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Pre-Surgical Complications (Part 2)

By MATTHEW HOLT

Strap in for the tale of why your hero is spending most of his life down YouTube rabbit holes of cardiology videos while blundering his way around many many medical centers and exposing many problems with American health care even before he gets close to the operating table. Yes it’s Matthew Holt’s pre-surgical complications – the complications that have arisen before he even gets his failing aortic valve fixed. And yes this is a multi-parter! Part 1 here

So on the Friday afternoon I was readying for my video call when there was a car parking emergency. I had to move two Sprinter vans and a car belonging to guests who were all out apres skiing out of our driveway so my wife could get her car out of the garage to get to an appointment she had. Although I was as quick as I could, I was about 10 minutes late for Dr Beygui but he very nicely called me up wondering if I was still okay to do it, was very cordial even though I made him wait, and we had a nice chat. He basically didn’t give me any new information in this conversation and yes UCSF did get paid for it! He was mostly assuming that I couldn’t walk a couple of blocks without getting short of breath but at the end of it we agreed that because I was in good physical shape and able to go snowboarding all day I would go ahead with a knee surgery later in the summer and only come back to him when I became symptomatic. 

Starting in March I got the requisite knee imaging (I had an MRI and 2 X-rays confirming my meniscus is gone and knee was pretty trashed), met with Dr Bini and the ortho team and started prepping for the surgery later that summer–which basically meant going to the gym and doing lots of weights and resistance training on my knees.

A little later I got an unexpected call from Dr Beygui’s physician assistant who told me that he was still trying to line me up for the open heart surgery. I told him I was still keener on a TAVR. He said that I shouldn’t have a TAVR because the TAVR valves only last 5 to 7 years. Yeung from Stanford’s original report told me they lasted about 10 to 12 years. Elmariah the UCSF cardiologist said that they thought they lasted 10 plus years but there was no good data. Given you can probably have one TAVR and then have another put inside when the first one fails and then maybe even another (TAVR in TAVR in TAVR), these numbers actually matter! 

Here’s the crux of the TAVR issue. If you can add 10 + 10 + 10 that gives you another 30 years of life which sounds pretty good to somebody in their early 60s. But if you can’t get more than 5 to 7 years out of a TAVR and can only do one more “TAVR in TAVR”, then you’re getting 10 to 15 years before you need to have a very complicated open heart surgery because it’s now replacing two different artificial valves. In that case I might not survive and I wouldn’t even be old enough to be President!

As you can see this decision is starting to get a little bit complicated. 

But the good news was that I could stop thinking about it because my heart wasn’t getting worse and the orthopedics (and anesthesia) team at UCSF was happy to do the knee replacement. 

As we were all steaming down this path I got a call from Dr Beygui’s scheduling assistant. My initial agreement had been to have an echocardiogram 6 months after the last one which would actually have been after the knee surgery. I’m not sure how much coordination between the departments there was given what happened a bit later but Dr Beygui requested that I have an echocardiogram before any surgery. As I was going in anyway to have a CT in mid-June to prep for the knee surgery, I said fine.

In another great drama of American health care it turns out that my insurance had changed. For most of the first half of the year I purchased a Blue Shield of California HMO on the ACA exchange called Covered California. In May my wife got a job and we then moved over to being covered by her employer’s insurer (well, ASO TPA as it turns out) Cigna.

Cigna and the entire University of California Health system decided to have a dispute which threatened that Cigna would not cover UCSF starting on July 1st. I won’t go into the crazy logic of why an insurance plan that one buys on an annual basis starting in January has contracts with providers that expire in the middle of the year, but welcome to America. Because of this the orthopedic team moved my surgery date up into late June just 4 days after all the prep imaging including that echocardiogram.

Oh and a few weeks earlier I had had a very minor snowboarding fall going very slowly in soft slushy snow. I banged my shoulder but for some reason it didn’t get any better. I actually went and had some physical therapy which seemed to help, but as I was hanging out so much at UCSF, I also had an appointment with the shoulder specialists. They sent me for a pretty uncomfortable MRI and the result from that was that I had total tears in all my rotator cuff tendons. The recommendation for that is surgery that also has a long recovery, but if you ignore it for too long the muscles can atrophy. Claude was very depressed for me when it interpreted that MRI report!

A spanner in the works

Those of you familiar with sod’s law can guess what happens next. The result of the echocardiogram was that the aortic stenosis had gone from being severe to being very severe. The precise number was that my peak velocity went from 4.6 m/s in Jan to  5.1 m/s in June  just 4 and ½ months later.

I discussed this with my trusted health confidant and Claude guessed that this might be a problem and the anesthesia team might not want to have me get the knee surgery.

The next sequence of events reveals that nobody in American healthcare talks to each other.

Continue reading…

A ridiculously stupid letter from a health insurer

By MATTHEW HOLT

It’s hard to imagine but I may now be in possession of the stupidest letter I’ve ever received from an American health insurance company–-and I’m the guy who got five identical letters on one day from Blue Shield of California telling me that they had changed my primary care doctor when I had initiated the change.

A little backstory.  As those you’ve been following along with my various telenovelas may remember that last year I was diagnosed with a failing heart valve.  I also have a failing left knee due mostly to snowboarding into a tree 24 years ago.

I was attempting to put off doing anything about the heart valve for as long as possible because it sounds painful and unpleasant, and I was hoping that I could go ahead with a knee replacement so that my snowboarding can continue apace. My doctors are at UC San Francisco and they agreed that I should have the knee replacement on July 6th, assuming that my heart valve had not got much worse. On June 16th I went into UCSF for a bunch of knee replacement pre-workup and they also checked my heart.

However, my new insurance company, thanks to my wife’s new job, is Cigna. Those of you in California may know that Cigna was having a big dispute with the University of California Health system and that its contract with them was due to expire on June the 30th of this year. Why a health plan and a big provider organization have contracts that expire in the middle of the year when the employers and people who use the health plan network buy them on an annual basis starting in January I don’t know –  and it’s ridiculously stupid. But let’s not get distracted cause I’m not talking about that here!

Because of the fact that they’d be out of network, the ortho team made the obvious suggestion that I move the knee replacement a little earlier, In fact it was planned for June the 22nd. This did not upset me too much as you may have seen that some corrupt Italians have organized a soccer tournament that would give me plenty of games on TV to be entertained by while I was lying around recovering.

Sadly one of the pretests I had on June 16th was an echocardiogram that indicated that my heart valve was in even worse shape than it had been earlier in the year.  After quite a lot of back and forth between the cardiac team, the knee team and the anesthesia team, everyone agreed to put off the knee surgery until we figured out my heart.

Meanwhile sometime late on Thursday the 25th or early on Friday the 26th of June, UC Health and Cigna stepped back from the brink and came to an agreement that will continue the UC system being in Cigna’s network.

Which all brings me to July 6th when I received a letter from Cigna

This is the one that contains more stupidity per square inch than any other communication I’ve had from an insurance company.

Continue reading…

Health in 2 Point00, Episode 245| Bright Health, Innovaccer, Cadence, Ophelia, and Apti Health

Today in Health in 2 Point 00, Jess and I talk about the plethora of notable deals in the Healthcare Space. Bright Health gets $750 million with notable investment from Cigna; Innovaccer gets $150 million, bringing their total up to $375 million; Cadence gets $100 million, bringing their total up to $141 million; Ophelia raises $50 million, bringing their total up to $64 million; and Apti Health raises $50 million, bringing their total up to $65 million.

-Matthew Holt

Digital Mental Health Hits Mainstream: Cigna’s Behavioral Health CMO on National Rollout of Ginger

By JESSICA DaMASSA, WTF HEALTH

Cigna is making digital mental health services available to its entire nationwide network of 14 million members, and it’s selected health tech startup, Ginger to deliver the new benefit. Cigna’s Chief Medical Officer for Behavioral Health, Doug Nemecek, and Ginger’s CEO, Russ Glass, stop by to discuss the deal and why Cigna is making such a commitment to expanding its behavioral health offering.

This is about more than just dealing with mental health in the aftermath of Covid; Cigna is actually looking at Ginger’s behavioral health coaching model as preventative. Will other health plans follow suit? Could expanded coverage for lower-acuity mental health services become commonplace? Doug talks about what’s ahead for mental health care from a population health standpoint, and how services like Ginger’s give primary care docs a standard, trusted provider to which they can refer patients when it comes to increasingly common concerns like depression and anxiety. For Russ and Ginger, who talk about using virtual care to right the “supply-and-demand imbalance” in mental health care, what will more than doubling their current client base (from 10 million to 24 million) do to their own ability to provide supply? It’s a moment-of-truth for the business of digital mental health and we’ve got the details!

#Healthin2Point00, Episode 188 | MDLive, Devoted Health, Medisafe, January AI

Today on Health in 2 Point 00, we cheat a little bit and go overtime. On Episode 188, Jess asks me about MDLive getting acquired by Cigna’s Evernorth division, Devoted raising a whopping $380 million, Medisafe getting $30 million in a round led by Sanofi, and January AI raising $8.8 million bringing its total up to $21 million. —Matthew Holt

#Healthin2Point00, Episode 161 | Partnerships galore & a new SPAC

Today on Health in 2 Point 00, we have some hot gossip re: Glen Tullman starting his own SPAC. On Episode 161, Jess and I discuss Bind Benefits raising $105 million, BridgeHealth merging with Transcarent and raising $40 million in a Series A, and Loyal raising $12.5 million in a Series A. Jess also asks for my take on a slew of new partnerships between Lyra and Calm, Cigna and MDLive, and Doctor on Demand and CareLinx. —Matthew Holt

Out of Network? Cigna, RICO and where’s the line?

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By MATTHEW HOLT

Sometimes you wonder where the line is in health care. And perhaps more importantly, whether anyone in the system cares.

The last few months have been dominated by the issue of costs in health care, particularly the costs paid by consumers who thought they had coverage. It turns out that “surprise billing” isn’t that much of a surprise. Over the past few years several large medical groups, notably Team Health owned by Blackstone, have been aggressively opting out of insurers networks. They’ve figured out, probably by reading Elizabeth Rosenthal’s great story about the 2013 $117,000 assistant surgery bill that Aetna actually paid, that if they stay out of network and bill away, the chances are they’ll make more money.

On the surface this doesn’t make a lot of sense. Wouldn’t it be in the interests of the insurers to clamp down on this stuff and never pay up? Well not really. Veteran health insurance observer Robert Laszewski recently wrote that profits in health insurance and hospitals have never been better. Instead, the insurer, which is usually just handling the claims on behalf of the actual buyer, makes more money over time as the cost goes up.

The data is clear. Health care costs overall are going up because the speed at which providers, pharma et al. are increasing prices exceeds the reduction in volume that’s being seen in the use of most health services. Lots more on that is available from HCCI or any random tweet you read about the price of insulin. But the overall message is that as 90% of American health care is still a fee-for-service game, as the CEO of BCBS Arizona said at last year’s HLTH conference, the point of the game is generating as much revenue as possible. My old boss Ian Morrison used to joke about every hospital being in the race for the $1m hysterectomy, but in a world of falling volumes, it isn’t such a joke any more.

Continue reading…

Health in 2 Point 00, Episode 42

As I’m back from a week’s vacation, Jessica DaMassa is slowly pulling me back into the groove with questions about Walmart dumping Castlight, yet more money for telemedicine with MDLive adding $50m, and get.health sponsoring a few tickets to health2con. All in 2 minutes, with a bit of filler!–Matthew Holt

 

Health Care’s Third Wave

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By DAVID M. CORDANI

Change and American health care have become synonymous. “Change” can be exciting and life-altering when it refers to the innovative new therapies and treatments that improve or extend life, many of those originating in the United States. Change, though, can be a tremendous source of anxiety for families concerned with the affordability of care and stability in their health care coverage choices. It is the tension between these two definitions of change that the United States has struggled to solve over the past three decades.

As we have all witnessed, the health care marketplace has gone through two successive waves of change over the past 30 years, with the third wave now upon us.  The first wave was managed care, which sought to rein in cost and quality relative to “unmanaged care.” But while managed care made some gains, it still proved to be unsustainable in its constraint of choice and its focus on financing “sick care” rather than on optimization of health.

The second wave of “reforms” saw companies like Cigna evolve – or change – from “insurance” to a health services focus, with more engagement and support for the individual and partnerships with health care providers and pharmaceutical manufacturers predicated on the health outcomes achieved rather than the volume of services provided.  The second wave has seen the health care industry as a whole work together to improve health, lower health risks and improve the cost structure of the employer-sponsored market, which has in turn subsidized the entire system.

In that environment, Cigna has been able to deliver the best medical cost trend over the past five years – below 3 percent in 2017 or half that of the industry. So why risk disrupting a winning formula by acquiring the pharmacy services company Express Scripts?  Because the system still isn’t sustainable and maintaining the status quo of rising costs means you are effectively moving backwards.

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My Wife Has Cancer. I Need to Know: Will She Have Insurance On January 1st?

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By TONY JEWELL

On February 16 of last year, I was in a New Orleans hotel room preparing for a meeting when my wife Becky called and said simply, “I have cancer.”

We knew it was possible, but that didn’t in any way lessen the impact of those three words.

I have cancer.

Everything that was right and comfortable was in that instant washed away by a million questions with no answers. At a time when we needed nothing more than certainty and clarity, there was only confusion and doubt.

Upon landing in Philadelphia hours later, I called to see how she was doing with her newly diagnosed breast cancer. Feeling numb, I managed to make one other call soon after landing. Not to friends. Not to family. Instead, it was to our insurance company.

That’s right: Other than my wife, the one person I most wanted to speak to in the world was a Cigna call center operator.

We hadn’t even had a chance to meet with her oncologist to discuss potential courses of treatment, but we had questions because we had recently changed our plan to carry higher out-of-pocket costs and lower deductibles. We needed answers to those questions so we could go about worrying about more important things.

What procedures are covered? Are the doctors at the cancer center in plan? What is the maximum out of pocket? What other limits should we know about?

A 15-minute conversation later, we were comfortable that insurance wouldn’t be an issue and had a decent understanding of what our share of the costs would be. At a time of absolute fear and confusion, our insurer provided a moment of comfort and clarity.

That is the kind of financial and emotional stress that millions of people face every day in the United States. That is also the kind of financial and emotional security the Affordable Care Act was supposed to provide — especially to those who currently lack health insurance. Continue reading…