WHY WE HATE PCN

by Paul Gibbs

Recently Utah House Majority Leader Jim Dunnigan, creator of the proposed "Utah Cares" plan and a member of the six person committee devising a new plan for Utah's coverage gap population,  made the point that those of us who have been critical of Utah Cares have focused almost exclusively on the less "robust" coverage provided Utah's Primary Care Network (PCN), and not on the high quality coverage his plan would offer to a large number of the people being helped. On one level, Rep. Dunnigan has a solid point: we absolutely have focused on PCN. However, I think that Rep. Dunnigan is conviently brushing aside the fact that the competing proposal, Healthy Utah, and any solution most of us are pushing for, would give that high qulaity coverage to everyone getting this assistance.  Taken in full context his defense loses its power. And because PCN remains among the discussed possibilitess for coverage, it's important to keep talking about its inadequacies.

So, what exactly is wrong with PCN? Why do we hate it so much? Why do so many people (and the people I've heard this from have been doctors and nurses) refer to it as "Pretty Crappy Network" or "Practically Covers Nothing"? The reason is that PCN is very limited in the coverage it provides. To quote their own website, the network covers:

• Visits to a primary care provider
• Four prescriptions per month
• Dental exams, dental x-rays, cleanings, and fillings
• Immunizations
• Eye exam; no glasses or contacts
• Routine lab services and x-rays
• Emergency room visits (restrictions apply)
• Emergency medical transportation
• Birth control methods

Those things it does not cover include:

Prescription eyeglasses, contact lenses, MRI’s, CT Scans, Dexa Scans, outpatient hospital services, specialty care, pregnancy related services, mental health services, occupational therapy, physical therapy and chiropractic services (emphasis added by me).

First, let's talk about those restrictions to Emergency Room care. The website description is as follows: If you feel you are having a life-threatening medical emergency, PCN will cover an ambulance ride (ground or air) to the nearest hospital. But, in order for PCN to pay for the ER visit and visit with ER provider, the final diagnosis must be an “approved” medical emergency. Even if your primary care provider tells you to go to the ER, the final diagnosis must still be approved by PCN . . . PCN does not cover MRI’s or CT Scans even if it is during an approved ER visit. Also, if a specialist is called into the ER to visit you, that service will not be covered. For example, if you have an injury and you were seen by an orthopedic specialist along with the ER doctor, then you must pay for the orthopedic specialist.

This is highly problematic and goes beyond the obvious intention to prevent unecessary ER use. For example, in February of this year my father went to the emergency room because of symptoms which he thought may have been a heart attack. Thankfully they weren't. Had he been under PCN coverage, he would have been left worrying whether this vist would be deemed a legitimate emergency (to avoid confusion for those who know me, the accident which lead to me father's untimely death a month later was completely unrelated, and insurance coverage was in no way a factor).

Now let's deal with some of the other issues. Coverage for Pimary Care visits is great. Nobody is disputing that. But lack of specialty care and important tests like MRIs or CT scans is obviously an enormous drawback. Essentially PCN will help you with smaller issues, but not the big stuff.

Let me give you two real life examples of the difficulties created here: My cousin Ben is on PCN, and it will let him visit a doctor, but it won't help him with removal of the 45 lb. growth on his leg which makes it nearly impossible for him to walk, let alone work. It won't help with the rental of the C-PAP machine he needs to care for his potentially fatal sleep apnea.

My chronically ill friend Clare Richardson describes her experience with PCN this way:  PCN was great for the most minimal possible needs: doctor visits were $5, blood tests covered, prescriptions were $5, it paid for one eye exam a year (not frames/lenses) and very basic dental (cleanings/fillings). When it comes to hospital stays, emergency rooms, or any further testing, you are out of luck. PCN didn't help me with a basic medical procedure like ingrown toenail removal, for example, and I have been unable to see specialists that could help me because specialists absolutely are not covered under PCN . . . . PCN is truly, absolutely the bare minimum that Utah can do for its citizens, and when you are on PCN, you feel that each time you turn around. You're better off than you would have been, but you're not healthy. If you are a chronically ill person, PCN places you in stasis. This far and no further.

Part of Dunnigan's defense was that the far more complete Medicaid coverage qould have gone to the lower income "most needy" people under the plan, and I have no doubt that something similar will be true of any plan which involves PCN. Again, to a degree that's a solid point. But it places an awfully high burden on the rest, people who still have low incomes (otherwise they wouldn't be eligible). The great irony here is that this concept, championed only by conservative members of our legislature, inherently goes against some of the more prominent pieces of conservative dogma we've been hearing it recent years: it penalizes people for having higher incomes, and it "rations" healthcare.

Our criticism of PCN is not based on trying to emphasize the negative. We appreciate that it's better than nothing. But it's not a real solution, and shouldn't be a part of the compromise between the members of the committee. Solving this Medicaid expansion issue requires solid, comprehensive coverage, and not just for the poorest of the poorest of the poor. PCN should not be a part of the discussion.