Talk about nothing changes! For this week’s trip back in time, I’m reprinting a post from September of 2005 about attempting to navigate the American healthcare system — and what a bumpy ride that is. Just for confirmation that we’re all still struggling with this same baloney, check out #patientsfirst on Twitter. Now, buckle up and enjoy the ride…
Amy’s Tour of Health Plans, aka Mr. Toad’s Wild Ride in Slo-Mo
If I learned anything since my diagnosis, it’s that American health plans are pretty much all the same if you don’t have any special needs. That is, we bounced around a fair bit between various HMOs and PPOs and POS’s over the years. Some had higher co-pays, others had higher deductibles. It didn’t make that much difference, and even though I have three kids, I never looked into it very carefully.
Then I got diabetes. I had to see an endocrinologist regularly. I had to see a diabetes educator and a nutritionist regularly. Since the diabetes affects everything, I had to see an ophthalmologist, allergist, gynecologist, podiatrist, and sometimes orthopedic surgeon. My life became a nightmare of pre-authorizations and referrals. Who was in my network? How much would I have to pay if they weren’t? Why does my local “Medical Group” have the right to restrict me from seeing the world-class diabetes specialists at my local university?
What I found out is summarized below. Note that this highly condensed info took me a goodMr_toad half-year to work out, and with every agency sending me off in another direction, getting there was a bit like taking Mr. Toad’s Wild Ride in very slow motion. (The details of your plan options may differ, of course!) And note that just as I’ve figured this all out, my husband’s company is CHANGING PLANS AGAIN!! Am I covered for Exploding Head?! Anyway, here goes:
HMO
Cheapest option, but everything goes through your primary care physician. This means you need a referral from your “family doctor” for every other doctor or treatment. A pain in the @#$!! for most diabetics, who generally only see their general practitioner at the point of diagnosis, and then move on to real diabetes care. Luckily, you can usually call in for a referral, and a single referral can often provide for a long-term treatment. Standard copays for doctor visits are just $10. BUT you are locked in to choosing providers within the local network, or Medical Group, contracted with your health care plan. This includes hospital care. You need to go to the Medical Group’s specified hospital, except for out-of-town emergencies, which are supposedly covered at 100% (in my experience, you still get billed for various treatments). The HMO is also the only plan option that offers “non-critical” medical services like education and training. (Hello, 18 M diabetics in America need this stuff!)
If you choose to go out-of-network (outside the Medical Group), you pay a percentage of the provider’s regular fees for each treatment. The stinger is that your health plan will not cover any percentage of an out-of-network service that your Medical Group claims to offer itself.
PPO
Most expensive, with a significant annual deductible, because you can see any doctor including specialists without referrals. Still, they make a distinction between “preferred” and “non-preferred” providers. Preferred have signed billing agreements with your health plan, so you as the patient pay just a 20% copay versus a 40% copay for providers who have no relationship with your plan and can charge whatever they like. With our provider, the PPO plan does not cover any “special programs” like nutritional counseling or diabetes education.
POS
The POS (Point of Service) option doesn’t cost much more than an HMO, and lets the patient choose for each medical service whether to use HMO or PPO benefits. So you can use your HMO option, and get a referral for an in-network doctor at a $10 copay, or you can go the PPO route and see a preferred provider at 20% cost or a non-preferred provider at 40% cost. Here’s the rub: these choices have caused a great deal of billing confusion, so much so that many POS plans have been cut altogether. It’s up to YOU, as the patient, to tell your doctor which option you’re using, or they’ll probably bill you incorrectly. Naturally, you’ll want to go the HMO route if your doctor’s in the local Medical Group, because it will cost you less.
With services like counseling and diabetes education, you often have no choice really. For example, under our plan, since these services are covered only by the HMO, you’re locked in to whatever your Medical Group happens to offer (unless that group grants you an exception). No matter that a nearby university has a world-class diabetes center! If your Medical Group offers “equivalent services,” they won’t be granting any exceptions — so you get whatever they’ve got, unless you want to pay full price out of your own pocket to upgrade your care. In my case, a half-hour visit with my wonderful educator at UCSF put me back $380 without the insurance. I haven’t seen her for a year.
All the diabetics I know have had similar troubles, discovering their plan doesn’t cover some critical portion of their care.
I know I’ve said this before, but 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 (!)
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.
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.
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.
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.
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.
You rock Darryl! This site is dominated be liberals and they cant help it. They were born that way.
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.
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.
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.
“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.
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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