Health Insurance Companies and the Ethics of Health Care…You Ain’t Gonna Believe This!

November 26, 2013

Some may know – especially those who have been following my most recent blogs related to a return of Prostate Cancer that I’ve been dealing with – but today was a Red Letter day when it comes to Health Insurance, Health Insurance Companies and how they ethically (oops unethically) deal with their customers.  I am not sure how we got here, but where we are when it comes to our health and how that is paid for is so broken it’s quite unbelievable.

WHAT’S THE SCOOP?

healthcareToday was a follow up visit with my local doctor.  Nothing special and almost a waste of time, but the appointment was scheduled and kept.  Routine visit – weight, blood pressure, temperature, and nothing unusual.  Today I was to receive the results of my bone scan and CT scan, but since I got a CD with the data ready to send to the Mayo Clinic (which of course I read – not that I’m a doctor, but I can read, and a report that says nothing was found was exactly what I was expecting), which I sent, I knew the outcome before the visit.

Doctor enters the room with a pleasant smile asking me how I am.  Now that was a loaded question since I am full of frustration over the way Health Insurance companies deal with their customers (namely me).  Of course since I am the one that wants treatment, I personalize their actions.  Yes, I know better, but to me it is personal since it is my health.  So…I proceed to vent to the doctor.

“Doc, I don’t know how you deal with these insurance companies day in and day out!  They are a pain in the ass.”

“You don’t know the half of it,” he responded, “and it’s only getting worse!”

For a few minutes he openly allowed me to vent, then looked at me, removing his glasses and said, “Let me vent a bit.”

AMAZING STORY!

Of course with no identifying information shared, my doctor shared with me the most amazing story I’ve heard (and I suspect that this is nothing in comparison to many many more stories like this out there).

“So I have a patient with advanced lung cancer.  He’s been a smoker most of his life, so as you can imagine his lungs are pretty damaged.  Likewise, he has cancerous lymph nodes in his chest.  So I suggested a form of radiation treatment that is more localized to his tumor so that I can spare what little lung he has left.  If I use traditional radiation the tissue damage will create substantial problems for this man who needs to salvage as much of his lung as possible.

I submitted my request to his health insurance company.  Their reply:  DENIED.  They wanted me to use the conventional treatment!

I told the person on the phone, because by now I was personally involved, that if it were their lung or even their father in a similar situation, they would want the better treatment.  The treatment that would salvage what lung he has left.

They then suggested that I resubmit the request showing the two treatments: (1) more effective treatment and (2) conventional tissue destroying treatment.  We did that.

Got the response today:  DENIED!

I was incensed and called again for a peer to peer discussion.  Not more than 30 minutes ago I was told that the conventional treatment was all that was needed, even though I know that the damage from that will substantially diminish his quality of life and could create more medical costs down the road.

Chuck, they just don’t care!”

HOW DID WE GET HERE?

How did we get to the point that a person checking off a checklist is the determining factor into the kind of health care we receive in the United States of American?  Are we really OK with care provided at the lowest common denominator?  We we can receive quality treatment but the insurance company will only pay for adequate treatment, is that OK?

SHARE YOUR STORY

You don’t have to name names, but feel free to share your story.  Maybe if enough of us get our stories told…SOMEONE WILL LISTEN.

FEEL FREE TO SHARE YOUR STORY OR YOUR COMMENTS.


When Prostate Cancer Returns – The Mayo Clinic Process Continues – Part 5

October 30, 2013

Not only is it disconcerting to find out that you have recurring prostate cancer, but then to have to deal with restrictive insurance companies and find out that it will only get worse, just adds icing to the cake of worry and stress.  The bright spot – dealing with the Mayo Clinic.

Health Care 2So here’s the deal.  You find you have a rising PSA when, without a prostate, your PSA should be zero.  Problem!

You then find that there is a wonderful test that potentially could identify where the growing prostate cancer is located so that appropriate treatment could take place.  Get the test!  Right?  Not so fast…

In the Mayo Clinic consult I find that in order for insurance to cover the test, they require other tests – CAT scan and Bone Scan – be done so that (my words – less expensive diagnostic tests) one can find out if there is a “cheaper” way to determine where the problem is.  At a simple level that makes some since, but reality and bureaucracy don’t often mix.

Starting cheap and controlling costs is the insurance company’s way of creating profit.  But at what cost?  My health?

Reality is – the only test that has a chance of detecting where my recurring prostate cancer is originating is the Cholene C-11 Pet Scan.  With a low level PSA (1.1) the chance a CAT Scan or Bone Scan will show anything is slim to none.  Ah, hell…None!  So…the ONLY option is the C-11 Pet Scan.  Now doesn’t it make sense that someone with some fundamental intelligence would look at the facts and circumstances and just order the C-11 Pet Scan from the get go?

The insurance approach has done nothing but waste money.  Start cheap and then (potentially) approve the one test that would work.  Arrrrg!

INSURANCE SOAP BOX TIME

But it gets worse – and yes now I am on my soap box.

So…knowing my insurance will change at the end of December 2013, I go to Blue Cross Blue Shield of SC to inquire about the “gold” plan for South Carolina residents for 2014.  What a eye opener.  First, they calculate the monthly cost which is high, but in this day and age that is expected.  So far no surprises.

Then I ask – what is covered and for how much?  That’s when it starts to get interesting.  I am told the deductibles and out of pocket expenses.  When it’s all said and done I’d be out of pocket $4,200 plus the monthly cost.  OK…not bad.  But wait there’s more.

So I ask, where are these insurance benefits available?  “You mean who can provide them,” asked the Blue Cross representative.  “Yes.”  Now dumb me, I figure that if you have the “Gold Plan” you should be able to get benefits anywhere.  WRONG!

I’m told that coverage is only available through providers in the network.  STOP!  Really?  Then the BC/BS representative said we’ve just added the Greenville, SC Hospital System.  I used to just be St. Francis.

I was blown away.  You mean to tell me that if I don’t choose a provider in your network, I have to pay for services out of pocket?  The response from BS/BS – YES!

Pardon the way I put this, but WTF?

I proceeded to ask, “So if I had a brain tumor and the #1 brain surgeon was at MD Anderson and they are not in the SC BC/BS network, I would either have to choose Dr. Nimrod or pay out of pocket for the best care?”  “Yes, that’s correct!”

OMG…if that’s what we have to look forward to with the Affordable Care Act then God help us.

BACK TO A MORE COMFORTABLE REALITY

Thank God for people that know how to navigate this mess.  Back to simplicity.  I email through the Mayo Clinic system to find out next steps and was provided the phone number for those (blessed) folks who get pre-approval for people like me who need the help and are pissed with insurance companies (who made them the decision makes for my health?).  I simply called the Mayo Clinic – got a lovely lady on the phone who was interested in helping me.  She listened to my story, found the CPT code, got my insurance information and is proceeding today to be my advocate with my current insurance provider.

The C-11 Pet scan is scheduled and the journey continues to health…


When did the Insurance Company become Your Doctor? Wonder if Insurance Companies have any Ethics?

January 18, 2010

You can tell it’s winter when you start to find yourself hanging around people who seem to have the upper respiratory crud.  Unfortunately, both my wife and I have been dealing with it.  You know – coughing and sneezing, etc.  Now, I’m sure you didn’t start to read this to find out our medical condition, but it sets the stage.

My wife, not one who likes to go to the doctor, broke down today and paid the Doc a visit.  Sure enough she had a form of bronchitis for which the Doctor prescribed an antibiotic.  So far so good.  She paid her co-pay and went on to the pharmacy.  Her prescription was filled and all seemed well.

Well…that is…until she checked out the instructions to the antibiotic.  Instructions stated “take one pill each day for five days.”

STOP!

One would assume that there were five pills since the she was to take one each day for five days.  But when she opened the bottle – there were four pills.  “Wal-Mart”, she thought, they shorted her a pill.  So she called them.  The result…no shortage.

Seems that the INSURANCE COMPANY says they will only pay for four pills.  WHAT?  YEP.  They will PAY FOR 4 PILLS.

Now, when my wife told me this, we both shared our disbelief.  A prescription that should be completed – (take 5 pills) – was shorted by 20%.   Maybe it’s a myth, but I was always told that to be effective a prescription should be taken through completion (i.e., all 5 pills).

MY QUESTION:  When did INSURANCE COMPANIES become the DOCTOR?

So, on the way home, I stop to get come cough syrup and ask the pharmacist what the deal with this is.  His response.  “You don’t have a clue how bad it is and it’s getting worse.”  INSURANCE COMPANIES are effectively practicing medicine and we’re letting it happen.

So, as a business ethics speaker and author, I wonder, do you feel that this right?  Are INSURANCE COMPANIES practicing medicine?  And, when did the Doctor lose control of the care of his/her patients?

I bet you have stories too…feel free to share…

YOUR COMMENTS ARE WELCOME!