Insurance Companies They Should Be Shot

Today, CIGNA announced that they will not cover the opioid OxyContin for customers who are insured through a job, starting in 2018.  CIGNA last year said it wanted to cut opioid use by 25 percent among its customers by 2019.

What about those who suffer from bone cancer?  While Angela was sick the pressure from her cancer cracked open her bones.  She uses opioids, including Oxy-Contin, every day to cope with the pain.  She tried marijuana, it wasn’t enough.  Prior to taking her current medication, each day the pain of putting weight on her broken bones would send her into spasms until she curled up into a ball. 

She suffered terribly while she was sick.  After months of treatment, a miracle occurred and she went into remission.

After struggling to survive cancer, she still needs these drugs.  The bones in her feet and ankles were broken beyond repair.  Every time she put any kind of weight on them, excruciating pain would shoot up her legs.  She found that by taking opioids she could manage the pain and even walk with a walker.  Being mobile allowed her to get out of the house on her own, resume a semi-normal life, and be happy.  Take the pills away and she returns to a life of suffering, the pain of walking on broken feet and breathing with broken ribs that cannot be repaired.

Angela is covered under her husband’s plan which means that she can, starting in 2018 be denied coverage for her opioid prescription.  Who is her insurance company to say that she is not entitled to the drugs that make her able to play with her grandkids, read a book, or watch TV without curling into a ball of pain?

The insurance companies say that OxyContin is addictive and by not allowing access to the drug, they are preventing people from becoming addicts.   

"Our focus is on helping customers get the most value from their medications — this means obtaining effective pain relief while also guarding against opioid misuse," said Jon Maesner, Cigna's chief pharmacy officer on Wednesday.

They said that they “might” allow prescriptions to be honored that they determine are medically necessary?  What this means is that people like Angela, who are in horrific pain, will have to wait each month until the insurance company decides its OK to give her her medicine.  Who are they to determine what is medically necessary and what is not?  They are not doctors, they have not seen any of the patients whose treatment they are denying?   Does this mean that if they don’t want to pay for it you can still get the prescription if you pay for it yourself?  Isn’t that just another way of insurance companies avoiding payment for things you thought you were covered?

Because some bad doctors and some bad people have abused their prescriptions, CIGNA is deciding they are going to deny life-saving treatment to those who are in need.  When did the insurance company staffers start practicing medicine?   How is it possible that in most states, it is illegal for people to practice medicine without a license, criminal to write prescriptions without a license, and yet, these companies are deciding how much of what drug you can take and for how long?

Maybe the real issue is that they want to save money?  Did anyone consider that?  Doctors who comply with the law provide oversite to try and determine whether their patients have become addicted to opioids.  Today, doctors write prescriptions one month at a time.  If they want their prescriptions renewed, they have to visit their doctor monthly; urine tests must be run to assess the level of drugs in their system.  In addition to the prescription, all this costs money that the insurance company is under an obligation to support.  Perhaps instead, they should monitor doctors who do not put people on a monthly cycle by checking visits and urine test charges?   I thought doctors were supposed to determine how sick you were, and prescribe accordingly?

CIGNA is clearly making medical decisions about what treatment patients should receive. What insurance companies are supposed to do if a doctor deems a treatment is medically necessary is pay for it.  That is why you bought the insurance in the first place.  

That they do what they are supposed to so should not be the exception rather than the rule. Of course you have to meet your deductible and pay your co-pay if those things apply; but, otherwise, insurance companies are not supposed to step into the shoes of your doctor and decide what is medically necessary and what is not.

Minda Wilson

Author of Urgent Care

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Republicans vs. Democrats – Someone should spank them both

In the recent weeks,
Republicans and Democrats have again put their hat into the ring that is healthcare reform. Republicans still want to honor their promise to repeal and replace.  Democrats want to protect their legacy.  Since neither plan considers affordability, either way, the people will suffer.

Republicans have revised their plan in hope that they can get something passed before the end of the month.  If this happens, they will avoid having to start all over and create a new bill.  Their plan replaces tax subsidies; instead of the government paying money directly to insurance companies they will make payments to the states in the form of block grants. People would be able to increase their contribution levels to Health Savings Accounts and other pre-tax benefits. The states would use the money to subsidize their own health plans.  The penalties for uninsured individuals who are uninsured as well as corporations who do not offer insurance would be eliminated.  Limits would be placed on Medicaid spending.  And, hard to believe, the repeal of the medical device tax, which has been on the agenda since day one, is also on the table.

With no federal programs in place, the states will have to create their own.  Since health insurance is still controlled at the state level, this would not make significant changes in the markets.  The financial and other safeguards that were put in place, i.e. no preexisting conditions, no higher premiums for older adults, would be determined at the state levels.  With subsidies gone, and if the federal government continues to limit payments to the states for Medicaid and other programs, it is likely the level of care available will be affected. Each state would decide who would be protected and how.  Just like it was before Obamacare.

All these changes do nothing to control the cost of insurance.  Insurance companies can still charge whatever they want. It is still up to each state’s Department of Insurance to set prices; and, so far, these institutions have done nothing to control runaway insurance premium costs.  The Democratic answer seems to be Bernie Sanders’ latest proposal “Medicare for All!”.  The first problem is that the government actually pays for very limited coverage, Parts A and Part B only.  The rest is covered only if seniors purchase supplemental insurance.

Senator Sanders’ own state adopted such a single-payer plan.  It lasted less than a year.  When Vermonters found out that to keep the program going without filing bankruptcy they would have to raise their state income tax payments from 14% of income to 24% of income, they chose to abandon the program.

Paying out an additional ten percent of one’s income proved too much a disincentive for Vermont’s citizens. That is in a state with relatively few illegals, a relatively healthy population, and low healthcare costs.  You can imagine the financial impact such a plan would have on a national scale.  A 10 percent increase would be nothing when you start adding in the cost of illegals, the underinsured, etc.

The solution to all of this is rather simple.  If health insurance is treated like a utility, we can regulate the money that comes in and make sure that money is used to pay for medical expenses instead of health insurance oversight, review and administration.  Maybe if the legislation focused on that, we might get somewhere.

Minda Wilson

Author of Urgent Care

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Why have we become so afraid of standing up

Why have we become so afraid of standing up to the insurance companies?

Anthem is pulling back from 16 of 19 pricing regions in California.  59 percent of current enrollment, about 153,000 California’s will lose their existing coverage in 2018 and will, hopefully, find another plan that allows them to keep their doctor on the exchange.

Brian Ternam, President of Anthem Blue Cross of California, said the individual market in California has become unstable so he believes they can no longer offer individual plans.

Trump is threatening to cut subsidy payments for low-income individuals.  

From the insurance company’s point of view, this means that, if an individual pays their portion of their insurance premium, even if the government doesn’t pay, the insurance company must pay their portion of all covered expenses for that individual.  To get the money the federal government owes them, the insurance company must sue the fed government to collect.


But Ternam’s statement is not true.  Anthem is offering individual plans, but only in 3 pricing regions.  They are doing this so that they do not lose their right to come into the market in 2019;  which would happen If they pulled out altogether.

 What is most interesting is that Dave Jones, the California Insurance Commissioner didn’t grow a pair and take a stand.

Even though Anthem is leaving 153,000 without individual coverage, Anthem will still be offering employer provided insurance, Medicare Advantage, Medicare Supplements Policies, Medical Policies, and grandfathered plans purchased before March 2010.



Since he has negotiated with insurance companies in the past, it seems that Commissioner Jones was very capable of cutting a deal.  “You, Anthem, want your business, Medicare, Medical plans approved; you want to do business in this state; you have to offer policies in all 19 pricing regions under the same terms and conditions as you are offering them in the 3 remaining regions.  You are either all in or all out!”  It is inconceivable that Anthem would choose closing its doors altogether rather than find a way to offer policies in the individual markets.

Why have we become so afraid of standing up to the insurance companies?  

Even without Anthem, there is sufficient interest from other carriers so that no pricing region in California will be without a coverage option.  If one door closes, another door will open.

Minda Wilson

Author of Urgent Care

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What Happens If

What Happens If the President Pulls the Plug?

Everyone is worried about rate increases in the President pulls the plug.  That is the farthest thing from insurance company’s minds. The rate proposals for 2018 have already been submitted to the states.  Each state’s department of insurance is then responsible for reviewing and approving and/or rejecting the rate proposals.








If the rate proposals are accepted; the insurance companies are on the hook to offer insurance at the rates that they proposed.  If they are no longer willing to offer certain plans at the rates they originally proposed, the states have the absolute right to bring down the stick.

They are allowed to say to any insurance company “you don’t want to offer individual policies at an affordable rate to our citizens; then we will not let you offer the extremely lucrative Medicare and/or Medicare Advantage, and or group insurance programs, etc., that you want to offer in our state.

No individual plans mean you are out of business.  

Your license is revoked; you are done!  

If all the states decided to do this, then the CEO of United Health, who earned more than $100 million last year, would be out of a job.

It is that simple.

It is not Washington that can help you fight these massive increases it is your state government.

Minda Wilson

Author of Urgent Care

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Republicans quickly reject their own revised bill

Yesterday, Senators voted for debate, not passage.  Once they agreed to debate the first thing the Republicans did was quickly reject their own revised bill,  the Better Care Reconciliation Act, once their leading proposal for repealing and replacing Obamacare.

The Senate rejected the bill, 43 to 57, despite having added a provision from  Sen. Ted Cruz (R-Texas) favored by conservatives and another from Sen. Rob Portman (R-Ohio) to court centrists worried about Medicaid cuts.

The Cruz provision allowed insurers to offer several plan types including cheaper plans that cover smaller ranges of benefits as long as that state offers one plan that has the broad coverage required by Obamacare. 


The Portman provision, the Medicaid wraparound, provides $200 billion dollars of support to states whose Senators were concerned about cuts to their Medicaid programs.  The incentive of $200 billion for their states was not enough. Of the 57 votes against, 9 were Republicans.

Minda Wilson

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its bad and know it will negatively impact Americans.

 "It's a sad day when..."

It's a sad day when your Senator votes yes for a healthcare bill even though they know its bad and know it will negatively impact Americans.  The Senators feel they have to vote yes in order to meet their promise to advance the ball on repeal and replace.

"Even Senator McCain, a man who is dying of metastatic brain cancer, who has nothing to lose, voted yes for debate, even though he is not behind the bill as it stands.  Remember, the Senators  voted yes for debate, not passage."

They did it because voting no would mean that they are 
"telling America that they are fine with Obamacare".

Minda Wilson

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Longer wait times to see a doctor, dramatic increases in the cost of insurance

"The Party’s Over"

With the death of the current incarnation of the Republican plan, we have to take a minute to consider what will continue to happen if nothing is done to repeal and replace or revise Obamacare.

The good news is that the expansion of Medicaid will continue and the federal government will continue to subsidize the states that cover those eligible for the expansion who apply.

This has had significant benefits by making working poor eligible for healthcare benefits.  In states like West Virginia, workers that are now covered have seen their wages increase, their children’s attendance at school increase and their use of the emergency rooms for medical treatments has significantly declined.  

That is where the good news ends.

In a large number of countries and in some states, there will be no carriers writing policies for coverage in the individual market.  That means that people who live in those counties/states will not be able to purchase health insurance of any type; and, the, in addition, they will be penalized for not buying insurance that is absolutely unavailable to them in any form.

For those that can purchase health insurance, including businesses, rates are expected to increase at least 20% for coverage next year.   Many companies are struggling to pay current premiums.  In certain states, including Texas, Connecticut, Maryland and Virginia, carriers have asked for premium increases in excess of than 50%.  A business that is struggling will be forced to drop their healthcare coverage.   If your business bought coverage and can no longer afford it, your employees may or may not be able to get coverage of their own, depending on where you live.

Co-pays will no longer be considered part of your co-insurance payments and, as such, may not count toward your deductible.  With individual deductibles on the increase from $2500 to as much as $5000, you might be surprised to learn that your co-payment will no longer count against your deductible.  This means that only co-insurance payments will apply.  Co-pays range from $45 to $115 per visit, depending upon the doctor.  Most plans now require a co-payment for all doctor visits and, in addition, you will be responsible for a co-insurance payment.  If you are on a 70-30 plan,  in addition to your co-payment you will be responsible for paying 30% of the amount billed to your insurance company.  This means that after you pay your co-pay, and the doctor bills the insurance company for the visit if the bill is $100 you will owe another $30 on top of your co-pay.  You now have to pay $75 for your visit, but only $30 counts towards your deductible.

The exchanges will continue to be funded by the government.  The exchanges duplicate 100% of the functionality provided by insurance company web sites. Since the taxpayers already paid for the cost of developing these insurance company sites, every year we support the exchanges we are paying again for something we already paid for.

The 5 million, plus, illegals that currently get healthcare paid for by the government will continue to receive this healthcare.  A number of subsidies paid will continue to be above and beyond what is really called for.  The Obama administration did not implement the electronic verification of citizenship nor did they implement the electronic verification of income.  Income and citizenship are input on the honors system.  We simply take your word.   Because all verifications are essentially done manually, if you claimed you were a citizen and you aren’t or you claimed an income below what you actually earned, you get the benefits you asked for.  Too bad for the tax payer!

Networks are going to get narrower.  It will get harder and harder to see a doctor.  Almost one-quarter of doctors are over 64, retirement or frustration will end their medical careers.  Since 2013, the year Obamacare went into effect, in addition to the loss of doctors due to changing careers or retiring, approximately 10% of doctors each year opt out and accept only cash.  This is especially true in the large cities and applies more specifically to professionals with excellent reputations who are tops in their fields.   These guys are so good, they can command any price, and people are willing to pay it. Why should they accept insurance when the reimbursement rates offered don’t cover the cost of doing business.

New doctors are not going into private practice; they are becoming part of large hospital systems and thus only take on patients that their hospital system will treat.  If your provider doesn’t have a contract with a big research facility and you have something that requires the sophisticated treatment such facilities can offer, you are out of luck unless you can pay for it.

The bottom line is this, the trends that started with the Affordable Care Act, less access to care, longer wait times to see a doctor, dramatic increases in the cost of insurance and even more dramatic increases in the out of pocket cost of care, will continue unless something is done.

Minda Wilson

Author of Urgent Care

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