Mitigate Partners Comic

Mitigating Matters

A group of nationwide ethical health Benefits Advisors are collaborating to shake up the vast power once exclusively held by the BUCAHs (big five health insurance providers, Blue Cross/Blue Shield, UnitedHealthcare, Cigna, Aetna, and Humana). Mitigate Partners is shining light on the TRUE--surprisingly affordable-- cost of healthcare when the middlemen are cut out.

We, physicians, do not receive any real training in the “business” of healthcare, and we often find out how things work anecdotally from our patients, administrators, the news, or from our own experiences.  

When my insurance changed from Aetna to Blue Cross-Blue Shield I learned firsthand just how messed up, expensive and unethical the financial side of the house of medicine had become. I was diagnosed with post-menopausal osteoporosis years ago, and have been taking biannual injections of a brand-name monoclonal antibody that has helped to inhibit further bone resorption. The average retail cost of denosunab (Prolia™ ) is approximately $1,300.00 (although the average retail price is approximately $2,900.00). 

When I had Aetna as my insurance carrier, my PCP pre-certified and ordered the medication directly from CVS Caremark, the Pharmacy Benefit Manager (PBM) affiliated with Aetna, and the medication was administered by injection in my internist’s office. I had no personal out-of-pocket expenses, and the office collected from my insurance company a modest payment for administering the injection itself (CPT code 96372). What Aetna paid CVS-Caremark for the Prolia remains a mystery because the companies are incestuously tied to one another and there is little to no transparency in this relationship.

When I changed jobs and had Blue Cross-Blue Shield as my insurance carrier, I was told by my PCP’s office that hospital policy would not allow me to receive the injection in the office because “it wasn’t covered.”  I would have to go to the hospital’s on-site “infusion center” to get my medication. 

I thought that it was odd--and dangerous, as we were mid-pandemic--for me, a frequently exposed healthcare worker, to have to get a subcutaneous injection at my rural hospital’s cancer center. It made no sense to potentially expose immune-compromised patients when the hospital and offices were not allowing ANYONE inside their doors for fear of COVID19 spread.

When I got my bill and Explanation of Benefits, I immediately understood why “hospital policy” had prohibited me from getting the injection in the office. Apparently, the “Blues” plan pays handsomely for a monoclonal antibody injection (considered a “specialty” drug) when it is administered in a cancer infusion center. 

My local rural hospital billed my insurance almost $4,000.00. My insurance company paid a percentage of the billed charge, and the hospital wrote off a large percentage. I was billed the difference, but the experience left me confused, angry, and perplexed. I had received the same exact drug (which had not gone up in wholesale or retail price) using the same technique (a subcutaneous injection) at two different locations within a few hundred yards of one another with wildly different billed costs and reimbursements. I felt like I was in the Twilight Zone. 

I paid my bill, and thankfully I have the financial means to be able to afford to.  I also understand the medical importance of preventing further bone loss. But what if I was a non-medically savvy or cash-strapped patient? I would likely forgo my bi-annual shots and end up with much more expensive and debilitating complications from untreated progressive osteoporosis.    

WTH (What the Health) are “BUCAHs”?

And why do hospitals have to play by THEIR rules? Doctors are notorious for acronyms and abbreviations, and I don’t know about you, but I get a little jelly when someone in the healthcare space spits one out that I have no idea what they are talking about. The first time I heard the term “BUCAHs” I feigned understanding what it stood for and was frustrated that I couldn’t figure out what it meant, even when I “googled” the term. 

It wasn’t until I was introduced to Carl Schuessler and his fellow Mitigate Partners that I understood what “BUCAHs” are and why they are considered part of what he calls “the cartel.” Schuessler is a thought leader and a pioneer in the field of EMPLOYER-built healthcare solutions and is shining some much-needed light on INSURER-built, middlemen-heavy expensive healthcare. 

Insurance-built healthcare is clearly NOT a financially wise solution for most employers, nor is it an affordable option for most of the employees who depend on those benefits. The days of “great” health

Health Insurance is NOT Health CARE

insurance for most American employees seems to be long gone. High deductibles, prior authorizations, narrow specialist networks, and restrictive formularies for medications often stand between the patient and the healthcare that they need.  Physicians get frustrated by being told by an insurance representative how they should practice medicine.

Bluntly put, the health insurance industry cares more about profit than they do the patients they serve or those who provide care. By negotiating fee schedules with physicians and other healthcare providers that pay much less than the cost of the care provided, they make obscenely handsome profits. 

Insurance companies have a fiduciary responsibility to their shareholders, NOT to the covered lives they represent. Opaque pricing combined with self-serving policies and priorities, layers of bureaucracy, and very well-paid executives at the very top are bankrupting school districts, small hospitals, and many of our nation’s small businesses. 

ACA - how did it become the UCA? 

The Affordable Care Act (also known as “ObamaCare”)  has turned out to have quite the OPPOSITE effect on the cost of healthcare for many healthcare consumers (patients) and has driven down reimbursement for the healthcare entities that provide that care. The population most affected has been the working middle class who often joke about the “UNAffordable Care Act” that eats up most of their paycheck. An unexpected doctor’s visit for a cough and fever or an ER visit for an injury often throws this kind of family into a financial tailspin due to high deductibles, large copayments, and unreasonably high-priced medications and procedures.

Health Benefits Managers as Heroes

As Publisher and Founder of Physician Outlook, I believe that it is important for ALL of us to learn about models of healthcare delivery that save money and provide excellent care, where both patients and physicians (and the rest of the healthcare team) report high levels of satisfaction and great outcomes. 

This issue is dedicated to recognizing the healthcare heroes like Carl Schuessler and the Mitigate Partners colleagues that are doing the “behind-the-scenes’’ work that makes healthcare affordable. They are revolutionizing the concept of employer-built benefits that attract and retain quality employees while simultaneously saving everyone money AND restoring a personalized healthcare experience.

Entities like the BUCAHs and the big corporate hospitals (who all are plagued by misaligned incentives) must be coerced into becoming transparent, and we ALL (patients and physicians) need to be given choices when it comes to our healthcare.

P.S. It may have been a little late, but after many hours on the phone with my insurance company and their PBM/specialty pharmacy Accredo,  I was able to negotiate going back to my PCP’s office instead of the infusion center for my last Prolia shot. The out-of-pocket amount I have to pay is approximately $700 (directly to the specialty pharmacy this time). Trying to make sense of the bill and EOB is a job for another day, and a battle to fight on a different front.  I plan on introducing Mitigate Partners to my small self-insured private university employer, hoping they can explore and possibly reap the benefits of a custom-built employer plan. Even if they decline and continue to go with the “BUCAHs” I look forward to learning what the ACTUAL price of Prolia would be in a custom-built plan.

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