Something touched a nerve yesterday. I kind of lost my composure when someone tried to defend the insurance industry and responded out of emotion – perhaps putting aside some reason in the process.
I used to get mad at myself or embarrassed when this happened, but now I stand back and try to analyze my reaction. What is it that touched a nerve in me? Why did I feel so strongly? We don\’t feel things without reason, and my reaction doesn\’t necessarily betray weakness on my part, it shows the depths of my emotion. That passion usually comes from something – most of the time it is personal experience; and my personal experience says that insurance companies are causing my patients harm. That makes me angry.
I don\’t think the people in the insurance industry are bad people. I think vilifying people is the easy way out. The people there feel like they are doing the right thing, and are no less moral than me. But I do not think the way to fix our system is through letting them do their business as usual in the name of \”free market.\” Defending the current system of insurance ignores some obvious problems in our system:
1. They are financially motivated to withhold services
If you hire a contractor to work on your house, how wise is it to pay them 100% in advance? You have just given them financial incentive to do as little work as possible, as it will maximize their profits to do so. The insurance industry is in such a situation; despite any good intention, they are put in a position to decide between profits and level of service. It is much better to pay more for better service, not worse; but that is what we have done with health insurance companies.
2. They have been given the ability to withhold services
If all United Health Care (for example) did was to provide insurance, they would not be vilified as they are. But since the only data available for medical care was the claims data they hold, they were put in a position to control cost. This was sensible initially, as they had both the data and the means (denying unnecessary care) of cutting cost. It\’s OK that women aren\’t kept in the hospital for a week after having a baby. It\’s OK that I can\’t prescribe expensive brand-name drugs when there is a reasonable generic alternative. There was a whole lot of fat to cut, and they did a good job cutting that fat.
The problem came when all the fat was gone and they were used to big profit-margins. Once there was not any more unnecessary care to cut, they had two ways to keep their profit-margins: increasing premiums or cutting services. They did both. Both of these have hurt my patients.
- Patients have had premiums increased or have been dropped because they were diagnosed with medical problems. I have had patients beg me \”don\’t put that in my record,\” as they know a diagnosis of diabetes or heart disease will be disastrous. I am then caught between the pleas of my patients and the demands of honestly practicing and documenting my care.
- I do what I can to follow evidence-based standards, but there are times when people fall out of the norms. Medicine is not science, it is applied science. This means that I am trying to take an individual and somehow match them with the scientific data. Sometimes it works, but everyone is different. If something is true 90% of the time, 10% of the people will be exceptions to the rule. I have repeatedly been told by \”gnomes\” (people with minimal medical education who sit in front of a computer screen with a protocol for care) what \”good medicine\” looks like. They see things as black and white when it is just not that way. This has caused people to be unnecessarily hospitalized, it has required them to get unnecessary tests to follow their rules. There is no arguing with people in front of computers.
3. They covertly ration
Dr. Rich Fogoros (who I recently met) has coined this phrase to explain what happens in our system. Because it doesn\’t look good to deny necessary care, insurance companies (including government-run ones) resort to making things exceedingly complex. This makes it look like care is being offered, but not taken advantage of. What does this mean?
- The burden of proof is put on the provider to show the tests ordered are necessary. The assumption is that a test will be denied unless the doc can prove otherwise.
- Tests are sometimes inappropriately denied. They then can be appealed, but the appeal process is even more difficult than the initial approval process, and so some people give up. Every time someone gives up, less is paid out by the insurance company and their profits go up.
- The rules for coding and billing are so complex, that it is very easy to make mistakes. This means that an appropriate test ordered by a doctor that is not perfectly coded doesn\’t get paid for. The patient gets the bill and must get the doctor to appeal the denial. This appeal process, again, is difficult.
Because of this, I have to hire staff whose sole task is to learn all of the rules of the different insurance carriers (including public ones) and then play the game properly with them so that we get as few denials as possible. I probably spend $70-80 thousand per year to deal with the frustratingly complex system we have.
————
I have health insurance. I do understand why it needs to exist, but I also see how harmful the current state can be to my patients. I get frustrated with Medicare and Medicaid as well, but that is not my point. Just because government run insurance has problems doesn\’t do anything to change the problems with private insurance. The fact that you can be killed by firing squad doesn\’t make the gallows any better.
The cost of care has gone up dramatically over the past 10 years while my reimbursement has dropped. Where is that extra money?
But the system is very broken right now. It needs to be fixed. Things need to be changed in both the private and public sector. When I was in DC I made the point that our ship is sinking and we are arguing about who will be the captain. The problems in our system are not simply who is writing the checks.
Honestly, I don\’t really care who writes the checks. All I want is for the system to reward good care and to stop hurting my patients. Those who deny the reality of either of these problems will invariably draw my ire.
While I think it’s correct to say that not all people in the insurance industry are bad people, there ARE an exceptional number of bad people in the insurance industry simply because the majority of people could never bring themselves to deny a life-saving medical procedure or medication from someone just to meet a quota or receive a bonus.
Imagine if someone told you that they’d give you an extra ten thousand dollars this year for every young mother you refused to treat for an aggressive cancer. Could you honestly take that money? Could you be the one to deliver the news? I personally couldn’t. Ever. For any amount of money. And yet: http://cbs5.com/local/cancer.treatment.denied.2.1007394.html
And that’s exactly what insurance companies ask of their employees every day. To be distrustful of those on the front lines of medical care and attempt to deny as many expensive treatments as possible, despite the doctor being in a far better position to determine proper care.
I would have far less anger towards the private insurance system if all claims adjusters were paid flat rates and given no incentive to destroy lives in return for cash. As it is, I would pay a premium for a government health plan just to know that the person processing my claim has no vested personal interest in denying me care.
Most people who work for insurance companies feel like they are doing good. The interview Bill Moyers did with Wendell Potter (http://www.pbs.org/moyers/journal/07102009/profile.html) shows how he was working in there for years, not realizing just what was really happening. I think it is counter-productive to vilify people. People usually are not consciously evil in their behavior, and approaching it that way turns it from a discussion to a crusade. Crusades don’t end up well.
It might be counter-productive to vilify insurance execs if you’re trying to win them over to your point of view, perhaps, but I think Martin Niemoller could probably tell you something about the intentions of good people who just “don’t realize” what is really happening.
You don’t have to intend to do evil in order to do evil. But that doesn’t make your actions any less horrendous. And, frankly, I’d rather end up in a crusade than sitting around politely suggesting that people stop committing evil acts.
Suppose your supervisor told you “If you don’t deny 1 in 10 of requests for payment that come over your desk, you will be fired”, and you need to keep your job to feed, clothe and house your family? Both choices are “bad”, but which is emotionally easier for you, denying payment for someone you’ve never met and who may not need the money, or denying food and clothing to your children?
I’m not saying the system is right, but that the wrong originates at high level, rather than with the clerk who processes your claim.
While I think it’s correct to say that not all people in the insurance industry are bad people, there ARE an exceptional number of bad people in the insurance industry simply because the majority of people could never bring themselves to deny a life-saving medical procedure or medication from someone just to meet a quota or receive a bonus.
Imagine if someone told you that they’d give you an extra ten thousand dollars this year for every young mother you refused to treat for an aggressive cancer. Could you honestly take that money? Could you be the one to deliver the news? I personally couldn’t. Ever. For any amount of money. And yet: http://cbs5.com/local/cancer.treatment.denied.2.1007394.html
And that’s exactly what insurance companies ask of their employees every day. To be distrustful of those on the front lines of medical care and attempt to deny as many expensive treatments as possible, despite the doctor being in a far better position to determine proper care.
I would have far less anger towards the private insurance system if all claims adjusters were paid flat rates and given no incentive to destroy lives in return for cash. As it is, I would pay a premium for a government health plan just to know that the person processing my claim has no vested personal interest in denying me care.
Most people who work for insurance companies feel like they are doing good. The interview Bill Moyers did with Wendell Potter (http://www.pbs.org/moyers/journal/07102009/profile.html) shows how he was working in there for years, not realizing just what was really happening. I think it is counter-productive to vilify people. People usually are not consciously evil in their behavior, and approaching it that way turns it from a discussion to a crusade. Crusades don’t end up well.
It might be counter-productive to vilify insurance execs if you’re trying to win them over to your point of view, perhaps, but I think Martin Niemoller could probably tell you something about the intentions of good people who just “don’t realize” what is really happening.
You don’t have to intend to do evil in order to do evil. But that doesn’t make your actions any less horrendous. And, frankly, I’d rather end up in a crusade than sitting around politely suggesting that people stop committing evil acts.
Suppose your supervisor told you “If you don’t deny 1 in 10 of requests for payment that come over your desk, you will be fired”, and you need to keep your job to feed, clothe and house your family? Both choices are “bad”, but which is emotionally easier for you, denying payment for someone you’ve never met and who may not need the money, or denying food and clothing to your children?
I’m not saying the system is right, but that the wrong originates at high level, rather than with the clerk who processes your claim.
Dr. Rob,
You left out reason #3 which is that they like to make health care providers and patients crazy. I recently had to have a neuropsych eval (related to MS). They paid for the evaluation portion, but refused to pay for the actual testing. Then they paid for the second visit to a vocation rehab counselor, after refusing to pay for the first. To top things off, I called to see if they would pay for cognitive rehab therapy, and they told me I would have to tell them the diagnostic code to get an answer. If docs struggle with the codes, how in the blazes are patients supposed to tell. Keep up the good work, but I don’t think reform, or anything short of making them all non-profits (which I guess some countries in Europe have done) is going to change their behavior.
I left out a bunch of things. I agree with you, though.
Dr. Rob,
You left out reason #3 which is that they like to make health care providers and patients crazy. I recently had to have a neuropsych eval (related to MS). They paid for the evaluation portion, but refused to pay for the actual testing. Then they paid for the second visit to a vocation rehab counselor, after refusing to pay for the first. To top things off, I called to see if they would pay for cognitive rehab therapy, and they told me I would have to tell them the diagnostic code to get an answer. If docs struggle with the codes, how in the blazes are patients supposed to tell. Keep up the good work, but I don’t think reform, or anything short of making them all non-profits (which I guess some countries in Europe have done) is going to change their behavior.
I left out a bunch of things. I agree with you, though.
Excellent piece, Dr. Rob. Thank you for so succinctly describing the despicable behavior of insurance companies.
I don’t know if insurance companies are run by bad people or not. But I do know that profit is the number one (and often only) concern. Patients will continue to suffer as long as profit is a primary motive.
Excellent piece, Dr. Rob. Thank you for so succinctly describing the despicable behavior of insurance companies.
I don’t know if insurance companies are run by bad people or not. But I do know that profit is the number one (and often only) concern. Patients will continue to suffer as long as profit is a primary motive.
This post hits right where I live at the moment. I’ve been waiting for approval for necessary surgery, that 5 doctors agreed I need! The system is a mess for timely and necessary patient care. I’m sick of the insurance companies having so much power over the trained and knowledgeable providers (that are trying to help their patients), and the helpless patients caught in the middle!
This post hits right where I live at the moment. I’ve been waiting for approval for necessary surgery, that 5 doctors agreed I need! The system is a mess for timely and necessary patient care. I’m sick of the insurance companies having so much power over the trained and knowledgeable providers (that are trying to help their patients), and the helpless patients caught in the middle!
I think people are used to my typos. It goes along with being distractible, I guess. I could cover myself and make another post entitled: “Why I get B Angry.”
This is where being a semi-regular on ICHC really doesn’t help me; I just read the title as LOLspeek!
I don’t do LOL speak. I have certain religious convictions that keep me from using it.
I think people are used to my typos. It goes along with being distractible, I guess. I could cover myself and make another post entitled: “Why I get B Angry.”
This is where being a semi-regular on ICHC really doesn’t help me; I just read the title as LOLspeek!
I don’t do LOL speak. I have certain religious convictions that keep me from using it.
Excellent piece, Rob. One aspect of the health insurance industry that I think hasn’t been mentioned often enough is the inherent conflict of interest these for-profit companies find themselves in. As with every other for-profit company, insurance companies are obligated to make a profit to provide income for shareholders. As you pointed out, they do this by limiting care. But most people don’t think of the company that way — they think of their insurance company as a safety net, to pay for medical services as they are needed. But really, their insurance company is in business to make a profit, and those expectations are in direct conflict. Until we overhaul the system in such a way that profit motive does not drive the behavior of these companies, nothing will get better.
Excellent piece, Rob. One aspect of the health insurance industry that I think hasn’t been mentioned often enough is the inherent conflict of interest these for-profit companies find themselves in. As with every other for-profit company, insurance companies are obligated to make a profit to provide income for shareholders. As you pointed out, they do this by limiting care. But most people don’t think of the company that way — they think of their insurance company as a safety net, to pay for medical services as they are needed. But really, their insurance company is in business to make a profit, and those expectations are in direct conflict. Until we overhaul the system in such a way that profit motive does not drive the behavior of these companies, nothing will get better.
You made so many good points. I am a clinical psychologist who specializes in neuropsychological testing. I face so many of these same issues every day. It is a constant battle to get authorization to do the testing that needs doing. I am always on the phone bargaining with the insurance companies for enough hours to see a client – and often the choice I face is either to not fully address the referral question, to stick the client with much of the bill, or to work for free. It is so depressing and demoralizing. And I’m talking here about PRIVATE insurance – my Medicaid and Medicare clients can get the services they need. When you have a system that is for-profit, it is inherently constructed so that care will be rationed.
You made so many good points. I am a clinical psychologist who specializes in neuropsychological testing. I face so many of these same issues every day. It is a constant battle to get authorization to do the testing that needs doing. I am always on the phone bargaining with the insurance companies for enough hours to see a client – and often the choice I face is either to not fully address the referral question, to stick the client with much of the bill, or to work for free. It is so depressing and demoralizing. And I’m talking here about PRIVATE insurance – my Medicaid and Medicare clients can get the services they need. When you have a system that is for-profit, it is inherently constructed so that care will be rationed.
Great post as always, Dr. Rob.
I’m not sure that “rationing” itself is proof of evil intent. Medical care is just too expensive. We can’t keep spending this much indefinitely or there won’t be a dime left for anything else in this country. Rationing either by private or government payers has to happen.
If we fight rationing itself we are in a losing battle. Instead we should demand that the rationing be done transparently with a prompt and responsive appeal system for the patients who have exceptions to the formula. Right now all the rationing happens secretly or they practice rationing by hassling. I hate my patient’s insurance companies as much as the next doctor, but the more we rail against rationing the more politicians and insurance companies will hide it. We must bring rationing out into the light of day and make it play fair and be honest.
(Just a note: I’m sure you meant for the title to read “Why I get Angry” without the extra “a” Doctor D does all sorts of typos on on his blog, so he always likes to help with another doc’s typo.)
Great post as always, Dr. Rob.
I’m not sure that “rationing” itself is proof of evil intent. Medical care is just too expensive. We can’t keep spending this much indefinitely or there won’t be a dime left for anything else in this country. Rationing either by private or government payers has to happen.
If we fight rationing itself we are in a losing battle. Instead we should demand that the rationing be done transparently with a prompt and responsive appeal system for the patients who have exceptions to the formula. Right now all the rationing happens secretly or they practice rationing by hassling. I hate my patient’s insurance companies as much as the next doctor, but the more we rail against rationing the more politicians and insurance companies will hide it. We must bring rationing out into the light of day and make it play fair and be honest.
(Just a note: I’m sure you meant for the title to read “Why I get Angry” without the extra “a” Doctor D does all sorts of typos on on his blog, so he always likes to help with another doc’s typo.)
Great post. I thought you were angry, and was deliberately staying out of it.
In fact I love the way this blog works, where it’s obvious that everyone who comments actually makes a contribution.
Great post. I thought you were angry, and was deliberately staying out of it.
In fact I love the way this blog works, where it’s obvious that everyone who comments actually makes a contribution.
Point #3 has been known for years as, “healthcare rationing by inconvenience.” Make it so difficult, drive the pt and physician crazy and maybe they will wear both of us down.
However, the insurance company can appear to provide the service to their insurees.
Point #3 has been known for years as, “healthcare rationing by inconvenience.” Make it so difficult, drive the pt and physician crazy and maybe they will wear both of us down.
However, the insurance company can appear to provide the service to their insurees.
Wow, I’ve read this post (and the comments) 5 times just this morning and I still don’t know where to begin! I just cannot get my thoughts organized around all the issues here. Maybe the healthcare system has stunk for so long that nobody can remember what a good healthcare system looks like? Or maybe we have never gotten it right?…..right or wrong did not matter as much before the system got so expensive I guess. I have no solutions (at the moment), but I do feel sympathy for you docs out there that have to deal with these insurance companies on so many levels. They do make providing timely care to your patients impossible and the coding/billing/ reimbursment system could not be more complicated.
It’s Friday and i just cannot do this post justice today! On a lighter note, football season starts in two weeks…..YEAH!
Wow, I’ve read this post (and the comments) 5 times just this morning and I still don’t know where to begin! I just cannot get my thoughts organized around all the issues here. Maybe the healthcare system has stunk for so long that nobody can remember what a good healthcare system looks like? Or maybe we have never gotten it right?…..right or wrong did not matter as much before the system got so expensive I guess. I have no solutions (at the moment), but I do feel sympathy for you docs out there that have to deal with these insurance companies on so many levels. They do make providing timely care to your patients impossible and the coding/billing/ reimbursment system could not be more complicated.
It’s Friday and i just cannot do this post justice today! On a lighter note, football season starts in two weeks…..YEAH!
I’m trying to formulate a response as well-thought-out as your post, so forgive me if I ramble. I am an RN employed by a mutual insurance company — one which is not non-profit, but not for-profit either, because financial issues are kept within the company & the members who participate in our plans. If we have a good year, we don’t have to raise premiums. We don’t have a highly-paid CEO, we don’t have stockholders, we don’t have profits, so it irks me when all insurance companies are tarred with the same brush as those who are for-profit. We do have service people who have to follow nationally recognized benchmarks to determine when services are covered & when services don’t meet criteria.We also have the employer groups who pick & choose which benefits to purchase for their plans, & who choose the financial level at which procedures & tests & surgeries & hospitalizations are paid for. Your “insurance doesn’t cover gastric bypass (for example) & it should” might be because your employer chose not to purchase that type of service for you and your co-workers. In 5 years here I’ve not come across any instance of coverage denied in order to meet a quota, or to maximize profits. Many times when people talk of denials they don’t realize that a denial may be based on inaccurate documentation, or wrong diagnosis codes, or failure to submit records, or a million-and-one other technical difficulties in the process.
All health insurance companies are not heartless, profit-driven, money-hungry entities out to make you suffer, & it’s unfair to denigrate all insurance companies because some are. OK, I’m getting off my soapbox now. I really enjoy your posts, the discussions, & the comments, & I’ll keep reading, but this thread of discussion compelled me to respond as a member & employee of a good health insurance company.
Peggy, RN
THANK YOU, Peggy. I don’t like it when people generalize about insurance companies. I think all generalizations are bad (heh). You pay the price of the stupid system we have as much as I do. The reason things get submitted wrong (for me at least) is that it is a maze of confusion and hard to get right. It would seem that smart people could sit down and come up with something better.
Are your rates better than other insurance companies? It would seem to me that if anyone could do it right, it would be a company like yours.
I don’t know if they are “better”, but they went up less than predicted. The financial people say that we are in good shape because of conservative investments over the years, & a fair share of diversification.We have our share of “fluff”, of doing things a certain way because that’s how the reimbursement system was designed. Our PPO docs probably get just as frustrated as you do about the mazes of confusion, and part of my job entails telling members how to work with the system to get things corrected. I happen to think we “do it right”; I also happen to think that YOU “do it right”, but the system is certainly broken on-the-whole.
An interesting tangent — our CEO just announced that members of a congressional committee asked a number of insurance providers, including us, to submit information they (Congress) will use in the efforts toward health care reform. Seems like Congress should have asked for the information BEFORE they started writing bills ! ! !
I’m trying to formulate a response as well-thought-out as your post, so forgive me if I ramble. I am an RN employed by a mutual insurance company — one which is not non-profit, but not for-profit either, because financial issues are kept within the company & the members who participate in our plans. If we have a good year, we don’t have to raise premiums. We don’t have a highly-paid CEO, we don’t have stockholders, we don’t have profits, so it irks me when all insurance companies are tarred with the same brush as those who are for-profit. We do have service people who have to follow nationally recognized benchmarks to determine when services are covered & when services don’t meet criteria.We also have the employer groups who pick & choose which benefits to purchase for their plans, & who choose the financial level at which procedures & tests & surgeries & hospitalizations are paid for. Your “insurance doesn’t cover gastric bypass (for example) & it should” might be because your employer chose not to purchase that type of service for you and your co-workers. In 5 years here I’ve not come across any instance of coverage denied in order to meet a quota, or to maximize profits. Many times when people talk of denials they don’t realize that a denial may be based on inaccurate documentation, or wrong diagnosis codes, or failure to submit records, or a million-and-one other technical difficulties in the process.
All health insurance companies are not heartless, profit-driven, money-hungry entities out to make you suffer, & it’s unfair to denigrate all insurance companies because some are. OK, I’m getting off my soapbox now. I really enjoy your posts, the discussions, & the comments, & I’ll keep reading, but this thread of discussion compelled me to respond as a member & employee of a good health insurance company.
Peggy, RN
THANK YOU, Peggy. I don’t like it when people generalize about insurance companies. I think all generalizations are bad (heh). You pay the price of the stupid system we have as much as I do. The reason things get submitted wrong (for me at least) is that it is a maze of confusion and hard to get right. It would seem that smart people could sit down and come up with something better.
Are your rates better than other insurance companies? It would seem to me that if anyone could do it right, it would be a company like yours.
I don’t know if they are “better”, but they went up less than predicted. The financial people say that we are in good shape because of conservative investments over the years, & a fair share of diversification.We have our share of “fluff”, of doing things a certain way because that’s how the reimbursement system was designed. Our PPO docs probably get just as frustrated as you do about the mazes of confusion, and part of my job entails telling members how to work with the system to get things corrected. I happen to think we “do it right”; I also happen to think that YOU “do it right”, but the system is certainly broken on-the-whole.
An interesting tangent — our CEO just announced that members of a congressional committee asked a number of insurance providers, including us, to submit information they (Congress) will use in the efforts toward health care reform. Seems like Congress should have asked for the information BEFORE they started writing bills ! ! !
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(I couldn’t leave this comment on the post at Better Health, so I’m leaving it here! )
I’m a divorced mother of three, self-employed, and will soon be uninsured. I defer or refuse medical care because I cannot afford it. The care I’ve been forced to seek has cost so much that it’s in collections and now my credit is suffering.
I have been repeatedly denied coverage as an individual for reasons such as “having sought fertility treatment” (twelve years ago) or “diagnosed with PPD” (seven years ago). And I was applying for a policy that didn’t even include maternity coverage.
I’ve also learned an ugly lesson about the frailty of coverage: if you have COBRA through a former employer, and that employer goes out of business, there’s no one paying those COBRA fees anymore, which means YOU are out of luck, instantly. Twice now I’ve had a few weeks’ notice that my coverage will suddenly end as of the first of the next month. Because I’ve been rejected from every insurance company we could find, I now go through the motions and check the box that says “please consider me for HIPPA if I do not qualify.” I never qualify, and HIPPA is slow to act. I expect to be swinging in the wind for a while, paying retail prices for medical care out of my own pocket.
By the way, I am extremely resourceful and well-connected; Dr. Val Jones is a close friend, and Dr. George Lundberg, former Editor in Chief of JAMA, Medscape.com, eMedicine, MedGenMed, and WebMD’s now-defunct online, peer-reviewed medical journal (see his new venture at http://lundberginstitute.org/). If I can’t get coverage with who and what I know, what hope do others with far fewer resources have?
What happens when medical bills in collections prevents us from being able to refinance an unmanageable mortgage or qualify for a car loan to replace the clunker that doesn’t qualify for Cash for Clunkers because I purchased responsibly in 1998 and got a car that gets over 18 mpg, the cutoff for qualification?
What happens when we make just enough to be ineligible for unemployment but sail below the poverty line with room enough for a big hat in order to qualify for our children’s reduced lunch programs?
These are the plates we have to keep spinning, and so much of it could be alleviated with adequate, affordable, individual and family health coverage that doesn’t need to be provided through a group plan. The stress associated with not being able to afford proper care coupled with the fear that something catastrophic might happen and wipe out the family does NOT make for a healthy parent able to raise healthy kids.
Wouldn’t it be useful to look at more affordable and generous coverage as preventative medicine and an overall boon to public health? I’d be less of a burden on the taxpayers and the insurance companies if only I could be secure in the knowledge that we could survive catastrophe.
In the meantime, I’m learning to care for stitches and dress wounds myself (or butterfly when I can’t go for stitches), make my own differential diagnoses, and keep a copy of the PDR, first aid book, and Merck Manual handy.
If I can’t find someone to care for us, even when paying painfully high premiums, I will have to become my own family’s primary care provider. And in most cases I can do it much more cheaply and effectively than the system already in place.
Melinda: those who say “there is nothing wrong with our system” should listen to your story. Jonathan Cohn’s book “Sick” is a good overview of people caught in similar situations. I’m sorry you’ve had to live through this. As a doctor I feel helpless when patients face things like this.
Very strongly seconded. Doubtless some Conservatroll will be along to accuse me of being a Socialist or even a Communist for saying this, but Melinda’s story is a perfect demonstration of exactly why private health care is broken.
Ok, can’t resist disclosure and a plug here (I said this on my site but missed saying what the relationship was here): Dr. George Lundberg is my stepfather. If you haven’t read his book, Severed Trust: Why American Medicine Hasn’t Been Fixed–and What We Can Do About It, have a look.
It’s knowing so much about the system and still not finding a way through it that drives me bonkers.
I actually met Your step-father. MedicaLogic merged with Medscape (debacle, actually) and I was on the EMR user group board. Our board had lunch with him and he was most impressive. Eloquent without coming off aloof.
(I couldn’t leave this comment on the post at Better Health, so I’m leaving it here! )
I’m a divorced mother of three, self-employed, and will soon be uninsured. I defer or refuse medical care because I cannot afford it. The care I’ve been forced to seek has cost so much that it’s in collections and now my credit is suffering.
I have been repeatedly denied coverage as an individual for reasons such as “having sought fertility treatment” (twelve years ago) or “diagnosed with PPD” (seven years ago). And I was applying for a policy that didn’t even include maternity coverage.
I’ve also learned an ugly lesson about the frailty of coverage: if you have COBRA through a former employer, and that employer goes out of business, there’s no one paying those COBRA fees anymore, which means YOU are out of luck, instantly. Twice now I’ve had a few weeks’ notice that my coverage will suddenly end as of the first of the next month. Because I’ve been rejected from every insurance company we could find, I now go through the motions and check the box that says “please consider me for HIPPA if I do not qualify.” I never qualify, and HIPPA is slow to act. I expect to be swinging in the wind for a while, paying retail prices for medical care out of my own pocket.
By the way, I am extremely resourceful and well-connected; Dr. Val Jones is a close friend, and Dr. George Lundberg, former Editor in Chief of JAMA, Medscape.com, eMedicine, MedGenMed, and WebMD’s now-defunct online, peer-reviewed medical journal (see his new venture at http://lundberginstitute.org/). If I can’t get coverage with who and what I know, what hope do others with far fewer resources have?
What happens when medical bills in collections prevents us from being able to refinance an unmanageable mortgage or qualify for a car loan to replace the clunker that doesn’t qualify for Cash for Clunkers because I purchased responsibly in 1998 and got a car that gets over 18 mpg, the cutoff for qualification?
What happens when we make just enough to be ineligible for unemployment but sail below the poverty line with room enough for a big hat in order to qualify for our children’s reduced lunch programs?
These are the plates we have to keep spinning, and so much of it could be alleviated with adequate, affordable, individual and family health coverage that doesn’t need to be provided through a group plan. The stress associated with not being able to afford proper care coupled with the fear that something catastrophic might happen and wipe out the family does NOT make for a healthy parent able to raise healthy kids.
Wouldn’t it be useful to look at more affordable and generous coverage as preventative medicine and an overall boon to public health? I’d be less of a burden on the taxpayers and the insurance companies if only I could be secure in the knowledge that we could survive catastrophe.
In the meantime, I’m learning to care for stitches and dress wounds myself (or butterfly when I can’t go for stitches), make my own differential diagnoses, and keep a copy of the PDR, first aid book, and Merck Manual handy.
If I can’t find someone to care for us, even when paying painfully high premiums, I will have to become my own family’s primary care provider. And in most cases I can do it much more cheaply and effectively than the system already in place.
Melinda: those who say “there is nothing wrong with our system” should listen to your story. Jonathan Cohn’s book “Sick” is a good overview of people caught in similar situations. I’m sorry you’ve had to live through this. As a doctor I feel helpless when patients face things like this.
Very strongly seconded. Doubtless some Conservatroll will be along to accuse me of being a Socialist or even a Communist for saying this, but Melinda’s story is a perfect demonstration of exactly why private health care is broken.
Ok, can’t resist disclosure and a plug here (I said this on my site but missed saying what the relationship was here): Dr. George Lundberg is my stepfather. If you haven’t read his book, Severed Trust: Why American Medicine Hasn’t Been Fixed–and What We Can Do About It, have a look.
It’s knowing so much about the system and still not finding a way through it that drives me bonkers.
I actually met Your step-father. MedicaLogic merged with Medscape (debacle, actually) and I was on the EMR user group board. Our board had lunch with him and he was most impressive. Eloquent without coming off aloof.
I had a simple adult checkup, basic blood work (cholesterol and blood sugar), and a vaccination last year. This was all done at an in-network (PPO) provider.
Of course, the insurance company (for-profit, publicly traded stock) denied payment on the blood work and vaccination, even though they were supposed to be covered under the plan. It took a while to convince them to pay as the plan stated. If they can be that incompetent at a simple checkup, can anyone have any confidence in them handling a more complex situation? Or is it something they are doing “accidentally on purpose” as “rationing by inconvenience”?
You’ll love this one: my daughter and I had the same debilitating symptoms in Feb, so I went to a clinic and asked that we be seen and diagnosed together so that they didn’t jump to different diagnoses because of our age difference. They took tons of blood, and found that we both had Parvovirus B-19, commonly known as Fifth Disease, a childhood disease that is greatly exacerbated in adults. I have had the painful symptoms with frequent flareups for six months now. The cost? $3,000 for blood work. That’s in collections.
Funny, the other bill in collections is also for $3,000 – I needed three stitches in my thumb. Oddly enough, the sutures were too tight and made the wound much worse than the original injury was. Oh, the joy.
I had a simple adult checkup, basic blood work (cholesterol and blood sugar), and a vaccination last year. This was all done at an in-network (PPO) provider.
Of course, the insurance company (for-profit, publicly traded stock) denied payment on the blood work and vaccination, even though they were supposed to be covered under the plan. It took a while to convince them to pay as the plan stated. If they can be that incompetent at a simple checkup, can anyone have any confidence in them handling a more complex situation? Or is it something they are doing “accidentally on purpose” as “rationing by inconvenience”?
You’ll love this one: my daughter and I had the same debilitating symptoms in Feb, so I went to a clinic and asked that we be seen and diagnosed together so that they didn’t jump to different diagnoses because of our age difference. They took tons of blood, and found that we both had Parvovirus B-19, commonly known as Fifth Disease, a childhood disease that is greatly exacerbated in adults. I have had the painful symptoms with frequent flareups for six months now. The cost? $3,000 for blood work. That’s in collections.
Funny, the other bill in collections is also for $3,000 – I needed three stitches in my thumb. Oddly enough, the sutures were too tight and made the wound much worse than the original injury was. Oh, the joy.
Well put.
I understand your insights – viscerally. I believed myself to be well insured with a $5,000 deductible policy. In April I woke up with a cervical herniated disc that “caught my attention.” I failed conservative management and opted for surgery. I understood the risks, benefits, and options. You see, I am a neurosurgeon.
I understood my choices: a two level cervical fusion or a one level artificial disc. The benefits of the latter: faster recovery, less risk, preserved functionality, and surprisingly enough, lower cost. I chose the artificial disc. It seemed like a “no-brainer.” Particularly relevant when such a statement comes from a neurosurgeon.
My carrier denied pre-certification arguing artificial discs were “investigational.” The FDA approved such devices in 2007 as being safe and efficacious. Further, many carriers across the country make payment for exactly the same procedure. I could not understand how a procedure could be deemed “investigational” by one carrier but “appropriate” by a sister company- particularly when their definition of “investigational” is about the same.
I had the procedure done. The pain immediately disappeared. My surgeon gave me a ride home that evening. (How’s that for service?) I went back to work part time the next day. And, I resumed cycling two weeks later.
The only residual effect of the surgery. My bills. The carrier allowed me to appeal, which I did. One of their hired experts concluded the carrier should make payment. Another argued otherwise. Their appeal procedures afforded me specific rights; but they failed to follow their own procedures. I filed suit a few weeks ago. And so it goes.
Ultimately, the business model for carriers is based on denying some number of claims. Most people will fold.
Well put.
I understand your insights – viscerally. I believed myself to be well insured with a $5,000 deductible policy. In April I woke up with a cervical herniated disc that “caught my attention.” I failed conservative management and opted for surgery. I understood the risks, benefits, and options. You see, I am a neurosurgeon.
I understood my choices: a two level cervical fusion or a one level artificial disc. The benefits of the latter: faster recovery, less risk, preserved functionality, and surprisingly enough, lower cost. I chose the artificial disc. It seemed like a “no-brainer.” Particularly relevant when such a statement comes from a neurosurgeon.
My carrier denied pre-certification arguing artificial discs were “investigational.” The FDA approved such devices in 2007 as being safe and efficacious. Further, many carriers across the country make payment for exactly the same procedure. I could not understand how a procedure could be deemed “investigational” by one carrier but “appropriate” by a sister company- particularly when their definition of “investigational” is about the same.
I had the procedure done. The pain immediately disappeared. My surgeon gave me a ride home that evening. (How’s that for service?) I went back to work part time the next day. And, I resumed cycling two weeks later.
The only residual effect of the surgery. My bills. The carrier allowed me to appeal, which I did. One of their hired experts concluded the carrier should make payment. Another argued otherwise. Their appeal procedures afforded me specific rights; but they failed to follow their own procedures. I filed suit a few weeks ago. And so it goes.
Ultimately, the business model for carriers is based on denying some number of claims. Most people will fold.
Exactly. They count on it. Don’t fold on this one, and good luck!
Exactly. They count on it. Don’t fold on this one, and good luck!
Hi,Great post and great contributions from readers. If the highly intelligent, experienced and connected folks who have made comments can’t figure out how to get the system to properly provide them with healthcare without costing an arm and a leg (pun intended) then really what chance do the uneducated have? None. I’ve been a patient and a healthcare provider in the UK National Health Service. Its not perfect and we all complain about it like we complain about the weather, but it works very well 95% of the time. When you have a problem you go see your family doc and she either treats you herself or refers to a specialist. The family doc makes the judgement about how urgent it is…..if very urgent, straight to the ER, if moderately urgent, then her referral request will say so, otherwise you get a referral and you might wait a month or so for the appointment. The docs diagnoses and the patients decisions about whether to seek treatment are not unduly influenced by the cost. You can’t get your Lasik done on the NHS, and if you are David Beckham your club might pay for your operation to be done privately at a time of your choosing (maybe even in the US), but overall it works very very well. For more of my musings check out :
http://www.healthline.com/blogs/smoking_cessation/2009/08/us-healthcare-reform.html
Hi,Great post and great contributions from readers. If the highly intelligent, experienced and connected folks who have made comments can’t figure out how to get the system to properly provide them with healthcare without costing an arm and a leg (pun intended) then really what chance do the uneducated have? None. I’ve been a patient and a healthcare provider in the UK National Health Service. Its not perfect and we all complain about it like we complain about the weather, but it works very well 95% of the time. When you have a problem you go see your family doc and she either treats you herself or refers to a specialist. The family doc makes the judgement about how urgent it is…..if very urgent, straight to the ER, if moderately urgent, then her referral request will say so, otherwise you get a referral and you might wait a month or so for the appointment. The docs diagnoses and the patients decisions about whether to seek treatment are not unduly influenced by the cost. You can’t get your Lasik done on the NHS, and if you are David Beckham your club might pay for your operation to be done privately at a time of your choosing (maybe even in the US), but overall it works very very well. For more of my musings check out :
http://www.healthline.com/blogs/smoking_cessation/2009/08/us-healthcare-reform.html
Let me offer up this: http://spindyeknit.com/2009/08/for-what-doth-it-profit-a-ceo/If the figures in that link are correct, (and I couldn’t find more current ones), then that’s over three and a quarter million people paying premiums at my daughter’s rate (or what would have been–she later found she’d been denied) and taking zero medical payout, not even to get a flu shot, in order to pay for that one CEO’s salary and benefits for one year.
Let me offer up this: http://spindyeknit.com/2009/08/for-what-doth-it-profit-a-ceo/If the figures in that link are correct, (and I couldn’t find more current ones), then that’s over three and a quarter million people paying premiums at my daughter’s rate (or what would have been–she later found she’d been denied) and taking zero medical payout, not even to get a flu shot, in order to pay for that one CEO’s salary and benefits for one year.