Lapho ubuhlungu obunenkani emathanjeni ka-Nick van Terheyden bungadambi, udokotela wakhe waba nesifiso sokuthi yini engalungile.
Ngaphandle kwevithamini D eyanele egazini, umzimba uzokhipha leso sakhi esibalulekile emathanjeni. Uma kungelashwa, ukuntuleka kwevithamini D kungaholela ekwakhiweni kwamathambo.
Ukuhlolwa kwegazi ekwindla ka-2021 kwaqinisekisa ukutholakala kukadokotela, futhi u-van Terheyden wayelindele ukuthi uhlelo lomshwalense wenkampani yakhe, oluphethwe yi-Cigna, lukhokhele izindleko zomsebenzi wegazi. Esikhundleni salokho, uCigna uthumele u-van Terheyden incwadi echaza ukuthi ngeke akukhokhele ukuhlolwa okungama- $ 350 ngoba โakudingekile ngokokwelashwa.โ
Incwadi isayinwe omunye wabaqondisi bezokwelapha bakwaCigna, udokotela oqashwe yile nkampani ukuze abuyekeze izicelo zomshwalense.
Okuthile mayelana nencwadi yokuphika akuzange kumphathe kahle uvan Terheyden, isakhamuzi saseMaryland esineminyaka engu-58. โLesi bekuyisinqumo somtholampilo esicatshangelwa ngumuntu ongangazi ngami,โ kusho u-van Terheyden, udokotela naye kanye nochwepheshe owayesebenza ezimweni eziphuthumayo e-United Kingdom.
Amagama angacacile enza u-van Terheyden asole ukuthi uDkt. Cheryl Dopke, umqondisi wezokwelapha owasayina, wayengalunakanga kangako udaba lwakhe.
UVan Terheyden wayeqinisile ukusola. Isimangalo sakhe besingesinye sezilinganiselwa ku-60,000 uDopke aziphika ngenyanga eyodwa ngonyaka odlule, ngokusho kwamarekhodi angaphakathi eCigna abuyekezwa yiProPublica kanye neCapitol Forum.
Ukuchithwa kwesicelo sika-van Terheyden kwakuyinto evamile ku-Cigna, omunye wezinkampani zomshwalense ezinkulu ezweni. Le nkampani yakhe uhlelo oluvumela odokotela bayo ukuthi benqabe ngokushesha isimangalo ngezizathu zezokwelapha ngaphandle kokuvula ifayela lesiguli, okushiya abantu benezikweletu ezingalindelekile, ngokusho kwemibhalo yezinkampani kanye nezingxoxo nababeyizikhulu zeCigna. Esikhathini esiyizinyanga ezimbili ngonyaka odlule, odokotela bakwaCigna benqabile izicelo zokukhokha ezingaphezu kuka-300,000 kusetshenziswa le ndlela, bechitha isilinganiso samasekhondi angu-1.2 ecaleni ngalinye, imibhalo ibonisa. Inkampani ibike ukuthi ihlanganisa noma iphethe izinhlelo zokunakekelwa kwezempilo abantu abayizigidi ezingu-18.
Ngaphambi kokuba abahlinzeki bomshuwalense wezempilo benqabe izimangalo ngenxa yezizathu zezokwelapha, odokotela bezinkampani kufanele bazibuyekeze, ngokwemithetho nemigomo yomshuwalense ezifundazweni eziningi. Abaqondisi bezokwelapha kulindeleke ukuthi bahlole amarekhodi esiguli, babuyekeze izinqubomgomo zokukhava futhi basebenzise ubuchwepheshe babo ukuze banqume ukuthi bavume noma baziphike izimangalo, kusho abalawuli. Le nqubo isiza ukugwema ukuphika ngokungafanele.
Kepha uhlelo lokubuyekezwa kweCigna oluvimbe isimangalo sikavan Terheyden ludlula lezo zinyathelo. Abaqondisi bezokwelapha ababoni noma imaphi amarekhodi esiguli noma basebenzise isinqumo sabo sezokwelapha, kusho ababengabasebenzi benkampani abajwayelene nalolu hlelo. Kunalokho, ikhompyutha yenza umsebenzi. I-algorithm ye-Cigna ihlaba umkhosi ukungafani phakathi kokuxilongwa nalokho inkampani ekubheka njengokuhlolwa nezinqubo ezamukelekayo zalezo zifo. Odokotela benkampani babe sebesayina ukuphika kwabo ngamaqoqo, ngokusho kwezingxoxo nababengabasebenzi abakhulume ngombandela wokudalulwa.
"Sichofoza ngokoqobo futhi sithumele," kusho omunye owayengudokotela wakwaCigna. "Kuthatha yonke imizuzwana eyi-10 ukwenza ama-50 ngesikhathi."
Akuzona zonke izimangalo ezicutshungulwa ngalolu hlelo lokubuyekeza. Kulabo abakhona, akucaci ukuthi bangaki abagunyaziwe nokuthi bangaki abathunyelwa kodokotela ukuze baziphike ngokuzenzakalela.
Ochwepheshe bomshwalense bangabaza uhlelo lukaCigna lokubuyekeza.
Iziguli zilindele ukuthi izinkampani zomshwalense ziziphathe ngendlela efanele futhi zibuyekeze isimangalo ngasinye, kusho uDave Jones, owayengukhomishana womshwalense waseCalifornia. Ngaphansi Imithetho yaseCalifornia, abadayisi bomshwalense kufanele bacabangele izimangalo zesiguli besebenzisa โuphenyo olunzulu, olunobulungiswa nolunomgomo.โ
โKunzima ukucabanga ukuthi ukuchitha imizuzwana kuphela ukubuyekeza amarekhodi ezokwelapha kuhambisana nomthetho waseCalifornia,โ kusho uJones. "Okungenani, ngikholwa ukuthi kufanele kwenziwe uphenyo."
Ngaphakathi kweCigna, ezinye izikhulu zabuza ukuthi ukuphika ngokushesha okungaka kuyawugculisa yini umthetho, ngokusho kowayeyisikhulu esingathandanga kudalulwe igama lakhe ngoba sisasebenza nezinkampani zomshwalense.
"Besicabanga ukuthi kungase kuwele endaweni empunga esemthethweni," kusho lowo owayeyisikhulu sakwaCigna, owasiza ukukhulelwa kwalolu hlelo. "Sithumele umbono kwezomthetho, futhi bawubuyisela emuva bethi kulungile."
I-Cigna yamukele uhlelo lwayo lokubuyekeza eminyakeni engaphezu kweshumi edlule, kodwa abaphathi bomshuwalense bathi izinhlelo ezifanayo bezikhona ngezindlela ezihlukahlukene embonini yonke.
Empendulweni ebhaliwe, uCigna uthe ukubikwa kweProPublica kanye neCapitol Forum "kuchemile futhi akuphelele."
UCigna uthe uhlelo lwayo lokubuyekeza lwenzelwe "ukusheshisa ukukhokhwa kwezimangalo zokuhlolwa okuthile okujwayelekile," kubhala uCigna. "Lokhu kusivumela ukuthi sigunyaze ngokuzenzakalelayo izimangalo uma zithunyelwa namakhodi okuxilongwa afanele."
Lapho ibuzwa ukuthi ngabe inqubo yayo yokubuyekeza, eyaziwa ngokuthi i-PXDX, ivumela odokotela bakwa-Cigna benqabe izimangalo ngaphandle kokuzihlola, inkampani yathi leyo ncazelo โayilungile.โ Inqabile ngokuphindaphindiwe ukuphendula eminye imibuzo noma ukunikeza imininingwane eyengeziwe. (Umshwalense wezempilo wabasebenzi beProPublica uhlinzekwa yi-Cigna.)
Odokotela bangaphambili be-Cigna baqinisekisile ukuthi uhlelo lokubuyekeza lusetshenziselwa ukwenqaba ngokushesha izimangalo. Isipredishithi senkampani yangaphakathi, esibukwa izinhlangano zezindaba, sibala amagama abaqondisi bezokwelapha bakwa-Cigna kanye nenani lamacala aphathwayo kukholamu enesihloko esithi โPxDx.โ Odokotela bangaphambili bathi izibalo zimele ukuphika ngokuphelele. UCigna akazange aphendule imibuzo enemininingwane mayelana nezinombolo.
Incazelo kaCigna yokuthi uhlelo lwayo lokubukeza belakhelwe ukugunyaza izimangalo ayizange ibe nengqondo komunye wangaphambili wenkampani. โBezikhokha zonke lezi zicelo phambilini. Bese bengekho,โ kusho uRon Howrigon osenenkampani esiza odokotela abazimele abaxabene nezinkampani zomshwalense. "Ukhuluma ngohlelo olwakhelwe ukuphika izimangalo."
UCigna ugcizelele ukuthi uhlelo lwayo aluvimbeli isiguli ekutholeni ukunakekelwa - lunquma kuphela ukuthi umshwalense ngeke ukhokhe nini. "Izibuyekezo zenzeka ngemuva kokunikezelwa kwenkonzo esigulini futhi akubangeli noma yikuphi ukwenqatshwa kokunakekelwa," kusho isitatimende.
"Inkampani yethu izibophezele ekuthuthukiseni imiphumela yezempilo, ukubaluleka kokushayela kumakhasimende ethu namakhasimende, kanye nokweseka ithimba lethu labaqondisi bezokwelapha abanamakhono aphezulu," kusho inkampani.
I-PXDX
Uhlelo lokubuyekeza lukaCigna lwasungulwa eminyakeni engaphezu kweshumi edlule ngowayengudokotela wezingane.
Ngemva kokushiya umsebenzi wakhe, uDkt. Alan Muney uchithe amashumi eminyaka ambalwa alandelayo eluleka izinkampani zomshwalensi kanye nezinkampani ezizimele zokuthi zingakuhoxisa kanjani ukonga ezinhlelweni zezempilo.
Ngo-2010, u-Muney wayephethe umshwalense wezempilo ezinkampanini ezingaphansi kweBlackstone, inkampani ezimele yamasheya, ngesikhathi uCigna emthinta ukuze asize ukonga ekusebenzeni kwayo, esho.
Abomshwalense banegunya elibanzi lokwenqaba izicelo zokunakekelwa, kodwa ukucubungula lokho kunqatshwa kungabiza amadola angamakhulu ambalwa lilinye, kusho abaphathi bangaphambili. Ngokuvamile, izimangalo zifakwa ohlelweni lomshwalense, zihlolwe ngunesi futhi zibuyekezwe ngumqondisi wezokwelapha.
Ezimangalweni zamadola aphansi, bekushibhile ukuthi uCigna avele akhokhe isikweletu, kusho uMuney.
โAbafuni ukusebenzisa imali ukuze babuyekeze inqwaba yezinto ezibiza kakhulu ukuzibuyekeza kunokuba bazikhokhele nje,โ kusho uMuney.
UMuney nethimba lakhe bake bayixazulula le nkinga ngaphambilini. E-UnitedHealthcare, lapho uMuney ayeyisikhulu khona, uthe iqembu lakhe lakha uhlelo olufanayo lokuvumela odokotela balo baphike ngokushesha izimangalo ngobuningi.
Iphendula imibuzo, i-UnitedHealthcare ithe isebenzisa ubuchwepheshe obuvumela ukuthi yenze โizinqumo ezisheshayo, eziphumelelayo nezilula ezisekelwe ezinhlelweni zenzuzo yamalungu kanye nezindlela zokwelashwa ngokuhambisana nemithetho yezwe neyombuso.โ Inkampani ayizange ibhekane ngqo nokuthi isebenzisa uhlelo olufana neCigna.
E-Cigna, u-Muney nethimba lakhe benze uhlu lokuhlola nezinqubo ezigunyazwe ukusetshenziswa nezifo ezithile. Isistimu izokwenqaba ngokuzenzakalelayo inkokhelo yokwelashwa okungafani nemibandela esohlwini. Ukuphika kwabe sekuthunyelwa kubaqondisi bezokwelapha, ababezokwenqaba lezi zimangalo ngaphandle kokubuyekezwa kwefayela lesiguli.
U-Cigna wagcina eqoke uhlu oluthi โPXDXโ - isifinyezo senkampani senqubo yokuxilongwa. Uhlu longi imali ngezindlela ezimbili. Kuvumele uCigna ukuthi aqale ukwenqaba izimangalo aseke wazikhokha. Futhi kwenze kwashibhile ukwenqaba izimangalo, ngoba odokotela benkampani akuzange kudingeke bavule ifayela noma benze noma yikuphi ukubuyekezwa okujulile. Bavele baphika izimangalo ngobuningi babo ngesiginesha ye-elekthronikhi.
"Izinto ze-PXDX azibuyekezwa ngudokotela noma umhlengikazi noma into enjalo," kusho uMuney.
Uhlelo lokubuyekeza lwenzelwe ukuvimbela izimangalo zokunakekelwa uCigna azibheka njengezingadingekile noma eziyingozi esigulini, kusho uMuney. Inqubomgomo imane ivumele uCigna ukuthi akhombe izimangalo enelungelo lokuziphika.
UMuney uthe kuzoba โuhlupho lokuphathaโ ukudinga odokotela benkampani ukuthi babuyekeze mathupha ukwenqatshwa kwesicelo ngasinye. Futhi kungasho ukuqasha abanye abaqondisi bezokwelapha abaningi.
"Lokho kwengeza izindleko zokuphatha emithini," esho. โAyisebenzi kahle.โ
Kodwa odokotela ababili ababengodokotela bakwaCigna, abangathandanga ukudalulwa ngamagama ngoba besaba ukwephula izivumelwano zokugcinwa kwezimfihlo nabakwaCigna, bathi lolu hlelo alunabo ubulungiswa ezigulini. Bathe izimangalo ezilethwa ngokuzenzakalelayo ukuze zinqatshelwe azinalo ulwazi oluyisisekelo njengobuhlanga nobulili.
โKwakukhungathekisa kakhulu,โ kusho omunye udokotela.
Abanye abalawuli bombuso babuze uhlelo lwe-Cign's PXDX.
EMaryland, lapho kuhlala khona u-van Terheyden, izikhulu zomshwalense wombuso zathi uhlelo lwe-PXDX njengoba luchazwe yintatheli luphakamisa โamafulegi abomvu.โ
Umthetho kahulumeni olawula izinhlelo zezempilo zeqembu ezithengwa abaqashi udinga ukuthi odokotela benkampani yomshwalense babe nengqondo futhi bavumelane nezimo lapho behlala phansi ukuze bahlole icala ngalinye.
Uma abaqondisi bezokwelapha bakwa-Cigna "benyathela ngerabha ngempela umphumela we-software efanayo ngaphandle kokubuyekezwa okwengeziwe, kungaba nzima ngomqondisi wezokwelapha ukuthi ahambisane nalezi zidingo," kubhala i-Maryland Insurance Administration iphendula imibuzo.
I-Medicare ne-Medicaid inohlelo oluvimbela ngokuzenzakalelayo ukukhokhwa okungalungile kwezimangalo ezifakwe ikhodi engalungile. Ayinqabi inkokhelo kwezokwelashwa izizathu.
Emhlabeni womshuwalense wangasese, u-Muney uqinisekile ukuthi ifomula ye-PXDX ikhulise umgomo webhizinisi. โNgokungangabazeki yonge izigidi zezigidi zamaRandi,โ esho.
Izinkampani zomshwalense ziyahlomula ekongeni, kodwa wonke umuntu uzozuza uma izindleko zokunakekelwa kwezempilo zehliswa futhi nokunakekelwa okungadingekile kwenqatshwa, esho.
Ukubuyekeza okusheshayo
I-Cigna ilandelela ngokucophelela ukuthi zingaki iziguli ezithi abaqondisi bayo bezokwelapha baziphathe njalo ngenyanga. Izikhathi eziyishumi nambili ngonyaka, abaqondisi bezokwelapha bathola ikhadi lamaphuzu ngendlela yesipredishithi ebonisa ukuthi bawasule ngokushesha kangakanani amacala e-PXDX.
UDopke, udokotela owenqaba u-van Terheyden, wenqaba izicelo eziyi-121,000 ezinyangeni ezimbili zokuqala zika-2022, ngokusho kwekhadi lomphumela.
UDkt. Richard Capek, omunye umqondisi wezokwelapha wakwa-Cigna, wasingatha ukuphikwa okuphazima kweso okungaphezu kuka-80,000 ngesikhathi esifanayo, i-spreadsheet yabonisa.
UDkt. Paul Rossi ube ngumqondisi wezokwelapha e-Cigna iminyaka engaphezu kwengu-30. Ekuqaleni konyaka odlule, udokotela wenqaba izimangalo ezingaphezu kuka-63,000 ze-PXDX ezinyangeni ezimbili.
URossi, uDopke noCapek abazange baphendule emizamweni yokuxhumana nabo.
UHowrigon, owayeyisikhulu sakwaCigna, uthe yize engabandakanyekanga ekuthuthukiseni i-PXDX, uyakwazi ukuqonda umnotho ngemuva kwayo.
"Zifake ezicathulweni zomshwalense," kusho uHowrigon. โKungani ungavele uziphike zonke bese ubheka ukuthi yibaphi abazobuya ngesicelo sokudlulisa icala? Ngokombono wezindleko, kunengqondo.โ
UCigna uyazi ukuthi iziguli eziningi zizokhokha izikweletu ezinjalo kunokuba zibhekane nenkinga yokukhalaza ukwenqatshwa, ngokusho kukaHowrigon nabanye ababengabasebenzi bale nkampani. Uhlu lwe-PXDX lugxile ekuhlolweni nasekwelashweni okuvamise ukubiza amakhulu ambalwa amadola lilinye, kusho ababengabasebenzi bakwaCigna.
โIzinkampani zomshwalense zikwazi kahle ukuthi zingasiphika nini isicelo kanti iziguli zizokhononda kodwa zibhale isheke,โ kusho uHowrigon.
UMuney kanye nabanye ababengabaphathi beCigna bagcizelele ukuthi uhlelo lwe-PXDX alusishiyeli isikhala isiguli nodokotela waso ukuthi baphikise isinqumo somqondisi wezokwelapha sokuphika isimangalo.
Kodwa uCigna akalindele ukuthi kufakwe izicelo eziningi. Emqulwini owodwa wezinkampani, uCigna ulinganise ukuthi bangama-5% kuphela abantu abangafaka isicelo sokuphikisa ukuphikiswa okubangelwa ukubuyekezwa kwe-PXDX.
โIsipiliyoni Esibi Kwekhasimendeโ
Ngo-2014, u-Cigna ucabange ukungeza inqubo entsha ohlwini lwe-PXDX ukuze ihlatshwe umkhosi ngokuphika okuzenzakalelayo.
Ukuhlolwa kwesistimu yezinzwa ezizenzakalelayo kungasiza ukubona ukuthi isiguli esigulayo sihlushwa yini ukulimala kwezinzwa okubangelwa isifo sikashukela noma izifo ezihlukahlukene ze-autoimmune. Akuyona inqubo ebandakanyeka kakhulu - ethatha cishe ihora - futhi kubiza amadola angamakhulu ambalwa ukuhlolwa ngakunye.
Ukuhlolwa kuguquguquka futhi akuhlaseli, akudingi inaliti. Isiguli sidlula ekuhlolweni kwenani lokushaya kwenhliziyo okuyidlanzana, ukuphendula komjuluko, ukulingana neminye imisebenzi eyisisekelo yomzimba.
Ngaleso sikhathi, uCigna wayekhokhela zonke izicelo zokuhlolwa kwezinzwa ngaphandle kokuzihlupha ngokubheka ifayela lesiguli, ngokusho kuka. a Inkampani isethulo. Izikhulu zaseCigna zazilinganisa izindleko nezinzuzo zokwengeza inqubo ohlwini. "Kwenzenjani manje?" kubuza isethulo. "Khokhela zonke izimo ngaphandle kokubuyekezwa."
Ngokungeza ukuhlolwa kwezinzwa ohlwini lwe-PXDX, izikhulu ze-Cigna zilinganisela, umshwalense uzokwenqaba izimangalo ezingaphezu kuka-17,800 ngonyaka owawumboze. Izokhokhela ukuhlolwa kwezimo ezithile, kodwa inqabe ukukhokhelwa kwabanye.
Lokhu kunqatshelwa "kuzodala umuzwa ongemuhle wamakhasimende" kanye "namathuba okwenyuka kwezindleko zephakethe," kuvuma isethulo senkampani.
Kodwa bazokonga imali elinganiselwa ku-$2.4 million ngonyaka ezindlekweni zokwelashwa, kusho isethulo.
U-Cigna wengeze ukuhlolwa ohlwini.
โAkuwona Umuthi Omuhleโ
Ngesikhathi u-van Terheyden ethola isaziso sakhe sokuqala sokuphika ku-Cigna ekuqaleni konyaka odlule, wayesenezimpendulo mayelana nokuxilongwa kwakhe. Ukuhlolwa kwegazi uCigna ayekubone โakudingekile ngokwezokwelaphaโ kwakuqinisekisile ukuntula kwevithamini D. Udokotela wakhe wayeqinisile, futhi watusa izithasiselo zokuthuthukisa izinga likavithamini lika-van Terheyden.
Noma kunjalo, u-van Terheyden wayelokhu efaka isicelo sakhe noCigna ngenqubo eyakhula ngokuxaka. Okokuqala, udokotela ohlukile wakwaCigna ubuyekeze leli cala futhi wema ngokuphika kwasekuqaleni. Ukuhlolwa kwegazi kwakungadingekile, uCigna wagcizelela, ngoba u-van Terheyden wayengakaze atholakale entula uvithamini D owanele.
"Amarekhodi awazange abonise ukuthi unenkinga yokuntula i-Vitamin D ngaphambilini," kusho incwadi yokuphika eyakhishwa uCigna ngo-Ephreli. U-van Terheyden bekufanele abhale kanjani ukuntuleka kwevithamini D ngaphandle kokuhlolwa? Incwadi yasayinwa umqondisi wezokwelapha wakwaCigna ogama lakhe linguBarry Brenner.
UBrenner akazange aziphendule izicelo zokuphawula.
Khona-ke, njengoba kuvunyelwe uhlelo lwakhe, u-van Terheyden wathatha ukwenqatshwa kukaCigna ekubuyekezweni kwangaphandle ngumbuyekezi ozimele.
Ekupheleni kukaJuni - izinyanga eziyisikhombisa ngemuva kokuhlolwa kwegazi - udokotela wangaphandle ongasebenzi kwa-Cigna ubuyekeze irekhodi lezokwelapha lika-van Terheyden futhi wanquma ukuthi ukuhlolwa kwakufanelekile.
Ukuhlolwa kwegazi okukhulunywa ngakho โkuqinisekisa ukutholakala kokuntuleka kwe-Vit-D,โ kufundeka umbiko ovela ku-MCMC, inkampani ehlinzeka ngezibuyekezo zezokwelapha ezizimele. UCigna wagcina ekhokhe isikweletu sikavan Terheyden. โLesi siguli sisengcupheni yokwephuka kwethambo ngaphandle kokwengezwa okufanele,โ kubhala umbuyekezi we-MCMC. "Ukuhlolwa bekudingeka ngokwezempilo futhi kufanelekile."
U-Van Terheyden wayengazi lutho mayelana nezimo ze-PXDX zokuphika ngaphambi kokuba athole ibhilidi engu-$350. Kodwa wayebona ukuthi iziguli ezimbalwa zaziphusha kanzima njengoba ayenzile ezicelweni zakhe.
Njengodokotela, u-van Terheyden uthe, ukhungathekile ngezinqubomgomo zenkampani.
โAkuwona umuthi omuhle. Ayinandaba neziguli. Ugcina ngokuzibuza: Kungani bengenza lokhu uma umgomo wabo omkhulu uwukunakekela isiguli?โ uthe.
โNgokwengqondo ngiyakuqonda. Njengodokotela, angikwazi. Kimina kuzwakala kungalungile.โ
Emzuzwini owodwa nemizuzwana eyisithupha ukuleli khasi, odokotela bakwaCigna bebengaphika izimangalo ezingama-79, ngokusho kwemibhalo yenkampani.
I-ZNetwork ixhaswa kuphela ngokuphana kwabafundi bayo.
Nikela