Blue Cross of Louisiana doesn’t give a shit about breast cancer
I'm on a 20+ city book tour for my new novel PICKS AND SHOVELS. Catch me in PITTSBURGH on May 15 at WHITE WHALE BOOKS, and in PDX on Jun 20 at BARNES AND NOBLE. More tour dates here.
A jury has ordered Blue Cross of Louisiana to pay $421m to a hospital specializing in a much sought-after type of breast reconstruction, primarily for cancer survivors. The insurer "preapproved" surgeries for thousands of patients, but then held back 92% of the payments it owed, with CEO Steven Udvarhelyi insisting that "authorization never says we’re going to pay you":
In a characteristically brilliant and deep investigative story, Propublica's T Christian Miller explains how Blue Cross of Louisiana colluded with other Blue Cross franchises around the country to steal hundreds of millions of dollars by denying claims they'd already approved:
The hospital at the center of this controversy is the Center for Restorative Breast Surgery in New Orleans, founded by two surgeons, Frank DellaCroce and Scott Sullivan. DellaCroce and Sullivan are pioneers of an advanced form of breast reconstruction called "autologous tissue reconstruction," which eschews implants in favor of the patient's own fat to construct new breasts. While other surgeons perform this surgery, DellaCroce and Sullivan are acknowledged as national leaders, having invented many innovative techniques and trained many of the other surgeons who perform the procedure. As a result, patients travel from all over America to the Center for Restorative Breast Surgery.
DellaCroce and Sullivan's procedure is extremely precise and labor-intensive, and it comes at a high cost. Accordingly, patients seek pre-approval from their insurer before undergoing the procedure, and in Louisiana, that usually means calling up Blue Cross, the state's largest insurer. Despite pre-approving the procedure, Blue Cross of Louisiana has held back over 90% of the payments it owed to the hospital.
Rather than throwing their patients into the Blue Cross meat-grinder, DellaCroce and Sullivan carried the unpaid balance on its books, repeatedly suing Blue Cross for the unpaid amount. Finally, last week, the a jury ordered Blue Cross to pay $421m to the hospital (Blue Cross is appealing).
The case dragged Blue Cross's sleazy behavior – normally confined to bureaucratic memos and telephone denials – into the public, and boy is it ugly. Blue Cross's official excuse for denying the claims was that it was acting in the best interest of the millions of Louisianans it insures: DellaCroce and Sullivan are simply too expensive – it's not realistic for people in an insurance pool to expect that kind of care. However, Blue Cross executives repeatedly signed one-off, "single case agreements" so that their own wives could get the procedure from DellaCroce and Sullivan.
In addition to this argument, Blue Cross insisted that the fact that it had pre-approved all of these procedures did not oblige it to pay for them after the fact. Rather, an "approval" is a bureaucratic, heavily disclaimed term of art that means, maybe we'll pay for this and maybe we won't. In court, however, the company was forced to admit that an "approved" procedure has to be paid for in all but the most exceptional instances, for example, when the patient cancels their insurance between getting approved and going in for surgery.
The insurer also claimed that there were checks and balances to prevent arbitrary claims denials, but then Blue Cross executive VP Paula Shepherd acknowledged that "an appeal is not available to review an underpayment." As Miller writes, "The insurer simply issued an edict — the payment was correct."
Meanwhile, Blue Cross didn't just save money by denying the claims it had approved – it made money. Other Blue Cross organizations in different states would pay 16% kickbacks to the Louisiana Blue Cross, splitting the take every time it denied a payment.
All of this added up to means, motive and opportunity to engage in unbelievably sleazy – and fraudulent – behavior. Overall, Blue Cross paid $43m on $500m worth of invoices from the hospital. In 60% of claims, it paid nothing.
Blue Cross is one of the nation's largest health insurers, and Blue Cross's argument for stiffing this hospital is the argument for letting insurers buy one another up and grow to unimaginable scale. In David Dayen's amazing 2020 book Monopolized, he lays out the procession of America's morbid health care monopolization:
First, we allowed pharma companies to merge to monopoly, which gave them the power to screw hospitals with sky-high drug prices. So the hospitals defensively merged into regional monopolies with the power to negotiate those prices down, but this also gave them the power to overbill insurers. So the insurers also merged until they could resist the hospital chains' pricing power and force rates down.
And indeed, 97% of doctors and hospitals have a negotiated rate with Blue Cross of Louisiana (remember, it's the state's largest insurer). But DellaCroce and Sullivan haven't joined the Blue Cross network, because the rates the insurer offered wouldn't even cover the costs of the surgeries.
The theory that monopolies will defend us from other monopolies is a disastrous example of "the old lady who swallowed a fly" strategy. For the strategy to work, everyone has to be a monopolist, otherwise they'll get steamrollered – on their wages, their care, or their compensation.
And of course, patients don't get to merge to monopoly (that's what governments are for, and we know how Blue Cross feels about single payer care). Workers don't get to merge to monopoly either (that's what unions are for, and no one hates a union more than a health care monopolist).
Blue Cross's position – the position of the entire for-profit health industry – is that they should be able to grow as large as they can, at the expense of us, the patients. In other words, they are economic tumors – so no wonder they're on the side of breast cancer.
If you'd like an essay-formatted version of this post to read or share, here's a link to it on pluralistic.net, my surveillance-free, ad-free, tracker-free blog:
Red is a short film about James (Parker Queenan- you know, the one who played Reed) a 17 year old closeted boy who runs into an old hook up named Aaron (Jance Enslin but we call him yahns) a year later.
(or atleast I think it was a year- don’t quote me on this. there was some time amount)
Red is based off a short story that Scott Sullivan (the amazing director) wrote before college while in the closet about his struggles. Because he was in the closet, Red won’t have a happy ending. Scott won’t let us be disillusioned that it does. Red is about truth, not trying to please others.
Red is supposed to be heartbreaking. To invoke tears. To be *real*. When we watch Red, we are meant to feel what he felt growing up. To show people that not only are they not alone, but that their feelings are valid. Yes, there is a lot of us who wave our flags and that's amazing, but you shouldn’t feel shame for not wanting to either. Red is going to demonstrate a part of the journey to acceptance often overlooked, or downplayed.
With Red, Scott is showing the world that being LGBTQ+ isn’t all internal glitter and rainbows. There's pain. There’s tears. There’s hatred. Our biggest enemy isn’t always a different person, but rather ourselves.
It’s something we need to watch.
I know that I empathize Scott, a lot- but when it gets down to it, understanding that these are Scotts feelings is important. The fact that he’s there, exposing his darkest thoughts to everyone is proof that it *does* get better. Scott hated himself when he was younger, and even admitted to thinking about suicide, but he made it. He’s accepted himself. If he can feel all he did and be okay, then so can we. To understand Red, and that these aren’t just randomly decided angst scenes is important.
(i tagged andi mack because you guys are the ones who will most likely care)
How does one begin to understand, to know without a doubt, the differences between dreams and reality? How does one comprehend the subtleties, the signs, when everything you know, everything you believed before used to say otherwise? After years of being dealt the same hand, of being reminded again and again that no matter what you do, no matter what you say, it would never be good enough. How do you look beyond what has been ingrained in you for so long and manage to see something good, when it is looking you straight in the eye?
I did not think it was possible, I could not dare to consider that things might be different, that I might actually be happy... but as I look upon his handsome face, as my fingertips trail over his fair skin, I cannot deny it. There is no question in my mind. I love him and yet... I can feel it, the lingering sense of unease and suspicion, always ebbing beneath the surface... reminding me of one thing. It impresses upon me the one prevailing and predominant fact, that no matter how high you climb, eventually you must come down. I find myself waiting for the proverbial shoe to drop, for the inevitable fall... all the while, clinging to this newfound hope that it will not. Gods how I wish to remain within this dream, with him and think of nothing else... but even I know that eventually we must leave this place, eventually we must return to reality...
A breath of wind slips through the open window, carrying with it the subtle salts of the ocean air, its cool embrace drifting over skin and leaving tingles in its wake. Even in the midst of such despair, of such dark thoughts I cannot help but smile at the sensation, at the comforts found as I lay entangled with him.
There is a profound sense of clarity in the light of the morning, in the softness of his peaceful expressions as he yet sleeps and it is in that moment that I realize... things are different now. No matter how certain, how desperate and dark the days were before... he has become my light and I... his. Somehow we managed to pull each other from that place, remind ourselves that there is something worth fighting for, someone...
I look upon him then, taking in the darkness of his raven locks and the subtle curves of his lips and I cannot help but think... Let the proverbial shoe drop, let the winds rip at me as I fall, I care not, for I have the one thing now that I did not have before, the one thing I never expected... a man worth loving, a man who loves me in return... A man who will catch me when I fall and whom I can say, without a doubt, that I would give my very life for, without hesitation, without question.
So let it come, let reality break down the doors and remind us of its fury... we are ready for it, come what may.
Mentions: @midnightshading
