Just a few thoughts as I've been navigating the health care system recently. OK, it's really a long rant, if I'm going to be honest.
Insurance companies are fine with the everyday things. They might push you to a generic medication or move you from one brand name to another, but it seems that they won't hassle you for basic care most of the time.
For example, I had a small basal cell carcinoma removed from my arm earlier this year. I paid out of pocket (hadn't hit my deductible for the year yet), but the forms were processed and it counted towards my deductible just fine.
For the past year and a half, I've been paying out of pocket to an out-of-state provider for some care that my insurance doesn't cover. But, I knew that going in, and while I'm not happy, I'm OK with that one.
But, when things get a little rougher, insurance is all about one thing - the bottom line of the insurance company. Your personal health decisions will be dictated by a bureaucrat, rather than what you think is best for your care.
For example, I had a significant health diagnosis recently (people who actually know me are welcome to send me an e-mail and I'll be glad to elaborate). The specialist I am seeing wants me to have a second opinion. I consulted with a friend who is an MD in the Boston area, and he recommended a particular provider and hospital. I went through a lot of work with that organization and got my appointment. The specialist's office spent a long time getting info to that hospital and information about the referral to my insurance company.
I kept checking my account online with the insurance company, waiting for the approval of the referral request. After more than a week with nothing at all showing up, I called the insurance company. They managed to "find" the referral, and insisted they would expedite its processing.
Five days later, the referral request showed up online, with a letter to me stating that they were asking the doctor for more information. There was also a copy of the letter to the provider, demanding that he justify why this hospital could offer something that another local hospital could not. At this point in time, I was three days away from my appointment in Boston, and it was clear the insurance company did not want to cover that visit. I forwarded the information to the provider (the letter to the provider was going by USPS, so it probably isn't there yet), and they followed up with the insurance company. The insurance company demanded to know why another hospital that is closer would not be sufficient. And, the closer hospital has a solid program as well, but this is my life that I'm talking about. Yet, a bureaucrat has decided what treatment is appropriate. It's not what is best; it's what they deem good enough.
Both specialists I've seen so far have expressed nothing but admiration for the provider I'd chosen in Boston. It was a great choice for a second opinion, they'd told me. "Give her my regards when you see her", they'd said. But, when it was time to fight the insurance company, they caved instantly. I'm sure they deal with this all the time, and they know it's a losing battle.
When the nurse informed me yesterday that the specialist wasn't even going to submit the form and try to get the approval, I was livid. I basically told her that if the doc wouldn't fight for me now, I wasn't sure I wanted any more to do with the provider and his hospital system.
Today, I cancelled the Boston appointment. The people there were very nice, and made it clear that it's a common occurrence. Many insurance companies refuse to allow patients to go to a non-preferred provider, because they don't have sweetheart financial deals worked out with them. That last sentence is my interpretation. I also understand that insurance costs and medical costs need to be contained. Yet, when insurance is suddenly needed for a significant diagnosis, I'm spending more time fighting the insurance company than I am dealing with doctors.
Today, I tried to make an appointment with the alternate provider that my insurance will allegedly let me see. This is a major teaching hospital. They wouldn't even let me get close to making an appointment. I got all kinds of instructions about having my doctor send information to them, and after reviewing that, they will get back to me (apparently, at their convenience) to set up an appointment. This is how large health care institutions work these days. They see themselves as scarce commodities that don't need to provide customer service. The sick people should consider themselves lucky to be getting care at all. When I finally get to providers, I'm fine. But the firewalls around the providers are outrageous, in my opinion.
So, I had to make another request to the specialist to send all of my information to a new hospital. Who knows how long that will take. And, I'll need a new referral form for the insurance company. That will probably be slow-rolled as well, and I'll probably find out that even in-network, preferred providers aren't allowed to offer second opinions. Overall, I'm frustrated and I'm furious.
On a similar tangent, I had a procedure done a month ago that led to my current diagnosis. That procedure has had some side effects, and there are multiple medications on the market to alleviate those side effects. I asked my doc for a prescription for one. I went to the pharmacy to pick it up. "Your insurance doesn't cover that medication", I was told. I contacted the provider for a different medication after researching allowable drugs on my insurance company's page. The doc agreed to write the script. I went to the pharmacy to pick it up. "Oh, that drug requires pre-approval", I was told. Eight days later, the doctor's office and insurance company are still fighting over that approval.
I'm left in limbo. I'm furious. I've complained to the insurance company and to the state. Not one person has acknowledged the issue from either organization.
The "system" has zero humanity. Period.
I would guess that there are a few other factors in play here. First, I have met all of my plan deductibles for this year. If the insurance company can slow things down and push this into next year, I'm sure they are hoping I'll have to pay more of the costs (medication and referrals) as deductibles. They are probably hoping I'll be on a different insurance company's plan by then. However, this company pretty much owns the market where I live, so that's an unlikely scenario. But, at least I would pay more. Right now, I would cost them money (aka profit).
Regretfully, my home state hired the same people for our local health care exchange that did the federal exchange. Even before this diagnosis, my wife and I had planned to pay the extra money to move from a high deductible plan to a higher end plan. It would cost us more up front, but our total costs would be more predictable. After this all went down, my wife talked to her employer - the source of our insurance. Her employer was still fine with us "buying up" in the exchange. And then, last week, her employer decided that we will be staying on our current plan until 4/1. Essentially, that means that any costs we incur from 1/1/2014 until 3/31/2014 will have a high deductible amount. This will amount to many thousands of dollars of cash out of pocket that would not happen with the new plan.
When we switch to the premium plan on 4/1, we will get credit towards the new deductible amount, but no refunds of overpaid amounts. So, our state's failure to get an exchange working properly will cost my family thousands of dollars. And, because we are going to start with a high deductible plan and move to a more fixed cost plan, we are limited by how much of our first quarter costs can be paid pre-tax, through an HSA.
This last part isn't an insurance company issue. It's a failure of our state government and a failure to follow through on a promise from an employer. The employer could still make this happen before the end of the year, but has chosen not to do that because it's easier. They've done this despite knowing exactly how it will affect my wife and her family. And, this is a small employer, who insures only a few people. It's not a huge corporate entity that can more easily justify a decision that only affects a small percentage of employees.
Of course, the company I work for isn't exempt here either. For years, my employer has provided no health care coverage at all. Well, if you wanted, they would reduce your salary and then contribute that amount pre-tax towards an individual open-market plan. So, you could save a few tax dollars. I've spent many years working for this company, with very limited benefits because I really believe in what the company is doing. But now, I'm left with no recourse in my health care insurance because of that. At any other employer I've worked for since college, this would not have been an issue. Suddenly, I'm questioning if my loyalty to the company (really, my loyalty is towards the founders of the company and my co-workers more than the corporate side of the entity) has been stupid. I could make just as much money with real benefits somewhere else. And, perhaps I should.
It's odd to wake up in the middle of the night, and find yourself trying to figure out if it was all just a bad dream. And then realizing that it's all real. And then, trying to figure out which is worse - the medical diagnosis and impending treatment, or the never-ending fight with bureaucrats. This week, the bureaucracy seems way worse than the diagnosis.
Lastly, this is not at all about the ACA. While I would have much preferred a single payer option from our government, and I hope we get there some day, I still think the ACA is better than where we were. If anyone wants to disagree with that, send me an e-mail. I will delete any political comments related to the ACA.
In reality, this is about our current health care system, and how navigating the doctors and the insurance companies is so overwhelming that you can't imagine how bad it is until you are truly sick. With a single payer option, this might have still been an issue. But, I wouldn't be fighting a profit-driven company to get the care that I would like to have - care that they have denied because because something else is good enough, in their estimation.
I've told my wife multiple times that I'm just going to quit the system and let my diagnosis run its course. And then, I realize, that's just what the bureaucrats want, so they can make more money in the end. So, I will fight on. But, I feel like I've learned a good lesson so far. In this crazy world of ours, where corporations are people, none of them are your friends. You're on your own.