Can an Insurer Survive a $1-Million-a-Month Patient?

Wellmark Blue Cross & Blue Shield in Iowa doesn’t want to find out, USA Today reports. The patient, an unidentified teenage boy, suffers from hemophilia, which prevents the blood from clotting and can, indeed, rack up costs in treatment. But $1 million is an outlier, some experts say, and an indication that the hemophilia that the boy suffers from is tricky to treat and requires multiple dosages of different kinds of anti-clotting medication.

“A million dollars per month is something we’ve never heard of,” Katie Verb, director of policy and government relations for the Hemophilia Federation of America, tells the newspaper. She added: “Without knowing all the facts, it’s hard to pin this on one disorder.”

Wellmark recently decided not to sell insurance on the Obamacare exchange in Iowa next year and this particular case reportedly helped lead the insurer to that conclusion. The other health plans on Iowa’s exchanges either pulled out or are close to doing so, possibly making the state the first to be unable to offer residents an ACA coverage option.

The boy’s family will presumably need to shop for another insurer to cover the care. The life-saving infusions needed to treat hemophilia can be expensive and they often have to be administered several times a week, but some patients require infusions several times a day, USA Today reports.

Michelle Rice is a vice president at the National Hemophilia Foundation. She told the newspaper that it’s feasible that aggressive treatment of a complicated case could rack up costs. “You’re giving the patient massive amounts of factor on a daily basis. You’re basically trying to get the body used to the factor, so it no longer rejects it.”

About 20,000 Americans have hemophilia, according to the CDC. It usually affects boys and men. Perhaps history’s most famous victim of the disease was Alexei Nikolaevich, the only son of Emperor Nicholas II, the last Czar of the Russian empire before it was overthrown in the Communist Revolution. Alexei’s condition so worried his mother that she turned to all sorts of healers of dubious quality, including the infamous Grigori Rasputin.

Wellmark officials say that while they understand and sympathize with the Iowan family, the 30,000 people the insurer has in its single coverage business in that state doesn’t create near the size of the risk pool needed to handle a $1-million-per-month patient.  

Duke University research associate David Anderson told the publication PolitiFact: “Everyone is trying to avoid the $12 million-man. Because whoever catches him basically can’t make money.

USA Today reports: “National health-insurance experts have theorized that the prospect of winding up with that extremely expensive Iowan might have helped scare off Aetna and Medica, the other two carriers offering individual health insurance in most of the state. Aetna has said it won’t sell such policies in Iowa next year. Medica has said it probably won’t.”

Source: USA Today