Wednesday, March 5, 2014

The Good, Bad and Ugly of U.S. Healthcare in One Spectacular Bike Crash

No that is not me, but that is about
what it looked like to Joe and friends
 Nobody sets out on a gorgeous mountain bike ride with the intention of pile-driving themselves into the earth head first, but that is precisely what I did a few Sundays ago. I biked in the California foothills with a group of friends on a trail I've ridden for 20 years. Unfortunately, I made a split second decision to hit a jump I've probably hit 15 times; but this time things didn't go as planned. I failed to pull up enough on my front tire and miscalculated my lift, launching my back end over my front and propelling me into a mid-air somersault. Actually, it was precisely the first half of a somersault. I landed squarely on my left shoulder where I gingerly broke my bike's fall and proceeded to bounce down the side of the mountain.

One of the friends enjoying my X-Games-gone-awry spectacle was Joe Getty of the Armstrong and Getty Radio Program. Nobody spins a funny story quite like Joe. Here is his account of the events:

The Good

Over the course of eight days following my accident, I was able to see an emergency room doctor, internal medicine doctor, and two orthopedists. I had an X-Ray and an MRI taken and the results were reviewed and interpreted by technicians as well as the orthopedists. My care was coordinated across two different medical group in two different cities. MRI results and X-rays were transferred from office to office and I received a copy with minimal effort on my part.

The quality care I received in the emergency room, each appointment, and in the MRI (where the technician informed me she was a "Friend of Armstrong and Getty") was unparalleled. It is hard to fathom gaining this kind of multifaceted, high quality care and follow up in any country where the government controls delivery. If you want to know what governmental delivery of healthcare in the U.S. looks like, just ask a veteran. The Veterans Affairs Department (V.A.) is a pure form of single-payer healthcare right here in America. In the V.A. it would have taken me months, if not a full year, to receive the same care I received in eight days in the employer market most of us still use.

I dodged multiple bullets with my injury. My crash resulted in no broken bones and no damage to my rotator cuff. I did, however, end up with a separated shoulder and tore two of the three ligaments in my AC joint. Luckily only one of those tears was complete and the second was a partial. Because I still have two ligaments partially in tact, I will not need surgery. I also tore my deltoid, but that too will heal on its own. After a few weeks of light duty and a little rehab I'll be back on the trail.

The Bad

After my emergency room visit, I was told that I should get an MRI as soon as possible to evaluate the extent of the soft tissue damage.

The emergency room was in one medical group while my family physician was in a different medical group. This should not have caused a problem as I have a PPO plan wherein both medical groups are in my network and I don't need a referral or per-certification for movement to a specialist. But I did need a referral from my doctor for the MRI.

Communication between the two medical groups was not very efficient. My wife stepped in and couriered my X-rays from the hospital to my primary doctor’s medical group. The emergency room rightfully would not conduct an MRI while I was there on Sunday because, technically, MRI's are not "emergency" procedures.

So my doctor ordered an MRI within his medical group at a nearby city (about 20 minutes away) on Monday. That facility, however, was going out on strike and won't be able to see me until mid March at the earliest.

I called back to get to another facility but also decided to cross check against my PPO network to ensure that I didn't go out of network for the MRI. My insurance carrier website was not up to date and not pulling up a valid MRI location within 60 miles. I know that is inaccurate. I know the emergency room I was in (which is also in my network) has MRI capabilities in the city in which I live.

My doctor was hesitant to "certify" me to go there because that is not in his medical group. If I were in an HMO this would be a problem, as all care has to stay vertically integrated. But on my PPO I can float across medical groups. There was great resistance and difficulty in making this happen at my doctor's office. But ultimately it happened for an evening MRI on Tuesday.

My wife, who is an insurance brokerage account manager and does this all day every day, had to work on this with me for over three hours to make the MRI happen. In total, for me to get the MRI set up as needed with all proper certifications and to move from one medical group to another we tallied:
  • over 20 phone calls; 
  • 3 faxes; 
  • 2 emails; and 
  • our delivery of my health insurance contract along with an explanation to my doctor as to why he should feel free to refer me out of his medical group over to another. (Clearly his reluctance to do so was (a) his employer/medical groups internal rules requiring him to refer in-group first and (b) his lack of understanding as to my particular plan's capabilities.)  
This underscores a reality for many enrollees. If you want ease of care and to be moved from station A to station B with minimal involvement on your part, select an HMO. They are simple and limited. But I have a PPO because I want to be able to get care from different medical groups, in different states, and to be able to go the very best specialist should I need it irrespective of what medical group he/she joins. This latter option, however, requires the patient be willing to be a junior healthcare specialist and involved advocate for themselves in order to navigate the system.

It can be brutally difficult to navigate your own care in the United States. I shutter to think at how difficult some of this would have been for folks not working regularly inside of the industry. And we are supposed to believe that more government, rules, regulations, policies and bureaucracies under
Obamacare are not going to make this worse? The bureaucratic policies already in place were the only real difficulties I had in this process. More is not the solution.

The Ugly

Because I have a PPO, I will now receive all of the required Explanation of Benefit Statements (EOBs). For those who have not received EOBs before (HMO patients), imagine endless reams of junk mail tediously explaining the minutia of every treatment you received and the cost for each along with your insurer's discount and your responsibility. This is where you can see that a $10 drugstore sling is billed at $195 dollars and discounted to $65 under your plan. It is absurd and confuses this healthcare attorney every time I review them. But this is not the bill. This is just an explanation of the bill. The actual bills will trickle in for the next four to ten weeks after they are generated by the medical office and adjudicated by my insurer. I will probably receive six to twelve different bills for my treatment. It is another myriad of complication that boggles the mind.

U.S. healthcare is absolutely phenomenal. It needs simplification, a greater degree of competition, and the infinite wisdom of the free market to help liberate it from its highly regulated, rule-oriented, top-down framework designed in the middle of the 20th century. The Patient Protection and Affordable Care Act (Obamacare) is a step in the wrong direction as it accentuates greater governmental involvement and works to squelch free market entrepreneurship. Thankfully for those of us who sometimes land our bike jumps on our heads, we still have access to the best care in the world. We need to fight to keep it and free it from the behemoth of government.

Postscript: A Little Humiliation is Good for the Obamacare Attorney

A few days after my accident, I had a meeting with an ex-NHL hockey player and a lifelong professional fisherman (think Deadliest Catch, as opposed a fly fishing guide). Both men are rugged and hearty to say the least. The fisherman has had four shoulder surgeries including the insertion of a metal anchor in one of his shoulders. He is on tap for a fifth shoulder surgery imminently. The hockey player has had three shoulder surgeries.
At that moment I think I knew exactly
how Daffy Duck felt after most of his
encounters with Bugs Bunny. 

One of them heard the story on Armstrong and Getty and asked me, “so what happened to your shoulder?”

I explained my grade-two separation with the torn ligaments and deltoid tear. I hadn't even finished the sentence when the hockey player exclaimed incredulously,

“Grade-TWO separation? GRADE-TWO?!?! … You will be fine Evel Knievel, your little shoulder owie's gonna heal up just fine. You won't need any surgery for a grade-two separation.”

Then the fisherman chimed in, bellowing laughter and hardly able to keep himself together.

“Maybe we ought to put some training wheels on Craig's bicycle next time he leaves the house so he doesn't get another shoulder ouchie.”