Purple Maze: The Dismaying State of Health Insurance, Even in a Healthy State

Working in the HIV field at a public hospital for 30 years has exposed me to a host of challenging clinical and social situations. I spend all of my professional time on HIV-related issues (mostly clinical, but also research, teaching and lecturing), yet only a small fraction of it is spent on matters directly related to HIV or antiretroviral therapy. Most is spent on primary care and social or insurance issues that are nonetheless important to our patients.

In some ways, we in the HIV field are fortunate in that vital wrap-around services are often supported by the Ryan White Program: Case managers, pharmacists, social workers and nurses are of immense value in providing quality care to many of our patients. Similar support is not available to other stressed outpatient clinics. Minnesota often ranks as one of the healthiest states in the U.S. (it ranked fourth in the United Health Foundation's 2016 America's Health Rankings report) and has one of the lowest uninsured rates (it was one of just five states with a rate below 5% in the U.S. Census Bureau's latest report on health insurance coverage), yet insurance problems abound that relentlessly devour staff time and energy and threaten the health of our patients. What follows is a sampling from the first week of 2017.

The New Year greeted many of our patients with new or different insurance plans that often created complexity and stress. Examples include medical assistance plans that do not include our clinic or medical center as in-network providers -- yet some of the new in-network clinics have little experience with HIV-positive people who have complex health and social issues. Some patients' new health plans allow them to see us in clinic but force them to use a different pharmacy (our 340B pharmacy provides superior service to patients and providers while providing some revenue to a public hospital expected to lose $25 million this year). Another twist in this winding road involves patients who can use our pharmacy but for whom our clinic is out-of-network. We plan to try to maintain those patients in-care but won't bill them for clinic services until perhaps next year when they can sign up for a plan that includes our clinic. Confused? Join the club!

We have three people working in our HIV program, which currently follows about 2000 patients, one-third of whom are immigrants from over 60 countries, including many in Africa. Although we see patients without insurance and try to provide them services, these three spend much of their time trying to figure out whether patients have or can soon obtain insurance allowing them to be seen in our clinic and to use our pharmacy. For a single patient, that process can take hours, often wreaking havoc on the clinic schedule or making the patient feel less confident that we care about them and know what we are doing (i.e., "Insurance can't be that messy and complicated, can it?"). To make matters even more unsettling, many of our immigrants are frightened about the changes in Washington, D.C., and they are fearful of losing the care they receive in our public clinic located in a sanctuary city.

How about my own stop to pick up refills for my aging mom and me at the local Walgreens? The initial bill for generic medications zoomed to hundreds of dollars. Guess what: It is a new year and they needed the new insurance cards and information. Fortunately, I had already received my new card and had it in my wallet, but I didn't have one for my mom's Medicare supplemental policy. Well, about 25 minutes later after lots of tapping on the computer, the information was updated and the cost of the medications was significantly reduced (though it was still high for generics; that will be the topic of a future blog). Thank goodness there wasn't a line at the pick-up counter or else I would have held things up for others, big time. So, this is a good outcome story, yet still aggravating and time consuming, and it only ended well because I was on top of things!

In upcoming articles, I will comment on a range of issues impacting our HIV clinic population from both the patient and provider viewpoints.