The ACA and My Obstetrician and Me

So as previously mentioned I am growing increasingly pregnant with each passing day, and today I had a my monthly prenatal appointment with my OB-GYN.

On the agenda for this morning was first, my gestational diabetes screening, which meant chugging 10 oz. of a drink called Glucola™ (verdict: kind of into it). Second on the agenda—aside from the usual peeing in a cup and hearing baby’s heartbeat—was for me to corner my OB about some brewing insurance woes I’ve been doing the “panic, avoid, make a fruitless phone call, Do 1 Thing” dance about for weeks now.

To back up: I signed up for individual insurance in the marketplace post-ACA which went into effect 1/1/14, right? Platinum plan, y’all, because I’m having a baby. My OB showed up in the database of the plan I liked, which was through a co-op which seemed great, and it had the lowest premiums of its level, along with no deductible, no co-pays for prenatal care, $500 for delivery. Perfect, done.

“Oh I should call the doctor’s office to confirm they take it.”

“Yes you definitely should.”

“But, ehhh, it’s the weekend. And it says they take it on their site, and on the insurance site. Oh it’s fine, I hate the phone, let’s do this.”

“Okayyyy, but…”

*cue ominous music*

I go into my first appointment after the New Year, so excited to finally have real insurance, like it’s some kind of special club or something.

“Okay what’s the name of your new insurance?”

“Well, they use the Magnacare network.”

Nurses for miles shake their heads, click their tongues. “Oh we don’t take that.”

“What? Yes you do. It says so on the website.”

“DID YOU CALL?”

“No.” I turned bright red at the counter. “No I didn’t call because it said you took it on your website and on the insurance’s website.”

“You’re supposed to call.”

“Okayyyyyy, so. I didn’t call. And this is my insurance. It’s already paid for. What do I do?”

They had me talk to someone higher up on the admin side and she let me know that actually, my OB does take Magnacare, but that the other doctors in the practice don’t, and they are trying to drop it. She made a grim face at me. I looked at her and then all the nurses and admins, still standing around listening and shaking their heads.

Someone asked me how far along I was. Twenty-one weeks. More head shaking. I didn’t call.

“Well you can see the doctor now,” the woman said, “But we are trying to drop it. It could be any time now.”

I wasn’t sure what to say. “Um, please don’t drop it?” “Can you give me a warning before you drop it?” “Can you update your godforsaken website?” Instead I just shrugged, said, “Um, okay, so I’m good for today?” then sat down and waited for my name to be called.

A week or so later I worked up the nerve and the energy and called the billing office to ask if and when they’d be dropping Magnacare, and what kind of lead time I would have — should I find a new doctor now? The woman I spoke to had no idea, and said to call the doctor’s office.

“Yeah you should definitely find out. Giving birth is very expensive without insurance. At least seven thousand dollars. You don’t want to get there and be surprised.”

Yeah no kidding, thank you.

I called my insurance — the co-op — and the woman on the phone was genuinely helpful. “Okay,” she said, “I think there is a policy about continuing care when pregnant. Let me find it.” She put me on hold and then came back to say she was going to read me the policy word for word. I typed notes as she spoke but the general policy is that, should your health care provider drop your insurance when you are in the second or third trimester of pregnancy, or in the middle of a terminal illness, the insurance company will agree to essentially pretend the provider is still “in-network” and everyone keeps paying what they were paying. The doctor’s office or hospital has to sign off on this, too. If they do, everyone fills out a form, I keep paying my insurance premiums and co-pays, and the insurance keeps paying the doctor what they were when the doctor accepted the insurance.

So today when the doctor asked me how I was feeling I decided it was time to stop avoiding the subject and living in coverage limbo and debating finding a new doctor at 28 weeks pregnant (all the while paying $515 a month for this coverage, I might add!).

“You might not be the person to talk to about this,” I started off, “But I mean, I don’t know how this works and I don’t know who to ask.”

Now I should say here that I like this doctor, but I like her less in a “she is the nurturing, relatable Mother Earth type I always imagined working with” way and more in a “I find her fascinating and compelling more as a character than anything else, and perhaps she is not the ideal candidate for delivering my baby, but she is very competent and oddly reassuring so I’ll take it rather than going through the trouble to find someone else,” way.

She raised her hand to cut me off and talk but then stopped herself, “Okay, well, let me know your question and then I can see if I can answer it.” LOL, okay Doctor, thank you for tolerating my preamble.

First I let her know that while she took my insurance, the other OB’s in the practice didn’t. I asked her if for some reason she wasn’t on-call that night and I delivered with someone else, would I have to pay out-of-pocket? FYI: No, the doctor would essentially be covering for her and it’s all billed as an entity anyway so coverage overlaps. Great.

“So we just have to hope you don’t drop our insurance, then,” Dustin says. And there he goes, I think (he is the bad-cop and I am the ‘please like me’ cop in these type of exchanges), then wonder if he is on the brink of a rant about how we should all be on a single-payer system.

I explain to her my situation, that some mysterious office worker told me they were ‘trying’ to drop Magnacare, but that they hadn’t yet. Then she very candidly, perhaps disturbingly so, explained to me what was going on. What is going on, apparently, is these new ACA plans do not pay doctors as much cash money as they would like.

She refers to the ACA marketplace plans as a “parallel universe” and a “gray area” where, basically, providers/practices/hospitals/entities won’t be reimbursed by the insurance companies at as high of rates as the non-marketplace plans. So there is regular Blue Cross Blue Shield and then ACA Blue Cross Blue Shield, the latter of which will only reimburse the provider X amount, whereas the former would have said, “$600 ultrasound? Okay fine.”

Having seen what the providers bill to insurance companies, vs. what they bill to individuals, I can see why the insurance companies would refuse to pay at the full rate. I do not say this.

She goes on, not quite mentioning the bottom line but she does use the phrase, ‘balancing the books’ so that’s where we’re at: “The hospital hasn’t decided yet whether to accept these plans or not,” she says, “They haven’t figured out what’s more advantageous,” (FINANCIALLY) “If they do accept those plans, more patients will be able to get medical care, but the hospital will be reimbursed at lower rates. If we say to patients, ‘No that plan is out-of-network and you have to make up the difference,’ we will lose patients but we’ll keep the ones with the ‘good’ insurance plans. They’re not sure yet how it will all shake out.” (FINANCIALLY.)

I nodded and tried to pretend that I was truly concerned about the hospital balancing its books.

She went on to tell me that since I was pregnant they will accept me and my insurance as in-network until I give birth (thank god), after which I will probably get kicked to the curb with my affordable insurance that reimburses healthcare providers at reasonable rates.

“We won’t leave you out in the cold,” she said, and I laughed nervously. “And we don’t want you to go broke.”

“Well,” I said, “I don’t know if anyone cares if I go broke, the insurance or the hospital.” Dustin and I laugh and he echoes what I said just a little bit harsher.

“Oh we care,” she says. “We care because if you go broke, then you won’t be able to pay your medical bills!”

We all laugh together as if this is the funniest thing in the world.

“Oh great, glad we’re all on the same page then,” I say.

“You know, this was supposed to make everything better for everyone, but I’m not so sure it has,” she looks off into the distance wistfully and I’m like, “Hmmm,” and Dustin shakes his head, and then she gave me the TDAP vaccine and ranted about parents not immunizing their children.

She offered to give us a list of places where “Dad” could go get the vaccination, too, and for a minute I was like, “Dad? Whose dad / who’s Dad?” Then I realized she meant dad as in the dad-to-be sitting right next to me, who was probably waiting to get on the train back to work with me and rant about her rant about the Affordable Care Act, and then to suggest for the hundredth time that we switch to a midwife.

 

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37 Comments / Post A Comment

bgprincipessa (#699)

Ahhhhh. Aaaahhhhhhhhhh.
That is literally my only reaction to this, because I just can’t handle it.
I would’ve done about the same what you did in that situation. I wish I could be more assertive and such, but alas. But seriously – ahhhhh. What a nightmare. UGh. TO YOUR FACE, she says these things.

I know, I know I knowwww that doctors have insurance and liability out the wazoo and that all that is expensive. But just. To your face! You, a person using ACA health care!

WayDownSouth (#3,431)

@bgprincipessa to be honest, I don’t see the problem with what the doctor said. Meaghan asked about the insurance situation going forward and the doctor replied. At the end of the day, the doctors have to make a profit for the medical practice to be viable. This doctor’s comments are a relatively common reaction to Obamacare.

bgprincipessa (#699)

@WayDownSouth I understand that – and honesty is great! And certainly helpful. But even though they are at heart businesses, I still see medical practices as more than that. You are playing with people’s lives. And… pregnant people? Lots of hormones. Lots going on there.

WayDownSouth (#3,431)

@bgprincipessa yes, I understand what you’re saying.

One of the issues that doctors face is that running a private practice can have high overheads and lots of investment involved. Patients are both people who need medical aid -and- revenue sources, so the doctors have to balance both perspectives. Furthermore, as you said, lives can be at risk if the doctor makes the wrong decision. It’s worse for some specialities — especially for delivering children, as people tend to expect perfect babies and can sue if they don’t get what they want.

As far as dealing with pregnant women, it’s delicate. It’s certainly risky to state that pregnant women aren’t always capable of adult reasoning — cue indignant expressions of outrage if that happens. On the other hand, as you said, there are a lot of hormones in play.

Meaghano (#529)

@bgprincipessa Haha yes, I appreciated her telling me — obviously I want to know and understand what’s going on — was more taken aback (if not surprised) by the situation itself. I think you’re right that we (or many of us) think of medical care as less of a business and more of a human right, moral/helping thing. Or we want it to be, even if we know it isn’t. At the end of the day it’s helpful to know the reality. But yeah, damn.

gyip (#4,192)

Ummm. This is pretty gross. I feel bad for you and your “dad.” (WAH)

Trilby (#191)

It doesn’t stop there. My daughter just had a baby on Obamacare insurance. Not sure how that’s going but she went to a pediatrician twice with the newborn and then found out they don’t take her ins. even though the Exchange said they do. Turns out almost NO pediatricians take Obamacare ins. actually. Good times!

Meaghano (#529)

@Trilby Oh god, really? Argh! That’s good to know, though. We are/were about to sign up with one and assumed if they took Magnacare that meant Exchange Magnacare but I will be sure to specify now.

@fo (#839)

@Meaghano oooooooh, the *other* thing to remember is that as soon as the kid is born s/he needs to be a +1 on your insurance. You have 30(??) days to add her after birth outside of open enrollment. And if you don’t do that timely, no insurance for the kiddo until 2015, and you’ll pay rack rate for every peds visit.

So, yeah, something *else* to deal with.

This doctor actually sounds amazing. Love her for her honesty!

Meaghano (#529)

@franceschances You know, I kind of appreciated it. Like if that’s whats going on I am grateful to know. I will just try to tell myself if it were up to HER she would be pro-everyone getting access to good, affordable medical care.

I totally almost put my mom’s name on my son’s birth certificate so the dad thing made me laugh out loud.

I have so many stories about dealing with the medical profession while trying to have a baby. I am glad you are working everything out and I hope you passed the glucose test! That 3 hour one is a beast!

Meaghano (#529)

@xtinamartinson Ha! Oh my god I do too though I don’t have high hopes. Fasting pregnant sounds horrrrrible.

@Meaghano I had to do it when I was pregnant with my son and it was the WORST. This time, I cornered the midwife and said “Tell me how to pass the glucose test!” She told me to eat an egg instead of a bowl of cereal for breakfast. It worked! Yay!

@fo (#839)

@xtinamartinson “eat an egg instead of a bowl of cereal”

From my wife’s experience, the *single* worst thing you can eat (glucose-test-wise) is a bagel. Better off eating a doughnut.

azile (#6,014)

“whose dad / who’s dad” is hilarious

andnowlights (#2,902)

I have so many feelings about this. 1) $515 a month for care is insane, even with maternity coverage. This makes me SO thankful for my employee sponsored plan (though it would cost more to have a baby) 2) I kinda understand the financial thing, having worked in a major medical center that last year had $500 MILLION in uncompensated care. That’s a lot of salaries, which is why they laid off about 750 people over the medical center. Granted, I also saw the salaries of some of the doctors and those were gobstobbingly high (9x my salary!), but without them, we’d kind be in trouble 3)Insurance is complicated and it makes me nuts even with my relatively simple plan, so this ACA thing makes my brain hurt.

@fo (#839)

@andnowlights “$515 a month for care is insane”

Um, what? The USA spends over $8,000 for every single person on medical care. $6,000 for *no deductible* coverage (yes, I understand co-pays etc) is actually pretty good.

Meaghano (#529)

@andnowlights I originally wrote a little preamble, “Everyone working full-time with good benefits pls take a moment of silence / gratitude for your life situation.” I’m sure there would still be some headaches, but I do miss not having to think/worry about this stuff (even though I do find it a little fascinating, I’ll admit).

WayDownSouth (#3,431)

@Meaghano the administration keeps delaying the implementation of Obamacare for companies and their employees (presumably because they fear the reaction at the next election). But eventually it’s going to be implemented. Based on the roll-out so far, the impact on the general community is going to be quite a bit more serious than what people have experienced so far

katie76 (#6,079)

@andnowlights

I’m not sure that $515 a month is really all that insane when you think about the fact this is is supposed to cover if you get into a major accident, like car crash, or need emergency surgery, etc etc.

I don’t understand why people are willing to fork out hundreds of dollars to upgrade their smartphones, or get a new purse, but aren’t willing to pay to get medical coverage for god’s sake. What is more important????

Meaghano (#529)

@katie76 Yeah I think it’s shockingly high when it’s an expense you aren’t used to paying — it’s definitely the next highest bill after my rent, which you know, makes sense, and is totally worth it at the end of the day. Just a major budget / expectations adjustment.

theballgirl (#1,546)

How disheartening. I cheered when the ACA was passed, even though I knew it would require LOTS of adjustments and amendments. Still, ugh. Glad they’re keeping you on board through the birth though! I didn’t love my GP either and also consider switching to a midwife (I never did)

@fo (#839)

Meaghan:

Whatever else you do, make “whose dad / who’s dad” get his DTAP booster (unless less than 5 years) so no one ends up with whooping cough (P is for pertussis) around the baby.

Meaghano (#529)

@@fo Oh, he is! (I was wondering which one of those letters whooping cough was).

lolapie (#5,967)

I’m with Dustin – go midwife! I’m only paying $3,500 for prenatal, delivery and post-natal. And all appointments are at my house whenever is convenient for me so I don’t have to wait in an office. I know it’s not for everyone…just saying… ;)

meatcute (#1,430)

@lolapie Amen, sister. I loved my midwives. LOVED THEM. In fact, I was sort of sad when it was all said and done that, after my six-week follow up, I didn’t have an excuse to go visit them every few weeks anymore.

@meatcute @lolapie I’m having the exact opposite experience with the midwives at my practice. They have not been interested in listening to what I tell them is going on with me and seem more interested in pushing their own goods & services. I love my doctors though, so I’ll deal. I’m nearly 35 weeks, so here we go. :)

prolol (#3,152)

I support what this Ob/Gyn said. She was honest. Doctors need to make a living, hospitals usually like to make a profit. The majority of people going in to the medical field want to be able to treat everyone with the best medical care available. It’s beyond most doctors’ training to be aware of every single insurance plan and everyone’s individual cost. It’s part of the practice, but the main thing medical school teaches you is how to treat people–not the economics behind it. And Ob/gyns especially deal with malpractice like woah. So…. $500 a month is expensive… But… You’re paying for someone’s expertise? So… That seems worth it. I feel like people think doctors should never expect to make an awesome paycheck. Yeah doctors get paid a lot, but they spend their entire 20′s in school, becoming experts in their fields and wracking up debt. I think they deserve to be well-compensated.

Walter14 (#6,080)

@prolol This! Coming from a family of doctors, I can’t stand ignorant people who complain about doctors’ salaries. They have no idea of the marathon that is med school/residency/fellowship and the enormous responsibilities and life and death decision making power that doctors are faced with EVERY SINGLE DAY.

lemonadefish (#3,296)

@Walter14
I have no problem with doctors making fantastic salaries, but the idea of the hospital itself making a profit turns my stomach.

Meaghano (#529)

@lemonadefish Ditto!

I appreciated my doctor’s honesty, totally. I did not expect to get a straight answer, or any background at all, so that was kind of awesome. (I don’t like her that much for other reasons, just a personality thing.) I was more aghast at the reality of the situation than the fact that she was telling me.

Eric18 (#4,486)

I’ve said this before, but one of the big problems I hear from my doctor friends is that we need more residency spots! We can graduate all the med students we want, but unless we fund more residencies for these guys/gals, we will never have enough doctors to care for the millions who are now eligible for health care.

jacqui (#6,028)

For future reference (maybe): The Health Care Handbook, which is being revised to cover ACA issues, too! (It’s written by a friend of mine, a medical resident.)

charmcity (#1,091)

@jacqui I read your comment and bought this immediately!

frenz.lo (#455)

Right now I have some ominous shit going on where I’m getting cc’d on letters from my midwives’ billing dept to my insurance company, begging to be reimbursed for some pretty standard prenatal testing, and replies from the insurance co where they say “medical review is required.” Who will win??? Me, probably. Right?
I am dragging my feet on calling to see if they will cover the AFP test, where they screen for neural tube defects like anencephaly and spina bifida. Like, most babies have closed spines and plenty of skull, right? The lab they used for the nuchal translucency test already sent me a bill directly. It is really frustrating.

charmcity (#1,091)

I am glad that you have a doctor who is at least somewhat familiar with the insurance issues (so often, practitioners focus on care and leave the insurance stuff to their back office staff, which is understandable but problematic for patients who don’t know those folks.) Because the ACA was only politically feasible if it preserved the existing private health insurance market, all of the problems endemic to that system are still there. But they are magnified because no so many more people are going into the individual market; before the individual mandate, market reforms like the bar on pre-existing condition exemptions, and the creation of discounts via advanced premium tax credits and cost-sharing reductions, the individual insurance market was a pretty rough place, and not a realistic option for most people, who would instead just be uninsured. However, what’s happening as this shakes out is that we have required everyone to have comprehensive insurance, required the government to help certain people pay for insurance, but held on to the old mechanisms for providing that insurance. It’s like tearing down a crappy old building because it was constructed on a sinkhole, but having to rebuild on the same foundation. One of the ways that insurance companies were able to lower premium costs on the federally-facilitated and state marketplaces despite having to provide much more comprehensive coverage and much more transparent cost-sharing schemes (i.e., the metal levels that tell you how much you pay in deductibles, copays, etc.) is to narrow their provider networks. That’s part of what people are running into now. Healthcare.gov and state exchanges also have out-of-date provider directories (Meaghan, that’s why they always tell you to call to double-check the website, even though it’s ridiculous and our generation assumes we can *rely on information published online*) but insurance carriers have always done a terrible job of updating that stuff. I have coverage through my job and I still have to call to double-check because the provider directories are usually wrong by a few months into the year.

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