As in many other technologically advanced democracies, the U.S. is blessed with highly trained dedicated medical personnel and superb facilities. However, we are also by far the most expensive healthcare system in the world. More than 30 cents on every dollar goes to, among other things, large, to some extent unaccountable, administrative bureaucracies that, on the whole, do not make a positive contribution to actual health care (Harrison, 2008; 2018). In fact, on a per capita basis, the administrative bureaucracies of American health insurance/plans are far greater than any other nation’s healthcare system’s. While this paper gives three examples from the health plan I belong to, similar and, perhaps, even worse administrative actions from some health plans are the norm. A previous paper by me gives additional examples of administrative decisions from other healthcare insurances/plans that were NOT beneficial to patients (Harrison, 2018). These are not exceptions; but the rule.
I have been a Kaiser member for almost 22 years. I have had the same primary care physician, both trust him and like him and intend to continue with him. And overall my experiences with various Kaiser healthcare personnel have been positive. Just to be clear, friends in some other plans also have PCPs they trust and have had positive healthcare experiences.
However, Kaiser administration is another story, and reflective of the divide between healthcare personnel and American healthcare administrations. The following are but three examples of problems I have experienced:
I. Kaiser Permanente Advantage HMO Monthly Report
Upon reaching 65 I switched from an individual Kaiser policy to Kaiser’s Medicare Advantage plan. I then started receiving a monthly report. It includes the following columns: Date of Service, Description, Billing Code, Provider billed the plan, Total cost (amount the plan approved), We paid, Your share [copay].
The Kaiser “Provider”, e.g., doctors, nurses, physiotherapists, etc. are Kaiser salaried employees and the facilities are owned by Kaiser. I have asked numerous Kaiser personnel about billing. They don’t bill. And “We paid” involved NO transfer of funds. The alleged amounts that the Provider’s billed is what really captured my attention as well as my copay. I’ll give just two recent examples; but I have kept my monthly reports and could give many more.
Percutaneous Tibial Nerve Stimulation (PTNS) for Overactive Bladder
As an old man in my mid-70s I have developed overactive bladder, basically need to urinate multiple times daily and often 6 – 7 times nightly (Kaiser Permanente. Overactive Bladder; Wikipedia. Overactive bladder). Percutaneous Tibial Nerve Stimulation “is designed to stimulate the nerves responsible for bladder control using the tibial nerve in your lower leg. During treatment, a small, slim needle electrode is inserted near your tibial nerve and connected to a battery-powered stimulator. The impulses travel to the tibial nerve and then to the sacral nerve, which controls bladder function. Each treatment lasts approximately 30 minutes, and you would typically receive 12 treatments one week apart (Mayo Clinic).” Research has found it benefits up to 60% of recipients, basically reducing number of times needing to urinate (e.g., Kaiser Permanente, 2001). The nurse then leaves the room and returns a half hour later to remove the inserted needle. This is done in groups of three. For each patient the procedure involves less than 5 minutes.
According to the monthly report Kaiser mailed me:
Provider billed the plan $453
Total cost (amount the plan approved $382)
We paid $367
Your share $15
We can look at the alleged provider billing in several ways:
1. For individual patient, $453 for a half hour means a nurse is billing per hour at a rate of $906.
2. However, since three patients at a time are being seen means a nurse is billing per hour at a rate of $2,718.
3. However, if one considers that the actual procedure and time spent by the nurse with each patient is only FIVE minutes, then the nurse is billing per hour at a rate of $5,436.
4. And since the nurse is seeing three patients at a time, the nurse is billing per hour at a rate of $16,308.
I was billed afterwards for a $15 copay. I always ask when registering at the desk if there is a copay and each time have been told NO and the nurse(s) doing the actual procedure have told me there are NO copays for nurse visits. The PTNS clinic has been in operation for well over 15 years, so if a copay is required, then it should be included when registering as all other office visits.
If one simply looks at the $15 copay, given the nurse sees three patients at a time, one can look at it, again, in several ways:
1. Six patients per hour, thus the nurse’s copay is $90 per hour.
2. However, given the actual time involved per patient is only five minutes, the nurse’s copay is $180 per hour.
I contacted Kaiser Member Services and explained the above, both the claiming the Providers billed them and their alleged payment and the absurd amount they claimed the Provider billed them as well as the high copay and being billed afterwards, not at check-in. Actually I’ve complained more than once. A Case Manager contacted me. She seems genuinely trying to pursue my case; but so far told me that administration replied that I was billed after the fact because it was a procedure. Well, among other things, I’ve had minor surgery to remove a benign tumor which took ca. 30 minutes where a doctor cut the skin, removed the tumor, and put a few stitches in. And I’ve had problems with eyelashes turning in and scratching my eye, so an Ophthalmologist anesthetized the eye lid and removed the eyelash root by electrolysis. I paid copays upon registration with no follow-up required copay. I consider the above two to be procedures. I wonder what Kaiser administration considers them? Given the PTNS clinic has been in operation for over 15 years and it is a PROCEDURE, if a copay is required, then it should be requested upon registration as any other procedure. However, a $15 copay for a nurse and especially for five minutes time is ABSURD (see above).
So why does Kaiser administration do this? In an extensive article by investigative journalist Steven Brill, he writes: “The chargemaster, I learned, is every hospital’s internal price list. Decades ago it was a document the size of a phone book; now it’s a massive computer file, thousands of items long, maintained by every hospital. [It] assigns prices to everything. . . Whenever I asked, they deflected all conversation away from it. They even argued that it is irrelevant. I soon found that they have good reason to hope that outsiders pay no attention to the chargemaster or the process that produces it. For there seems to be no process, no rationale, behind the core document that is the basis for hundreds of billions of dollars in health care bills. . . No hospital’s chargemaster prices are consistent with those of any other hospital, nor do they seem to be based on anything objective — like cost (Brill, 2013).”
Brill then goes on to explain how uninsured patients are then billed based on the Chargemaster, often exponentially higher than Medicare or any health insurance plan would reimburse them. Why? When not paid, the bill is turned over to collection agencies that hound people. I highly recommend reading the entire article.
However, I highly doubt that a non-Kaiser member would receive Percutaneous Tibial Nerve Stimulation therapy from Kaiser nor any of the other myriad of clinic visits by Medicare Advantage members. Maybe Kaiser administration thinks the insane amounts will impress Advantage members of the level of care they are receiving? But claiming they received a bill, paid certain amounts, then $15 copay for a 5-minute procedure by a nurse and claiming procedures are billed after the fact is just plain wrong.
Just one more brief example. As I mentioned above, I’ve had problems with eyelashes turning inwards and scratching my eye. Quite unpleasant. Since not always easy to get appointment with an ophthalmologist, an optometrist can remove with a tweezers (called an epilation, e.g., Stevens, 2008). You put your chin on a support as when getting eyes checked for glasses, the optometrists looks with a magnifying glass and removes one or two eyelashes. This immediately eliminates the scratching; but since the root not removed by electrolysis, the eyelash sometimes grows back after several months. I paid $5 copay at registration for the 15 minute allotted time and received NO follow-up bill for this PROCEDURE. However, according to the Monthly Report, the optometrist billed Kaiser $222 for Eye Exam, Kaiser Approved $174, Kaiser Paid $169, and my Share [Copay] was $5.
According to Steven Brill: “Medicare collects troves of data on what every type of treatment, test and other service costs hospitals to deliver. Medicare takes seriously the notion that nonprofit hospitals should be paid for all their costs but actually be nonprofit after their calculation. Thus, under the law, Medicare is supposed to reimburse hospitals for any given service, factoring in not only direct costs but also allocated expenses such as overhead, capital expenses, executive salaries, insurance, differences in regional costs of living and even the education of medical students (ibid).”
I found the allowed amount for Traditional Medicare Part B (Noridian Medicare). Note that higher amounts are paid if not in facility setting, i.e., for in office because Medicare takes into account overhead expenses (CodingIntel, 2021). Not sure if applies to Kaiser facilities; but, to be on safe side, I give both. Note. that without a Medigap plan, Medicare pays 80% to provider and patient responsible for 20% copay. I assume that Kaiser providers would be Medicare contracted Providers.
For PTNS (CPT Code 64566) the allowed amount is $144.46 (In Facility: $31.99). So $453 is not even close to the non-facility $144.46. Why would a Medicare Advantage Plan claim 3 times what Traditional Medicare pays?
For epilation (CPT Code 67820) Traditional Medicare allowed amount per units (one eye) is $22.77 (In Facility: $24.37. Higher in facility?). So, Kaiser’s Medicare Advantage is $222, 8 times what Traditional Medicare allows. Even if had been an eye exam (CPT Code 92004), which it wasn’t, the max amount allowed is $166.68. (In Facility: $102.76). The CPT Code is for a Comprehensive Eye Exam (Vicchrilli, 2020). Note that a Comprehensive Eye Exam requires longer than a 15 minutes session.
It would be appropriate for Kaiser to send a monthly report with: Date of Service, Description, and Copay, also giving total copays so far towards the current $4,000 max out-of-pocket. Not the current dishonest document currently being sent and the absurd post-treatment copay.
II. Kaiser’s Negotiated Rate vs Plan Coverage (this is the most egregious problem I’ve experienced with Kaiser administration).
I have suffered from Cluster Headaches (also called Cluster Migraines or Horton’s Syndrome) since my teen years. Cluster headaches have been called suicide headaches: “In the USA, 55% of the survey responders stated they have had thoughts about suicide, and 2% have actually tried to commit suicide (Rozen, 2012; See also Koo, 2021; Lee, 2019).”
According to Kaiser, Cluster Headaches “are severe headaches on one side of your head that happen in groups, or “clusters. They usually occur over weeks or months. . .The pain is often called the worst type of headache pain. . . Most people who get cluster headaches have one or two cluster periods each year. . .As you get older, it’s likely that you’ll have longer and longer times without headaches. At some point, you may not get cluster headaches ever again. . .The main symptom of cluster headaches is a severe burning or sharp, piercing pain on one side of your head. The pain spreads out from your temple and eye. Your eye may become red, watery, or puffy. The eyelid may droop, and you may have a runny or stuffy nose on that side of your head. The pain usually gets bad very fast. The pain gets worse within 5 to 10 minutes after the headache starts (Kaiser Permanente. Cluster Headache).”
In my case, the above description is quite accurate; for me, they usually last at least two hours, and usually twice daily for 10 – 14 days. For the first 25 years or so, I experienced two clusters yearly, then one yearly, then every other year. And over the past 15 years, one cluster every 2 years, one of the few positives of aging. When younger they occurred during exams, when working, even in the middle of the night. Over the years I have tried all of the medications listed by Kaiser (Kaiser Permanente. Medicines for Cluster Headaches). None worked!
Trained as a researcher, at least once yearly I do a search of the National Library of Medicine’s online website PubMed, which contains the vast majority of peer-reviewed medical journals, Google Scholar, and Google to see if there have been any new developments, treatments of Cluster Headache. Several years ago I discovered research that found breathing pure oxygen for 15 minutes worked in the vast majority of cases and without any side-effects (Cohen, 2009; Sands, 2007). Since then there have been several review articles (e.g., Gao, 2019; Petersen, 2014).
And Kaiser’s own website gives oxygen as the first choice treatment stating: “High-flow oxygen inhalation therapy, in which you breathe oxygen through a face mask to relieve headache pain. Oxygen therapy is one of the best treatments to stop a cluster headache. Oxygen therapy relieves headache pain within 15 minutes in more than 7 out of 10 people who use it. It works best when started right when a cluster headache starts. But you need to repeat the treatment when the next headache begins (Kaiser Permanente. Medicines for Cluster Headache).
In 2014 another cluster began. I immediately contacted my primary care physician, requesting oxygen. He ordered the oxygen; but received reply that I was NOT covered. So I went through about 10 days of hell. Next outbreak was in June 2017 late Monday night. Hoping coverage had changed, on Tuesday I again contacted my PCP. He ordered; but received reply that I was covered; but it had to be ordered by a neurologist. My PCP arranged an emergency appointment with a neurologist for Thursday morning. At the tail end of a cluster headache I drove to the appointment and the neurologist ordered the oxygen. I phoned Apria Healthcare, the company contracted by Kaiser to supply oxygen, and it was delivered and set up that afternoon. I woke up around 2 am Friday morning in excruciating pain. Put on mask, turned on oxygen, and started stopwatch. Then did my best to take deep abdominal breaths. The pain started to go down and ended. According to my stopwatch, only eight minutes had passed. I continued with the oxygen for the full 15 minutes, turned off, and went back to a peaceful sleep. It seemed like a miracle; but I have learned not to put too much credit in one episode; but over the next eight days I usually had two outbreaks daily and none last longer than 10 minutes. Since the copay was only $3.44 per month I decided to keep the oxygen.
When I tried to renew in June 2018, I was told I wasn’t covered. I phoned Apria to arrange pickup of the oxygen. I was asked if I was a Kaiser member. It was then explained to me that as a Kaiser member, even if my plan (Medicare) didn’t cover oxygen for cluster, that I could receive the oxygen for Kaiser’s negotiated rate, which was $17.21. Sounded too good to be true, so I requested to speak with an Apria senior supervisor. He confirmed that as a Kaiser member I could indeed receive the oxygen at the Kaiser negotiated rate. I explained to him that I may only need it for a month and that Apria would probably lose money for such a short usage. He replied that Apria has such a large contract with Kaiser that they were more than happy to provide oxygen for cases like me. I decided that since I only had been experiencing clusters every 2 years that $17.21 per month would start to add up, so I arranged for Apria to pick up the oxygen.
I then contacted my neurologist, explained what Apria had told me. I was later informed that the Neurology Department had then contacted Kaiser Durable Medical Equipment Department, explained that Kaiser members whose individual plans, whether Medicare or other, weren’t covered were eligible for the Kaiser negotiated rate. The Durable Medical Equipment Department promised to make this policy and notify their employees.
In April 2020, late on a Friday afternoon a new round of cluster headaches began. I phoned Apria, only to be told that I was NOT covered. I tried to phone my neurologist and Durable Medical Equipment; but it was too late in the day. On Monday morning I phoned neurology and left several messages. Finally that afternoon a nurse got back to me. I explained the situation and on Tuesday morning was told that an order had been placed directly with Apria. I phoned and the oxygen was delivered a couple of hours later. I really don’t understand and it hasn’t been explained to me why for a brief period it was covered then not covered; but more importantly I suffered unnecessarily for 16 days (10 first denial, 2 because needed neurologist to order, and 4 for second denial after Durable Medical Equipment had promised to make sure that members would be eligible at Kaiser negotiated rate).
I, of course, appealed through Kaiser member services; but they ignored the eligibility of members to receive for the negotiated rate, for them simply not covered by Medicare. I’ve tried several times to find out who to contact in Kaiser administration about making it policy for ALL Kaiser members, even if their individual plan doesn’t cover, to be eligible at the Kaiser negotiated rate. I was more than happy to pay the $17.22, even if it was needed for several months, to avoid “suicidal” level pain and it would NOT have cost Kaiser a red cent. Even if more patients availed themselves of this and Apria the following year negotiated for a slightly higher Kaiser rate, Kaiser could, in turn, increase the covered plans copay by some small amount. How does this compare to the immense suffering of those who are denied oxygen? Kaiser policy should have been decided long ago. I suffered 16 days of suicidal level pain unnecessarily. What does that say about Kaiser’s administration? Certainly not an indication of their caring about members. And just to be absolutely clear, my PCP and neurologist went the extra mile to try to help me. For instance, the neurologist sent the following to Kaiser administration:
“Dr. Joel Harrison suffers from cluster headache. This are severe debilitating 10/10 headaches. He has failed all meds and his only relief has ben from home O2. I urge you to cover this treatment as has been only treatment that provides him with some relief. He will end up with numerous ER visits if we do not cover this treatment and the cost of this and inadequate patient care is not worth the risk.”
I’ve phoned Medicare several times; but so far they still haven’t approved oxygen for cluster headaches (e.g., Shaw, 2019).
I have phoned Kaiser Durable Medical Equipment several times, only to be told I’m not covered. I call Apria every six months or so to make sure I still have ongoing order for oxygen as needed; but I also keep on speed dial number to my neurologist.
Even if Medicare were to approve tomorrow, besides myself, it would mean that over the past years numerous other Kaiser Medicare members have suffered unnecessarily and members on some of the other Kaiser plans will continue to suffer.
III. My Personal Action Plan
Every so often I receive an e-mail link to My Personal Action Plan. I am in my mid 70s. My most recent plan gives me a Heart/stroke risk of 9.6% and labels it moderate. Of course, this also means that my probability of not experiencing heart attack or stroke is better than 90%. The factors used to calculate this are: Age, Gender, Race/Ethnicity; Smoking Status, Cholesterol Levels; Blood Pressure; Diabetes; and Use of Medicines for Blood Pressure, or Cholesterol. It then states: Healthy eating, exercise, quitting smoking, and controlling blood pressure help reduce risk. Statins reduce plaque in the arteries, help keep the arteries open and reduce the risk of heart attacks and stroke with links to more detailed explanations.
The following is the risk estimator used by Kaiser (Kaiser Permanente National Clinical Practice Guidelines, 2018): American College of Cardiology. Risk Estimator Plus. Available at: https://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/
There are several problems with the above:
1. Reliability of Blood Pressure Measurements. Simply blood pressure fluctuates, both during the day and from day to day. Just out of curiosity, I have asked several times when visiting nursing station or doctor’s office, to take my BP at beginning and end of visit. Results differed sometimes by as much as 20 points. In fact, Kaiser’s own website states: “Making sure that blood pressure is actually high. After measuring your blood pressure, your doctor may ask you to test it again when you are home. This is because your blood pressure can change throughout the day. And sometimes blood pressure is high only because you are seeing a doctor. This is called white-coat hypertension. To diagnose high blood pressure, your doctor needs to know if your blood pressure. is high throughout the day. So your doctor may ask you to monitor your blood pressure at home to make sure that it actually is high. You may get an ambulatory blood pressure monitor or a home blood pressure monitor. These devices measure your blood pressure several times throughout the day (Kaiser, 2021 Apr).” More than one blood pressure measurement is necessary to be accurate and Kaiser’s computer uses only ONE (see also: Burkard, 2018; Lim, 2019; Mena, 2015, Shepard, 1981; TRUE Consortium, 2017).
2. Lipid Profile Variability and Lab Reliability. “Serum lipid levels vary considerably within individuals over short periods of time due to intrinsic factors, such as hormonal variation1 and illness,2 extrinsic factors such as diet, and analytical and quality control factors (Pereira, 2004).” “Notable day-to-day variability of total cholesterol (5%), triglyceride (20%), high-density lipoprotein cholesterol (10%), and calculated low density lipoprotein cholesterol (8%) levels was found (Bookstein, 1990).” See also Schectman, 1993.
3. Statins. Guidelines are based on reviews of research and approved by committees. While there is strong evidence that the benefits/risk of statins for certain groups is incontrovertible, newer guidelines that have extended who should be receiving statins have been questionable. And the cholesterol guidelines have been criticized because half of the members of the committee had strong ties with the pharmaceutical industry (Borland, 2014). One recent article “explain[s] the uncertainties about the benefits of statins, particularly in people at low risk of cardiovascular disease, and the need for better data to help shared decision making (Byrne, 2019).” Keep in mind that many of the clinical trials were sponsored by the Pharmaceutical companies (e.g., Godlee (2013 Oct 23).
Even if the BP and Lipid Cholesterols were completely reliable and valid (Note. reliable means that repeated measures are close, valid means they reflect the underlying condition. You could, for instance, have equipment that always gives a BP 20 points higher than it is.), there is still a major problem with risk estimators. Risk estimators are based on populations. Quite simply they predict what a population average would be; but not what the individual’s potential is. Why? Because they are limited in the number of variables/factors used. An individual with a low probability score could have some genetic predisposition, been exposed to some toxin, etc, so end up experiencing a heart attack or stroke within 5 years and someone with a high score could live to be 100. In fact, studies have found that the number needed to treat, that is to prevent a heart attack or stroke is, for instance, from one paper: “Among the subset of newly eligible, 127/1,742 (7.3%) had an ASCVD [Atherosclerotic Cardiovascular Disease] event during 10 years of follow-up. Assuming 10 years of moderate-intensity statin therapy, the estimated absolute reduction in ASCVD events for the newly eligible group was 2.06% (number needed to treat [NNT] 48.6 (Yeboah, 2016).” And the risk to benefit for the 98% not experiencing a heart attack or stroke may be: “Studies have found that statin use can be associated with an increased risk of myopathy, rhabdomyolysis, diabetes, and haemorrhagic stroke. Although these adverse effects are rare, the prevalence of milder non-specific side effects is still debated (Byrne, 2019).”
However, despite the above my major concern is what some term “industrial medicine,” namely, advice based on bureaucrats and computer algorithms. As I wrote above, I have had the same Kaiser primary care physician for almost 22 years and trust him. I know he devotes time weekly to reviewing his patients’ labs. He knows the patients (variables/factors not included in risk estimators), checks for changes in labs, etc. and if he feels it necessary, I know he will contact the patient. And, yes, I’m confident that with some patients he will recommend statins, discussing the benefits and risks with them. The Kaiser Personal Action Plan, in my opinion, undermines the doctor/patient relationship, assumes that their primary care physicians are NOT reviewing labs, etc, not doing their job. This is my major criticism of it. Another problem is that the average person probably doesn’t understand the limitations of such instruments and could potentially overreact, experiencing unnecessary anxiety, etc.
However, I would have no problem if they were to send the risk estimator to primary care physicians, so they, in turn, can use it together with other information on their respective patients. As the following says: “GPs are highly trained to prescribe based on the individual circumstances of the patient in front of them – obviously taking age into account, but also any other medication that the patient is using, and all the physical, psychological or social factors that may be impacting their health.(Press Association, 2017).”
Summary and Conclusion:
1. Kaiser sends a Monthly HMO Report claiming they were billed by Providers and paid approved sums. Neither true. And the exorbitant sums used are absurd.
2. Kaiser allows patients to suffer suicidally painful cluster headaches when their individual plan (Medicare) doesn’t cover oxygen, listed as the number one treatment on their own website, though Kaiser members can receive for the Kaiser negotiated rate. Wouldn’t cost Kaiser a red cent.
3. Kaiser sends Personal Action Plans to individual members, a form of “industrial medicine.” While these plans, based on one measure, may be useful for ones primary care physician when combined with his/her much more complete knowledge of their patients, it undermines the doctor/patient relationship, lacks strong validity and reliability and could be misinterpreted, overreacted to, by some individuals.
So we have a divide between a medical staff and administration. Why? I can only speculate; but the Medical Staff decided on careers in medicine because they care about people. And they deal directly with people. The administration may have some medically trained people; but they function as bureaucrats, number crunchers, not dealing with people directly who are in pain. I’ve contacted and complained to Kaiser member services about the above several times; but so far to no avail. So, as mentioned in introduction, we are blessed with well-trained healthcare personnel who often go the extra mile for their patients; but with the most expensive healthcare by far in the world, with a significant proportion of the extra costs going to, to some extent unaccountable, administrative bureaucracies that, on the whole, do not benefit us. Though personal, just to make clear, given our current system, Kaiser provides, on the whole, quality healthcare; but problems with its bloated administrative bureaucracy are reflective of our entire health care system.
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