Medical advancements stretch the $1M lifetime cap

By Ellen Gabler

Milwaukee Journal Sentinel

(MCT)

She wanted to see her son get married. She wanted to watch her daughter start kindergarten.

But 17 months later — after two failed bone marrow transplants, seven rounds of chemotherapy and 101 nights in the hospital — Goins had used up her health insurance.

"You think you have insurance," Goins said. "You think you are OK, and you are not."

Goins has since been scrambling to line up other health insurance, terrified that she will die and leave her husband and 6-year-old daughter with hundreds of thousands of dollars in medical bills.

But rising health care costs and medical advancements are making it much more likely for people to hit that million-dollar mark, especially if they receive organ transplants, treatment for cancer or have a premature baby.

The high rate of medical inflation means that coverage is worth a bit less each year — the price of medical services grew nearly twice as fast as overall prices in the past decade.

Some patients, for example, mull over divorce, he said.

The reasoning?

When Hari heard that Goins was approaching her lifetime limit, he started ordering the "bare minimum" of lab tests and spaced out her doctor appointments.

"I've been trying to see her in the corridor without actually generating a bill," he said.

With advanced treatment, cancer often becomes more of chronic disease that needs ongoing care, he said. And some of the newest and best treatments are the most expensive.

"I have patients who I have not been able to give what I'd like to give them because of insurance," he said.

Officials with UnitedHealthcare, the company that insured Goins through her husband's work, declined to comment, saying she has disputed some coverage decisions, and the company's legal team is reviewing her case.

FINDING ALTERNATIVES

Patients who reach their lifetime maximums may be able to find alternatives.

In addition, uninsured patients, or those with a coverage gap, have to wait six months before pre-existing conditions are covered under the high-risk plan. Private insurance plans often have this requirement, too.

Some patients qualify for charity care through their hospital, but their income must be low. And certain procedures, such as transplants at Froedtert, are not eligible for charity care.

For someone who hits a health plan's lifetime limit, lining up alternative insurance can be a difficult, confusing process — especially for a patient and family wrestling with a life-threatening illness.

Middle-class patients have the toughest time finding help, she said, because they often make too much to qualify for state aid but too little to afford the premiums of the high-risk plan.

"It's an added stress for people who don't need to be dealing with it," she said. "Instead of just putting your energy toward getting better, you are worried about your insurance company bugging you."

Goins had already been struggling for months to track her treatment costs. She watched her costs carefully, frequently making calls from her hospital bed to ensure that procedures were covered under her plan. Because of confusing wording in her benefits booklet, she thought the cap didn't apply to bone marrow and other transplants, but it did.

"I didn't want anything to drop between the cracks," she said.

A former registered nurse, Goins had worked for an insurance company, where she helped coordinate authorizations before her daughter was born. She understands the industry and its processes better than most patients do.

Last week, the executive committee from the high-risk plan agreed to backdate Goins' policy to cover earlier treatments.

The 53-year-old has been on the state's high-risk plan for about a decade. Since then, she's had five recurrences of cancer that spread from her breasts to her bones, leg and lymph nodes.

"I need them to move it along or I'm going to die," she said.

INCREASING THE LIMIT

A growing number of employers are increasing lifetime limits on their employees' health insurance plans to account for rising costs.

The increase in insurance comes at a cost, but not as high as many might think.

Ray stood up at a staff meeting and asked his co-workers to agree to the slight increase in their premiums. He offered to pay the difference if there were any objections.

"Of course there wasn't," he said.

More than a year ago, doctors didn't expect Goins to live much more than three months.

She survives with the help of blood transfusions four days a week.

Even though she has insurance again, Goins brings her own over-the-counter drugs to her transfusions. She can buy a whole bottle of acetaminophen for what the cancer clinic charges for a single pill.

Goins and her family now celebrate big on special occasions such as birthdays and Christmas.

She wants to be around for as many as possible, which is why she's trying to save every penny at her blood transfusions.

"Who knows how long another million will last?" she said.

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By The Numbers

Cap Costs

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