a health care story

i'm a little mad

Four (!) years ago, I had necrotizing pancreatitis. You probably know that if you read this newsletter, but new people are being born every day, and I guess it’s technically not illegal for a four-year-old to read it. I’m impressed by you, hypothetical genius toddler, as well as by your precocious taste and discernment. Now go watch Totoro.

Anyway, aside from my initial hospitalization in New York, I’ve been very fortunate to work, mostly, with the same doctor at the same hospital at the University of Michigan. (Parts of my medical team have come and gone, as is normal.) These days, I am very stable. There are aspects of life I’m still trying to improve, but it’s been over a year since I’ve done anything that seriously upset my pancreas. The primary condition that I’m left with day to day is called “exocrine pancreatic insufficiency”: that is, I take pancreatic enzymes with food because my pancreas is damaged and can no longer produce them in the quantities I need to receive nutrients.

Ending up at the University of Michigan was lucky; it is what the National Pancreas Foundation calls a “Center of Excellence.” I like my doctor, who is such a kind person I almost cried once sitting in his office. The last time I saw him we worked out a good way of continuing to monitor the situation. I have been grateful to have a doctor I like and trust through this process.

However, my insurer has decided that it’s time to play chicken with my medical providers. Which means it’s possible that after June I will lose access to my “Center of Excellence,” my doctor, and the rest of it.

It goes against my nature, but let’s try to be fair for a moment to health insurance companies. It is hard for any conflict to exist in which they do not appear to be the bad guy. BCBSM knows that, which is why they announced their side of the story first. Part of that is that when we deal with doctors we are dealing with people, whereas when we deal with insurance we are dealing with systems and forms. I know my doctor but I do not know “Blue Cross Blue Shield of Michigan.” I would like my doctor to get paid what he deserves but since “Blue Cross Blue Shield of Michigan” is not a person I have no such feelings for it.

So I’ve tried to resist my initial reaction of blaming BCBSM for everything and have looked for further reporting on this situation. There are two sets of competing claims: BCBSM states that Michigan Medicine is demanding a 44% increase in what the insurer pays the hospital. Michigan Medicine’s response is: that is false, that they’ve only asked for single-digit increases in payment, and that BCBSM actually wants to cut their current payments by 30%. Can they both be telling the truth in some technical sense? Yes, I think so, but I will put my speculation in a footnote because my math could be wrong or it could be right in theory but one of them could actually just be lying after all.¹

But, to be blunt, it’s just hard to find an explanation here that makes BCBSM look good. They control a huge chunk of Michigan’s health insurance market. Their explanation requires you to believe that Michigan Medical would cut itself off from much of the state’s population out of sheer greed. There is no reciprocal resource which BCBSM risks losing. Right now, thanks to BCBSM’s brinkmanship, hundreds of thousands of patients are being thrown into limbo, and some of them are in crisis situations. At Michigan Advance,² Andrew Bashi, who has a critically ill baby, writes:

The team at the University of Michigan’s C.S. Mott Children’s Hospital detected his condition before [Jibran, his son] was born, kept his mother hospitalized, and had a team ready when he arrived. At ten days old, his heart the size of a walnut, they successfully performed his first of several heart surgeries. During his three-month stay, their nutrition team guided him through prematurity without developing necrotizing enterocolitis, a life-threatening condition for which Jibran scored at the highest possible risk.…

The surgeries still ahead of Jibran, including one that requires stopping his heart entirely, chilling his body, and reconstructing its architecture while a bypass machine keeps him alive, can only be performed at a single hospital in the entire state; the University of Michigan.

And Blue Cross Blue Shield of Michigan wants to push that hospital out of its network.

Unlike myself, Bashi doesn’t have the luxury of being in a relatively stable situation. His child is sick now and requires surgery now. Bashi also can’t go somewhere else in the state. The kind of care his child needs is only available at Michigan Medicine.³

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This email is not a request for advice in dealing with this situation or in managing EPI or whatever else. In fact, I would like to actively not request advice. (I hate advice.) (Don’t give me advice.) If you live in Michigan there are steps it is possible to take (see here), but most of you don’t. That’s fine. One of those steps is “express your concerns through the media by submitting an opinion or a letter to the editor.” That’s what I’m doing. I am the media. (In this instance.) And the media says: pay my damn doctor.

1. Here are the exact words of the BCBSM statement: “After several rounds of negotiations, Michigan Medicine is demanding a 44% increase in payment over the term of a new contract.” And here are the exact words of Michigan Medicine: “Michigan Medicine is proposing either single-digit annual increases, which would still leave BCBSM paying well below other insurers in Michigan, or extending our current contract and tying any future increases to proven quality and cost outcomes for patients.”

These can both be true because “over the term of a new contract” means we are talking about the cumulative effects of smaller increases. For the sake of keeping the math easy here, let’s say BCBSM reimburses Michigan Medicine 50% of medical costs. Then we will go to this handy percentage increase calculator. A 44% increase from 50% is 72%, which is about what you’d get if you increased the reimbursement by 7% every year for five years:

• 7% from 50% is 53.5% (we will round decimals to the nearest whole number)

• 7% from 54% is 58%

• 7% from 58% is 62%

• 7% from 62% is 66%

• 7% from 66% is 72%
  

Now, I doubt the numbers here are this simple. But this is a version of events in which both statements are technically true. (Unless I got my math wrong, which seems possible.) In any case, the language of percentage increases can be really misleading.

2. I was completely unaware of Michigan Advance until this story happened, but I’m glad I found them.

3. If you were an editor at a national publication, and you were reading this missive, you might think to yourself: “Oh, if only I had Andrew Bashi’s email, I’d contact him about publishing a version of his story.” I do not know this gentleman, to be clear, but I’m guessing he’s pretty mad, and his email is right here.