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The law bans insurers from charging based on pre-existing conditions. It limits how much insurers can raise premiums without justification. But it doesn't guarantee health insurers will cover expensive treatments. The Affordable Care Act's pro-consumer changes may actually lead to more claims being denied.
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© 2014 Idaho StatesmanWhen Gov. Butch Otter an-
nounced May 1 that he’d accom-plished his aim of growing Idaho’seconomic output to $60 billion be-fore he left office, he saw that itwas good.
“Almost five years ago, we es-tablished a specific benchmark forcreating jobs and growing thestate’s economy and I’m thrilledthat we’ve achieved that goal de-spite weathering some of thetoughest economic times in mem-ory,” the two-termgovernor said.
Left unsaid by Otter is the de-
pressing reality that Idaho’secono-my didn’t grow at all in his first sixyears in office. In fact, from calen-dar 2007 to calendar 2012, thestate’sannual economicoutput fellfrom $51.4 billion to $51 billion in2005 inflation-adjusteddollars.
Only in 2014 is the inflation-ad-justed economy forecast to showreal growth. The numbers arebleaker still when accounting forboth inflation and population in-crease. Idaho’s gross state product
per capita of $34,180 in late 2007 isprojected to fall to $32,251 by theendof2014,adeclineof 5.6percent.
“We, collectively, are worse offthanwhenOtter took office,” saidBoise State University economistDonHolley. “The same canbe saidformost every state exceptNorthDakota.”
Though he mentioned a jobs
goal,Otter never set a specific tar-get, said Idaho CommerceDirector Jeff Sayer.
“Creating new jobs is obviouslyan important outcome that occurs
Otter’sboastaboutIdaho’seconomydoesn’taddup
Thestoryofaclockandall it represents
TIMWOODWARD LIFE, L1HAPPYMOTHER’SDAY!
IdahoStatesmanMAY11,2014* 64° / 38° SEEA17
P. CLOUDY
$2
EVEOFREFERENDUM INUKRAINEBRINGSCLASHES A7
SUNDAYEDITION
ABOUTTHENEWACCELERATEIDAHOPLAN A14
See ECONOMY,A14
IDAHOSTATESMAN:AMcClatchyNewspaper, 1200N.CurtisRoad,Boise, ID•P.O.Box40,Boise, ID83707• (208)377-6200•©2014 IdahoStatesman,Vol. 149,No. 293,6sections,60pages
INSIDETODAY “TheGoogle guysmight’vebeen coders,and theFacebookguys— Idon’tknow.” SAMMY SMITH, 10, at a coding event for schools NATION,A9
Reaching the governor’s ‘Project 60’ goalwaslargely a result of inflation, not growth.
BYAUDREY [email protected]
© 2014 Idaho StatesmanIt all happened so fast. Until it didn’t.
Then itwas unbearably slow.Clyde Rasmussen had been chopping a
log to burn in the fireplace in the Boisehome he shares with his wife and businesspartner,Emma. Itwashardly strenuous ex-ercise for Rasmussen, an avid biker andskier.Butwhen hewas done, his back hurt.Sohewent to a chiropractor.Thenhewenta couplemore times.
Itdidn’thelp.“I thinkyouneed to see aphysical thera-
pist,” the chiropractor told him.So Rasmussen, a real estate agent in his
late 50s,went to a physical therapist,whosaid, “Youneed to get anMRI right away.”
The Rasmussens took that seriously.They headed to a Downtown medical im-agingcenter. Itwas lateonaFridayeveningby then, so an employee sent them to an
emergency room,whereClyde got anMRI— a scan that costs anywhere from hun-dreds to thousandsof dollars.
Early Monday morning, they got a call.Thedoctorwhohadordered theMRI spot-ted something suspicious. He told Ras-mussen to see a neurosurgeon near SaintAlphonsusRegionalMedicalCenter.
When the couple arrived, the doctorpulled up a medical image to show themwhat he saw. “I hate to tell you this,” hesaid, “but youhavemultiplemyeloma.”
Therewere holes in Rasmussen’s spineand therewas “ahuge tumor,”Emma said.
Multiplemyeloma isakindofbloodcan-cer that starts in bone marrow, affectingplasma cells. It ravages the bone, stresses
AffordableCareAct limitswhat youpay, requires coveragefor all,butdoesn’t force insurers topay for treatment
2007 $55.25billion 1,519,640 $51.94billion $34,1802008 $54.33billion 1,544,350 $50.32billion $32,5862009 $54.98billion 1,563,250 $50.51billion $32,3102010 $56.35billion 1,577,320 $50.95billion $32,3002011 $57.8billion 1,589,750 $51.17billion $32,1862012 $58.34billion 1,603,840 $50.50billion $31,4862013 (est.) $60.55billion 1,621,120 $51.75billion $31,9242014 (est.) $63.22billion 1,641,100 $52.93billion $32,251
Note: Inflation-adjusted figures are in2005dollars;figures represent activitymeasured for the fourthquarter.Source:BoiseState economistDonHolley, IHSEconomics
CHARTING IDAHO’SECONOMY
In4thquarterofyear
Current(unadjusted forinflation)grossstateproduct Population
Real (inflation-adjusted)grossstateproduct
Real (inflation-adjusted)grossstateproduct,percapita
0
10
20
30
40
50
Not eligiblefor review
Denialsupheld
Denialsoverturned
Total reviews
13
2010 2011 2012 2013
30
45
39
Consumers who have exhausted aninsurer’s appeals process can ask theIdaho Department of Insurance for anexternal review of their case under a lawthat went into effect in 2010.
Source: Idaho Department of Insurance
FIGHTINGFORCOVERAGE
MATTM.MCKNIGHT/ Special to the Idaho StatesmanClydeandEmmaRasmussen stayed inaone-bedroomapartmentat theCancerCareAllianceHouse inSeattle for the firstpartofClyde’streatment.Nowthey’repayingalmost$2,000amonth foranapartmentnot far from thecancercenterwherehis recovery ismonitored.
After potcures pain,prison stillcan follow
BYROBHOTAKAINENSTATESMANWASHINGTON BUREAU
LarryHarvey, 70, found a remedy forhis gout and chronic knee pain.
“At night that thing just throbs,” hesaid. “Butmywifecanmakeamarijuanacookie, just a small one. And I’ll eat itand in five minutes, the pain is gone,man. Imean, the pain is gone.”
Harvey stopped eating his cookies inAugust 2012, after federal authoritiesraided his farmnearKettle Falls,Wash.,seizing 44 pot plants, his 2007 Saturn,his guns and $700 in cash.
With his trial set to beginMonday inSpokane, the retired trucker and com-mercial fisherman faces aminimum 10-yearprison sentence if he’s convicted.
“That would be a life sentence forme,”HarveysaidTuesday,munchingona salad in the basement cafeteria of aU.S. House of Representatives officebuilding on CapitolHill. “Youmight aswell takemeout and executeme.…Thefederal government isgoing to try toputme inprison for growingmyownmedi-cine.”
Medical marijuana advocatesbrought Harvey to Washington, D.C.,last week to make his case to membersof Congress, saying it’s time to legalizethe drug for the more than 1 millionAmericans who use marijuana for me-dicinal purposes.
“I just want to make sure Congressknowswhat’s happening so they can fixthe law,”he said.
Washington state allows bothmedical and recreationalmarijuanause,but state lawsmeannothing inHarvey’scase.Congresshasclassified thedrugasa Schedule 1 substance, meaning it’sdeemed to have nomedical value.Har-veywon’t be allowed to use hismedicalailmentsasadefensebecauseof the fed-eral prohibition.
“A lot of people inWashington don’tbelieve this is happening, but you can’tdeny it anymore — that the policy iscompletely out of whack — when you
Even inWashington state,wheremedicalmarijuanause is legal, thefedsmaydecide toprosecute.
WHENTHE INSURANCECOMPANYFIRST SAYSNO
See INSURANCE,A16
READABOUTTHEAPPEALSPROCESSANDTHEEXPERIENCESOFTWOIDAHOANS A16SeeMARIJUANA,A15
ParadeMagazinepolled1,000moms to findoutwhatmattersmost
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the kidneys and crowds outhealthy blood cells. Justmore than45percentofpeople livemore thanfive years with the disease. It’smore common among Clyde Ras-mussen’s demographic, men olderthan 50.
His disease was at its most ad-vanced: Stage III.
Emma Rasmussen recalled thedoctor saying: “You need to havesurgery right away, like tomorrow.I can tell you, 99 percent, if youdon’t get this (surgery) almost im-mediately, youwill be paralyzed.”
ClydeRasmussen,whomEmmadescribes as the picture of emo-tional strength, looked like hewasgoing topassout, she said.
Thenextday, hewent under theknife. He emerged weak, barelyable towalk.
It was a couple of days beforeThanksgiving 2012.
AFFORDABLECAREACTAfter the surgery, Rasmussen
graduated to an array of cancertreatments — radiation,chemotherapy, a list of expensivedrugs.
But this year, they hit a road-block: Their insurance companystoppedpaying.
TheRasmussens, like other Ida-hoans, would learn that althoughinsurersare requiredunder theAf-fordable Care Act to cover every-one—even thosewith ahistoryofexpensive maladies — they canstill refuse topay for treatments.
One industry whistleblowerthinks insurers will deny moreclaims as they try tomakeupmon-ey they must spend on otherhealth care law requirements, in-cluding providing colonoscopiesand other preventive care at nocost to the patient. Idaho’s largestinsurancecompanies say that’snottrue, and they note that patientsmay appeal decisions they thinkarewrong.
Frustrated Idaho consumers of-ten plead their cases to a state reg-ulator, the IdahoDepartmentof In-surance, after an insurer rejects aclaim or declines to green-light atreatment. The department haslooked into more than 200 suchcomplaints filed since 2011 againstIdaho’s two largest insurers, BlueCross of Idaho and RegenceBlueShield of Idaho.
Clyde and Emma Rasmussennavigated the appeals process —and told their story to theDepart-ment of Insurance and the IdahoStatesman — as they waited inSeattle for Blue Cross of Idaho toagree to pay for a bone marrowtransplant.
‘EVERYTHINGWASSTARTINGTOBEDENIED’
The Rasmussens traveled toSeattle in April 2013 to get theopinion of a Seattle Cancer CareAlliance specialist, Dr. WilliamBensinger, on therecommendation of their St.Luke’sMountain StatesTumor In-stitute doctor.
TheSeattle specialist saidClydeshould take two drugs and have astem-cell transplant, followed by abonemarrowtransplant.
The couple returned to Boisewith a plan.Clyde had two roundsof chemotherapy and a transplantof his own stem cells. Insurancecovered that. The only thing leftwas to receive a stranger’s bonemarrow, and the Seattle cancercenter booked that procedure forFeb.21.TheRasmussens arrived inSeattle about a month early, sodoctors could prepare Clyde’sbody for the transplant.
But Blue Cross of Idaho beganto balk.
“In January of this year, itseemed like everything started re-ally changing with Blue Cross,”Emma said. “It was kind of like, allof a sudden, everythingwas start-ing to be denied.”
She said the insurer declined topay for a new, expensive drug butalso stopped covering a drug thather husband had been taking for awhile. (The manufacturer of thenew drug ended up giving it to theRasmussens for free — a fairlycommonpractice.)
Blue Cross of Idaho sent adenial letter to the cancer centeron Feb. 12, nine days before theprocedure, saying that the trans-plantwouldn’tbe coveredbecauseitwas “investigational.”
Blue Cross had reviewedClyde’s case and decided the spe-cific type of transplant his doctorswanted to give himwasn’t allowedunder themedical policy.
The cost of the transplant —$801,000 in a lump sum — was abrick wall between Clyde and ahealthy stranger’sbonemarrow.
The couple filed an appeal toBlueCross on Feb. 14.One of Ras-mussen’sdoctors followedupwitha letter Feb. 20, saying the trans-plant was “the best long-term sur-vival option” for Rasmussen. Henoted that Blue Cross already ap-proved preparatory work for thetransplant, “which seems costlyand senseless if the plan toproceed… is abandoned.”
The insurer respondedwith an-other denial Feb. 25. Recent re-search cast doubt on earlier evi-dence that a transplantwould real-ly accomplish much more thantreatments Rasmussen alreadyhad received, the letter claimed.
ATICKINGCLOCKEmma Rasmussen was desper-
ate when she called the IdahoStatesman.
“I’ll sell everything I own tokeep him alive,” she said. “If hedoesn’t get (the treatment cov-ered), his life expectancy is notvery long.”
Her husband had 33months leftto liveunderhisdiagnosis.A trans-plant could buy him several moreproductive years.
Clydebegan towonderwhetherthe insurance company’s first re-sponsewasalwaysadenial, “just totest you.” He wondered whetherBlueCrossdid themathanddecid-ed it would just be cheaper to lethimdie.
“It quickly changed from amed-ical challenge to a political andeconomic argument,” he said.“You spend years paying into aninsuranceprogram, andyou like tothink they’re going to take care ofyou.”
Thecouple stayed inSeattle, liv-ing in the cancer center’s guesthouse for $91 a night, hoping BlueCrosswouldbe convinced.
Clyde still went to the hospitalevery third day, spending six toeight hours undergoing varioustests,withEmma by his side.Theypaid for everything themselves.
Clyde was still hard at workfrom Seattle, handling his real es-tate business and setting up openhouses remotely.
But doctors said the longer thatClyde took pretransplantmedica-tions, themore riskhehadof dam-aging his internal organs. Thenumber of months he had left wasdwindling.
Meanwhile, he stayed currenton his Blue Cross premiums of$342.98 permonth.
INCREASINGLYCOMMON?It’s not as though insurance
companies have just started deny-ing claims because of the Afford-able Care Act. They have beenheavily criticized for years forturning down payments or notcovering peoplewho have serious— and expensive—medical prob-lems.
Sometimes, insurers rejectclaims because they lack docu-mentation—if apatienthasmulti-ple doctors for the same medicalissue,butonlyone setof records issubmitted with an appeal, for ex-ample.
But other times, they’re just be-ing greedy, says an insider-turned-critic of the health insurance in-dustry. He thinks that they couldget stingier as they follow the Af-fordableCareAct.
“I have a concern that insurersmight even be more aggressive inclaims denials and refusing to au-thorize coverage for proceduresbecause therearegoing tobeotherways inwhich they are going to befacing reduced profitmargins, andtheymaybe looking forotherwaystomaintain those profitmargins,”saidWendellPotter,whoprevious-ly worked as head of communica-tions for insurers Cigna and Hu-mana.
Insurance companies do a bal-ancingactamongcompeting inter-ests—making sure premiums arelow enough to keep customersfrom running into a competitor’sarms, but high enough to covermedical claims; not paying healthcare providers too much, butenough to keep them from drop-ping out of the network; and earn-ing enough income to satisfy
shareholders, members or regula-tors.
Potter has testified beforeCon-gress and written about what hecalls “deceptive public relations,advertising and lobbying efforts”by the insurance industry.
“It’s all about the money,” hesaid,andhe thinks that’sespeciallytrue with for-profit insurers —who are basically nonexistent inIdaho, except for large-employerhealthplans.
Blue Cross of Idaho and Re-gence, aswell as twoother compa-nies selling plans on the Idahohealth exchange, have not-for-profit status.
“Iwill say this,”Potter said. “Re-sources are not infinite, and insur-ance companies shouldn’t be ex-pected to pay everything thatcomes their way, because there isfraud in health care, so they needchecks in place.”
And claims are reviewed by hu-man beings with varied qualifica-tions and backgrounds. Whethersomething is covered can be “luckof the draw,”he said.
There are no industrywide cri-teria forwhat qualifies a treatmentas “investigational,”Potter said.
“In some cases, those kickbacks(of claims for more information)and denials are such that thehealthcareproviderorpatientwillgive up, or think they don’t havethe ability to resubmit,”he said.
WHO BEARSTHE COST?Blue Cross said the new cover-
age requirements under the Af-fordableCareAct don’t affect howmany claims it denies. Its premi-umsdo, however,build inwhat thecompany expects to spend onnow-mandatory services and onpeoplewho’vegonewithout insur-ance and nowmight discover theyhave seriousmedical problems.
The company, like other insur-ers, has amassive setofpoliciesonwhat itwill andwon’t cover.
Dan Zuckerman, an oncologistand hematologist who is medicaldirector of the Mountain StatesTumor Institute, said he is “havingtodomore appeals andmorepriorauthorizations” for treatment, ask-ing insurers to cover $10,000 can-cer treatments.
“We have not decided as a soci-ety, ‘Howmuch arewe really will-ing to allocate to health care, andwhat typeofhealthcare?’”Zucker-man said. “... The insurers are putin the difficult position of makingvalue judgments.”
Josh Jordan, spokesman forBlueCross of Idaho, said the cost of adrug or a surgery never factorsinto insurance decisions. Instead,he said, BlueCrossmedical direc-tors make their calls based onmore than 500 medical policiesandnational research.
“It’s 100 percent aboutstandardsof care,”he said.
EVERYTHINGCHANGESThe Rasmussens were still in
Seattlewhen they heard onMarch5 that Blue Cross had reversed itsdecision.
It had been about a week sincethe Rasmussens appealed to theDepartmentof Insurance.
“I’mjust thrilled,and I’mactual-ly shocked,”Emma said.
Clyde Rasmussen went fromwaiting on paperwork to waitingon the bone marrow of a 33-year-oldmale donor to arrive in Seattle,where it would be pumped intohim through an IV.
Whathadchanged?ThedoctorsforClydeRasmussen and a doctorhired by Blue Cross to reviewmedical procedures talked to eachother.
“Sometimesadditional informa-tion comes to light, andwe’re ableto take another review,” said for-mer Blue Cross spokeswoman
KarenEarly,whohas sincebecomespokeswoman for a Montanahealth insurance cooperative thatplans to enter the Idaho marketthis year.
“This is how the system is sup-posed to work. Sometimes a con-versation is the best way to makesure everybody is on the samepage. …Our physicianswill alwaystalk tophysicianson the phone.”
Blue Cross said it rejected thetransplant at first based onmedical records and letters. Butthe same day the Blue Crossdoctor — whose identity was notdisclosed— talked toRasmussen’sdoctor, the insurer reversed its de-cision.
Though the doctors at BlueCross are “always” willing to talkwith a patient’s doctor, they don’talways reach out by telephone,Early said.
ONE LASTHURDLEClyde Rasmussen’s transplant
happened on a Saturday morninginApril, exactly amonthafterBlueCross agreed to cover the proce-dure.
Thecouplewillbe inSeattleun-til July, as doctors monitor howClyde’s body is handling the newbonemarrowand the immune sys-temweakening thatpreceded it.
They’ve rented an apartmentthere for about $1,900 a month. It
takes seven minutes to walk fromthere to the cancer center.
“Our next hurdle is we’re sup-posed topayup to$5,000ayear forhousing and other associatedcosts”before the insurerwill reim-burse them, Emma Rasmussensaid.
“We’re already way past that,and I filed that (claim) right away.And I haven’t heard anythingback,” she said.
They went past the $5,000threshold in 2013, too. As of earlyApril, they were working on ap-pealing adenial for that claim.
A spokesman for Blue Crosssaid Friday that the Rasmussensshould get a letter in the mail thisweekwith goodnews:The insurerhas agreed topay travel costs.
It could have paid them earlier— first, though, it needed proofthatRasmussenwas inSeattle foraprocedureBlueCrosswouldcover.
AudreyDutton: 377-6448,Twitter:@IDS_Audrey
FROMTHEFRONTPAGE
Idahoconsumershavea fewweapons to fightaclaimdenial.
Insurancecompanieshavean in-ternalappealsprocess—usuallywitha time limit,soopenyourap-peal early.
Itpays to read themedical policythatapplies toyourclaim.Look foryourpolicyonyour insurancecom-pany’swebsite.Checkwithyouremployer toseewhether yourplandoesn’tcover thatcost. Italsopaysto reachout to thehealthcareproviderwho filed theclaim,sincetheremighthavebeenanerror.
But sometimes the insurer stillwon’tpay.
In thatevent,consumersmay re-questanexternal reviewthroughthe IdahoDepartmentof Insurance.Idaho insurerspushed tohavea lawpassedseveralyearsago tocreate
external reviews,with insurerspay-ing for the review.
Idahoans requestedmore than100external reviews in thepastfouryears.The reviewsoverturnedone-thirdof insurers’denials.Morethan$430,000 inclaimpaymentswere recovered in2011and2012.
"Don’teveracceptnoasa finalanswer,” saidWendellPotter,whoonceworkedasaspokesman for in-surersCignaandHumana. “Youcanalways request reconsidera-tion,youcan fileanappeal,andkeep filingappealsuntilyou’veex-hausted theappealsprocess.”
CLAIM DENIED:WHAT YOU CAN DO
BeverlyWhite,anOreana resi-dentwhohasBlueCrossof Idahoinsurance throughher jobwithOwyheeCounty,contacted theStatesman inFebruarywhenadoc-tor saidsheneededbacksurgery.The insurerwouldn’tpay for it,un-lessWhite triedphysical therapyfor 12weeks.
That’sbecause Idahodoctorsdomorebacksurgeries than thena-tionalaverage,whilephysical thera-py isoftenall it takes to fixbackpain,aBlueCrossspokesmansaid.Backsurgery ismuchmoreexpen-sive thanphysical therapy.
Whitestartedphysical therapy,but shewasn’thappyabout it.Shehada50percentco-pay.Shedrove110miles round-trip twiceaweektoseeherTreasureValley therapist.Andshestill feltawful.
ButafterBlueCrossgotmore in-formation fromaseconddoctor,shegotheroriginal request.Whiteisdoing “verywell”after surgeryonApril 11.
Herdoctor sayssheneeds todophysical therapyasshe recovers.Butall thoseotherappointmentsuseduphalf ofherplan’sannual24-visitallowance,shesaid.
BACK SURGERY
Peggy JoWilhelm,aBoise resi-dentwhohasBlueCrossof Idahoinsurance,hada rareandundiag-nosedvasculardisorder. Itcon-foundedeverydoctor shesaw—even thosewhoexaminedherattheNational InstitutesofHealth,underaspecial programformyste-rious illnesses.
Thedisordercausedbleeding inherbrain,whichputher inacoma.
Onedrugseemed like itmightwork.
DanZuckerman,acancerandblooddisordersphysicianandmedical directorof theSt.Luke’s
MountainStatesTumor Institute,wantedWilhelm to tryanexpen-sivedrugcalledAvastin.Hewasoneof fivespecialists in thecountrywhosaid itwas themost realisticoption for savingher life.
BlueCrossstillwouldn’tpay forit. “Itdidn’tmeet theappropriatestandardofcare for theconditionshehad,” said Josh Jordan,spokesman forBlueCrossof Idaho.
ZuckermansaidWilhelm’scaseisspecial:Howcould therebea“standardofcare” forherconditionwhennobodyknew for surewhatwasplaguingher?
A RARE DISORDER
INSURANCECONTINUED FROMA1
Audreycovers thebusinessofhealthcare for the IdahoStatesman.
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MATTM.MCKNIGHT/ Special to the Idaho StatesmanEmmaRasmussen sorts throughdocuments thathaveaccumulated since2012 inClyde’sbattlewithcancer.Theyhavebeenmeticulouswith record-keeping,and theysought letters fromcancer-careadvocatesas theychallengedBlueCrossof Idaho’sdenial ofabonemarrowtransplant.
