12 Responses

  1. Scott Strange
    Scott Strange July 22, 2009 at 8:58 am | | Reply

    Good summary, Amy. In answer too “Why are US health plans so restrictive on services that have the potential to ward off the big bills?”, I would suggest the answer is really simple. They are gambling that by the time those “big bills” arrive, you will be on someone else’s plan. You mentioned yourself how often people change insurance plans. Sad, but it is all dollars and cents.

    Cover a foot amputation? SURE!!! Cover education so that amputation never happens? Not Covered.

  2. saramy
    saramy July 22, 2009 at 2:30 pm | | Reply

    Amazing that things haven’t changed at all, except perhaps to get more convoluted for We with D since you originally posted your very clear, concise and calmly delineated rundown of the insurance programs. THANK YOU. I sometimes feel that perhaps I over-react when the crazy confusing insurance systems suck the patience out of my soul. Reading your post is most comforting because it reminds me that it is a most appropriate response to get highly frustrated trying to navigate a system which is so obviously screwed up.

  3. Lauren K
    Lauren K July 22, 2009 at 2:58 pm | | Reply

    Health plans, whether they are HMO, PPO, POS, or IPA, have one thing in common — when you get sick, you will be screwed out of care and coverage in every way possible.

    There is no such thing as over-reacting to a system that puts money, mere pittances, above human life and suffering. I have watched more than one patient die while trying to get chemotherapy “authorized.” I watched a patient die of a rare cancer when his insurance company decided it was too rare to treat, claimed that there was no evidence that chemo would help, and advised the patient to “appeal” if he disagreed with the decision.

    Can you imagine — being diagnosed with a rare and aggressive cancer, having your only hope “denied” for a bogus reason, and sliding closer to death every day that the insurance company stalled, dragged their feet, and claimed that they had no responsibility to pay for treatment.

    Another patient I know had a PET scan to determine whether he was cancer-free after treatment. Well, he was cancer-free — that was the good news. The bad news? Because the scan didn’t find cancer, his insurance plan ruled it “not medically necessary” and the patient was several thousand dollars out of pocket. It took over a year of appealing and re-submitting the claim to get the scan partially covered.

    The stories go on and on and on. Why do we stand for it? A for-profit health care system is ludicrous. The insurance companies bottom lines’ get healthier while patients get sicker — it’s repugnant.

    As for me, of course Blue Cross doesn’t cover my test strips. I also had to spend months convincing my health plan that insulin was medically necessary for a type 1 diabetic, only to later be told that I had to use a “generic” insulin, and according to my insurance, there was no such thing. So I was supposed to go to the pharmacy and pay cash for old-school Humulin, and do without Lantus altogether. What?!

    I would like just one for-profit insurance company CEO or politician against reform to walk the halls of a hospital ward and meet the patients whose lives have been destroyed in the name of bonuses and stock prices.

  4. Debbie kay
    Debbie kay July 22, 2009 at 6:42 pm | | Reply

    I agree with all of you. For profit companies should be banned. I dont think food companies should make profits either. We all have to eat too. Why should restaurants make a profit on feeding us? Thank goodnes we have a President who will change all that. No one should make a profit on health care or food. That’s why the Government should run it all. Thank you Amy for showing us how bad it really is and how the President will stop this profit nonsense in all sectors of the economy. Diabetes is a horrible, horrible, horrible, disease and no one should profit from it.

  5. Darryl Silk
    Darryl Silk July 22, 2009 at 6:46 pm | | Reply

    Lauren K and Debbie K are way out of the mainstream on this. I suspect neither has actually treated patients in a private practice setting. Hospitals dont count Lauren. Go work in the real world for a few weeks and then come back and rant somemore about profit. Better yet…go to Cananda.

  6. Nancy
    Nancy July 22, 2009 at 6:49 pm | | Reply

    You rock Darryl! This site is dominated be liberals and they cant help it. They were born that way.

  7. Lauren K
    Lauren K July 22, 2009 at 7:13 pm | | Reply

    Darryl, I worked in private practice multi-specialty and urgent care clinics for 6 years before I started medical school. As for the “real world,” physician reimbursements are declining because insurance companies slash fee schedules and delay and deny claims. Insurance companies’ delay tactics hugely increase the overhead of any private practice that accepts insurance. The problem with our system is insurance companies making money by screwing hospitals, doctors, and most importantly, sick people.

    When I had a managerial position in the clinic I spent 70% of my time trying to get coverage authorized and claims paid for. I spent about 25 hours a week just dealing with insurance companies who were dragging their feet, had lost claims, or took 90 business days to process appeals, while a patient’s future hinged upon the treatment. Much of the time, I was arguing for services that were not even billed by my clinic — I was trying to obtain authorizations for MRIs and PET scans so patients could get them done by imaging centers and the physicians could make further decisions about whatwas necessary. Is that efficient? Or is that dealing with a byzantine bureaucratic system? Because that’s what we have now.

    Taking care of the sick should not be a liberal or conservative issue. As human beings living in a wealthy society, it is shameful that we do not care for our most vulnerable members.

  8. Vicki Baker
    Vicki Baker July 22, 2009 at 7:14 pm | | Reply

    Just consider what will happen to diabetics under the HEALTH CARE REFORM that will work to save money. To reward the patients that do not cost the program money? Where were we fall? Also how will we make do with less to save monies? Go figure.

  9. Chris Q
    Chris Q July 23, 2009 at 9:07 pm | | Reply

    My husband did without decent medical insurance most of his life. Too bad for him that he was found to have Type 1 diabetes at age 9.

    Now he’s a gainfully employed, taxpaying, voting citizen with health insurance. But it’s too late to avoid the laser surgery that saved the vision in one eye, too late to avoid the neuropathy, the heart complications, the kidney transplant or the cancer that his doctor blames on the immunosuppressants that keep his kidney functioning.

    We’re pretty good at negotiating the system these days, and we pay through the nose for his medical care despite his insurance coverage, which conveniently excludes many of the medications and treatments he needs to keep being a gainfully employed, taxpaying citizen.

    Whatever health care reform brings, it can’t be worse than he’s experienced already. And it might save some 9-year-old from becoming him one day.

  10. Jan
    Jan July 25, 2009 at 9:03 am | | Reply

    “I still don’t get it: Why are US health plans so restrictive on services that have the potential to ward off the big bills? Why shouldn’t patients have the freedom to take advantage of the best educational resources in their area, even if these resources aren’t the health plan’s devoted business partners? Happily, diabetes is very manageable with good training and education. If not properly managed, diabetes complications are going to cost the health plans a hell of a lot more than university counseling sessions would.”
    I do get it. Greed. The insurance company denying your benefit TODAY does not believe you will be claiming benefits for complications for many years in the future, oh, say, ten, fifteen or twenty years down the road. By that time, they are betting many people will not be working for the same employer or using the same insurance plan. They are hedging their bets. They don’t believe they will have to pay for complications for the majority of the employees covered. They want to save money today. They do not care about future costs because they don’t believe they will have to cover them.

  11. Jan
    Jan July 25, 2009 at 9:11 am | | Reply

    AND, if any of you are old enough, think back to the early days of the HIV epidemic. Early 80′s, before there were drugs that could help manage the disease. I was told by an AIDS activist in my office that insurance claims were routinely denied and stalled because the lifespan of these early cases was just a few years. By the time the insurance companies would be forced to comply and pay benefits the person would have died. Insurance companies are completely heartless… thinking ONLY about the bottom dollar.

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