Affaire du coeur, Part 5

Well, everything worked out, didn’t it? Not quite.

A few days later, Regence again turned down Tory’s coverage for other medications required as a result of the transplant. Regence claimed that these secondary medications weren’t covered under her transplant insurance.

We had been through this once, and this time I wasn’t going to waste time calling, faxing, and writing the people who didn’t respond the first time. This time I contacted the Seattle Times and the Insurance Commissioner’s office directly.

Again, Plan B was resurrected, except this time, we had even less time than before. We were already at the deadline we had originally set for Plan B, and set it in motion again with real intent to follow through with it.

Pressure was applied to Regence. And again, Regence blinked.

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January 20, 1999

Insurer Bumbles Question About Drug Coverage
Shelby Gilje

Seattle Times Staff Columnist

Get it all in writing!

That’s the best advice I can give a consumer whether it’s Victoria Doyle, a heart-transplant survivor, who has been in a complicated dispute with an insurance carrier over drug coverage, or someone who can’t get a widget they ordered.

Ten days ago, it appeared that Doyle’s dilemma was resolved. Based on a letter Regence BlueShield sent to Don Sloma, a deputy in the state Insurance Commissioner’s Office, I wrote that the carrier had decided the transplant benefits in Doyle’s policy would cover medications she needs to survive – immuno-suppressants and drugs to control cholesterol, blood-pressure and stomach acid.

But just three days later, Regence reversed itself, saying it had approved only the immuno-suppressants Doyle requires, under her $200,000 lifetime transplant benefit. The other medications would be charged against her prescription coverage, which is capped at $500 a year, leaving Doyle to pay $4,300 a year out of pocket.

Regence spokesman Chris Bruzzo explained that the health plan’s pharmacists ruled the other drugs were not related to the heart transplant.

But Doyle says her physicians contend all these medications are required because of the transplant. And, she adds, she did not have high blood pressure or cholesterol, or stomach-acid problems before the transplant.

Bruzzo said the first letter to Sloma, signed by Waltraut Lehmann, Regence’s manager of regulatory affairs, dealt only with the immuno-suppressant drugs. The other medications were reviewed separately.

“We were not aware of the other drugs that she felt ought to be applied (to the transplant benefit) and we should have taken a broader view of all her medications,” Bruzzo said.

“The positive thing is we did review it and we have approved all seven drugs. And we are apologizing to Doyle for the challenges.”

Lehmann’s initial letter did not single out the blood-pressure, cholesterol or stomach-acid drugs for added review.

It said, in part:

“We did not recognize that her drugs should be counted against her transplant benefit, instead of her retail-drug benefit. Consequently – we are sorry to say – she was informed that, when she reached the $500 limit on her retail-drug benefit, her medication would no longer be covered.” The letter mentioned a billing problem, but said it would be corrected. There was no hint that the review of coverage would continue and that a different outcome was possible.

“We took that (Lehmann’s first letter) to mean an `all clear signal,’ ” said Jim Stevenson, a spokesman for Insurance Commissioner Deborah Senn.

Lehmann’s second letter to the insurance commissioner’s staff said Regence’s decision was final: the added medications were not transplant-related. Lehmann said she understood Doyle would appeal.

Doyle said when she asked Regence and the insurance commissioner to review her coverage, she asked about all the transplant-related medications, not just the immuno-suppressants. But Doyle acknowledges that she made that request over the phone, not in writing.

Frankly it doesn’t make much sense to me to tell a consumer they are covered one day, then inform them a few days later that they are only partly covered.

It’s also odd that Regence has been paying for all of the medications since Doyle bought the policy in November 1996. Doyle says she always has purchased the medications through the pharmacy at the University of Washington Medical Center, where she had the transplant in 1991.

No one could explain the change of heart to me.

When Regence seemed to be reneging on its promised coverage last week, the insurance commissioner’s office re-opened its probe.

I made some more phone calls. Among other things, I asked Regence for a letter that specifies what drugs it will charge to Doyle’s transplant benefits.

Doyle says if she has future questions about coverage, or gets phone calls she will ask for everything in writing.

Doyle’s dilemma is one more reason to support the insurance commissioner’s proposed rules for more drug-coverage disclosures by insurance carriers – before consumers sign up for health plans.

Shelby Gilje’s Troubleshooter column appears Wednesday and Sunday in the Scene section of The Times.

Copyright (c) 1999 Seattle Times Company, All Rights Reserved.

This time, Regence finally covered Tory’s meds. She had literally 3 days worth of meds left, before the final word came through. Imagine having 3 days left to live.

We weren’t going to have the last word, though. The medical director at Regence, decided have something positive to say about Regence.

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and is reproduced here in whole without permission.

Editorials & Opinion: Wednesday, January 20, 1999
Doctors And Health Plans: Making The System Work
Donald Storey

Special To The Times

I’M a physician, so I know precisely the importance of a great doctor-patient relationship. People get the care they need, when they need it. And they stay healthier. When you like your doctor and trust what he or she has to say, and they listen to your concerns and needs, it makes all the difference in the world.

I was 20 years in private practice in internal and pulmonary medicine. Now, I’m the medical director at Regence BlueShield, our state’s leading health plan, with more than 1.1 million members.

So, when I heard some doctors – even those who are friends and longtime trusted colleagues of mine – characterizing a new contractual agreement we distributed last summer to providers in this state as a “master-slave relationship,” well, that didn’t sit too well with me.

I’ve worked with health plans my entire medical career; on occasion I have disagreed with them. But I was never their slave. And I was never told how to practice medicine. I would not tolerate that when I was in private practice, and I won’t tolerate it as medical director at Regence BlueShield.

That’s why when I felt the backlash from my colleagues last summer, my one and only reaction was this: We need to find a better way for doctors and health plans to work together. Period. We must have enough of a partnership to come together, with trust and credibility, to resolve those problems. That’s what is best for our patients and health-plan members.

We listened to physician leaders from groups such as the Washington State Medical Association and the Pierce County Medical Society, as well as many individual providers and practitioners who had voiced their strong concerns about our newest contract. And then we got to work on making changes to our contract.

We went back to the physician leaders in our state and showed them the changes. Case in point: On several occasions, we met with the executive director and president of the Washington State Medical Association, the most vocal critic of our initial contract distributed last summer. They gave us input, were given comprehensive reviews of our revised contract, and given time for additional response and comment.

We’ve made the first move to the physician community in this state – taking the negative feedback from doctors on our new contract and going back to doctors for input and review. What’s more, we are committed to this path.

Physicians in this state probably won’t say our revised contract is perfect or that every word suits their purposes. And that’s OK. But they will say it is a definite improvement and that we worked together, in good faith, to settle our differences.

So why, if we’ve learned to work better together, can’t all physicians put an unqualified stamp of approval on this contract? This is a business contract and our responsibilities do differ. Physicians are responsible for the medical advice and care they provide to patients. Health plans are responsible for taking the premium dollars our members give us each month and ensuring that they are spent in the most efficient and effective manner possible. And we may have, at times, a difference of opinion with our providers over how those dollars are spent.

But the key will be how we settle our differences. At Regence BlueShield, we believe there is a middle ground that will allow us to work together on behalf of patients and members, even when the issues are complex and contentious. We know the issues are tough, and will only get tougher. We will go head-to-head with our physicians and other providers over how much we reimburse them for medical services, among other key issues. Because that’s our responsibility – keeping costs reasonable while ensuring that health-care consumers have access to quality providers and medical services.

Early this year, physicians throughout our state will receive our new, revised contract, and we think they’ll be pleased with the changes we’ve made. They’ll know we’ve listened to their concerns and responded in a positive manner.

We believe we have started to lay a solid foundation of collaboration. Our actions over the latter part of 1998 in working closely with physicians in crafting a fair, responsible contract are a practical example of our future intentions.

We won’t settle for “Us versus Them” anymore. I hope my colleagues feel the same way.

Donald D. Storey, M.D., is medical director at Regence BlueShield, and was a practicing physician for more than 20 years in Washington. He is also a board member of the Washington State Medical Association, the state’s leading physician organization.

Copyright (c) 1999 Seattle Times Company, All Rights Reserved.

This editorial just happened to run at the same time as this last article. It was an attempt to make them look like the misunderstood good guys.

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