Health Insurance Clusterfuck

Anthem Blue Cross and Blue Shield: We are greedy asshats, and we are going to pay you LESS for your brilliant orthopedic surgery skills.

Surgeon: Are you kidding me? Reach into those deep pockets and pay me what I deserve. No deal!

Patient: What a colossal thorn in my balls!! I kind of feel like I just got broken up with. I’ve grown quite fond of my surgeon and his crew, and I am bummed to have to leave them behind.

I don’t know exactly what’s going on, but it’s convenient to identify a clear villain (my health insurance company) to unload my lingering frustrations onto. Two weeks ago, I got a voicemail informing me that my PAO surgeon is no longer a participating provider in my health insurance plan. I have a solid back-up plan: transfer my case to Dr. Bellino at Stanford. He still takes my insurance. It would delay this PAO process by a few painful months, but in the grand scheme of my life, is that really a big deal? Probably not. HOWEVER… I don’t want to let go of Dr. Diab and his group at UCSF. I’ve totally invested heart chakra vibes into this man, and it’s sad that this has to happen. I’m not grieving the loss until I know I’ve done all I can to keep that door open. It really is like a break-up! I’m the girlfriend in denial. I know we can work this out! Please just give this relationship another chance! Haha. I guess the question is: Is my right hip pain manageable enough to try to wait and see if the insurance issue gets resolved? (and MAYBE get to snowboard and ride a mountain bike in the meantime?) Or should I switch surgeons and try to get this surgery shit over with as soon as possible? I’m masterminding another, more far-fetched back-up plan that requires switching insurance plans outside of the designated open season to one that my current surgeon is contracted with, e.g. Aetna. It would mean paying a couple of thousand dollars more in out-of-pocket expenses. I’m trying to explore all options and then wait and see which doors the universe opens for me.

I have never delved all that deeply into the various types of insurance plans out there because I never had reason to. When I started working for the Feds 9 years ago, I chose a PPO plan (Blue Cross and Blue Shield Federal Employee Plan Basic Option) with inexpensive copays, reasonable premiums, and a big list of physicians to choose from. It’s been fabulous up until now, and in fact is one of the main reasons I’ve been holding on to my job during this now 2.5-year-long hip saga. Yesterday, I did some research into two types of plans available to me through Aetna: a consumer-driven health plan (CDHP) and a high-deductible health plan (HDHP) with a health spending account (HSA). I’m no dumbass, but reading those brochures about made my head explode! The fee-for-service plan with copay for each service seems logical enough, but these CDHP and HDHP plans seem unnecessarily complicated. If I am allowed to switch plans, I will need to make a complex Excel spreadsheet comparing premiums, deductibles, coinsurance rates, HSA funding, and max out-of-pocket expenses for the entire year, not to mention research which doctors, physical therapists, and facilities would be in network.

In 2013, my medical expenses were approximately $262,238. I paid $2,525; Blue Cross and Blue Shield (BCBS) paid $51,898. Apparently, the remaining balance is my “member discount.” What does that mean, exactly? Would a different insurance company be charged the same amount for the same surgery and 5-day hospitalization at UCSF but just have a different member discount? Would my current insurance company be charged the same amount for the same surgery and hospitalization at a different institution such as Stanford? Basically, I’m wondering how charges and payments vary among physicians, facilities, and insurance companies. Is the reason my insurance plan was dropped by my surgeon because he is paid a lot less by BCBS than by Aetna? Does all this restructuring have something to do with health care reform associated with the Affordable Care Act? There is clearly a lot I don’t understand.

The system is unequivocally broken, and the patients are the ones suffering the most. Many of us have very shallow pockets and are just barely getting by. I worry about my retired, not-wealthy parents, whom I fear may be one major illness away from financial devastation. In the past, I’ve just paid my copays and went merrily on my way. Now, I find myself wanting to understand the complexities and corruptions in the health insurance industry. Perhaps I will make it a personal crusade to help sort out this clusterfuck.

Onward, troops.