This Is Not a System That Works for People

In the midst of ...everything... I maintain a constant slow boil about the ongoing unforgivable clusterf*** of the American health care system: That we pay so much for inequity, with mediocre to bad outcomes and religious zealots dictating access to important parts of care. And that's without mentioning the profit-takers who stand between people and their health, resulting in health care debt that's at the root of many people's downward spirals.

While I was away from home recently, I almost missed seeing a story in the Star Tribune that is an exemplar of this. ("The care was crucial. He had insurance. His hospital bill? A whopping $155,493." Gift link.) 

Late in 2022, a 61-year-old named Mark Christensen was diagnosed with a sudden-onset case of leukemia, where intensive, hospitalized treatment would save his life. He had good insurance. He was admitted to a Saint Paul hospital within his insurance network and treated for a week or so of a one-month intensive course. It was just before Christmas when he started to develop some complications and the hospital "was having temporary holiday staffing issues" so they recommended he transfer to another local hospital, also in the insurer's network, that would be a better fit for his complications.

He was transferred by ambulance a few days after Christmas, treated for another 20 days or so, and went home in mid-January.

The problems began when he was billed for the second hospital stay. The insurer billed him for more than $155,000 because the transfer was "not medically necessary." 

Christensen appealed the decision through multiple levels. At one point, an external review agency told him that the decision against him was "in the best interest of the patient" (!).

I'll let you read the whole story — which is worth doing if you have good blood pressure — but the short version is, he got it straightened out, but it wasn't easy and it wouldn't have happened in any normal circumstance:

• Christensen called on several "navigators" and an organization called Cancer Legal Care, the latter of which was essential in getting him somewhere. Many people would not have kept going or known where to turn.
• Christensen got letters from doctors at the first hospital to support his appeals, showing that the transfer was medically necessary — that he was moving to a higher level of care. Again, most of us would not have known how to do that or felt empowered to do it.
• It was the Cancer Legal Care, a nonprofit based in the west metro, that finally made the difference. How many areas, particularly in rural parts of the country, have such a resource? 
• Cancer Legal Care's Bill Foley contacted the Star Tribune and magically, three days after the newspaper contacted the insurer in October 2023, Christensen was notified that his treatment would be covered. I'm sure that had nothing to do with it, right?
  

I love this statement from the insurer about why they finally reversed the decision: 

...the complexity of the billing process resulted in a miscommunication between the hospital and health insurer.

Miscommunication. Yeah, I'm sure that was the cause, and the problem couldn't have been figured out in the several earlier times when Christensen was in touch with the insurer.

There are way too many "but for"s in this case to equal a system that works for people. But for Christensen's education level and other life advantages, his health level after treatment to be able to pursue the case, the competence of the hospital's navigator, the existence of Cancer Legal Care, the existence of the Star Tribune (something not to take for granted in the age of the newspaper diaspora)...

Insurers are banking on one of those things failing, or not existing, so they can wring every dollar they can out of anyone who doesn't fight them to the death, and beyond death.