Adventures in (GIC) Health Care

If you live in Massachusetts and access health insurance through the Group Insurance Commission (GIC), you are likely aware of the swirling vortex of controversy that has surrounded the January 18 GIC decision to limit health care options for all subscriber/members whether active of retired.  I'm pretty sure the GIC didn't anticipate the outcry and reaction of members.  That is a disgrace. GIC needs to be transparent in their actions and they need to hear from each and every member about the changes they are proposing.The public hearing for the Northeast Region was hosted by the UML O'Leary Library. Chaos from the start. Although many attendees had followed GIC's direction to RSVP (and never received a promised response back), names were not on the pre-registration list. By arriving 30 minutes early, I was able to take a seat inside of the auditorium; not everyone was so lucky. Many who responded to the public hearing invite were not allowed in to the room as it was at capacity.Roberta Herman, a physician and Executive Director of GIC, made an introduction to the meeting by reading a release from GIC's board offering that the Board would add an agenda item to their regularly scheduled February 1 meeting. In sum, the item would suggest that the decision to exclude current health care providers from GIC's 2018 offerings be rescinded. Dr. Herman alluded to hearing the GIC's subscribers loud and clear and she suggested that the decision to limit providers would be reversed. I, however, would suggest members continue to pressure GIC about this issue. Please continue to contact GIC directly via mail or email AND continue to contact state representatives.Those who did speak were passionate in stating their displeasure at the current GIC decision to limit carriers and in making the case that GIC has not fulfilled its obligations to public employees OR the municipalities belonging to the group. The rates for 2018 have not yet been set nor have the plans have not been approved, so cities and towns are being asked to commit to GIC's offerings blindly. Watching GIC roll over last year to outrageous increases in pharmaceuticals by shifting the costs to members by means of doubled co-pays (retirees), decreases to formularies, and a 67% increase in deductibles doesn't leave one with much hope for 2018's plans and rate increases.Here, however, in no particular order are some points raised by speakers at the hearing last evening.  If you are upset disgusted by the middle-of-the-night attempt to pull the rug out from under GIC subscribers, don't let up the pressure. As one speaker stated last night, the only reason for GIC to backtrack on this effort to limit providers is that they got caught.

• Harvard Pilgrim and Tufts, two programs GIC proposed to eliminate account for 90,000 members each while Fallon accounts for 20,000. The membership of GIC has been reported at 420,000 (plus) - so about half of the membership has to pick something else.
• Active employees' choices are further limited by WHERE in the Commonwealth they live. Neighborhood Health Plan and Health New England are not offered in some geographic areas. Checking last year's decision-making guide, which is all that is currently available to us, Health New England (HNE) serves Worcester and west; Neighborhood Health Plan (NHP) does not serve Berkshire, Hampshire or Franklin Counties. Here's the link to last year's guide as a "loose" reference.
• Comprehensive services for transgender employees are available through two of the eliminated plans - Tufts and Harvard Pilgrim. Those services are NOT available through the plans on the consolidated list.
• Despite what Governor Baker claimed earlier in the week (MassLive story updated to reflect the Governor's more recent statement about poor rollout), subscribers may indeed be unable to access doctors (specialists and primary care) and hospitals with whom they have established a relationship. Several speakers, including medical professionals, spoke about medical entities that do not accept insurance benefits from the GIC-approved vendors (Unicare, HNE, NHP) as the reimbursement rates are unrealistically low.
• Medical professionals spoke about both questionable financial stability of at least two of the companies approved by GIC and the quality ratings for all three of them.  One speaker - and I am so sorry I didn't catch his name - had done research through Consumer's Union. The ratings for all Massachusetts insurers and the NCQA (quality rankings) can be found here.  Notice which 3 providers have exemplary ratings. I know I did.

What happens next is still in flux.  While the GIC is making a motion to rescind their decision, there is no guarantee that the motion will carry, unless of course, public pressure continues to make it difficult for GIC to make decisions without being thoroughly transparent. Bigger issues also need to be addressed. GIC plans/benefits have deteriorated greatly over the last years, as have private sector insurance benefits. With a group as large as GIC's though, there is opportunity to push back at out-of-control health care costs, particularly the outrageous profiteering from drug companies.The GIC also needs to fix the decision-making process to be more transparent. Stakeholders should never be blind-sided by news that impacts such personal decision-making as healthcare. Public Hearings should happen well in advance of decision-making. Participants - cities, towns, public agencies, subscribers - should hear at least a year in advance when plan consolidation or any other major changes to health benefits are under consideration. What happened in this case was that cities and towns were required to commit to belonging to GIC a month prior to the consolidation decision. That's bad enough, but the impact of plan changes to deductibles, copays, and premiums are still to be developed and are unknown.Representation on the GIC board must include more members from stakeholder groups. Currently the health economist position is vacant. Is there proportional representation from public service unions, or is the "quasi-appointed" (the GIC's term, not mine) group so heavily populated by folks with no skin in the game?Stay awake people. The January 18 move to consolidate and change health care for more than half of us was accomplished under cover. It could happen again. Don't let it. 

Keeping Things Real

The Group Insurance Commission or GIC here in Massachusetts is at it again. Fellow public employees, active and retired, will recall last year's efforts by the commission to bring health costs under control. I'd like to think attention was paid to questioning spiraling health care increases, particularly from pharmaceuticals, when the GIC set last year's rates and policies. However,  the cost controlling aspect of last year's adventures in rate setting became less about holding-the-line on increased costs,  and more about shifting all the increases to the subscribers.Last year, subscribers found deductible increases doubling, retirees had co-pays in medi-gap insurances doubling, and some drugs were removed from formularies.  We survived that one, although as a retiree, I noticed my health insurance premium increased 13% over 2016. That cost change does not include increases from raising the deductibles (a 67% increase for individuals last time around) or increases to co-pays, particularly targeted toward retired members last year.The GIC held a meeting last year and seemed shocked that GIC members from across the Commonwealth were upset by these increases.Now before anyone goes all "you should be glad you have health insurance at all" on me, yes I am glad to have this benefit. I too, have experienced private sector insurance increases and realize that health coverage increases are pretty steep no matter whom you work for. Unless of course, you happen to be a member of Congress and get something pretty sweet for practically no cost - but that's another story for another day.So fast forward to 2018. In fact, let's go right to January 19, 2018 and the GIC Commissioner's regular monthly meeting.  This time, the Commissioners decided to eliminate some of the plans and offer fewer health care choices.  Read about which ones here, but interestingly three plans that were eliminated from the GIC's offerings are ones that serve half of the GIC's 442,000 members (that would be Harvard Pilgrim, Tufts, and Fallon). Read the Boston Business Journal article to get more specifics on which plans made the cut and which did not. If you believe Governor Baker, "practically everybody" will be able to keep the same trusted doctors and hospitals with whom they have an established relationship. On behalf of the 50% of us who are going to need to change plans, I say we shall see.GIC members may have an opportunity to find out more as the Commission takes this information on the road around the Commonwealth. In Lowell, that opportunity presents itself this Thursday evening, January 25 (5 pm) at UML's O'Leary Library on South Campus (Rom 222). That address isUMass LowellO’Leary Library*, Room 222 (South Campus)61 Wilder StreetLowell, MA 01854Parking: Wilder Lot/Visitor Metered Parking LotYou must RSVP to attend the meeting. Please be sure to do that by emailing the GIC at gic.events@massmail.state.ma.us. The link below should take you to the GIC's flyer for other venues across the state.

GIC PUBLIC HEARING - 2018_FLYER

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Step Therapy Reality Check

WBZ's I-Team recently broadcast a story of a 22-year-old college student's experience with medical insurance that should be a cautionary tale for all. Reading Eitan Kling-Levine's story and the subsequent price he paid with his personal health should shock you.And in case you think this would never happen to you, let me share a personal experience with "step therapy", albeit one with lesser consequences and a happier ending.Several years ago, I was diagnosed with mild to moderate obstructive sleep apnea. Not only a relational inconvenience as the snoring kept my partner awake, it was a source of concern as I was continually exhausted from interrupted sleep. The standard protocol for this would be a CPAP, something I had familiarity with as my Dad had COPD and had attempted to use one.Now I, the patient, know myself fairly well and, as an extremely light sleeper on a "good" day, I knew the noise of the CPAP would keep me awake as much as the sleep apnea did. And then there are the usual side-effects. So I did quite a bit of research and discovered that in my case a dental device called a mandibular advancement device (MAD), fashioned by a dentist with sleep apnea expertise, would be a more effective solution. And, to my great amazement, a renowned expert in this therapy had a practice in Worcester, MA - 40 minutes away. So I set about getting approvals and referrals.My primary care doctor and the neurologist in that network, all submitted their paperwork. Everything was proceeding smoothly until a pinhead at the insurance company intervened and rejected the referrals. As I had not "failed" with a CPAP  (a $2,000-$3,000 expense), I was not approved for the MAD device ($1,400). In other words, I was not allowed the use of a less costly, more appropriate therapy unless I stepped through the CPAP therapy and failed.  Does that make any sense?In the end, through the advocacy of a very skilled and persistent referral department in my health care provider's practice, the MAD device was eventually approved. It took over 6 months; that was 6 months of loss of sleep, anxiety over a load of paperwork and frustration that a solution to a health problem was put on hold by an insurance company.  It could have been worse as you learn from reading Eitan Kling-Levine's story.Step Therapy is bad for the health of people, good for the health of someone's bottom line. From what I can read, the Massachusetts bill correcting this insanity has been referred to committee.Hopefully that isn't "step therapy" for killing the measure.