James L. McGee, CEBS

I have worked with health plans from many different directions most of my working career. All of it has been  around union negotiated plans and Taft-Hartley plans: union trustee, health insurance marketing representative,  communications manager at a state data agency that published report cards on doctors and hospitals, consultant, and now plan administrator.  

Now, I administer a public sector benefit plan that provides a generous benefit package to approximately 10,000 employees and retirees and to their dependents.  Too much of my staff’s time is spent assisting participants with those transitions in and out of the health care system or navigating the complicated silos within the health care system. 

I use the word “system” not as defined in the dictionary, but as generally used for lack of a better word to describe that assemblage of public and private institutions and practices in this country that somehow manages to deliver high quality health care to some people and to ignore others.

I spent time in Germany and know German.  If anyone from Germany wants to leave their comment in German or leave it for me to translate, please do.

Fortunately, I have been relatively healthy so my own personal encounters with the delivery system have been somewhat limited, but instructive nevertheless.


One Response to James L. McGee, CEBS

  1. Paul Krissel says:

    My parents fall into the medicare silo. Social Security also provides over 2/3 of their total income. They are just over the poverty line. My dad is also a WWII veteran, so falls into the VA silo. They live in a small city 50 miles from a large city where the VA hospital sits. Locally there is a small VA clinic that provides only very limited service. Neither of them is particularly ill, but they suffer many of the physical ailments of the elderly: Both of dad’s knees have been replaced, and mom has the wet form of Macular Degeneration. Oh, and last year they moved across country to be near us. They had all their silos figured out where they moved from, and the process of figuring out all the options for choosing silos and providers in their new home was mind-boggling.

    Because medicare has so many holes in it, they chose a medicare supplemental insurance plan. Because my dad was concerned that he might not be able to always travel the 50 miles to the VA hospital, they area also paying for supplemental medicare insurance for him as well. And of course they have to pay the medicare premiums on top of the premiums for the supplemental plans, and the part D premiums. So they are paying almost $4000 per year in premiums. It wasn’t long ago that $4000 would buy a pretty good comprehensive insurance plan, and now it just covers the supplemental plans.

    Even with all that, their out of pocket expenses were an additional $3000 last year for copays, deductibles, and so on. So $10,000 for a couple who have barely more than that in annual income, and who are still fairly healthy for their age.

    Then the silos between all these plans come into play over and over. Mom was referred to an Eye Institute that is part of a public university. They are the seat of expertise on Macular Degeneration. This is 50 miles form their home, near the VA hospital, but my mom feels the trip twice a month is worth it to be seen by a top researcher in the field. But the University, as a matter of some principle only a bean counter could appreciate, has decided not to sign on as a member of any preferred provider or HMO network. So mom has a $120 copayment for each visit. Since medicare won’t pay this, and since the Institute does not accept her supplemental plan, she has to pay this medicare deductible. When she appealed this to her supplemental carrier, even though they acknowledged that the nearest network provider was 60 miles away, and was not any less expensive, they ruled that the silo rules are the rules and they would not cover the copayment.

    This has been even more complicated than I have written. Calls back and forth to billing departments and clinics have been a baffling mix of conflicting and contradictory information. It is re-enrollment time for the medicare supplemental plans. They have had sales reps from some of the 10 plans available in our city come out to the local senior center to explain why theirs is the best. I have tried to help my parents match their needs with the plans. I am reasonably intelligent and have been in and around the health plan world for decades. I can’t figure it out. There is something very wrong with this system when an elderly couple, who worked all their lives have to go through so many hoops and pay so much out of income they do not have, and still end up confused and upset.

    How can we possible justify the dysfunctional and fragmented system we have in the US when dozens of countries around the world have experiments that have worked, providing broader coverage with better health outcomes? This is not rocket science! Just pick any of the other systems out there and adopt them. Of course, then those who profit by this current dysfunction would have to be cast aside. My parents are growing more broke by the day under this system and soon (especially with what the market has done to their pittance of life savings) will have only social security left to rely on. And how will they handle these costs then?

    Oh yes, I forgot. Just as my daughters are becoming independent and will soon be out of my silo, I will be taking on two new dependents. Except they don’t fit in my retiree health care silo, so this will be out of pocket for me too. Good thing I am one of the few people left in this country with a defined benefit pension and retiree health care, which covers my wife and me.

    What a system.

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