Tag: healthcare

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Coverage caps

There’s a law in Florida called the Baker Act; a law which gives law enforcement and medical professionals the authority to hold people with mental illness – specifically those who show signs of being a danger to others or themselves.

There are few (if any) public facilities to provide this emergency care, so patients are cared for in private facilities… usually a floor set aside at the local hospital (the so called “psych ward”).

Since these institutions often are not publicly funded, “Baker Acted” patients are expected to pay for their care. Since most health insurance policies in the U.S. have unconscionable caps on the number of days covered in a 12 month period, and because mental illness can require extended periods of hospitalization, patients usually pay through the nose.

Because patients without coverage can not easily bargain as a group for the prices paid, patients without coverage usually pay more than insurance companies (for the same services). In fact, hospitals have been known to make up financial losses from insurance contracts with the fees charged to the uninsured.

As it happens, someone close to me is in the hospital, and she used up her hospitalization coverage (which only covered a percentage of the cost anyway) earlier this year. If I’m not mistaken, the bill submitted to insurance earlier this year was in excess of $60,000.

Imagine you had a really good job, with what was considered above average health benefits. Imagine what your finances would look like after paying 20% of a 60k hospital bill, plus 100% of what ever happens from here on out (which looks to be worse this time). Then ask yourself if you still like our health care system as it is.

With all the stress that undoubtedly accumulates in direct proportion to the accumulation of medical bills, it’s a wonder anyone recovers from a hospital stay.

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Back in the ER again

I’ve had a vested interest in the health care system this year, as some of you may know. Yesterday I got to live out the hospital admissions nightmare that some of you may have read about in the media. We went to the ER yesterday morning around 8 a.m. As of this writing, my mother is still waiting in the ER to be admitted. For those of you keeping score at home, that’s about thirty-one hours and counting.

It’s not just the one hospital that is full either. The ER staff called around – spanning five counties, and there are no beds open within about a 90 minute (drive), or 60 mile radius. And none of that is country driving either, so we’re not talking about 90 minutes of cows – where you wouldn’t expect to find any hospitals. We’re talking about 60 miles of freshly paved suburbia… just the place you’d expect to find a health care bounty.

Let’s hear it for the multiple payor system!

(To be fair, not ALL of the hospital beds are full… just kind my mom needs.)

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Our health

If you’ve been paying attention to the news in the U.S. you know health care is on people’s minds. Talk has been spreading almost as fast as the ranks of the uninsured/underinsured.

Michael Moore has fanned the flames of debate, spawning talk about the universal coverage offered by our fellow industrialized nations. We hear lots of stories in the U.S. about Canadians crossing our border to avoid waiting in line for certain tests or procedures. The garden-variety opponent of universal coverage brings it up constantly. ”I would never stand for a system that made me wait for a test I needed.”

That’s easy for a fictitious couple to say in a televised attack add, or for a healthy middle class couple with (what they think is) good coverage (which they’ve never really had to use). What I want to know is this: how many Canadians would trade their system for ours? How many of those folks coming to the U.S. for a procedure or test would really choose to ditch their universal system in favor of ours?

I’ve heard a few anecdotes which suggest there aren’t many.

We bemoan big government, but could it really do worse than the quagmire we’ve got now? Almost every time I’ve had to deal with my insurance providers, I’ve yearned for the relative tranquility of the lines at the DMV.

Must… stop… scratching

Foreword: I generally like my doctors.

Sometimes I wonder if my doctor has a string in his back and someone gives it a pull every time he’s supposed to speak…

“Good morning doctor.”

“You’re looking good today.”

“Yeah, but I can’t shake these fevers.”

“Your blood cultures have been negative.”

“Well this rash is killing me.”

“You’re on a lot of medication.”

“Is there any chance I’ll be going home soon?”

“You’re looking good today.”

“Is there anything else we can check, or anything else we can do?”

“Your blood cultures have been negative.”

“Do you know that you’re starting to drive me crazy?”

“You’re on a lot of medication.”

Scared sick

The other night we had a family get-together. Over dinner we discussed the good fortunes of a niece/cousin who won $250K from the lottery. “She’s so lucky, I’ll bet her life is a lot easier now…” one person said. Always the Devil’s advocate, I disagreed. “Does she still have to work? Does she still have to take care of the kids every day? Does she still have to clean the house? If she still has all of the same responsibilities, how is her life any easier?” I asked.

“Well, she paid off the house so she doesn’t have to worry about a mortgage payment, and she bought a new car….”

“Yeah, but most people can’t quit their job over a couple hundred thousand dollars. Well, maybe some do… if they use it to start their own business. But most of the self employed folks I know work more, not less. Plus, they have to worry about insurance. That doesn’t sound easier to me.” I replied.

“Well I wouldn’t turn it down” my fellow conversant replied.

“Don’t get me wrong, I wouldn’t either. I’m just saying that $250K might make my life a little nicer, but I’m not sure it would be any easier. I couldn’t quit my job. I’d still have to get the kids up early in the morning for school. I’d still have to do… (sigh)… laundry.”

The point I was trying to drive home, and failed, was that we too often confuse luxuries as necessities. The average American replaces their car less than every five years. My family has traveled to New England for vacation almost every year. Many (perhaps most) Americans have mobile phone service in addition to home phone service, cable TV, DVD players, and sneakers produced with more R&D than Eddison put into his light-bulb – or the Wright brothers put into their plane (actually I just made that up, but I wouldn’t be surprised). In that $250K buys you a new car, pays off your house, funds a few more vacations, or provides some financial security… there’s no question it’s really (really) nice. But does it make life easier?

All right, I’ll concede that I may have taken my argument too far. Heck, if two-hundred and fifty large dropped in my lap I’d be down right giddy. Plus, there’s something to be said for not having to worry about some things.

—

This morning I picked up the next book in my queue: Sick, by Jonathan Cohn. It’s the story of the health insurance system in the U.S.A. – specifically: how it’s broken, how it got to be that way, and who it has victimized. So far I’ve read the stories of three middle to upper-middle class families who were victims of our current system. One common theme for these stories was a certain amount of fear. They knew they didn’t have healthcare coverage, they wanted it, they couldn’t get it, and they feared the consequences (this was before they got sick and found out what those consequences really were). Perhaps fear is too strong a word, but it was on their minds. They were concerned, if not a little worried. Personally, I’d be worried if I didn’t have health insurance. It’s one of the reasons I’ve alluded to which makes government employ so attractive (to me). I’ve had my share of struggles with my insurance company; some of which has been described here, but by and large healthcare is one less thing I’ve got to worry about.

I thought back to my dinnertime conversation last night. I thought about needs versus wants, and I wondered what life would be like if more people didn’t have to worry about certain needs. What is it like to live in a country where (presumably) no one has to worry about health insurance? What is it like when no one has to worry about trading a week or two of grocery money for a single visit to the doctor? What is it like when people generally don’t have to worry that they’re one hospital stay away from financial ruin?

I wonder if, controlling for all other variables (if that’s possible), people who live in countries with universal coverage are generally happier? How many people in the U.S. stay at jobs they don’t like because of their health insurance? How many people would be doing the work they loved, rather than the work that happened to come with low insurance premiums, under a universal coverage system? How would that effect overall productivity in the economy? How would that effect the quality of goods produced or services provided if they were born of passion rather than necessity? If people were happier, how would this effect outbreaks of violence, or crime rates? With potentially fewer financial worries (re: 40 million Americans with no coverage of any kind), what would happen to divorce rates? Would we all get along a little better? Perhaps I’m being a bit naive, but it seems like this could have a HUGE impact on a society – potentially for the better (much better).

Even if such a system was more expensive (and I’m not convinced it is), and even if some rationing of care occurred, isn’t it possible that these other (possible) positive effects – combined with more (relatively cheap) preventative care would make Americans (as a whole) healthier? To me, this is how we really could make everyone’s lives easier – not to mention better… much better.

And the band played on

“Hello, Mr. Kauffman? This is (censored) from (my HMO). I just wanted to give you a call to let you know that we’ve resolved the issue with your daughter’s PCP (primary care physician). The claim submitted in October 2004 will be resolved, and you will not be responsible for any charges previously billed by the PCP.”

“You mean the 10/1, 10/2, 10/3, and 10/5 claims that I called about last week; I believe it was 11/28 of this year?”

“I don’t have the exact dates in front of me. I just thought I would give you a call on my break to let you know the issue has been resolved.”

“But you think ALL of the claims from October 2004 will be resolved? What about the other dates that I was billed for? Specifically, I’m referring to the claims denied for July 2002, March 2005 and May 2005?”

“Sir, you didn’t ask us to check on any dates besides the October 2004 claim.”

“Au contraire, mon fraire. Claim… S. That’s CLAIMS… as in plural. When I called on 11/28 I noticed, and was concerned, that the representative was focused on 10/04. I asked about four claims for October 2004; PLUS, on three separate occasions I clarified with your representative that the bill from the PCP listed three dates of service OTHER than October 2004 – specifically: July 2002, March 2005, and May 2005. I see that my efforts were in vain.”

“Sir, my break is over. I’ve got to get back to the phones.”

Click.

Talking to my insurance company on the phone has proven to be an excellent source of energy. Now I just have to find a constructive outlet for that energy.

Another epic struggle against the forces of evil

Health insurance, billing departments, complaint resolution offices, and the automated phone answering system… horsemen of the apocalypse or God’s warning shot across the bow of today’s later day ark of bureaucracy and civilization?

All I know is that I don’t want to pay $800 for services that were supposed to be covered by my health insurance provider.

See if this sounds eerily familiar… your doctor sends you a bill for services your health insurance provider (HIP) denied coverage. You call your HIP and verify that these kinds of services are normally covered; but, they tell you your doctor never submitted the claim. You call your doctor and they tell you they did. You call back your HIP and they tell you your doctor didn’t. You call back your doctor for proof they submitted the claim, and they tell you it was submitted electronically… or in other words, fat chance getting your proof. You ask to speak to a supervisor, and they tell you she’ll call you back. A week later you get that call in the evening, at dinner time, at the precise moment your one year old son starts tossing a grand fit, whilst in the throes of hunger. The supervisor assures you she will have someone call your HIP and get things all straightened out… and that if she has any problems she’ll be back in touch. When she doesn’t get back in touch in two weeks, you become hopeful… until you get another bill in the mail for $800. So you call your HIP with the specifics of the bill (again), and they advise you they’ll forward the information to their complaint resolution office, who will respond in two weeks with their results.

My guess is there’s some research out there which suggests “two weeks” is the optimum answer to give to a complaining customer. It’s not enough time to seem like NEVER to the customer (like three months would), while still giving a fair chunk of time to actually do something; and, (most importantly) it gives the customer plenty of time to forget the complaint in the first place. What I’d like to know is if they actually intend to be DONE in two weeks, or if they’re giving a research based answer of placation. In either case, I’ve got my calendar marked. Maybe this is one case where business should run more like a government?

Running a business more like a government, revisited

Here’s my list of the world’s largest bureaucracies, listed in order from biggest to smallest: the U.N., the U.S. health care industry (lumping providers and insurers together), the old Soviet Union, and the Federal Government. Feel free to quibble with my order – I’m not married to it – but you’ve got to admit that they all deserve to be on the list. Today I have no qualms with world organizations or sovereign nations (red commie bastards and otherwise). No friends, today my ire is directed at everyone’s favorite whipping boy: the health care industry – and specifically, one unnamed provider of prescription medication.

It all started with an order for drugs by mail. By now most of you are familiar with the mail order drugs phenomenon – the Sam’s Club of prescription medication. Well we were a little late to the party, but we were eager to take advantage of the cost savings realized by buying bulk. We placed our order and waited the recommended two weeks for delivery. In no time at all we received an email confirmation that our order was received, then, nothing. When our patience finally gave out, Cheryl (our designated corporate complaint liaison), picked up the phone. The news was not encouraging. We were told that our order was not shipped because they needed our authorization to ship a partial order (due to one of the prescriptions being denied by insurance). Never one to shy away from a telephone confrontation, Cheryl replied, “Did you ever consider soliciting our authorization, or did you plan to wait for us to get desperate enough to call you?”

Ah, the delightful smell of conflict in the air,

Cheryl gave them authorization to ship the partial order, and asked them not to pursue clearance for the denied medication (we no longer wanted it). Two days later we received our medication, sans the one we needed most – and unexpectedly including a 90 day supply of the denied (and unwanted) medication. That prompted, you guessed it: another appearance by our corporate complaint liaison. The mail order company explained that our much needed medication was no longer on our insurance formulary, and that they would send a return label out to us for the unwanted medication (and a refund). The next day, we filled the same prescription (that was not filled by the mail order joint) at our local pharmacy. If we found any of this the least bit funny at the time, this next bit would have us blowing our milk out our nose, our local pharmacy owns the mail order service.

Another two days pass, and I discover a voice mail message on my cell phone. It was the mail order service. They wanted to speak to me about getting money off the price of prescription number xxxxx. I called them back the next day. It turned out that in return for our troubles they were willing to discount my next refill of the prescription indicated in the message. You guessed it. It turned out to be the medication they originally said was denied, and then shipped anyway.

“Let me get this straight. You want to give me half off a prescription that was denied by insurance, that we said we didn’t want, and that you already sent to us once by mistake?”

“Can I put you on hold?”

It turned out she wasn’t really asking.

Dear Lord, I never thought I would need to ask you this favor, but could you please make them stop sending me drugs I don’t want?

Government v. Business, revisited

When conservatives say that government should be run more like a business, I hope to God they’re not referring to the insurance business.

Let me start by saying, the facts of the case I’m about to explain are mostly undisputed. The involved parties are: me, my wife, my daughter’s doctor, my daughter’s specialist, our insurance company, and our pharmacist. Here are the pertinent, undisputed facts:

1. My daughter has been correctly diagnosed with a condition that generally responds to medication.
2. This condition should be treated.
3. There is a relatively new medication that sometimes works when other’s do not.
4. This medication is not normally covered by insurance, unless the other alternatives have been tried first.
5. My daughter has taken all of the available, relatively cheap, alternative medications; which did not work.
6. My daughter’s doctor has submitted the correct documentation in order for insurance to approve the medication.
7. My daughter’s doctor wrote the prescription one month ago, and we attempted to get it filled immediately.
8. Our pharmacy is in possession of a properly completed, hand written prescription from our daughter’s physician.
9. Insurance has approved the prescription.
10. We have attempted to pick up the prescription more than once, AFTER insurance “approved” the prescription.
11. We still have not been able to actually purchase the medication.

That last one bears repeating: we still have not been able to purchase the medication. Why on earth not? Now we get into the disputed facts:

1. Insurance claimed that Beth’s doctor did not send them anything on a timely basis. In fact, Beth’s doctor provided us with FOUR fax transmittal receipts, showing they did submit the documents on four different occasions – to the fax number provided by the insurance company. The first fax was less than one week after the doctor wrote the original prescription (immediately after we learned it would be necessary – based on my hunch, that insurance would not cover the script without some extra effort). The last fax was found right after Cheryl lost her temper with the unsuspecting insurance customer service rep. I find it amazing that force of will can affect the physical world in such a manner. I was taught in high school that matter could be neither created nor destroyed – but apparently it can be teleported with sufficient emotion.

“Nope, we still haven’t received it.” **ANGRY RESPONSE CENSORED** “Oh, here it is.”

2. The pharmacy did not submit the insurance claim correctly. In fact, in a rare display of dedication from a low wage, pharmacy tech, this author watched the pharmacy call the insurance company on two separate occasions – so that the insurance company could walk them through the process to make sure it was submitted correctly.
3. Beth’s doctor is not authorized to write prescriptions that are covered by our insurance company. In fact, we got prior approval to see the doctor – which we verified with our insurance company on the morning of our appointment. Further, insurance had approved two prior prescriptions written by this same doctor (less than three months ago). And finally, I called them on my cell phone from the pharmacy lobby – and they assured me the prescription had been approved. Why would they tell me the prescription was approved on the phone – as written by this doctor, and then deny it when the pharmacy submits the claim? How, in the name of all that is holy and good in this world, can my daughter’s prescription be approved by the insurance company, but the pharmacy claim be denied? Is it approved or not? It seems to be a black and white issue, a boolean variable, one or the other, MAKE A DAMN DECISION AND STICK WITH IT, #@$ !@%& *&!!

Here’s the score, as it stands today: one month, 25 phone calls, two trips to the pharmacy, two hours in the pharmacy lobby, 60 cellular minutes (30 of those cellular minutes spent in said lobby – the other 30 spent long distance from New Hampshire), zero prescriptions filled, AND TWO IRRITATED PARENTS.

I am pleased to announce that this month is the benefits open enrollment period for state employees. We have until October 15 to make a change to our chosen health insurance provider.

Frustration, insurance style.

What is your favorite part about seeing doctors. Some would say that they don’t like to be poked and prodded. I suppose I don’t like it anymore than the next guy, but I’ll survive. Some people are aggravated by the long waits in the lobby. I guess I’m more patient than average; either that or I’ve long since been beaten into submission by countless lines and waiting. Growing up within driving distance of Disney World builds up your tolerance for that kind of thing. Here’s what gets my gourd: showing up for an appointment not knowing if your referral (otherwise known as “pre-authorization for care”) has been completed by your “PCP” (Primary Care Physician ) and health insurance provider. It sometimes feels like I’d have better odds getting a straight answer from a politician.

What could possibly have brought this issue up? It wouldn’t be because I’m sitting in a doctor’s office now, could it?

Don’t get me wrong, I’m mostly happy with my health care – even my health insurance provider. I usually get what I want out of it, it just takes a little effort. It’s just times like these that I wonder if the private sector can really do everything better. My experience suggests the notion is nothing but a pipe dream – and someone definitely inhaled.