Unhealty healthcare

Source: pernambola.blogspot.com

I've avoided working in the US for too long, despite being a (now-former) software engineer and it being the source of the majority of interesting opportunities. There's a lot of reasons why, but near the top is its healthcare system. There's lots (and lots) of reasons why it's bad, but despite hearing the problems, it can be easy for people to dismiss them ('hey, it's not really that bad, right?'). So rather than stats, I thought it might be good to present my own anecdote as a case-study instead. As someone lucky enough to have lived on three continents (worked & studied in Australia, worked in Switzerland, and studied in Canada) I'll also add observations of what I'd expect from other countries, for comparison.

For some context: Last summer I accepted an internship position at Facebook, and after failing to secure a spot outside the US in their London office, I ended up living in Menlo Park (California) for three months. This meant having to navigate the US healthcare system :( Most interns find this not a problem; as young, healthy people, we're unlikely to need anything in a three month trip. However, as someone with type-1 ('juvenile') diabetes, who can only easily bring a few months worth of supplies in and needs to get more while there, it means it's a certainty. I was eager to experience US healthcare, perhaps masochistically, to see if it really was as bad as people said.

Problem 1: Responsibility

Source: PICList

When moving to Switzerland, my employer at the time (Google) took care of everything visa-related. The Swiss have what some consider the best healthcare system in the world - expensive, and required, but it works. Soon after arriving, I was presented a list of options: a few different levels of the price vs. coverage tradeoff, and a few providers at each level. I signed up with one (Sanitas), and was done, everything else happened through their website.

Canada was even easier. I got my study visa from the government, and after moving, they cover some things via their Medical Services Plan (MSP) system (like Australia's Medicare). For everything else, UBC has their own university health & dental plan for its students, which you're automatically enrolled in.

Here's how it works in the US:

• I get offered an internship from Facebook, which needs a J-1 visa.
• To get a J-1, I need to be 'sponsored'. This is handled by a company called Cultural Vistas, separate from Facebook. As far as I can tell, they make sure I abide by the law and don't stay after my visa expires.
• My welcome package from Cultural Vistas included two different health insurance cards, with no details about what each is for. Before giving up investigating, my best guess was:
• UnitedHealthcare Global which seemed to be meant for emergencies, like medical evacuations. They advertise themselves as the only 'single source provider', yet for some reason I was also covered by...
• BCS PHCS, which seems to be for normal claims (e.g. medicine), made of:
• BCS (a regular insurance company)
• PHCS (a.k.a 'Multiplan'): I honestly have no clue. Challenge for readers: try to figure out what they do from their site.
• The UnitedHealthcare card included the line "Client: ASRM, LLC". The BCS card mentioned claims can be filed online at www.claimsnet.com/asrm, or mailed to ASRM, LLC. Not to be confused with the American Society for Reproductive Medicine, it turns out ASRM LLC is a 'benefit management platform'. i.e. they manage claims for other insurance companies.
• Facebook employees are also covered by Aetna. When arriving, I was told that the non-US interns (i.e. ones that had coverage from Cultural Vistas) were not covered by Aetna, which seemed fair enough, no need to double up. Unsurprisingly, I didn't receive any Aetna stuff when arriving. Then surprisingly, about a month before leaving, I got an Aetna card with not many details about what it was for... (?! - see later).
• I also received another card (from memory, not long after joining) from Envisage Global*, an insurance company that seems to specialize in international J-1 coverage. It turns out that claims for them go through Seven Corners, which appears to be...another insurance company?
• *warning: an aside, but the envisage homepage currently includes a 'blurry street view' background video, which not only slows down your browser while playing but is also 33MB...

You can see the problem. Other than Facebook, there are eight companies listed above: the sponsor, five insurance companies, and two...platforms? If I get sick, who do I contact? Where do I send my claims? If I have a question about coverage, who do I ask? Who to contact when things go wrong? This should all be hidden from the end user. For example, if you're on a J-1, insured by Envisage, then they should be your point of contact for questions and claims. Whether they sub-contract out your paperwork (or risk) to a second company who themselves sub-contract the management platform to a third should be irrelevant to the person making the claim. 

Why is this important? In Switzerland, I filed all claims to Sanitas. In Canada, I file to the uni plan. In the US, for my insurance claim after buying the insulin, I:

1. Filed to BCS. 
2. Realized I made a mistake on the form (whoops...my bad), so filed again with BCS.
3. After getting no response for a long time, asked for an update. Soon after received a rejection in the mail (pre-existing condition, not covered).
4. Asked the health people at work about what my coverage should be. Before starting, I had triple-checked that diabetes supplies were covered, as I knew this would come up.
5. At the same time, filed to Seven Corners, as maybe they were the ones, not BCS.
6. Health people at work said I should be covered by Aetna (?! - see above). 
7. After getting no response for a long time again asked for an update. Soon after, received a rejection over email (pre-existing condition, not covered).
8. Started a massive email thread with Facebook plus Cultural Vistas asking what each of the seven insurance-related companies were for, and which one should cover my pre-existing diabetes medication.
9. Work again said Aetna, so I also filed a claim with them.
10. A very helpful lady from Cultural Vistas was the first person to explain that UnitedHealthcare Global and BCS (& PHCS & ASRM) were the old obsolete way, Envisage Global was the right one (i.e. Seven Corners is the right place to file), and added a representative from them.
11. The Envisage Global person looked into it, and a little while later, found there had been an error, and mailed the claim amount to me. This was now October, having filed in July.

P.S: I still haven't heard back from Aetna. After the resolution, I felt I should cancel my still-outstanding claim with them, but my theory now is that they never even received it. It needed to be physical mail, so maybe it got lost on the way? 

Also, questions: How many people quit this process at an earlier step? Why did I twice not receive a rejection until I separately followed up and specifically asked. What happened with Aetna?

Problem 2: Pricing

Epipens made the news recently due to large price increases. Not many people realize, but insulin is undergoing similar treatment. Which is even crazier, as the product space is a lot more competitive - Eli Lilly, Novo Nordisk and Sanofi all make a range of insulins that are competing(ish), yet as can be seen above, they tend to increase prices at remarkably similar times...

My insulin purchase was no exception: pens normally come in packs of five, and a pack of Humalog plus a pack of Lantus** cost over US$1000. In Canada, the same is around CA$300 (US$225).  Yes, there are some valid reasons why the price of medicine may be high for some treatments. But a flight from SFO to YVR costs under CAD$700, so when it is cheaper for me to fly 1300km twice to go to Canada for a day and get back just to buy my insulin, something is wrong...

One thing that was noticeably bad about this was how buying medicine was linked to insurance. For example, there was a pharmacy at work, yet only people covered by Aetna could get stuff there. This would have been perfect for me, had I not been in my quantum superposition of both being covered and not covered by Aetna. From my understanding the pharmacy I ended up going to (a normal CVS) also sells to customers at a different rate than it sells to insurance companies. I'm not sure about the latter in Canada/Switzerland/Australia, but for the former, pretty much all pharmacies acted like shops: they simply sell goods. Whether or not your good will be paid for by you, or a particular insurance company, is irrelevant, it is the same price for all, and anyone can shop there. I'm sure there's some technological hurdle to being able to get insurance to pay for medicine at the counter, but I don't see a problem with letting anyone pay out of pocket at any pharmacy, and having the same price for everyone.

Note, in Switzerland, it was even better. My endocrinologist (i.e. diabetes specialist) was essentially their own pharmacy. They didn't write prescriptions, they just give you your medication when you leave. They send you a bill a few days later, which is then paid by either you or your insurer.

** What is important about Lantus? Well...

Problem 3: Options

This is minor, but also the most surprising. Lantus is what's called a basal insulin - long acting, you inject only once or twice per day to give an underlying, base level of coverage (compared to short-acting taken at meal times). For basal insulin, the longer it lasts the better and safer it is. You want the level to be as constant throughout the day as possible, shorter lengths tend to be more variable, hence it's easier to get dosages wrong (in both directions).

In Switzerland, I was introduced to Tresiba. An injection of Tresiba lasts up to 42 hours, which is makes it very friendly, having a fairly constant output if injected once per day. Unfortunately you can't get it in Canada, so here I'm currently using Toujeo, which lasts 18-26 hours according to wikipedia. For me it seems on the shorter side, so I need to inject twice a day, and the variability is noticeable.

For an unknown reason, in the US I was prescribed Lantus. I've found it slightly worse than Toujeo, and much worse than Tresiba. Apparently Tresiba was approved for use in the US in 2015, and Toujeo has been around for even longer, but the CVS person hadn't heard of either, and couldn't find them in their system. Perhaps I just got unlucky, and it was only for 3 months, but still...

Conclusion.

My experience with US healthcare therefore is spending a few months using sub-standard insulin that cost more than flying back to Canada, and then dealing with four companies (five if you count Aetna) over three months to have my claim processed. I'm planning on spending my next summer in Vancouver instead... Please, USA, I know you have lots of things on your plate to fix, but hopefully the health of your citizens should be pretty high on the list. The experience was by far worse than the three other countries I've lived in, hopefully this has been even slightly informative to readers, and good luck to anyone who has to endure US healthcare.