This month’s newsletter will take a decidedly different path as I devote this issue to a personal experience relayed by an agent I know. His screen name is Dr. Who, hence the title of this month's newsletter.

His background is not unique but I will mention he has worked the Medicare market for over 20 years. Once he was introduced to this new managed care plan in 2006, he shifted his focus and offered, almost exclusively, Advantage plans.

Here is his story . . .

The Diagnosis

I was in the insurance business, running my own office from circa 1984 until Oct 2023 (retirement). From day one I was a proponent of Advantage Plans and then cancer hit. In Jan 2021 out of the blue, within two days, my wife was diagnosed with AML Leukemia. 

The closest hospital that could handle the AML said, if their treatment doesn't work, 2 weeks to live. It kind of worked but two months after living in the hospital, they were at the end, they took me aside and said, all we can offer is palliative care. 

What? They already admitted they messed up, previously telling me, "something went wrong, we don't know what went wrong but we have to figure it out, so it doesn't happen again."

Me being the advocate stepped in, I had been living in her hospital room (Covid time) and had a lot of time to work on research. This hospital is #32 in the list and Johns Hopkins Baltimore is #4. Gotta get to JHH. The hospitals were equal distance from my home, both 55 minutes. Except JHH was out of State (I live close to State line). The Medicare Care Advantage carrier said --- oops you can go to JHH but it will be OON (out of network). 

Lucky for me, we had a pocket full of money, something the general population won't have but it was something we had to do.

Bone marrow transplant completed at JHH and she has been cancer free and one more bone marrow biopsy in March 2024 and if the biopsy is clean the oncologist fires her. A big problem was the Advantage Plan Networks. Being close to the State line made an out of State hospital, one that has better outcomes the natural choice. Next choice was 300 miles away but that hospital was still in double digit outcomes.

Many, many, many denials from the insurance company. On the phone conversations I told them about my experience with insurance and we will be talking the same lingo. Then there were the meds, the plan D type stuff. You get cancer and you are almost immediately in tier 4 meds and some that need prior approval. Xospata (Gilteritnib) was just one med out of a big basket that took a fight. It was a $30,000 a month lifesaving immunosuppressant drug for AML relapsed patients. It was a med that worked but the cost...wow. Just for that med we ended up paying five digits a year out of our pocket. Each year we hit the catastrophic tier by February.

After a bone marrow transplant you eventually need all your childhood immunizations again. Yeah that was a problem and cost us several thousand out of pocket, they would not even pay toward OON.

I now have a very bad personal taste, experience with an MA plan and their Network plan. Our Network was PPO and God help any patient that is in an HMO. Between what they 100% balked on coverage, the OON costs, etc. the cost would be something that would bankrupt many, many people in the general population. It drained a lot of money from our account, last Oct I sold my agency and recouped some money.

I have also firsthand experience the difference in life saving medicine of one hospital and the other #32 hospital. If I had not been the advocate to get her out of that #32 hospital would have placed her in a SNF to die.

So yep - my first-hand experience showed me that MA Networks are a big problem. And I say find a med supp (Medigap) without a network. I've been around forums long enough that I am already putting my flame suit on and ready for the "the plan you chose was your choice." Yep - I was a believer in MA plans and bought my own sales pitch. 

Epilogue

My wife can walk, not far, she's in daily constant peripheral neuropathy pain but other than that she is doing well. It was a humbling experience.

I try not to think too hard about the past three years because if I do, darkness creeps in and I start to remember all the bad and lonely nights. Aside from living in the #32 hospital for almost two months, JHH required a 60 day stay. JHH is great. 

Everything that came up, the problems, etc. Hopkins was already waiting in the wings. It wasn't their first rodeo. Around 18 months post transplant when she got fungal pneumonia, they were not surprised and knew what to do. Cytomegalovirus (CMV) on (X) day after transplant, yep they are aware and already checking for it. There are hospitals that don't even check for CMV. Before the meds to handle it, CMV was the #1 mortality for bone marrow recipients. Average person CMV is no big deal, most have already had it but to a transplant patient it is a very BIG deal.

Limited Access to First Class Health Care

Earlier in the day I was reading about another JHH doctor for pain and his site said they don't take MA plans. I know my brother-in-law went to the Cleveland Clinic for transfusions for melanoma. I remember my sister talking about not being able to afford them. I need to call her anyhow, I'll ask.

The article in the link mentions our city / county hospital, the big main hospital dropped some MA plans. The hospital is one of two hospital's but they are the hospital with ancillary locations all over the country, they are and have been the big dog.

Before MA plans came along with their Sirens song, I did have some good traditional gap insurance companies in my file cabinet to offer. I think the people need to hear the "this could be you story" and traditional gap policies have to back the bigger stage.

The Stories are Real

The stories are real and they are often tales of horror. Yeah if you never get a dreaded disease, a MA plan will usually work. I had my gallbladder removed last fall and it worked out fine. But who can know the future? Read the headlines and these days cancer cases are increasing. Rates of cure have gotten better but now there are more cases. Without any insurance I could have paid for my gallbladder removal but could never have paid for a leukemia event with bone marrow transplant.

The agents that don't believe the stories have probably never sat and looked closely at their spouse's chest to make sure it is still going up and down, the breath of life. They've never had to move furniture in the living room to make room for the hospital bed. They live in denial.

Many nights I lay there on that hospital cot, by wife silent and asleep, talking to .... well you can give it a guess and it wasn't anyone walking the floors.

My number one is sitting at night with a blanket covering us and my wife and I watching tv. Not enough money in the world to buy such a thing as our evenings.

The stories are real and they are often tales of horror. Yeah if you never get a dreaded disease, a MA plan will usually work. I had my gallbladder removed last fall and it worked out fine. But who can know the future? Read the headlines and these days cancer cases are increasing. Rates of cure have gotten better but now there are more cases. Without any insurance I could have paid for my gallbladder removal but could never have paid for a leukemia event with bone marrow transplant.

The agents that don't believe the stories have probably never sat and looked closely at their spouse's chest to make sure it is still going up and down, the breath of life. They've never had to move furniture in the living room to make room for the hospital bed. They live in denial.

Many nights I lay there on that hospital cot, by wife silent and asleep, talking to .... well you can give it a guess and it wasn't anyone walking the floors.

My number one is sitting at night with a blanket covering us and my wife and I watching tv. Not enough money in the world to buy such a thing as our evenings.

In Closing...

I am sorry if this is a difficult story to read, but it is one that is never mentioned in the “Joe Namath” ads, much less the agents that are heavily promoting all the “free” goodies you can get from a plan that does not charge a premium.

No cartoons in this edition. There is nothing funny about battling a tough disease like cancer.

Feel free to pass this along to people you know, especially folks who are turning 65 and looking at their Medicare options.

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Take care,,

Bob