Who’s Afraid of the HealthCare Wolf?

Here I am living with a chronic disease, and blogging my brains out about it, and yet I’ve been shielded so far from all the agonizing over health insurance. I’ve been lucky enough to be covered by my husband’s employer’s plan — since pre-diagnosis, so Hah!, they were stuck with me. But I do realize this arrangement may not go on forever, and that prospect scares the heck out of me.

Nobody’s arguing that healthcare reform isn’t sorely needed in this country. But it’s pretty obvious that this life-sustaining topic has become a very visible political football as the candidates queue up for the 2008 presidential election. And there will probably be a lot more TALK before we see much meaningfulHidinghead action.

The Census Bureau reported last month that nearly 47 million Americans lack health insurance coverage — including lots of wealthy families, because they can’t find any policies that make fiscal sense.

OK, so now California has come out with a ground-breaking plan to get all of its citizens covered, which could set the standard for the whole country, lobbyists say. Nobody’s fingers are crossed as tightly as mine for that experiment to succeed.

But in the meantime, if you have diabetes or any chronic illness, you’re still screwed. Because as healthcare industry consultant and guru Matthew Holt points out, “(Private) insurers will do anything they can to not sell insurance to people who might use it. That’s because healthcare costs are extremely concentrated among a very few people. Sell a few too many policies to sick people and insurance companies’ profits evaporate…”

And as all we sickies know, just “having coverage” is often not enough. Even WITH coverage, so many aspects of our care are a fight and a hassle and ‘DENIED’ for some inane administrative reason, disguising the real reason, cheapness.

You wouldn’t believe (or maybe you would!) the reader emails I get about this sort of thing. For example, this note of late from reader Sara M.:

I just received another annoying letter from my company Oxford about using less expensive medications. Oxford is a United Health Care Company and we’ll remember that their CEO recently got in trouble for backdating stock options, meaning he made a crap-load of money off the backs of us paying our premiums. Basically I read this letter as yet another attempt to control what it is I take and as punishing me for using the insulin I use (as if it were not the wisest consumer choice to make).

I’m advised that Humalog is a Tier 3 drug and that Novolog, which is a Tier 1 or Tier 2 alternative medication, would be cheaper for me to use. Of course the letter has all sorts of legally directed verbage in it like “the alternative medications treat the same conditions for a lower co-payment. You can save money by using medications that treat the same condition, but have different active ingredients, if your doctor decides that it is appropriate for you to do so. If you want to lower your costs for prescription mediations, talk to your doctor and about these less expensive alternatives. If an alternative medication is appropriate for your care….” blah, blah, blah. And of course, also “we realize that everyone reacts differently to medications and one may work better for you than another, so talk to your doctor…decisions about which medications you take remain between you and your doctor.”

Of course they say all that while they CLAIM they’e not telling you WHAT to take, but they really are driving the prescriptions we take because of cost. So, if Humalog really is my best insulin, I’ll get a little extra punishment. This is healthcare in this great country today. And what did Bush say about everyone being covered? The poor can just go to the emergency room (or something).

I hear you, Sara. You wouldn’t believe (or maybe you would!) the hoops I had to jump through to get certain prescriptions pre-authorized, and then pre-authorized again every time they run out — or to get my CDE sessions covered, using just the right HIPAA code to nail the provider so they can’t wiggle out of coverage based on some stupid semantics. I actually paid over $400 for the hour-long appointment in which my doctor diagnosed me with diabetes back in 2003; somehow the code was wrong, so this one got stamped “patient responsibility.”

Sure, healthcare reform is about getting everybody covered. But it’s also about making that coverage have some actual value when you really need it. Like when you get saddled with a medical issue for life.

According to the Partnership to Fight Chronic Diseases, a national advocacy coalition, “between the Iowa Caucus and election day, more than one million Americans will die from chronic diseases.” SHUDDER …


18 Responses

  1. Clemma
    Clemma September 19, 2007 at 8:50 am | | Reply

    So true. As another diabetic friend said to me recently, my greatest financial fear is not losing my house, it’s losing my health insurance.

  2. anne
    anne September 19, 2007 at 9:10 am | | Reply

    I work in a medical institution and have had to deal with various insurances. Actually I avoid doing it because it makes me so angry, but my coworker tells me about it. For some, the patient or doctor may call to get pre-authorization for a procedure. The insurance co. rep will say something like “it is pre-authorized” or “no auth required” but then when they get the bill, they say, “Oh I’m sorry, it’s not a covered benefit.” ??? Blue Shield is particularly egregious. And if they do agree to pay, it is never the correct amount. Why don’t these companies have to behave like legitimate businesses. It is such a scam. I have to say that Kaiser Permanente actually pays when they say they will. There may be other good ones too…I’ll look into it.

    Another tactic they use is to neither deny or authorize a procedure especially when there is a time constraint. Then, the patient can choose to have the procedure (which for our case is under extremely urgent and serious circumstances) under the assumption that the insurance may deny it and they would be responsible. Of course the insurance would usually deny it afterward. It is manipulative and cruel. Meanwhile we don’t get paid half the time and can only continue to perform our services because of our attachment to a larger institution.

  3. Albert
    Albert September 19, 2007 at 9:33 am | | Reply

    That last line certainly put things into a chilling perspective.

    I’m definitely noticing a trend of getting screwed by insurance companies. But I also wonder how much of the responsibility for making treatment reasonably affordable lies in the hands of the corporations that develop and manufacture them.

    It seems like some people just want to make a buck. But in the end, it’s not just money that’s being taken, but lives that are quietly being lost from one’s inability to afford/receive proper treatment.

    I too wonder how the next president will approach this issue.

  4. Scott
    Scott September 19, 2007 at 10:37 am | | Reply

    This is an area that I have devoted a fair amount of coverage to recently.

    As I reported on August 31, 2007, according to a 2006 report published by the International Diabetes Federation, the authors used estimates that approximately 45 million people in the U.S. (roughly 17% of the working-age population, we know this has since been revised to 47 million) are not covered by health care insurance. Still, using simple, back-of-the-envelope calculations, if roughly 6% of people in the U.S. have diabetes, of the 45 million people with no healthcare cover, we can conservatively estimate that approximately 3 million people with diabetes in the U.S. lack healthcare insurance. According to a number of different studies, their prognosis is lousy. For example, analysis of a study done in 2002 revealed that when compared to people who had health insurance, people without any form of health insurance who have diabetes received fewer preventive diabetes care interventions and showed generally less-desirable diabetes outcomes. Specifically, a higher percentage of uninsured people had HbA1c levels of 9% or higher; fewer had an annual blood lipid test and/or annual foot exam. It’s hard to imagine, but on average, fully one-fourth (25%) of people with diabetes go without a checkup for 2 years if they have been without health insurance for a year or more vs. only 5% of diabetes patients with insurance.

    However, as I also reported that the American Cancer Society’s marketing efforts may benefit people with diabetes by devoting its entire $15 million advertising budget to the consequences of inadequate health coverage. Lets hope that this, along with the new Public Service Announcements on hemoglobin A1C’s might force our politicians to act since they have done little besides talk about the issue since President Clinton’s (and now candidate Hillary Rodham Clinton) plan was defeated in 1993.

    Think about it. Next year, it will be 15 years since we had Federal representatives seriously examine this issue. Its time to stop talking and start doing something about it!!

  5. Profilewriter
    Profilewriter September 19, 2007 at 1:40 pm | | Reply

    Another problem with insurance, even if you have pretty good insurance, is that you don’t know whether your doctor’s advice is motivated by concern for your health or by requirements imposed by an insurance company.

    I just had blood work that came back with a fasting BS of 129, and then more blood work that showed an A1C of 6.3.

    I told the doctor I want to take this seriously because of family history etc., and will start testing my blood.

    No, he said. No need to test.

    When I pressed him, he said, “insurance won’t pay for supplies.”

    That turned out to be not true; I went to an endo who promptly prescribed test supplies.

    I have asked my doctor several times about the advisability of a stress test. I’m 59, have high blood pressure, high cholesterol, and now diabetes. He keeps saying “well, let’s wait and see.”

    It’s hard to know whether he thinks I don’t need one, or whether he doesn’t want to use up his quota of tests and anger the insurance carrier. I’m a writer, and, in the course of writing articles, have been told by doctors that they are under pressure to limit the number of tests — especially expensive tests — that they prescribe.

    My plan is to tell my doctor that I want to know when, and to what extent, his advice is based on insurance constraints.

  6. Adam
    Adam September 19, 2007 at 1:56 pm | | Reply

    I haven’t had health insurance for about 4 years. Not my choice. Health insurance is about keeping people from getting the best treatments and the most effective medicines.

  7. Melissa
    Melissa September 19, 2007 at 3:49 pm | | Reply

    Hmmmm, apparently what is considered cheaper medications varies from insurance company to insurance company as well. Sara M. stated that her insurance company rated Humalog at a higher cost than Novolog, my insurance company has it the exact opposite, I pay a higher copay to get my Novolog.

  8. Michelle
    Michelle September 19, 2007 at 5:22 pm | | Reply

    and then if you can get insurance the make you broke trying to use it – in our case and my husbands premiums on our family policy were going to be $800 a month plus 20% on everything after a hefty deductible. This was just what the normal healthy person paid in his company – a rather large company, nation wide company, retail (think thanksgiving day and floats??) He was a VP at said company too, so we were not poor, nor were we wealthy – we were doing well but that much in health care for a child with a chronic condition is unreal, not to mention the normal and customary things like other child breaks ankle, ear infections, etc etc etc. $50 for an office visit for a specialist ( endos for both kids every 3 and 6 months, opthalmologist for one child, ) on and on. the costs alone would have totaled into the thousands. Like most people, I don’t have a few extra thousand dollars laying around. We drive sensible cars we live in very modest house in a very old neighborhood and our kids go to a urban catholic school – old run down. We are not living high on the hog. Those expenses would have broken us financially.

    In the end, my husband went back on active military duty (having just come off an 18 mth deployment in Iraq) just so we could get the free health care. (thank you taxpayers) The pay cut for military and the savings on health insurance basically evened itself out.

    I just wonder how someone of lesser income can handle it. Middle class america, folks earning 25k a year – how do they do it?

  9. jim
    jim September 19, 2007 at 5:32 pm | | Reply

    I don’t know what I would do if I didn’t have health insurance through my wife’s job. I couldn’t afford my supplies and medications. The thought just freaks me out.

  10. CrazyACpumper
    CrazyACpumper September 19, 2007 at 5:46 pm | | Reply

    In response to Michelle:

    How do we do it? We don’t most of the time. We call our doctors and ask for help. We ask for samples and consistently explain the same thing over and over again:

    (in my case)
    I now have no insurance. Because of lapses in insurance coverage and prescription needs, I am broke. I had to rethink my career path now I work from home. Unfortunately my job does not offer health insurance right now. I have applied to programs via the state I live in. I have not heard anything, they could take another 2 months to decide for all I know. In the meantime, I have looked into this program and that, I have not heard back. What can you do to help? I have no money and I NEED insulin, test strips, insets and cartridges….etc etc etc.

    This is what I have gone through for the past 5 months. And as of recent (past two weeks) I was denied left and right because I make too much money at my part time job. The last option the state offers does not cover dental, vision or durable medical equipment (pump supplies). And since there as been a lapse in continuous insurance coverage, there would be a waiting period because I have a pre-existing condition.

    The other part we do, we advocate. We research and gather data. We organize and prepare. It is a worthy project but in the meantime my immediate needs are not being met. How does this make any sense? It doesn’t. It is a sad state of affairs.

    If you don’t advocate for yourself, no one else will. (unfortunately the state I live in does not offer good options for a Type 1 Diabetic)

    Scott is right, it is time to do something about it!!!!!

  11. Dina Hayes
    Dina Hayes September 19, 2007 at 6:19 pm | | Reply

    I also have Oxford and it’s just the opposite. I’ve bought both Novolog & Humalog in the past year and my copay for Novolog is more expensive than Humalog…that seems arbitrary.

  12. RichW
    RichW September 20, 2007 at 11:26 am | | Reply

    I have a great idea. Make all insurance companies non-profits. Could do the same for pharmaceutical companies. In a perfect world, those companies that contribute to the common good would be willing to provide insurance and medications at a cost no more than what it takes to stay in business. Now who would responsible for “making” an industry non-profit?

  13. Frank Varon DDS
    Frank Varon DDS September 20, 2007 at 7:37 pm | | Reply

    As a dentist focusing on diabetes care issues, I share many of the frustrations that most people in healthcare see with the reimbursement process and the institutions that control it. REMEMBER THIS: THE NUMBER ONE REASON FOR PEOPLE FILING BANKRUPTCY IS BECAUSE OF HEALTHCARE EXPENSES.

    This country should be ashamed of how we have treated people like cattle and when they get to the right age, send them to the slaughter house.

    I know this will be harsh but I feel at times (when the glass is half full) that we are in the middle of a medical holocaust. If you get sick, to hell with you. but I still want your money. Reimbursement for many procedures continues to drop while the govt makes statements that healthcare expenses go up by some ridiculous %. they seem to be including the double digit increases in health insurance premiums. As I tell my agent, I wouldn’t be in business if I had double digit increases year in and year out.

  14. Jim Paige
    Jim Paige September 21, 2007 at 12:57 am | | Reply

    Unfortunately, you are only a “lay-off” away from being thrown into the healthcare nightmare that diabetics face…

  15. joanna
    joanna September 21, 2007 at 4:55 am | | Reply

    It seems like its always those who do not have a chronic diease like diabetes who tell us what we can and cant do !

  16. Jolene
    Jolene September 21, 2007 at 1:11 pm | | Reply

    Sorry you guys are so afraid to loose health “insurance”, but I’m afraid some of the forced options being thrown around out there scare me more. If you really believe that a government run health insurance program is going to benefit you — spend a year in the military system where you have no choice of doctor, no choice of medications, no options at all but what “they” say you are to have, and if you don’t agree — too bad.

  17. AmyT
    AmyT September 21, 2007 at 2:56 pm | | Reply

    Wow, Jolene, who said anything about a government-run program? And why so bullish?

  18. Trusted.MD Network
    Trusted.MD Network September 24, 2007 at 6:45 pm | | Reply

    Grand rounds: Anniversary edition

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