How Dorothy Utilized Her Care Navigation Solution's Call Center
Chapter 3, The Scam Behind the Curtain
Dorothy spent the next day feeling very low. Auntie Em found her lying in bed, looking out the window in her bedroom, staring into the slate gray Kansas sky.
“Dorothy! What’s wrong?” She asked.
“I can't walk all the way to Boston by myself! I have to go see the Specialist, Dr. Skinman told me, and he’s all the way in The Crimson City! But with no direct flights, it's going to be a real hassle to get there. I might as well walk!”
“Didn't you tell me you had a service that your employer provided to you? Someone, to help you navigate all of this complexity1? I mean that handout about the yellow dotted line, with the Patient Journey? That does seem prescient, but, maybe there's actually a person who could help?”
Dorothy realized she had a card, in her wallet, that her employer gave her:
Wellness Inequality Targeted Care and Health (W.I.T.C.H.)
A Care Navigation Solution
And there was a phone number. So, she called.
“Greetings, and thanks for calling Wellness Inequality Targeted Cared and Health. My name is Glinda, and I’m your WITCH.”
“Oh, my, thank goodness!” said Dorothy. “But wait, do you work for the insurance company?”
“Oh, my, no! I do not! It used to be my job to work for an insurance company. There used to be several in the land. There was NorthernLife, SouthCare, EastWell, and WestHealth. But there's been a lot of consolidation in the market. I just couldn't work for the bad guys anymore. They are awful. One might even say wicked. So I couldn't do it. Now, I work at WITCH, and I get to be good and help members navigate their benefits. You, Dorothy, you're a member. I know it probably sounds like doublespeak, but you are a member of something very special. You're a member of a health plan, and your employer, well, they're the sponsor of that plan. And they have some very special responsibilities2 to you.”
“Well, that's a relief to hear. But I'm confused, I thought my insurance was UnitedHealthShare3?”
“Oh, Dorothy! There has been major consolidation in that industry. Everything is UnitedHealthShare now! When they acquired WestHealth, that's when things got really wicked.”
“Not to be obtuse, Glinda, but I don't understand why you're helping me.”
“It makes all the sense in the world Dorothy, you've entered a very strange land. And although you're still legally in Kansas, most of the actual back end for your care has been outsourced. Your employer uses UHS only as their third-party administrator4. And behind the scenes, your employer, which sponsors your health plan, will pay for all of the care you get.5 But they're still using UHS to process the claims. So, although it looks like you have UHS, they are just there to provide you with that little logo on the insurance card you have. All of your actual healthcare is paid for by your plan sponsor. And they contract with me, a good WITCH, To help you on your Patient Journey.”
“Ruff!” barked Toto, and again, “Ruff!”
“It’s probably worth mentioning we offer Veterinary Insurance Navigation for Service Animals too,” said Glinda, with a lift in her voice that let Dorothy know that Glinda was an animal lover also.
Later that evening, Dorothy was tossing and turning in her bed. She couldn’t stop thinking about what Glinda had told her. She was sure she had good insurance! Or had been sure. That feeling that she had nothing to worry about… was falling apart. Now she was worrying about whether she should worry. Maybe Dr. Skinman was onto something with his OCD diagnosis? Unable to sleep, she sat up in bed.
Toto felt her move and nuzzled her with his little dog nose.
“Oh, Toto!” exclaimed Dorothy. What was that Toto had been sleeping on? It was her “Patient Journey” handout from Dr. Skinman’s office! Dorothy picked it up and began to read it more closely. Hours passed, with Dorothy reading this one medical term, then cross-checking it on her computer. It was all so complicated! Eventually, as dawn broke, Dorothy fell asleep, right there on her laptop's keyboard.
My contention, as you’ve probably ascertained, is that the complexity is part of an elaborate scam. When I say scam, I mean exactly the definition of the word scam:
a dishonest scheme; a fraud.
There are historical reasons why it's such an excellent scam that makes so much goddamn money. Understanding a scam means understanding the financial incentives, and some of those have historical antecedents.
This footnote will provide a little history of how this scam began and why. A note on word choice regarding healthcare: The actual care of human health is referred to by the two-word combination of health SPACE care. Healthcare, in one word, is an industry, and I’m arguing a dishonest scheme.
The first health insurance program was developed in Texas, at Baylor Hospital, now associated with Baylor College of Medicine. It was 1926, and the “Baylor Plan” was born. Dallas school teachers paid $6 Per Year, and were “extended hospital care without any additional charge.” This was essentially pre-payment for hospital services, which some would need and others would not. The risk for any one person was spread out over the whole group. This later became “Blue Cross” and the rest of “insurance” as we know it. It sounds so good–wholesome even!--spread the risk out! This “risk sharing” feature is crucial to all insurance products, but timing led to one very important peculiar feature–this was during the great depression. There were wage freezes in place across the country. From the beginning, employment law and subsequently tax law drove health care and how it’s reimbursed.
The responsibility that employers, also known as Plan Sponsors, have to plan members like Dorothy is that thanks to The Combined Appropriations Act of 2021 (CAA 2021), is to act as a Fiduciary. This is probably the most important footnote in this whole book. A fiduciary is defined by the US Department of Labor:
The primary responsibility of fiduciaries is to run the plan solely in the interest of participants and beneficiaries and for the exclusive purpose of providing benefits and paying plan expenses. Fiduciaries must act prudently and must diversify the plan's investments in order to minimize the risk of large losses.
This is in no way a parody of any specific 1/2 trillion dollar company. I mean, there has been so much consolidation it could be any of them because they are all acquiring each other until there is nothing left.
Third Party Administrators is what we call medical claims adjudicating and processing companies when they're not responsible for paying the claims themselves or underwriting the risk. These companies are hard to run, give the archaic nature of health claims!
This arrangement is referred to as a “self funded plan” and places employers in the unenviable position of having to directly build expertise on benefits design and navigation. Benefits brokers and advisors have tremendous power in these scenarios, and fiduciary roles as well. The most serious of them become healthcare economics wizards and advocates, along with performing miracles of care navigating themselves on a regular basis. They are the unsung heroes of American healthcare in your author’s personal opinion.