Yet another health insurance ripoff

This one is a bit complicated. It has to do with out-of-network providers--those who are not contracted with the health insurance plan.* Big insurers such as UnitedHealthcare, Cigna and Aetna use a data analytics firm called MultiPlan to determine how much out-of-network medical providers should be paid. Both MultiPlan and the insurance companies cut reimbursements to providers as much as possible, which means saddling patients with large bills. The smaller the reimbursement, the larger their fee.

Example: A woman with a complicated and serious condition saw an out-of-network specialist, whose bill was open to negotiation by her insurance company, UnitedHealthcare. UnitedHealthcare paid the doctor $5,449.27—a fraction of what he’d billed the insurance company. The patient received a bill of more than $100,000. The difference between the bill and the amount paid equals a savings for the employer who provides the insurance. But it also means big money for both MultiPlan and the insurer, since both companies often charge the employer a percentage of the savings as a processing fee.

The burden can fall hardest on people with chronic or complex conditions who see specialists, including treatment centers for mental health or substance abuse treatment. Here’s another example, this one related to a substance abuse treatment facility: For providing treatment, the facility received $134.13; for processing the claim Cigna received $658.75; for recommending a payment amount, MultiPlan received $167.48.

MultiPlan affects more than 100,000 health plans covering more than 60 million people. It has annual revenues of about a billion dollars. Former employees talk about a numbers-driven culture in which their bonuses were tied to their success in reducing payouts. It’s a private equity company, as are many physician groups and hospitals nowadays. Last year it identified nearly $23 billion in bills from various insurers that it recommended not be paid.

To be honest, I don’t fully understand the intricacies of these shenanigans. Nevertheless, I thought it was worth mentioning.

                   

                   * "Out of the way--I'm a doctor!" "Out of the way--he's not in-network."

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I learned too late about Advil

I used to take Advil (ibuprofen) for aches and pains—always on golf days. After about ten years of this (I’m guessing) I started getting acid reflux and heartburn—a condition in which stomach acid flows back into your esophagus (the tube that connects your mouth to your stomach). Normally, when you swallow, a band of muscle (a sphincter) around the bottom of your esophagus relaxes to allow food to flow into your stomach, after which the muscle tightens again. If that sphincter isn’t working as it should, stomach acid can flow back up into the esophagus. It’s usually worse if you’re lying down.

I’d had no idea that Advil and other anti-inflammatory drugs could cause acid reflux and heartburn. It can also increase the risk of stomach ulcers. That’s because it increases acid production in the stomach, inhibits the production of mucus that lines and protects the stomach lining, and irritates the esophagus. I quit taking Advil and the acid reflux stopped, although I still get heartburn occasionally. I wish I’d known.

Advil is in a class of drugs called non-steroidal anti-inflammatories (NSAIDs), which also include aspirin, Motrin, Naproxen, Aleve, and others. To get a tad technical, the fundamental mechanism of NSAIDs is to inhibit the COX enzyme. The problem is that the enzyme comes in two forms: COX-1 and COX-2. COX-1 protects the stomach and gastrointestinal tract (good). COX-2 induces inflammation (pain). Unfortunately, with NSAIDs you can’t reduce inflammation caused by COX-2 without also reducing the protective effects of COX-1.

Pharmaceutical companies have been trying to develop pain-relieving drugs that target just COX-2. No luck so far. Maybe that’s the way Mother Nature wants it.

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Resistance exercises: a good thing to do

I used to go to Jazzercise classes. They shut down during Covid and I never went back. But I signed up for Jazzercise on Demand, so I continue my exercise regimen that way. Several times a week I do 20 minutes of aerobic/cardio exercises and 10 minutes of weight training, using five-pound weights. (Ten minutes doesn’t sound like a lot, but it’s about all I can stand, as are five-pound weights.) The primary benefit of muscle-strengthening activity comes from the way it taxes the muscles: it generates microscopic tears in muscle tissue that prompt the muscle to repair itself and build more fibers to become stronger.

In addition to increasing muscle strength, various studies and analysis of muscle-strengthening exercises have shown—

• A 10 to 17 percent lower risk of all-cause mortality. Data on 100,000 older Americans showed that those who did both aerobic and resistance training had the lowest mortality of the entire group.
• Less loss of muscle mass as we age.
• Stronger bones. Muscles pull on bones and in response bones add new cells and get stronger.
• For cancer survivors, less fatigue and improved quality of life; for diabetics, improved glucose storage and circulation.

Experts recommend two or more sessions a week of muscle-strengthening. They say any kind of resistance training will do, such as pulling on elastic bands, push-ups (not me!), free weights or weight machines. The important thing is to put strain on your muscles. But you also need to allow sufficient rest between workouts to allow the muscles to repair themselves.

Experts also say to increase weight and intensity over time. I’m not doing that. Somehow, my five-pound weights get heavier each time I use them.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Consuming the chemicals in plastics

 By now, we’ve all been warned not to heat up food in plastic containers: the chemicals leach into the food. There are more than 16,000 chemicals used in plastics manufacturing and over 1,000 of those are suspected of disrupting our endocrine systems. In fact, they’re called endocrine-disrupting chemicals (EDCs). A common example is BPA, which stands for bisphenol A, an industrial chemical that has been used to make certain plastics and resins since the 1950s. It’s often found in food and beverage containers and in resins that coat the inside of food cans.

Our endocrine systems act like well-oiled machines, releasing certain hormones in precise quantities and at precise times to reach receptors spread throughout the body. The endocrine system helps to moderate everything from fertility and reproduction to growth, metabolism, immunity and brain development. The problem with EDCs is that they mimic, block, and otherwise disrupt normal hormone functioning and lead to a cascade of signaling that is not supposed to happen in that moment. Synthetic EDCs have a similar structure and size to dozens of hormones, including estrogen, testosterone, and thyroid hormones. BPA, for example, mimics estrogen. Pregnancy and fetal and infant development are considered periods of heightened vulnerability to the effects of EDCs. (I’m glad I reached adulthood before EDCs were so ubiquitous.) 

Many researchers think there is no “safe” consumption level for EDCs because these chemicals don’t act in a predictable way. The European Food and Safety Authority has established a safe limit of 0.2 nanograms of BPA per kilogram of body weight per day. With that limit, you can exceed your daily tolerable exposure level by eating one five-ounce can of tuna.

It all feels rather hopeless. Our recycling box always has plastic containers in it. The warnings seem too late for me, so I don’t worry about it. But maybe you should.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.