CASE THREE: BRETT FORMIN

Brett Formin[1] is a 30-year-old male with Type I diabetes. He was originally misdiagnosed with Type II diabetes at age 13. Upon diagnosis of his Type I diabetes at age 15, Brett started using insulin, an insulin pump, and a continuous glucose monitor (CGM). Throughout his teens and young adulthood, Brett felt grateful to be on his mother’s insurance plan. She had very comprehensive coverage through her job with the New York Police Department. Therefore, Brett and his family were not particularly concerned about affording his medications and devices at this time.

Brett’s diabetes was well controlled until he was hospitalized multiple times for diabetic ketoacidosis (DKA), peripheral neuropathy, juvenile rheumatoid arthritis, and asthma beginning at age 20. Around this time, Brett was also troubled by chronic ulcers on his right foot. He sought the care of a podiatrist and required multiple doctor’s visits. He would ultimately require two separate surgeries to remove diseased toes. At age 24, Brett developed severe nausea and vomiting. After several doctor’s visits, he was ultimately diagnosed with gastroparesis. Within the following years, Brett visited the emergency department several times for gastroparesis complications and underwent gastric peroral endoscopic myotomy (G-POEM).

At age 29, Brett was admitted to the hospital for diabetic ketoacidosis (DKA) and required intubation. He was extubated after 2 days and needed treatment for pneumonia. Brett became aware of significant, worsening numbness and weakness in both hands and his lower extremities at this time. Brett’s functional quadriplegia prevented him from sitting upright, standing, or walking. Brett was unsatisfied with his medical care at his current hospital and decided to transfer hospitals. Upon admission to the new hospital, Brett was treated for acute kidney injury and respiratory failure. Brett’s numbness and weakness was attributed to an acute exacerbation of his diabetic neuropathy.

Upon discharge from the hospital, Brett began acute physical therapy. 2 months later he was able to stand and walk with the assistance of a walker. He then transitioned to outpatient physical and occupational therapy. He is now able to walk with a cane.

Given this major hospital stay, Brett was grateful to also have comprehensive insurance coverage as an adult. In addition to sick leave policy, Brett prioritized healthcare plans when looking for his current job in public relations. Specifically, he looked for low deductible policies since he anticipated that his yearly insulin supply alone would meet this requirement as well as PPO plans that allowed him to have broader physician coverage. When he faced his major hospitalization at the age of 29, Brett had already met his $3,000 out of pocket maximum and therefore felt confident that his insurance would kick in. While this out-of-pocket cost is certainly not negligible, Brett appreciates that he knows in advance how much he will be spending on healthcare each year. Given the physical and emotional turmoil of his hospitalization, Brett is not sure how he would have coped if he also needed to worry about significant financial burdens during and after his stay.

[1] This is a pseudonym for the patient to protect anonymity

Explanation of Benefits (EOB)

Note the EOB is different from the bill as it breaks down what parts of the bill will be covered by insurance and which parts the patient is responsible for. In contrast a bill shows a granular breakdown of all charges related to a patient’s medical encounter.