The Human Cost of Coverage Gaps, Pt. 1

Pattie McCluskey had long relied on her doctors at the Mount Sinai Health System—until an insurance dispute with Anthem Blue Cross Blue Shield suddenly threw that care into jeopardy. In this episode of The Vitals, Pattie shares what it means when a patient with an established care team must confront disruption around appointments, medications, and procedures already tied to her health, daily life, and well-being.  

Guest host Dr. Raja Flores speaks with Pattie about the real-world consequences patients face when longstanding medical relationships are disrupted: the stress of navigating dozens of calls to the insurance company, the fear of losing life-saving treatments, and the confusion and frustration that arises when medical procedures are inexplicably disrupted by insurance negotiations.  

Together, the pair discuss what happens when access to trusted specialists becomes uncertain, how patients can advocate for themselves in times of hardship, and why continuity of care remains so critical—especially for those with chronic medical conditions. 

If you’re a Mount Sinai patient with Anthem insurance and need more information, please visit this website: keepmountsinai.org 

🎧 Subscribe to The Vitals and explore more podcast programming from Mount Sinai for expert conversations on the biggest issues in medicine, research, and patient care: https://www.youtube.com/playlist?list=PLCT7BA-HcHliU8QIXyuk_74L_uH0gyKGt 

🎧 Subscribe to The Vitals and explore more podcast programming from Mount Sinai for expert conversations on the biggest issues in medicine, research, and patient care: https://www.youtube.com/playlist?list=PLCT7BA-HcHliU8QIXyuk_74L_uH0gyKGt

Transcript

00:00:00:08 - 00:00:34:05

Dr. Raja Flores

Hello and welcome back to the vitals. The Mount Sinai Health System's groundbreaking roundtable video podcast. I'm your guest host, doctor Raja Flores, a thoracic surgeon here at Mount Sinai Hospital. On this episode, we're discussing the consequences of contract disputes between Anthem Insurance and the Mount Sinai Health System from the perspective of a mount Sinai patient. If you need some background on the anthem situation and just how absurd some of their claims are.

00:00:34:07 - 00:01:00:00

Dr. Raja Flores

Check out the previous episode of this show, titled When Coverage Breaks Down the Hidden Cost of Health Care Disputes. To walk us through her experience as a longtime Mount Sinai patient who holds Anthem Insurance. We're joined by fellow New Yorker Patti McCluskey. Before we start, I want to give a disclaimer that we haven't told miss McCluskey what to say.

00:01:00:02 - 00:01:14:07

Dr. Raja Flores

And I'm only just meeting her for the first time. She's here simply to share her story. And you can decide. Miss McCluskey, welcome.

00:01:14:09 - 00:01:29:23

Dr. Raja Flores

So welcome. Patti. I appreciate you speaking to us and giving us some insight from a patient's perspective about, what you've been dealing with with anthem now. If we can just learn a little bit about you. Are you from New York? Where are you.

00:01:29:23 - 00:01:32:12

Pattie M.

From? New York. I live up in Croton, New York.

00:01:32:14 - 00:01:38:23

Dr. Raja Flores

All right. And, And so when were you first diagnosed with peripheral artery disease?

00:01:39:01 - 00:01:56:02

Pattie M.

I think it was, it started off actually with a diagnosis or going to a new going to a cardiologist. I'd never been to one. So I went to, a doctor who was very helpful of telling me about my genetic predisposed to heart issues.

00:01:56:02 - 00:02:00:10

Dr. Raja Flores

And so you go to a cardiologist just for a routine. And were you feeling any symptoms?

00:02:00:10 - 00:02:20:04

Pattie M.

I didn't really feel symptoms. But I knew that my family had a long history of, heart attacks and, needed to at least get a read of where my body was in the in the scheme of things. But I'm generally pretty healthy. But I found with my first cardiologist that I had a lot of chronic diseases.

00:02:20:04 - 00:02:44:02

Pattie M.

High blood pressure, high cholesterol. Diabetes too. So, my cardiologist, was incredibly helpful about showing me that I need to, you know, get rid of all the chronic diseases or get them all under control and, go from there. So he, did all the stress tests and everything on my heart, and my heart is very strong.

00:02:44:04 - 00:03:10:09

Pattie M.

And then he was able to help me cut in half almost all of the high, readings I had for cholesterol and for high blood pressure. So then we turned our efforts towards, understanding the rest of my arteries and and the blood flow. Because I had had foot surgery and I knew that, the blood going down to my foot doesn't necessarily come back up to my heart.

00:03:10:11 - 00:03:32:13

Pattie M.

So he made it clear, like, there's, like a systematic thing I need to to look at. So in 21, I, they did some tests and I, they said I had ped and insufficient venous problems which he sent me to Mount Sinai doctors. They kind of send you to another. They work with another doctor to help you.

00:03:32:13 - 00:04:04:22

Pattie M.

So he brought on board a, a vascular surgeon, and a new cardiologist. So the vascular surgeon took a very methodical approach to. Hey, well, let's look at your, your veins. Let's then look at your arteries and, understand this better. So it's been, since that time period, I've been getting treated by multiple doctors who all kind of work together to figure out how to make sure my, my health is health is improved.

00:04:05:00 - 00:04:06:18

Pattie M.

Yeah. So that's where it started.

00:04:06:18 - 00:04:29:11

Dr. Raja Flores

You know, it's interesting because a lot of patients hear about diabetes, and they don't realize what happens when you have the right speeds. And your perfect example, yes, you have diabetes. You develop, narrowing of the arteries to your feet, right? Which means you're predisposed to get an infection in your feet. Amputations. So it's a big deal.

00:04:29:12 - 00:04:44:04

Dr. Raja Flores

So patients who have diabetes have to have health insurance. Yeah. Because they have a life of chronic illness. Right. So access to to health care, right?

00:04:44:04 - 00:04:45:09

Pattie M.

Is paramount. Vital.

00:04:45:10 - 00:04:52:16

Dr. Raja Flores

Yeah. So how did you first hear about this anthem insurance interruption?

00:04:52:18 - 00:05:13:16

Pattie M.

I guess I heard, rumblings about it. And I didn't pay that much attention to it. In in the summer. So then I thought, you know, things are things are going to, change with the new health care. Let me just figure out how do I make sure that I can continue my care with my Mount Sinai doctors?

00:05:13:18 - 00:05:35:03

Pattie M.

So that's when I heard about it. But my doctor was on board because I had gotten a memo that said there's going to be continuity of care. Which I just thought then, oh, it's great. This is what I fall under, and I can keep going to my doctors. So my doctor, put a form in for continuity of care.

00:05:35:05 - 00:05:57:04

Pattie M.

I think I remember it was like December 20th of 25, and I had a three month window to figure it out, to make sure that everything was approved and done. So that's where I heard that it was going to happen and be cut off. But I also thought from anthem, they were going to continue to cover the care for people who needed it.

00:05:57:06 - 00:06:17:00

Pattie M.

In later times, I heard now that the memo that I cut was different from a lot of the other information, because in the end, with the contract, they basically said either a transplant or a heart attack or, I mean, just things that I didn't have were only going to be covered for continuity of care. So I don't know where that.

00:06:17:02 - 00:06:27:08

Dr. Raja Flores

So for your particular disease, diabetes, peripheral vascular disease. What did anthem advise you to do?

00:06:27:10 - 00:07:06:23

Pattie M.

They weren't advising anything, really. I mean, they just were doing the insurance end of it, trying to make sure that my doctors filled out the right form and applied for it. Yeah. So that's the extent of that. But then I read, other forms that were put out, but then I kind of got into the, the, the fight that was going on, it seemed between the two, insurance between the tenants in Mount Sinai and just being a normal consumer, I just assumed it was someone wanting rate hikes or someone wanting more for a contract and kind of like, you know, teachers or whomever, whatever your union is, it's like you're just fighting

00:07:06:23 - 00:07:33:17

Pattie M.

for more. But I really, really dug into it and realized that, anthem is owned by a company that's like $2 billion. Right? So it's a really big, big company. And they, they I don't think that they actually kind of understand that people are behind all these insurance, claims or whatever. So I think that, is is that what you wanted to.

00:07:33:21 - 00:07:34:13

Pattie M.

Well, who.

00:07:34:14 - 00:07:46:05

Dr. Raja Flores

Have you spoken to from anthem? Because there's got to be a contact person. Yeah, right. Because you have this big insurance company anthem, which, like you said, you know, billions of dollars, etcetera, right?

00:07:46:05 - 00:08:11:03

Pattie M.

Who who do you deal with directly? Right. That's really good because that's the crux of the problems. A lot of times. I literally started to to have a notebook, and I just took down every single conversation, every single person. I learned midway through that if you have an interaction number like a, like a confirmation of the conversation, that was something to always write down because you want to be able to reference what you were told on the phone.

00:08:11:05 - 00:08:16:04

Dr. Raja Flores

Were you able to figure out where you dealing with nurses, physician assistants? Doctors?

00:08:16:05 - 00:08:45:17

Pattie M.

That's the crazy part because I helped my mother in law get, you know, Medicare. You know, I helped that system. I've helped other people kind of just figure big, you know, companies out of what they need to, to do or what has to happen. And this one is most discombobulated, I guess experience, because I contacted them, I think it was among 30 to 32 calls to me, to 32 calls.

00:08:45:17 - 00:09:03:15

Pattie M.

I have everything dated and all that. So I and then my experience with my contact was I knew I had to speak to the medical management group and I got, you know, you get a different person each time, which is fine, because if they take good notes, they'll know what you're trying to do.

00:09:03:17 - 00:09:15:19

Dr. Raja Flores

So then it seemed like chaos. Did it feel like it was, sort of a chaos of the whole, the structure.

00:09:15:19 - 00:09:16:20

Pattie M.

Structure? Yeah.

00:09:16:20 - 00:09:18:22

Dr. Raja Flores

Not one person, but yeah.

00:09:18:22 - 00:09:19:17

Pattie M.

I find that.

00:09:19:17 - 00:09:20:06

Dr. Raja Flores

Organized.

00:09:20:07 - 00:09:43:08

Pattie M.

The individual people I spoke with on the phone, they all just wanted to help. Yeah, but they were just usually a not well trained or b didn't understand the context to what the whole thing falls into. So you have like insurance and then you have medical management. So that requires pre authorizations. And I've done that a lot. But this one was in particular with Continuity of Care.

00:09:43:08 - 00:10:07:15

Pattie M.

You had something called the number which was like a case number. And then you have from your doctor you get codes. It's like, oh, she needs, you know, an angioplasty or she needs, you know, you know, something with her, her veins and you get those. But then the continuity of care program, the people answering the phone didn't understand necessarily that, what was and wasn't covered under continuity of care.

00:10:07:15 - 00:10:10:21

Pattie M.

So then my doctor jumped in, who was fantastic.

00:10:10:21 - 00:10:12:08

Dr. Raja Flores

And these are Mount Sinai docs.

00:10:12:08 - 00:10:13:19

Pattie M.

My Mount Sinai doctor have.

00:10:13:19 - 00:10:14:18

Dr. Raja Flores

To say.

00:10:14:20 - 00:10:51:21

Pattie M.

They had, the, my doctor's pa was the one that actually took the reins on trying to figure all of this out. And I literally would apologize each time I, I messaged him because I know that was taking away from his patient care all too well, and he, you know, also deals a lot of older people. So it's like, you know, little old people are not getting they need but I guess the contact piece that you were asking, so I, I've contacted them well over 30, 30 times, and then I figured out who the supervisor for that group was, and I understood that the person I was going to call was two

00:10:51:21 - 00:11:06:12

Pattie M.

rungs up in the hierarchy. So I'm like, oh, she'll help me. You know, I was just excited to find. And then I spoke to her once and she gave me her cell phone number. So like if you have a problem, just call me and I'll help get straightened out. You know, after that, and, you know, it was crickets.

00:11:06:12 - 00:11:12:10

Pattie M.

I just didn't hear from her every time I left a message. And that was like 12 or 13 messages.

00:11:12:12 - 00:11:34:15

Dr. Raja Flores

That's what I find. Individuals, whether they're with the insurance company or doctors, nurses, they want to help, they want to take care of you. But there's a system in place that I see with insurance companies that it's not helpful. No, it does not the way it is. There's a system in place that just is not working right.

00:11:34:15 - 00:11:43:15

Dr. Raja Flores

And whether it's purposeful or not purposeful, I don't know. Sometimes it's hard to believe, right, that you can't get your act together to take care of this patient.

00:11:43:15 - 00:12:00:15

Pattie M.

Right? Right. And I think that there's just a I mean, there's a lot of training issues. There's a lot of, well, I guess what I would say was that the person not calling me back, who was two rungs up on the ladder is just an indication of of, you know, leaders. I mean, you're you're the bosses aren't the bosses can do that.

00:12:00:15 - 00:12:24:03

Pattie M.

You know, anyone can do that. So, yeah. So the con so funny. This morning, I thought I had gotten the continuity of care. We thought that we had faxed over and got approved for our continuity of care. And I, my doctor went in literally Saturday and Sunday to see if they had faxed confirmation. They didn't. So, I was all prepared to go in and get my procedure tomorrow.

00:12:24:05 - 00:12:26:19

Pattie M.

But now it turns out getting pulled.

00:12:26:19 - 00:12:27:10

Dr. Raja Flores

Those days.

00:12:27:10 - 00:12:31:07

Pattie M.

So that. Yeah. And I just go now.

00:12:31:08 - 00:12:33:04

Dr. Raja Flores

You need a procedure, but you can't have it.

00:12:33:04 - 00:12:59:19

Pattie M.

Done. Yeah. Oh, yeah. That's kind of where we're at right now. And I'm too young to have, like, these, like, heavy leg issues. It's it's just crazy. So anyway, but this and, you know, plastic supposedly would help my blood flow and stuff like that. But you asked about the contact. So my PR has been just like writing, and then I had anthem call him just to say I'm not crazy, like, this is what they're telling me, and this is what we need to do.

00:12:59:21 - 00:13:14:22

Pattie M.

And he just was diligent about trying to figure it out. And we still haven't figured that out. So yeah. So I'm, I'm out in the cold with getting my procedure, and now the window closed. Right. It's a continuing which is three months, and it's like that door closed.

00:13:15:02 - 00:13:20:13

Dr. Raja Flores

You know, it's interesting because I deal with that with my own patients, patients who have lung cancer.

00:13:20:14 - 00:13:22:22

Pattie M.

Oh, right. And there's a time frame.

00:13:23:00 - 00:13:41:15

Dr. Raja Flores

And it's a long, not only do I operate on them and try and cure them from from their cancer, I follow them to make sure there's no recurrence. And I haven't huge number of patients who are Grantham patients. And they say, doc, what do I do now? And I don't know what to do. I try and get them in the right hands.

00:13:41:15 - 00:13:44:01

Pattie M.

But yeah, I pass them off.

00:13:44:03 - 00:13:50:06

Dr. Raja Flores

I try, but it's, it's difficult. I don't know who accepts what. And that's.

00:13:50:06 - 00:13:50:21

Pattie M.

Not your role.

00:13:50:21 - 00:14:12:03

Dr. Raja Flores

So I just homeless and you have my phone number. As time goes, you have anything, you call me and I'll talk to you. You know, it's. You already have this bond with the patient, right? And now the insurance company says I can't treat you anymore. Right? But you're a human being that's in my life. So call me.

00:14:12:03 - 00:14:25:01

Dr. Raja Flores

Let me talk to you. Let me figure. Going in the right direction. But it doesn't just what I've noticed. It doesn't just affect the patient. It affects their whole family. There's a whole world around them. Has it affected your family at all?

00:14:25:01 - 00:14:46:03

Pattie M.

The way? It's really like this morning I was. I had to tell my husband, it's like I think my is getting pulled and you know, and then I know he has to get some, some treatments for things. So my, my deductible and his deductible are linked. So now that I'm not doing I'm not getting this, it affects how he's going to get treated.

00:14:46:05 - 00:15:07:16

Pattie M.

And it's like a part time job. I think we have a kind of it's kind of I think it's a full time. It's a kind of a joke at this point of how many times I've called, how many times I've spoken to different people. You know, you just try every tactic that you can. But what really bothers me, actually, is I have, elderly parents, and they would never be able to navigate this.

00:15:07:16 - 00:15:34:21

Pattie M.

They would never be able to have a the, the endurance or the, you know, to to get this figure it out. So you know, we have like 200,000 people in for anthem I think of Mount Sinai. I do not know. And the I'm sure it's a very high percentage of older people. And I don't know how if they don't have a child or a son or daughter just advocating for them, even then, you're not going to get it figured out.

00:15:34:21 - 00:15:50:19

Pattie M.

So, and I just keep thinking that I've negotiated and figured out and navigated so many other things in my life, but this is something which is beyond the pale of of what's reasonable to ask of a patient.

00:15:50:21 - 00:16:10:17

Dr. Raja Flores

So if you had an anthem executive right in front of you, what would you tell them? What? What is it that you want anthem executives to know as a patient, as a daughter, as a family member, what you've been going through? Feel free to write in to the to the camera.

00:16:10:21 - 00:16:52:18

Pattie M.

I would say the order of things I would want to say is that anthem needs to realize that there's people behind all of these numbers and all of these procedure codes and everything. And they need to understand the ramifications to a family of, you know, trying to figure out deductibles, trying to figure out what procedures to get some, you know, some are life threatening and, being aware of that and putting the processes in place that your group or your or your different layers of groups can figure it out and have clear guidelines about how do you know there's going to be exceptions, there's going to be problems.

00:16:52:18 - 00:17:38:02

Pattie M.

But, it shouldn't be like this that I've done this since December 20th. It's now March 30th. My procedure was just pulled, this morning, and I'm not going to get that. So then we have to re juggle my procedure versus my husband getting treated for something. That's one big thing. But I think the bigger picture is that this is really hard on families that I know a lot of Mount Sinai folks are probably older, and if they don't have a son or daughter or whomever advocating for them to make all the different phone calls to get, you know, get the information, they're lost and they don't get what what's been promised.

00:17:38:02 - 00:18:02:21

Pattie M.

And if you're told that for these three months, if you do X, Y, and Z, you'll get care because you know, the day, you know, diabetes doesn't go away. It gets worse. And when I'm not getting these procedures, it gets worse. And it's really frustrating to think that you're trying to take care of yourself or you're trying to take care of your family, and there's just huge roadblocks and nonsensical things that are said.

00:18:02:21 - 00:18:23:00

Pattie M.

And you have, you know, phone reps who you know, honestly, they're trying to help you, but they don't have the right information. Half the time. They don't understand, you know, the codes versus, you know, the doctor codes versus other kinds of codes. So for anthem to, announce that there's this great continuity of care thing to keep that going.

00:18:23:00 - 00:18:42:23

Pattie M.

I mean, that's not happening. And it's really, really frustrating. And I guess the other thing I'd say is I really tried to educate myself about all the disputes and the the headlines were always like, they're trying to gouge, you know, higher rates. But what I discovered was that, no, it's the contracts. You know, it's not about rates.

00:18:43:05 - 00:19:04:17

Pattie M.

I think Mount Sinai started off way, way below the rates that most other institutions get. And so they're just trying to get a fair share. They're trying to get single digit, you know, increases to try and claw back or get to a better place so they can keep the doors open. And it is all about, the contract language.

00:19:04:17 - 00:19:25:01

Pattie M.

And other doctors have mentioned that the anthem just, you know, would negotiate to a Friday night and think you have a contract or something. And then they'd walk away or they'd say, we're not talking to you. It just sound almost childlike of like, I'm taking my ball and going home. And then they refuse to negotiate and then rears its ugly head.

00:19:25:01 - 00:20:02:18

Pattie M.

In two weeks and more time has passed and more patients have gotten, you know, having problems. So it just feels like there has to be something from the top that's dictating or setting the agenda for what you guys stand for. I mean, I understand you stand for profits, but in a way that's reasonable. And I find that, like Mount Sinai, doctors are always working with each other, always working with their patients, always trying to figure out how to get you the best care, and also just very collegial and just like talking to all their other colleagues to figure out you as a whole person, not just, you know, one, you know, your arm or

00:20:02:18 - 00:20:27:07

Pattie M.

something like that. So that's what I'd say, that the, the people at the top need to actually set the agenda for your what you believe in what you want. Every person who touches a patient to, know what they have to leave that person with, you know, either better knowledge or what the next step is or I mean, that's just, you know, comes hence.

00:20:27:09 - 00:20:31:19

Pattie M.

But that is what I would, ask of anthem at this point.

00:20:31:21 - 00:20:57:15

Dr. Raja Flores

You know, I think you said something that hits home. The hospitals are just trying to keep the doors open so that they can take care of their patients. Right. What's Anthem's objective? But as a doctor, from my standpoint at Mount Sinai, I've been able to take care of everybody, rich, poor, homeless. I, I can take care of anybody that God puts in my path.

00:20:57:17 - 00:21:18:21

Dr. Raja Flores

And that's why it's particularly upsetting when I can't take care of a patient that is put in front of me. Right. And I do understand that we have to be able to keep the doors open. You have to pay the bills and make payroll. That's the objective of the hospital in order to take care of one people. What is Anthem's objective?

00:21:18:21 - 00:21:32:09

Dr. Raja Flores

And I think we'll see as things go forward, exactly where things fall. But I want to thank you for being here. That's all of my questions. Is there anything else that you wanted to say?

00:21:32:11 - 00:21:52:18

Pattie M.

No. I'm just, in awe of the doctors at Mount Sinai, and I've never had such great care. And the fact that the doctors act like doctors, they just like they talk to each other. They figure out, like, what a whole person needs to have to be healthy. Whereas there's the discipline. I mean, the the I guess the industry just requires doctors to only take care of your foot.

00:21:52:20 - 00:22:06:00

Pattie M.

Only take care of your hand. But not here. And I just want this to be available to rich, poor, you know, whomever that they can get this kind of care. Because I feel like it's a privilege.

00:22:06:02 - 00:22:41:07

Dr. Raja Flores

That's all. For this episode of The Vitals, I'm your guest host, doctor Roger Flores. Subscribe to the Vitals and the Mount Sinai Health System's other video podcast programing on YouTube, Apple Podcasts, Spotify, or wherever you get your podcasts. If you're an anthem patient and need more information on how to navigate this unfortunate situation, scan the QR code on your screen or click the link in the description below to get in touch with the show or suggest an idea for a future episode, email us at podcasts.

00:22:41:07 - 00:22:43:13

Dr. Raja Flores

At Mount Sinai Talk.