Hypoliquidemia has now come to health care

The venerable University of Texas MD Anderson Cancer Center in Houston will accept patients with traditional Texas Medicaid health insurance, and some patients in Medicaid managed care plans. Memorial Hermann, another large health system in Houston, will accept traditional Medicaid patients and also those in Medicaid managed care plans. Neither institution will accept the Blue Cross Blue Shield HMO silver plan sold on the Affordable Care marketplace, according to NPR, and as clearly outlined on the MD Anderson website.

As it turns out, the conservative state of Texas is able to obtain best in the world health care for its poorest and sickest citizens, while the private market representative, Blue Cross Blue Shield in this case, is barring its “customers” from the best and most popular Houston hospitals, including the public system (!), and all the doctors that go with these hospitals. This situation is hardly unique to the Lone Star state.

The Affordable Care Act (ACA) is mandating that insurance companies take as much money from people as they are presumed to be able to pay, then proceed to top it off with taxpayer subsidies to make up for any shortcomings, and engage in these activities without discrimination based on formerly diagnosed illnesses. For their part, the people are mandated to make these payments, whether collectively through the government, or individually through their own pocketbooks, or most often both. While the ACA prescribes in great detail the mandatory flow of money from the people to health insurance corporations, and the services due to the people in return, it leaves the definition of the means by which these services are to be provided largely to the wisdom of the corporations, as long as they can show that, theoretically, the services can be provided. And indeed in many cases, many people, in practically every state, are now receiving excellent theoretical coverage for theoretical medical services.

If you happen to have cancer, and are looking to purchase health insurance, no insurer can turn you down or charge you more because of your preexisting condition. Thanks to the generosity of the ACA, you can select any one of the diverse insurance plans offered by each payer. You can choose a plan with a tailored, high-performing network focused on keeping you healthy, which includes almost no cancer hospitals and no cancer specialists, or you can buy a lusher and more expensive plan that includes some cancer facilities and doctors, or you can buy an exorbitantly priced health insurance plan that includes the likes of MD Anderson Cancer Center.

If your cancer is found after you enrolled in that affordable plan for healthy people, you can always decide to switch to a plan that treats cancer and pay the difference. It’s all up to you, and the cash in your wallet, because now you have choices you never had before the ACA was enacted. This has absolutely nothing to do with preexisting conditions. It has to do with high-performance, tailoring, focusing and all sorts of other patient-centered features and benefits.

With great choice, comes great responsibility. All but the most expensive plans available for your selection on the Affordable Care marketplace, and most employer based insurance plans as well, are consumer driven. Basically you get to make all the big decisions regarding your health care and you need to empower yourself to rise to the occasion if and when disease or accidental misfortune materializes in spite of the system’s best efforts to keep you healthy.

For those with little expertise in insurance jargon the best illustration may come from the home mortgage market. See, your affordable health insurance plan is very similar to the pre-2008 affordable mortgage for your pre-2009 home. In addition to your affordable monthly payments, there is a balloon payment due the day you are diagnosed with cancer, heart disease, or just slip and fall while cleaning the gutters. This payment is also known as your high deductible, and unlike your mortgage balloon payment, your high deductible is a self-renewing source of anguish, which springs back to life every January 1st.

There are handy calculators available to let you estimate the size of your balloon payments, and hospitals are setting up specialty services to evaluate a new vital sign called “liquidity” before any procedures are undertaken. Think of it as an expanded pre-op clearance. If your liquidity is lower than the price of your treatment, hospitals may help you elevate liquidity levels through various financial instruments, such as credit card debt, and refinancing for your balloon payment. It is not by accident that entities with brilliant track records in financial markets, such as Citigroup, are seizing the emerging opportunities in the brand new health care financing market, and are introducing innovative solutions “designed to simplify and enhance the health care payment experience.”  Be on the lookout for more innovation here, since this market is projected to run into the hundreds of billions of dollars by the end of the decade.

To bridge the gap between our vibrant financial industry and our old and tired health care system, a new diagnosis seems to be in order. Hypoliquidemia is a disease of the financial system. It is characterized by low levels of liquid cash in your bank account, low credit scores and low socioeconomic status (SES). Other signs and symptoms may include anxiety, depression and various phobias. Hypoliquidemia is diagnosed through a series of evidence based standardized screenings, ported from the financial industry and administered by your whole-person oriented care team. Moderate hypoliquidemia is severely exacerbated by prolonged encounters with the medical system, and although not a life threatening condition in otherwise healthy individuals, it may be lethal when comorbid with other severe illnesses.  The secondhand effects of hypoliquidemia can be extremely debilitating to hospitals and physicians who fail to take the necessary financial stewardship precautions when treating large numbers of hypoliquidemic patients.

Physicians, primary care docs in particular, are at increased risk of being affected by the spread of hypoliquidemia, since they are usually the first point of contact for patients entering the health system, and also because they lack the sophisticated diagnostic tools needed to measure liquidity levels before medical services are provided. The most likely effect of treating low liquidity populations consists of increasing levels of uncollectable bad debt. The only known protection mechanisms for individual physicians are to require cash or credit card payments at the time of service, or to avoid encounters with potentially hypoliquidemic patients altogether, i.e. those with ballooning high deductible insurance plans.

Finally, according to a must read article in Managed Care, hospitals are already setting up “financial screening techniques that stratify access to their services” because “having an insurance policy will not guarantee access to care in the future.”

Hypoliquidemia is reaching epidemic proportions in the U.S. and there is no cure in sight, and there will be no mercy either. For the desperate, there is an old folk remedy which has been used successfully by inadequately liquid citizens in need of nursing home care in their old age. To attenuate the effects of hypoliquidemia on serious comorbid conditions, you need to counterintuitively drive your liquidity levels to zero. You need to quit your job, assuming you have one, and deplete any and all meager assets you may still have. Since regulatory climate is extremely important to treating hypoliquidemia, you may have to move to a region with suitable environmental controls. Once all these steps are executed successfully, you should be able to qualify for Medicaid and gain access to academic centers of excellence, including places like MD Anderson Cancer Center, if that’s what you need to survive. The most common side effects of this remedy are: premature death before the course of treatment could be completed, persistent exacerbation of hypoliquidemic symptoms, suicidal ideations and universal health care delusions.

Margalit Gur-Arie is founder, BizMed. She blogs at On Healthcare Technology.

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  • Patient Kit

    You’re both scaring me and depressing me, Margalit. I have both a cancer dx and a hypoliquIdemia dx. I already lost everything I had last year, qualified for Medicaid and got good treatment for ovarian cancer from one of those great teaching hospitals in NYC. I’m alive with NED. Now, I’m in the process of trying to rebuild from zero. I’ve been working freelance for 6 weeks for $19/hr. For now, I’m still on transitional Medicaid. But my days are numbered. Soon, I will be deemed to be making way too much money to continue qualifying for Medicaid.

    And, unless I find a job that provides good insurance, I’ll have to choose between (1) becoming uninsured and discontinuing the regular surveillance for cancer recurrence and all medical care, (2) trying my luck at the NY state exchange wheel of misfortune or (3) “losing” my job so I can qualify for Medicaid again.

    Thankfully, I have nerves of steel and am getting used to living on a tightrope without a net and I have acquired some skills that would be useful when living under a bridge. I will be sure to report here on what happens to me next in this lovely healthcare system of ours.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      I think NYC may not be so bad. I played with this site http://www.nyhealthinsurer.com and saw lots of the big box names on even the cheapest plans. You need to remember that in addition to the premium subsidy, there are deductible subsidies as well, so all in all things may be okay for you.
      I think the biggest hit is going to eventually affect the employer market and people with incomes above 200% FPL (or so), but still poor by any objective standards, so coming up with an extra two or three thousand dollars is still not in the realm of possibilities. And that’s most of the country.

      • Patient Kit

        I do think NY is one of the better states to be in when it comes to the exchange plans. And, given my current circumstances, until I get further back on my feet with a permanent job, not just week-to-week freelance work, I’ll likely initially qualify for a subsidy. Even with all the issues and problems, it’s better to have the exchange options than not have those options.

        I’m trying for a transitional Medicaid extension first but, if I do have to buy something on the exchange, I do know that the hospital where I’m currently being treated accepts about 8 of the exchange plans including Empire BCBS, UHC, Oxford, Emblem and several others. I don’t know yet which, if any, of those plans my doc who is based at that hospital takes. But if he takes any, that’s the plan I’m buying. Hopefully, if I go that route, it will only be stopgap until I get some decent employer-based insurance again. I have some irons in the fire toward that end.

        This whole situation is nerve-wracking. But it was even worse before the ACA and the pre-existing conditions clause for people in my position. Thanks for the link. It’s a good, useful site to compare plans on. I wonder how many different insurance statuses I can compile since my OVCA dx. So far, this 1.5 years has spanned three — good BCBS just as I was losing it, uninsured for 6 months and then Healthfirst Medicaid. Next up — exchange plan and then, hopefully, employer-based insurance.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          If I may ask, what is a Medicaid extension? Not sure I’ve heard that term before, but it sounds like a good thing….
          Addendum: Never mind :-) I just saw your explanation below to doc99. Sounds like a very useful program…

  • doc99

    @Patient Kit, you may be able to get some accommodation by consulting NY State’s Insurance Division of the Department of Financial Services, explaining your situation. Also suggest you begin to get your records of diagnosis and treatment together, in the event that any new insurance plan does not list your gyn oncologist in the network.

    • Patient Kit

      Thank you. Very good advice. I can’t even consider the idea of having to change GYN oncologists at this point. That would be devastating to me and I’m going to try everything to avoid that happening. I trust him with my life and don’t want to start over with a doc I don’t trust at all.

      My first strategy will be to try to get the state to extend my transitional Medicaid for as long as possible since I have a documented cancer dx and am only working freelance week-to-week. My doc has written a letter to try to help me make my case on this. The idea behind transitional Medicaid is to help people who have major medical issues get back to work without threatening our health status that could end up sending us back to square one of public assistance if we get sicker while we don’t have access to our doctors. The idea is to disincentivize not working in order to keep Medicaid. My future lies in the hands of either a good employer-based insurance (I have a few possibilities pending and am actively job hunting, concentrating on big employers) or the exchange plans. My GYN ONC takes a lot of different insurance so I hope I can find a way to stay with him.

  • QQQ

    “The Affordable Care Act (ACA) is mandating that insurance companies take as much money from people as they are presumed to be able to pay, then proceed to top it off with taxpayer subsidies to make up for any shortcomings”

    It isn’t the government assisting the poor with affording heath care
    that I have a problem with, our government has always done that. My
    problem is that our hard earned money is paying into a grievously broken
    system. My other problem is that a privately owned company’s product
    has been forced onto citizens and businesses as a tax. It obviously
    isn’t going away soon… at this point what I’d love to see are citizens
    organizing and starting their own companies to provide insurance under a
    mutual or nonprofit model. We just need some of the leaders who are
    capable of making this happen to decide justice and morality are more
    important than bonus checks..

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      I completely agree, and I think you might like this latest update on precisely these types of co-ops http://www.modernhealthcare.com/article/20140226/NEWS/302269953
      There is still a long way to go, and I did not look to see how good these things are, but it’s a start….

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Is that for specialty care as well? I somehow thought it’s for primary care only, but I could be wrong….

  • Lisa

    But if I remember correctly, Texas didn’t expand medicaid.

    • RenegadeRN

      Not Jason, but you are correct. Most of the state’s population are NOT happy about it either.

      • Lisa

        And I hope Texans remember this when they vote.

  • jpsoule@hotmail.com

    Just an observation : Anytime artificial price controls are imposed on a service or any product, these distortions happen. Medicare tells me to the penny what I and every physician taking medicare and medicaid can charge for all services and procedures. Any commercial insurance you wittingly or unknowingly ‘sign-up for’ does the same. Physicians under contract to the government (eg VA), institution or large group must work as dictated.

    My suggestion is to stay as independent as possible. Do not accept medicaid, medicare or bad commercial insurances if you don’t want to. Pick and choose your professional work according to your individual preferences. Work part-time in an ER, walk-in clinic, or locum tenems if you need extra income.

    You earned whatever degree you have, don’t be brainwashed into being a miserable automan. Don’t accept a life of “quiet desperation”.

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