It has been over eighteen months since I last posted an item on this site. As a retired healthcare system CEO I was getting tired of complaining about poor provider reimbursement from Medicare and Medicaid. Kvetching about the greed of health insurance companies who made out like bandits during the Covid years similarly seemed like a negative use of my retirement years. It was time to put my healthcare experience behind me and just enjoy life as a civilian.
That worked well for a short period of time until reality reared its ugly head. I began to learn first hand about issues like how insurance companies make it difficult to use promised benefits, how a lack of coordination leads to access difficulties for patients who have insurance for a condition but no one to assist them in navigating healthcare’s treacherous waters and how physicians are unsupported by the administrative quagmire in which they they practice medicine. Everyone seems to care but in reality no one cares.
One of my grandsons may have special needs due to prematurity and other factors. We don’t really know for sure because even though my son and his family have excellent insurance through CALPERS, the health maintenance plan in which they are a member contracts out coordination of some specialty services. He. needs an evaluation by specialists.
My son’s public employer pays a hefty monthly fee to CALPERS for coverage which then contracts with the health plan. You would think access to needed services would be easy. You would be wrong.
My daughter-in-law has been trying for over a year to gain access to professionals who could provide an evaluation of my grandson and provide appropriate treatment. His pediatrician who is a conscientious physician seems to be defeated by the constant demands for information necessary for a referral to a specialist. The health system where my grandson has received care since he was born five years ago did away with case managers for this type of problem in a Covid related cutback. Now we must rely on the grace of his previous case manager who helps my daughter-in-law as best she can when she can in dealing with the health plan and its contracted minion. She too is stuck in a quagmire but we are very appreciative of her efforts.
Then there is the company (the minion) with which the health plan contracts to manage this kind of situation. So far, all they have done is provide my daughter-in-law with a list from the Internet of possible referral sources. My daughter-in-law has to try to ascertain who is taking new patients (virtually no one) and what hoops need to be addressed (many). There is no active problem solving by this contracted minion and no attempt to provide access to needed services. Meanwhile my grandson gets older and he has to be home schooled while his twin brother goes to school everyday.
This experience has been an eye opener for me. There is no entity—not the health system, not the health plan, and not the contracted minion—managing this process. My daughter-in-law is trying to manage the process. It’s non-managed care that is richly funded with no one caring.
When I was still a CEO, a community member approached me in anguish about the lack of services locally for his son who had a similar condition to my grandson. Insurance was not a problem as he had an excellent plan. He and his wife (a registered nurse) knew that the sooner their child had access to the health care services he needed the more likely his long term development would be closer to normal. I listened with sympathy but to my regret now did nothing.
Caring is not enough. My daughter-in-law and I are working on systematic plan to make sure the health system, health plan and contracted minion meet their responsibilities per the covered benefits.. They are all paid prospectively as part of an overall health maintenance process. It’s not a question of money. They need to get their act together. Now is the time to show they care as much as we do.
The Over The Hill HealthCare Outsider 