dollars off of the unsustainably high cost of healthcare in this country today.

But what I look forward to most of all, is the drying up of the huge pharmaceutical lobby pool, when they don’t have so much money to splash around.

Wouldn’t it be great if We The People could get our elected representatives back?

2018 Rate Review

New for 2018, Marketplace rates for children will rise 20% to 53%, on top of the additional average 20%-30% rate increase insurers in Ohio demand in 2018.

Child rates in the past they have always been 63.5% of the adult base rate until the age of 21. Next year, 0-14 will be 76.5% of the adult base rate, with ages 15 to 20 being 83.3% to 97% of the adult base rate.

2018. We all know how it’s going. We are supposed to feel lucky that we can at least still buy health insurance. And after what we witnessed in Congress this year, and how it could have gone, but for one vote, we know we’re damn lucky.

We were warned that rates would go through the roof this year. That’s due to the uncertainty of the government reimbursing insurers for CSRs, the uncertainty over the insurance requirement mandate, the uncertainty of a repeal, as well as the totally understandable (not), predictable, ever-rising, unsustainable, runaway medical and non-negotiable pharmaceutical cost factors, that alone amount to a 7% rate increase in 2018, along with the resumption of the ACA tax on premiums that was halted last year, and some increases in administration costs. We are braced for rates to going up 20 to 40% or more. Hands above our heads, they got us, we’ll pay!

The ACA, warts and all, has survived the Congressional guillotine, and the 6% of the U.S. population that comprises the individual insurance market is certainly grateful for another year of being able to buy health insurance.

But what a sneaky thing the child age rating hike is, which raises the rates for all children under the age of 21 by 20% to 53%. CMS snuck that in on December 16, 2016, just after Trump was elected. That, on top of all the “uncertainty,” the rising medical costs blah blah blah, 2018 is going to be a real doozy.

Which is why a typical family may see a rate hike of 29% for themselves, and 71% for their children.

Family in 2000 has been through it all

Take your typical Ohio family – say, John and Pam, who are 55. They have two kids who are 17 and 20. John is an independent contractor and earns $78,000. Pam is an adjunct university professor and earns $21,000. Together they make $99,000 before taxes, just over the 400% Federal Poverty Level that would qualify them for a health insurance subsidy. Their net income after taxes is $78,000.

Having to buy individual insurance, they chose Molina, because that was the only plan in which they could find doctors who would accept them as patients.

Toledo, Ohio is a closed town when it comes to doctors accepting new patients. When it became too costly in 2016, John and Pam had to give up their Medical Mutual PPO insurance and hence their ProMedica doctors that they had been going to for 20 years. Molina was one of the cheapest insurance plans they could buy. But they had to find new doctors, because their long-time doctors didn’t accept Molina insurance.

Mercy doctors were in the Molina network, and they were not as closed as ProMedica doctors.  That’s why they chose Molina over CareSource, another cheap plan, but one with a 90% inaccurate provider network, a network that supposedly included ProMedica doctors, but not really. (ProMedica, when last checked, had only one primary care family practice doctor accepting new patients, but you’d have to call back in a month to schedule an appointment, which supposedly would be scheduled for three months after that.*)

If they had made just two thousand dollars less (see Kaiser subsidy calculator here), John and Pam would have qualified for a $3,334 subsidy this year (undoubtably it would be more than $6,000 in 2018 because the SLCSP which is tied to the subsidy may be 20-30% more, in tandem with the rest of the plans; see rate increases below.) The subsidy would have reduced their health insurance premiums to 10% of their gross income for a silver plan, but alas, they make too much money to qualify.

John and Pam chose a gold plan with a lower deductible because they couldn’t afford the risk, just in case, of having to come up with $7,500+ to meet the deductible before the insurance would kick in.

With an increase of over $6,000 in 2018 for health insurance, their tightest budget, cutting down on food, recreation, transportation and clothing, exceeds their net income. Forget about helping with their kids’ education or even saving for their own retirement, which is coming in 10 short years – in 2018, they are going into credit card debt on their necessary expenses just to be able pay for health insurance.

As it was, in 2016 John and Pam paid 22% of their net income on health insurance, $17,448, at $1,454/month. It was a lot more than they were paying just a few years before. An affordable and reasonable percentage, in keeping with the spirit of the ACA, would be 13% of their take-home, or 10% of their gross. John and Pam make more money than most families in Toledo, but to have 22% of their net income going to pay for health insurance really hurts.

In 2016, John and Pam’s rates were $554.50 each per month, and the kids’ rates were $172.62 each.

But next year, in 2018, John and Pam’s health insurance will go up 39%! It will surpass housing as biggest chunk of their budget, becoming a whopping 31% of their take-home income, $24,240 for the year; $2,040/month. The astronomical but necessary expense squeezes out any money that could ever have been saved for retirement, which they need to fund, and eliminates any possible budget they may have hoped for to help their kids with higher education expenses.

While John and Pam’s health insurance is going up 29%, health insurance for their kids goes up 71%. The family’s health insurance premiums next year will cost $6,792 more than last year!

In the midst of uncertainty and rising medical and unnegotiable pharmaceutical cost factors, what a sneaky rate hike this children’s age rating hike is, and what a scary thing it is for families like John and Pam’s. Thanks, elected officials, for looking out for our best interests. Maybe it’s time to stop the killing and let everyone in on Medicare, expanded and improved.

OTHER OBSERVATIONS

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Toledo is down to five insurers for 2018, listed on the left -- Ambetter, CareSource, Molina, Medical Mutual HMO, and Paramount.

2018 Rate Review Observations

Anthem is the only insurer right now in 19 Ohio counties, and in 2018 they will be exiting the Ohio individual market, except for one teeny tiny county, Pike, for a non-exchange plan that probably has 5 members, just so they can keep their foot in the door and not be banned for five years in case they want to come back. Awe.

Anthem has about 18% of the individual market in Ohio, and they insure millions of Ohio corporate and state workers. 40,000 individuals are presently covered by Anthem, and 10,000 people may not be offered any individual plan next year as a result.

In Toledo, Anthem has the worst, smallest provider network, and it was 66% inaccurate. It is highly expensive, and went up quite a bit last year.

Anthem more than tripled their premiums in seven years, just like Medical Mutual did, who left hanging an estimated 100,000 people covered by their PPO plans, completely exiting  and extinguishing the sale of PPO’s in the individual market,  thus eliminating the only national network plan sold to individuals in Ohio. Last year two insurers covered nearly 50% of the Ohio individual market, and now they are gone.

Also gone this year is United Healthcare and Aetna, so just like that, our four largest insurers of the individual market are gone from the individual market, and Ohio let them, even rewarding the insurers with our state employee insurance business. Ohio either has no business sense, or our state really doesn’t care whether or not 300,000 Ohioans can buy insurance in the individual market.

Four things that Ohio can do to mitigate this healthcare crisis:

1.

Ohio should do what New York is doing this year, and ban insurers who leave the exchange from any future participation in public programs such as Medicaid.

Governor Cuomo announces aggressive actions to protect access to quality affordable health care for all New Yorkers  New York State website
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o

2.

Ohio should propose a Medicaid buy-in for anyone in the state, like the plan that Nevada’s legislature just passed for it’s citizens. After all, our commercial insurers in the individual market (Anthem, Medical Mutual, United Healthcare, Aetna) have been replaced by Medicaid insurers (Buckeye Ambetter, CareSource, Molina), and since all of Ohio is covered for Medicaid, it makes sense that these insurers can also cover all of Ohio for the individual market, and with great ease.

Nevada’s legislature just passed a radical plan to let anybody sign up for Medicaid  VOX
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VOX

3.

Ohio should pass an emergency “any willing provider” law so that citizens can take their insurance dollars to any provider willing to accept them and the payment. At an average of 80% inaccuracies in our provider networks, have the worst that have been reported in the entire country! It’s only civilized that Ohio gives us an”any willing provider” law.

4.

Oscar Insurance Corporation of Ohio, a new insurer for Ohio this year, should cover all the counties that Anthem has left hanging.

But they won’t be covering even one of them. It comes to Ohio to set up shop with Cleveland Clinic in the five counties around Cleveland.

It’s a perfect example to show why market-driven health insurance does not jive with societal needs, and it never will.

Click the photo to visit Oscar’s News page

(Dream on, hoping for a private, for-profit insurance industry to voluntarily go into 19 counties for the business of a mere 10,000 people who won’t otherwise have insurance, when the company can get the same business by simply marketing to the east side of Cleveland. But for some reason, the for-profit, so called “free market” health insurance model persists. And it has nothing to do with what is best for our country.)

5.

Here’s something the federal government can do: Open up the D.C. Exchange to people without an option, as per U.S. Senator Claire McCaskill’s proposal.

McCaskill proposes expansion of DC exchange Columbia Daily Tribune, May 18, 2017
Check out this video clip on McCaskill’s Facebook page from June 9, where she asks the Senate for a hearing on the secret health insurance plan that the Republicans are going to impose on Americans without any discussion with Democrats or the public!

The D.C. Exchange sells insurance for everyone in the country, that is, everyone who is a member of Congress or their staff. I have researched the plans and found that they are really inexpensive compared to what is sold in Ohio. Moreover, it’s quality PPO insurance with national provider networks.

At one time, the ACA was going to have just one exchange for the entire country, like this exchange in D.C. But then the insurers got their mitts on the shaping of the ACA. They sliced it up into hundreds of different state and county plans. Four short years later, insurers are leaving, and hundreds of counties will have no insurance option. It seems logical to open up the D.C. exchange, for everyone. What would be wrong with doing that?

Click on the photo to visit the DC Health Link

On a final note, the chart below shows the three largest insurers in Ohio, from a report made to the state of Ohio by the actuarial company, Milliman, in 2011. I added to the original chart in light blue, to show the individual rate increases since 2010. (The dark blue along with the red and green show the 2010 rates.)

With the withdrawal of Anthem, none will be in the individual market next year! Our three biggest insurers in the individual market in 2010, gone!

It’s no wonder, because our regulators let their rates go up over 300% in 7 years, while the rates for the group plans went up only a total of 30%. Wow. You’d think that all the new members of these plans had leprosy. I hope they are cured, at least.

Divide, divide, divide. Divide and subtract some more! The huge free market health insurance system is so close to knocking off those 23 million people who just don’t fit in their money-making calculations.

The Wild Wild West of American-style Pharmaceuticals

Pierre scans July 20160012

This is my great great grandfather’s photo of the Kickapoo Indian Medicine Company.

The Kickapoo Indian Medicine Company, of New Haven, Connecticut, sold “patent medicine” before they had patents for medicine. They sold snake oil when it was the cure-all. They weren’t really Indian. Kickapoo Medicine was often laced with alcohol, morphine, opium, or cocaine.

Fast forward to 2017. The shenanigans continue. Many mass market brand-name drugs that are nearing the end of their patent and even after the patent is over are being given orphan status. Orphan status allows the drug company to have a longer period of exclusivity on a drug and raise the price even higher than it was before.   Drugmakers Manipulate Orphan Drug Rules To Create Prized Monopolies     see also Orphan Drugs Lookup  new on Feb 10: Grassley launches inquiry into orphan drugs after KNH investigation

Meanwhile, generic drug manufacturers, taking advantage of patents that are no longer exclusive, have colluded with other drug manufacturers who make the same drug to raise their prices as much as 8,000%. A lawsuit is pending.   Alleged Scheme To Fix Generic Drug Prices Started At Dinners And ‘Girls Nights Out’

And now Trump wants to loosen regulations to encourage start-ups and get drugs to the market faster —  TRUMP’S PLAN FOR LOWERING BIG PHARMA DRUG PRICES COMES AT A HIGH COST

YEE-HAW!

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Healthcare Insecurity

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The brand-new barrier that Ohio and Medical Mutual have put between patients and healthcare: the elimination of PPOs in the individual market.

While ProMedica doctors survey their patients’ “Food Insecurity,” (ones who can get in to see ProMedica docs, because when you call them from the insurers’  lists of accepting new patients, they actually really are NOT accepting new patients) I’m experiencing “Healthcare Insecurity.”

Medical Mutual eliminated our “real insurance” PPO plan on December 31, 2016. In 2013, their PPO was the only kind of insurance they offered to individuals, and there were 101,380 of us covered by their PPO insurance, more than 25% of the entire Ohio individual market and the biggest market share of any insurer in the state and it remained like that through 2015, but in 2017, Medical Mutual , after raising our rates more than 300% during those three short years, is putting us all out on the street.

No more PPOs anymore for the individuals of Ohio who buy their own health insurance — only skinny, extremely inaccurate provider networks for us.

We must either resign ourselves to our fate, that can we no longer have the best healthcare, like the people have who work for the state of Ohio or for big corporations, or we must marry for health insurance, simply so we can have a chance for decent healthcare along with everyone else.

To think that Mary Taylor and the state of Ohio did not look out for us when Medical Mutual withdrew PPO insurance from the individuals. Not a peep about the pending doom, and my complaint got buried.

Yet the state of Ohio gives themselves Medical Mutual’s PPO as the state employees’ health insurance. In fact, in the past nine years, Medical Mutual made an average of $192,000,000 per year insuring Ohio state workers.

Shouldn’t the state of Ohio have said to Medical Mutual, if they were going to eliminate PPOs for individuals, thereby hurting 100,000 Ohioans directly and damaging the options of all Ohioans, then they will no longer be getting Ohio’s state employee insurance business?

The state of Ohio and Medical Mutual are working in concert to snuff out individuals. Are they stupid or are they sly foxes? What’s next — the state using grant money to give themselves an art show called “After Hours”?

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Provider Network Complaints Get Buried

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The good news is, I finally received some of the provider network consumer complaints that I asked for from the Ohio Department of Insurance.

The bad news is, for many of the complaints, we don’t get to know the outcome because the Ohio Department of Insurance kicks the complaint over to another department, and they make it confidential. The following are paragraphs from the Ohio insurance department’s closing letters for various provider network complaints:

Due to this error we are referring our findings to another division within the Department for further review. Please be aware that investigations by this division and the records pertaining to these investigations are confidential by law. Consequently, the Department will not be able to provide you with any information as to whether an active case investigation will be opened on the matter or if an active case investigation is opened and the status of the investigation.
Based upon our review of the facts and circumstances presented, we determined that CareSource provided you inaccurate information regarding their provider network. The Department is also concerned about the likelihood that additional members have received inaccurate network information as well. Therefore, this matter has been referred to another division in our agency for investigation.
Due to incorrect information provided to you by Buckeye, we have forwarded our findings to another division within the Department for further review. Please be aware that investigations by this division are confidential by law. Consequently, the Department will not be able to provide you with any information as to whether an active case investigation will be open on the matter you reported or if an active case investigation is opened and the status of the investigation.
Caresource did not initially administer the claim in accordance with the terms of your policy; therefore, we have forwarded our findings to another division within our Department for further review. Please be aware that investigations by this division and the records pertaining to these investigations are confidential by law. Consequently, the Department will not be able to provide you with any information as to whether an active case investigation will be opened on the matter you reported or if an active case investigation is opened and the status of any investigation.
We have forwarded our findings to another division within our Department for further review. Please be aware that investigations by this division are confidential by law. Consequently, the Department will not be able to provide you with any information as to whether an active case investigation will be opened on the matter you reported, or the status if an investigation is opened.

What is the law that they claim prevents them from revealing the status or results of the investigation? The new provider network rules they put into place this year. They wrote in a clause that gives them the power to keep investigations confidential.

http://codes.ohio.gov/oac/3901-8-16

(2) All documents provided to the superintendent under paragraph (G) of this rule shall be considered work papers of the superintendent that are subject to section 3901.48 of the Revised Code and are confidential and privileged and shall not be considered a public record, as defined in section 149.43 of the Revised Code. The original documents and any copies of them shall not be subject to subpoena and shall not be made public by the superintendent or any other person, except as otherwise provided in section 3901.48 of the Revised Code.

Clever!  So all of our provider network complaints get buried. Companies get to keep doing this, because the Ohio Department of Insurance doesn’t care. They reward them instead, with confidentiality. And after two years, they destroy the original complaint, buried, burned, deleted.

I told you they are run by the insurance guy!

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Related: Ohio Citizen Rate Review Provider Network Survey, Summer 2016

Related: Passing the Buck: My letter to complaint examiner

Anthem Blue Cross Blue Shield Network

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Thank you doctor, you were the only one I could find who is accepting new patients!

13 not 39!

Ohio Citizen Rate Review Provider Network Survey, Summer, 2016
Ohio Citizen Rate Review Provider Network Survey, Summer, 2016

How would you like to be a doctor and always have to know all the ins and outs of networks, that an insurance company like Anthem can put you in, or not?  See, this Anthem instruction to doctors. Think of the money that could be saved on healthcare if we could delete these time-wasting, manipulative administrative rules that have nothing to do with healthcare and everything to do with getting in the way of healthcare, so they can make more money.

“How do I know if I am participating in one or more of the networks?” the doctors ask Anthem…

Below is an excerpt from an Anthem BCBS Ohio letter to doctors in 2013. Information is given on the new healthcare.gov insurance, that the networks are “more focused,” to log on to the network directory in October to see if their name is on it.  The utter nerve of Anthem BCBS!

And so it is with Medicare Advantage too, I’m sure. As if that is our future, and the future of health insurance is to control utilization through extremely limited provider networks that will frustrate patients so much that we will die first, before achieving the most basic task of finding a doctor!!  But that IS their plan. No Doubt. My educated opinion.

Death panel by provider network.

Patients should be allowed to see any doctor who will take them, without the Orwellian control of the big brother insurance company controlling and withholding their care. A for-profit corporation deciding in effect, who lives and who dies.

As we look back at what has happened since 2013, we can find a lot of examples of surprise out-of-network bills and a whole new way that insurance and maybe even providers limit our care and make money at the expense of our health on our healthcare and taxpayer dollars.

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Doctors, don’t put up with this lunacy from the insurance industry! Take back your profession! Don’t let them tell you what network you are in — you tell them! In fact, cut out all of the networks altogether. Do you like having to spend so much time on administration, having to hire employees whose sole job it is to handle many networks’ multitude of bullshit that gets in your way of practicing medicine? Stop doing the insurance industry a favor. You are the ones with the service we need, not the other way around.

Health insurance is merely a payment system from patient to doctor that benefits a large group of people. Insurance companies work for us, we don’t work for them. Don’t give them the power!

Here’s the grand network scheme: Insurers seek limited insurance exchange plan networks

Anthem Blue Cross and Blue Shield

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the teeny-tiny network of Anthem Blue Cross and Blue Shield

Anthem and Cigna are planning a merger. Anthem had already merged with Wellpoint, by far Ohio’s largest insurer, in 2004. In 2014, Wellpoint changed its name to Anthem. It goes by Community Insurance Company on the rate filings.

Here in Ohio, Anthem is especially after Cigna’s Medicare Advantage business. These two companies are the largest members of the health insurance industry’s lobbying organization, AHIP, which is now headed by the Centers for Medicare and Medicaid Services’s former Administrator, Marilyn Tavenner. Talk about a conflict of interest. Marilyn Tavenner was the one responsible for the Marketplace’s disastrous rollout in the Fall of 2013. And what a small world it is — United Health’s Andy Slavitt took her place at CMS. Here is an interesting discussion on Physicians for a National Health Program’s website.

The health industry seems to be slowly creating its own single-payer system, one that will ensure massive profits for many years to come for these players — Anthem, Aetna, United Health, Centene (our Ohio Buckeye Ambetter) and Molina.

a perfect example of why health insurance company mergers are
bad news

Anthem is the most expensive plan sold on the Marketplace in Toledo. You have to be rich to buy it, but even so, buyer beware — you might not be getting a doctor.

Anthem is the granddaddy of the micro-narrow network. They’ve blessed us with only 36 PCP doctors, which is maybe 6% of Toledo PCP doctors, for our population of over 300,000, that has about 450 PCP doctors, but only 13 are actually accepting new patients. Nevermind that they advertise that 36 are accepting new patients, Anthem can do no wrong. In reality, they are giving us a choice of only maybe 2% of Toledo PCP doctors. What you see is not what you get, but Anthem is above reproach. We lowly Toledoans have to accept that and be grateful, because Anthem is almost holy in the eyes of our government and regulators. They must see something we can’t see, but they don’t see what we see. They have their own employee insurance.

Ohio Citizen Rate Review Provider Network Survey, Summer, 2016
Ohio Citizen Rate Review Provider Network Survey, Summer, 2016

13 not 39!

and look at that price….

These are the only eight internal medicine primary care physicians on Anthem's provider network they advertise are accepting new patients. But when you call them, they tell you that they are not accepting new patients.

In the healthcare.gov screenshot of Anthem’s gold plan above, all eight internal medicine primary care physicians in the provider network are shown as accepting new patients. I called each one of these doctors, and four out of the eight told me that they are not accepting new patients. This is false advertising, misleading, inaccurate, untruthful, and reckless for Anthem not only to present us with such a very small network to begin with, but to lead us to believe that it is actually open to us.

In November 2015, California fined Anthem and Blue Shield $250,000 and $350,000 respectively for their “unacceptable inaccuracies” in their provider directories, and they will be paying millions of dollars in damages to the members as well. Read the details here. My survey shows major flaws with Anthem’s provider directory in Toledo. Did the California provider network directory scandal even faze Anthem Blue Cross and Blue Shield of Ohio even a single tiny smidgen bit?

the birth of Anthem’s skimpy provider network

“How do I know if I am participating in one or more of the networks?” the doctors ask Anthem…

Doctors don’t join the Anthem network, they are put into the Anthem network without even being aware. Without being asked! The boldest of Orwellian schemes.

PG204294
Thank you doctor, you were the only one I could find who is accepting new patients!

How would you like to be a doctor and always have to know all the ins and outs of networks, that an insurance company like Anthem can put you in, or not?  See, this Anthem instruction to doctors. Think of the money that could be saved on healthcare if we could delete these time-wasting, manipulative administrative rules that have nothing to do with healthcare and everything to do with getting in the way of healthcare, so they can make more money.

Patients should be allowed to see any doctor who will take them. We could do this if we could get legislators to enact an “any willing provider” clause in our insurance laws, that would make our insurance portable, so that we could go to a provider willing to accept us who is willing to accept the insurer’s payment terms.

Why should insurance companies be allowed to create arbitrary networks which are not serving the purpose of containing costs for the members, which, 35 years ago, was the original reason for creating networks — but that have morphed into the negative effect of controlling utilization and causing bankruptcies, thereby working against the best interests of the members?

As we look back at what has happened since 2013, we can find many examples of surprise out-of-network bills and an entirely new way that insurance and maybe even providers limit our care to the detriment of our health, and at great expense! Surprise billing is the number one cause of medical bankruptcies, which have increased dramatically in the past five years. Healthcare costs are the biggest cause of bankruptcies in the United States.

Below is an excerpt from an Anthem Blue Cross and Blue Shield of Ohio letter to doctors in 2013. Anthem is giving information to doctors on the new healthcare.gov insurance, saying that the networks are “more focused,” and to log on to the network directory in October to see if their name is on it.

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HOW WE CHOOSE DOCTORS AND HOSPITALS FOR OUR NETWORKS

Before providers join our networks, we check to see that they have the education, licenses and training to provide care. While we don’t have specific quality, member satisfaction or patient safety measures for selecting providers and hospitals to participate in our Marketplace networks, we monitor and promote quality of care within many of our networks using programs like Enhanced Personal Health Care (EPHC), Quality-In-Sights®: Hospital Incentive Program (Q-HIP®), Blue Distinction, Blue Physician Recognition, Blue Precision, Physician Quality Measurement (PQM), Anthem Quality-In-Sights®: Primary Care Program (AQI).

This from the Anthem provider directory preamble on what they tell their members.  Hmmm….even more Orwellian, all those programs. They have to find something to spend all that extra commission on that they make from our health insurance dollars — skimming 20% for themselves every year, their administration budget and profit growing at the same rate as the annual premium hikes. Wish my savings would grow so fast. But the bank crisis bailout of 2008-2009 took care of that. Even with all this extra money insurance companies make, they still can’t get the hang of keeping up to date with their teeny tiny micro narrow provider network database. Only 13 PCP physicians — you’d think they’d be real tight and in touch with their tiny cast of doctors through one of their nifty programs like Blue Distinction or Blue Precision, or Anthem Quality In Sights. But Anthem has no insight.

Read more here, about the birth of the narrow network: Less Choice, Lower Premiums: Many exchange plans will offer narrow networks.   What a joke — “lower premiums!” Which goes to show, it matters little what they say — they just do whatever they want, anyway.

Here’s an article about the “any willing provider” clause:  AHIP seeks reversal of “any willing provider” clauses.

how other Toledo provider networks stack up to Anthem:
Ohio Citizen Rate Review Provider Network Survey, Summer, 2016
Ohio Citizen Rate Review Provider Network Survey, Summer, 2016

Anthem Blue Cross Blue Shield PPO Rate Review

It’s ironic that Anthem is the most expensive insurance sold on the Marketplace, yet it has the smallest of any network.

Anthem has a membership of 40,000 covered lives in Ohio, which is about an 18% share of the Marketplace. The Toledo area membership is undisclosed.

Anthem is asking for a 9.9% average rate increase for 2017, with the increases ranging from 3.4% to 20.3% depending on how unlucky you are. So your $1,845 premium plan in 2016 could very well be $2,300 in 2017, with the age factor figured in.

When premiums go up so much compared to other plans that only the sick spring for the extra bucks because the plan has something special, that is what is called a death spiral. But with Anthem’s micro-narrow provider network, there’s really not much that Anthem Blue Cross and Blue Shield has to offer to the sick.