Health Care That Works: Solving The Curious Case of William Jay

 

By Matt Perry

Nearly everyone has a health care horror story. For William and Madeline Jay, theirs is worse than most.

After being forced to switch supplemental Medicare plans last year, William was no longer covered for the continuous glucose monitor, or CGM, he’s relied on since age 68 to test his Type 1 diabetes and prevent repeated bouts of unconsciousness, not to mention expensive trips to the ER.

This year The Curious Case of William Jay was finally resolved when the Berkeley couple signed up for health coverage from the only integrated health plan in California that offers both insurance coverage and medical services: Kaiser Permanente.

“Kaiser has been extremely responsive and compassionate,” says Madeline. “Bill’s sense of dignity and worth as a person is restored. He was devastated at having to fight for life-preserving equipment.”

The cautionary tale is a lesson in perseverance, integrated health systems, and the importance of doubling down on preventive health.

Even before their new insurance began, Madeline was able to choose a primary-care physician and schedule appointments that would take place two days after their coverage started on January 1. William’s physician immediately referred him to a specialist in endocrinology.

Kaiser then prescribed further diabetic care: a podiatrist, physical therapist and more blood tests.

“No hesitation,” says Madeline. “All within three weeks.”

Kaiser was heralded as one the best health systems in the country by renowned physician and healthcare writer Atul Gawande in his 2009 New Yorker piece The Cost Conundrum.

What makes Kaiser different?

As both health insurer and medical provider, Kaiser may spend more on prevention, but enjoys better outcomes and greater profits with lower service costs.

It’s the golden calf of healthcare.

“They were proactive in their care,” says Madeline, “where before we had to ask for it.”

All last year, the Jays fought with United Healthcare to have William’s CGM covered. The device monitors glucose levels to alert diabetics when they need to take insulin, even in the middle of the night when skin pricks aren’t feasible.

But United Healthcare did not consider the CGM a medical necessity, the Jays said.

The Jays’ Kafka-esque experiences, which Madeline logged in excruciating detail, included initial assurances that the CGM would be covered, followed by denials.

By contrast, Kaiser issued a new and improved CGM right away.

“They gave him the newest model of everything,” says Madeline. “They said ‘Of course it’s medically necessary.’”

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