50 million Americans are gambling on high deductible health insurance plans. The stakes are high. They pay low(er) premiums but — in the event of a medical emergency — will have to pay out thousands of dollars for their treatment. There’s a good chance that many of you reading this have a high deductible health insurance policy.

The Attraction of High Deductible Health Insurance

Accidents can happen so it’s better to be safe than sorry. That was why Brian and Cristina (Cris) — like many younger or relatively fit Americans, including 44% of millennials — chose a high deductible health policy to protect them against catastrophic medical bills. After the accident both Cris and Brian realized that neither of them had a clue what their policy really meant, what was covered and the financial implications, if the worst happened. Their main consideration was the low monthly premium of $1,075 (in a healthcare world where $14,040 for a family per year is considered low). When Brian cycled into the Martinez Hills on March 11 of this year, he didn’t give a thought to his PPO 5500 Bronze policy and what would happen if… then, on the Alhambra Valley Road, if happened.

The Crash 

Brian and Cris live in the Bay Area. Brian is a plumbing contractor who grew up in Oakland. Cris teaches Italian, was born in Italy, and emigrated to the US four years ago.

Cris: Our families were connected. My grandmother was a very good friend of his grandmother. Long story. After World War 2, his father was taken as a prisoner of war in Africa and brought to Oakland, so in Oakland he met his future wife, a first generation American born of an Italian family, so when Brian’s dad was sent back to Italy as an ex-prisoner, he lived in Milan at my family’s house for a year; there was this friendship between the families and so we first met when we were kids.

There could be a movie in there somewhere. Brian is also an experienced road cyclist and is a member of an Italian-based team called GS Berti. That day he was out training with a partner.

Brian: There were branches by the roadside left by a storm. The rider in front of me pinched a branch, it rolled up and got stuck between the wall of my tire and my front fork. What we’re taught is when you hear something tumbling in your bike, stop peddling, don’t look down and wait for it to tumble out. So I went through those procedures but the message in my head was that it was taking too long. I looked down. The wheel locked and with the forward weight, I supermanned off the bike, over the rider in front of me and landed face first on the pavement. I bounced, body and face first and the trajectory forced my neck back. It all took about 15 seconds.

“Brian’s Not Hurt”

Cris was at home when she got the phone call. Brian’s training partner told her that there had been an accident but that Brian wasn’t hurt…

“…but people never tell you, do they? It was a horrible situation and I just ran. I wasn’t sure what I would find.”

The ambulance had taken Brian to the John Muir Hospital in Walnut Creek. He was conscious but in bad shape.

“They had to stitch his nose, the lips, the inner lips, basically his whole face. That took an hour and a half.”

But then, and more importantly, they had to understand how much damage he had done to his neck. “Brian was afraid of being paralyzed. He could move his hands and feet but felt a tingling pain which was diagnosed as a neurological shock.” He was taken to the trauma unit. The accident hadn’t broken Brian’s neck but the damage to his C3, C4 and C5 vertebrae was restricting the spinal cord and he was diagnosed with Central Cord Syndrome.

This is the most common form of incomplete spinal cord injury characterized by impairment in the arms and hands and to a lesser extent in the legs. The brain’s ability to send and receive signals to and from parts of the body below the site of injury is reduced but not entirely blocked.

Injuries in this area are very serious, and can cause paralysis in arms and legs, restrict the ability to speak or breath and other vital functions.

Cris: The surgeon came to see us and said you have two options. You could not do surgery but obviously that is risky because let’s say in a year you fall off again and bang your neck in the wrong way, you can be paralyzed. Obviously not an option. So the second option was to do the surgery. The surgeons inserted discs in 4, 5, and 6 bones and fixed them with tiny screws. So after the surgery, Brian was moved to the intensive rehabilitation department which is always in the same hospital. I must say the treatment he had besides the surgery was really great.

“For Us, American Healthcare is Really Crazy!”

Often it is the outsiders, the immigrants, the new arrivals brought up in a different culture who see clearly the brokenness of healthcare here. When I first talked to Cris, just after Brian’s accident, she was in financial shock as the first bills arrived, but now it is a few months later, and that emotion is tempered by an amazement at the complexity and confusion of this unworkable system.

Cris: In Italy hospitals are free for citizens and foreigners, so for us it’s really crazy in the USA. Brian would have had the same treatment in Italy, but without the worry of expecting a bill.

What is remarkable is that although Cris admits not understanding their PPO 5500 Bronze policy administered by Blue Shield of California before the accident, she now talks like a medical billing professional. She has been forced to learn a lot in last five months and is at ease navigating the system because she has spent hours on the phone. Eventually, Cris found out how much Brian’s hospitalization had cost.

“The itemized bills totaled $489,000. And at that point, I was really astonished. What is this bill? It cannot be!”

She is right. This should not be. It is an obscene price that we accept as normal because it happens to tens of thousands of Americans every week who receive emergency care or necessary treatment for life-threatening conditions.

Brian and Cris have paid some out-of-network charges but are still waiting for a final accounting. “In fact, I’m really surprised because we’ve not received one bill from John Muir and it’s been five months.” Also, another problem is that their EOB kept changing as John Muir and Blue Shield negotiated the bill. She remembers that it reached $9,000 at one point, but is now closer to $17,000. The amount is still changing.

Learning about deductibles

Cris also learned about deductibles. She had no idea that her policy had two different deductibles and two different out-of-pocket amounts. This is how it reads–

Deductible

• For participating providers: $5,550 per individual / $11,100 per family
• For non-participating providers: $9,500 per individual / $19,000 per family

Calendar year out-of-pocket maximum

• For participating providers: $6,800 per individual / $13,600 per family
• For non-participating providers: $9,800 per individual / $19,600 per family

The terms participating and non-participating providers are Blue Shield language for in-network and out-of-network and a good example of how even variations of terminology can confuse policy holders

Cris and Brian had read the $5,550 figure and assumed that this amount was their annual liability.

“I didn’t realize there were deductibles for in-network AND out-of-network. I had to learn that. Really weird. I expected we had to pay the $5,550 deductible and then all the rest will be dealt with by the hospital and insurance. I didn’t have any idea that my out-of-network deductible was another $9,500.”

And she was even more confused from the very beginning by not knowing until it was too late which medical services were in-network or out-of-network.

“I asked why do we have to pay $3,000 for the ambulance. Because it’s out-of-network. Why do we have to pay the anesthesiologist? Because he’s out-of-network?”

She raises her hands in frustration.

Cris: My husband is in an emergency. What do I say? I don’t want this treatment because it’s out-of-network? You’re totally in the hands of these people. It was so weird. Patients are not informed of the out-of-network treatments that happen in a hospital. It took me forever to work that out.

Five Months Later

Brian is doing much better. He has been working with the physiotherapist, doing PT and OT for two months out of the hospital. They both want to thank the doctors and staff at the John Muir for doing a fantastic job and getting Brian back on his feet.

Cris: Right now, he can’t work properly, but he does consulting, so he can do little jobs, but we are waiting at the end of September for his follow up when they look at his spine. The neurosurgeon was very pleased. The surgery was perfect. The bones are fixed. But he must be very careful for the first six months. So he has a couple of guys with him. He sees his clients. He’s busy. Not just riding his stationary bike. He’s a very active person.

Cris spent a few weeks in Europe in the summer to work and visit family. Everyone asked her what happened. She told them.

“My friends in Italy or France or Germany. I tell them the story! They can’t believe it. They say that is so crazy.”

P.S. Just before posting this story we received this message from Cris–

“I have NOW downloaded the new Explanation of Benefits from Blue Shield and the amounts have changed… AGAIN!!! $17,119”

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