Doctors and patients need to learn to live with health insurance companies

by Marie Cooper

Consider two patients with the same managed care plan.

One has multiple sclerosis and receives an infusion of Tysabri every month. It needs pre-certification. The requirements are black and white. The patient qualifies if they have relapsing/remitting MS and have failed other therapies. The drug costs $2,000, the infusion center is another $1,000. The infusion center is a contracted provider that has two of their staff people dedicated to keeping track of needs for referrals and pre-authorization’s for their patients.

To the patient, this is a seamless process. She shows up every month and receives her treatment. She has no co-pay. Patient A loves her insurance plan.

The second patient had a fall and broke her right humeral head a year ago. Following an open reduction internal fixation, she has physical therapy three times a week. PT has been effective, but recovery is slow. Things are fine until the tenth week, when PT is denied, as the patient has a PT benefit of 30 visits per injury per year. The patient and the physician are incensed. This is medically necessary. The doctor has ordered it. The patient needs it. But the contract says only 30 visits will be covered. Two levels of grievances uphold the decision, it is a contractual exclusion. The patient is welcome to continue attending physical therapy. But the insurance company will not pay for it. Patient B hates her insurance plan.

Patient A and Patient B are the same person.

I use these examples to show the best of managed care and what makes people unhappiest about managed care. Managed care is designed to save money and increase profits while paying for needed care. Americans, in a culture that traditionally wants to have its cake and eat it too, has a love/hate relationship with their insurance carriers because they don’t necessarily get everything they want when they want it.

Insurance is a business and, for now, it is here. It what we have. The old days are gone and are not coming back. So I suggest the best way to cope is to deal with it.

I don’t mean that to be obnoxious. I mean deal with it in a way that is productive and emotionally healthy for doctors and patients until something better comes along.

Doctors
* Have one person (or more) in your office dedicated to dealing with managed care. Or, for practitioners with small offices, hire a part time consultant. It will pay for itself in better organized claims and increased revenue.
* Know the rules; understand that these are contracts and if something is contractually excluded, that is it, it is just not covered. It is not a malicious plot, it is a business model intended to save money, employer money and employee money. Almost all of the time, it is the employer who chooses limits in a plan, not the insurance company. And the limits are chosen to save money.
* Document everything the patient says about their condition, even if it seems innocuous or offhand. That way down the road, if something needed 6 months of conservative treatment, you have it documented. Too many progress notes simply say “no complaints” or “better”, which practically begs a denial.
* Know the criteria for your most common procedures so you can have the documentation to back up your request.

Patients
* Read your Evidence of Coverage – the book you get when you enroll. Know your benefits and their limits.
* If you don’t understand something in the EOC, go talk to your benefits rep in the Human Resources deptartment.

Remember that insurance is a business. It is not personal. If something is denied, look at your part in the process. Did you follow the guidelines? Is it a contractual exclusion?

It is not a perfect system. There is greed, carelessness and errors. It can seem complicated and capricious and unfair. But it can work.

However, if providers and insurance companies don’t work together, everyone suffers. Doctors do not receive their well-earned compensation. The insurance companies cannot sustain themselves financially because they will lose members. But most of all, it is the patient who loses the most if providers and insurers continue their hate fest.

Marie Cooper is a freelance writer and management consultant at Achievement Strategies.

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  • http://twitter.com/chukwumaonyeije Chukwuma Onyeije

    I think it *is* cynical to put this debate in terms of people “wanting their cake and eating it too”. Shame on you Marie Cooper. Your argument appears to suggest that people who face medical bankruptcy are in that position because somehow they were either greedy or they wanted to get something for nothing.

    Numerous European countries show conclusively that for the same amount of money that we currently spend we could easily achieve close to universal coverage and improved health related outcomes on a number of fronts. Rather than telling physicians and patients to “deal with it”, I think it is time for insurance companies to adjust their business models to address the fact that we currently pay the most and (in many cases) don’t get the best care or outcomes.

  • stargirl65

    * Have one person (or more) in your office dedicated to dealing with managed care. Or, for practitioners with small offices, hire a part time consultant. It will pay for itself in better organized claims and increased revenue.

    I am a solo doctor with one employee. This is the way for me to stay afloat. You want me to hire someone simply to get things authorized? Work that I won’t even earn any money for doing? It is NOT my job or responsibility to complete a bunch paperwork designed to deny or delay needed care. If it is not covered then the patient must simply pay for it. Or they can try to get things through.

  • http://kalamazoopost.blogspot.com Tony61

    Ms. Cooper, spoken as a true bureaucrat… “deal with it” even thought the “it” provides no value to the product and only acts to diminish access for necessary care. How about this: revolution.

    As a physician I can tell you that the days of insurance companies each dictating arbitrary standards and barriers designed to exasperate doctors and patients should end. If Tysabri is indicated, then the the patient should get it. If physical therapy is warranted, then the patient should get it. I know it sounds crazy.

    Doctor’s progress notes are designed to track progress for the benefit of the patient, not for insurers to dissect for “evidence” to refuse necessary services.

    In our community there are a dozen different insurers and each has several insurance “products” and each employer can sign up for ala carte benefits. Knowing the ins and outs of each of these leaves a morass to navigate for physicians and patients. Insurance companies seem more than able to consort with each other to set benefit limits, yet they are amazingly unable to comport with recognized medical standards in a way that makes sense for sick patients.

  • R Watkins

    “The infusion center is a contracted provider that has two of their staff people dedicated to keeping track of needs for referrals and pre-authorization’s for their patients.”

    And you think this is good? I consider it a disgraceful waste of human and financial resources that could be used for true health care.

    Shame on you, Marie Cooper.

  • http://www.linkedin.com/in/achievementstrategies Marie C

    Chuklwuma, while I generally think that Americans as a culture do want to have their cake and eat it too, that is not what I am saying here. I mean this essay as a reminder that managed care is a business. Dealing with it as a business can shift the way the most common problems are addressed. I am suggesting taking the emotion out of the equation makes things easier for everyone.

    I do not address at all issues of medical bankruptcy. That is far beyond the scope of this article.

    As far as greediness, that is primarily on the part of the industry. Consumers/members want things that are not covered often because they simply do not understand what their coverage is, not because I think they are greedy.

    Dr. Stargirl, could you share the services of a consultant with other solo practitioners in your area? A small practice would not need someone for many hours in a week. Perhaps a consultant could do a training for several staff members?

    My point is not about ‘giving in’, so to speak. I am not about criticizing doctors or patients. Rather I am writing about making the best of a flawed system until we, as educated professionals, can figure out how to create and implement better one.

  • http://medicinacodigoabierto.wordpress.com/ Medicina Código Abierto

    Healthcare requires pooling risk of a population. Insurance is just *one* way to do it. Healthcare financing does not need to be a business.

  • http://www.linkedin.com/in/achievementstrategies Marie C

    Ouch you guys!! lol

    Come on, this is my point. There is so much emotion instead of putting heads together to cope or change it.

    There can be better ways to do things, let’s figure out how. But in the meantime, this is what there is. If we don’t like it, what are we doing to change it?

    “Bureaucrat” is unfair. I am a realist. When I face an obstacle, I try to problem solve instead of wasting my time getting angry.

    The people who do insurance work in medical offices, like many lay staff, are not people with multiple degrees and skills who have endless career opportunities. These are people who hone careers they wouldn’t otherwise have. They develop an incredible knowledge base. They are not clinical people and these smart, savvy staff members are certainly not wasted.

    Finally, I am not ashamed of anything (except maybe that time I found the cat licking the roast and I served it anyway; but hey, nobody died). I do not pronounce Managed Care to be wonderful. I said it is what it is. I have not said it should never change. I said let’s figure out something better.

    This isn’t a perfect world. Do what you can to make things better, not worse. And life is short. Don’t waste it being angry. Be an agent of change or find a way to live with what you can’t change.

  • skepticus

    Health insurers are pernicious middlemen. They are the epitome of what the economists call the agency problem.

    Their incentives are perverse: Once they get your premium they have the incentive to pay as little as possible on your health.

    Go HSAs! Let’s limit health insurance to costs above 10K–and allow individuals to save for catastrophic illnesses.

    Get insurance companies out of peoples’ and doctors’ lives.

  • http://kalamazoopost.blogspot.com Tony61

    I give Marie a lot of credit for speaking out in defense of the bogeyman du jour, ie health insurers. She speaks truth about managed care being here to stay as evidenced by the TeaPartiers who are fighting the grass roots fight for the status quo, for whatever weird reason.

    She says, “There can be better ways to do things, let’s figure out how. .. instead of wasting… time getting angry.”

    Sure, and that my be good advice, but I would argue that sometimes it’s appropriate to get angry and those on the side of health reform have not been angry enough… certainly not compared to the Teabaggers.

    Doctors (and nurses) should have one goal: the welfare of their individual patient. Period. Yes, rationing may need to occur, but that is not the purview of the doctor and now we have too many people trying to decide how to ration the care: Medicare and all the payers have fairly arbitrary standards. As a physician I ask– I beg– pick one friggin’ standard and stick to it. I’m NOT going to “hire more staff” to sort it out just so they can make it more and more complicated so that I’ll need more and more staff.

    Really, I’m not going to do it. Enough! It’s time to get angry and demand one standard, one payment. If we are going to have the status quo of 17% of our GDP going to health care then none of us will survive. Insurers may need their profit-margin so they can keep the game going and if that’s the case, then we need to get rid of insurance companies. Nothing personal, Marie; you seem like a very intelligent person, I’m sure you’ll find a job doing something useful.

    Personally, I figured out that the status quo was not going to easily change about 4 yrs ago… I sold my practice, now work as an employee of a large hospital. The hospital has teams of staff to “optimize billing and coding and reimbursement and contracting” and they throw me a few pennies after all their bills are paid.

    And I count the minutes until I qualify for “socialized” Medicare and can call it quits. I know you mean well, Marie; I just disagree with you.

  • Nuclear Fire

    I completely disagree with the concept that managed care or insurance companies are here to stay so deal.

    There is a small and growing movement of doctors that just don’t accept insurance for philisophical and practical reasons. See Hello Health or many of the micropractices out there.

    I personally believe that so-called insurance is bad for medicine in general and for patients and physicians in individually. Physicians are under no obligation to accept it. Patients are free to choose to finance their healthcare expenditures that way but we don’t have to accept it as payment nor spend time justifying our decisions to a non-medical entity. Maybe if the patients have to deal with the companies directly they’ll vote with their wallet and the companies with change to retain their business.

  • http://www.linkedin.com/in/achievementstrategies Marie C

    Tony, you make an excellent point that I neglected. I hate to see people waste their energy on pointless anger. But anger that is a catalyst to create positive change can be a very good thing indeed.

    Nuclear Fire, I agree with you, I don’t think managed care as it exists today is going to survive or is here to stay. What I would like to encourage people to do is deal, as I say in my article, until something better comes along.

    We clearly need an improved, more equitable system. I believe the creation of such a system has to be a joint effort. We have some brilliant minds in this country. Enlist their expertise. Lobby your legislators. Work to change what you don’t like. If you can’t, support the ones who are working for change.

    I salute the earnest practitioners who have commented here and put their patients before anything. And I appreciate the thought provoking and passionate responses. Thank you all so far.

  • LynnB

    I just WISH I could quit getting angry on behalf of my patients .

    A DME company in my town sent every patient they saw a heating pad –just like the ones you buy at the drugstore-when they got glucose strips, urostomy supplies, walkers after a fracture , or whatever. They then sent me a DME form to go to the insurance company so they could get $100 for it. I kept getting forms and finally called a couple of alert patients . They didn’t ask for them. One said “sure” when they offered her a free heating pad. One had no recall of any conversation. I called the insurance company , full of righteous indignation . They had no interest and still use the same con artist company . I guess they can always get work ferreting out our abusive practices like putting in Foley catheters during abdominal surgery and trying to kill the patient by leaving them in for 24 hours .
    I saw 19 patients yesterday –12 insurance plans . We have 4.5 employees per doctor already, some of whom work with billing . For a 213 I get $21 before taxes .If I hire another employee I am going to have to work at the paper mill in town (if I can get out of call) , since the mill pays more than my $40 including charting time per hour on weekends . Right now our PHO billing employees are primarily focused on being sure we won’t get caught by the Medicare bounty hunters for such egregious waste faud and abuse as failing to write the time on a progress note in the hospital.

    In the meantime a patient on Remicade comes to hospital with facial cellulitis worsening after 36 hours on po antibiotics . She has no fever (DUH) . The admit is observation . I protest, overruled by coders because I “just don’t understand” . She pays inflated hospital prices for her simple IV antibiotics , 6 doses, and has to re-finance her house to pay for a 48 hour hospitalization. To make this even better I write to our carrier, taking 2 hours on a SUnday evening to round up the data. No dice, it was originally billed as obs and that is that .She ‘s on Medicare with a supplement and at least she gets the Remicade for her RA , which I am sure could have been avoided by taking personal responsibility for her health. Yes, maybe we could hire a hot shot coding company, but there is a big cost and in primary care IM , there are no profits to recover.

    I have many type 1 diabetics who are allowed to get insulin pumps AFTER they are pregnant, like after all the major organs are formed. Strong work there, all of the cost, half of the benefit. .. If they are dipdoodles with an A1c of 10, they get a pump, pregnant or not, since they have failed conservative therapy, to compensate for the fact they are not checking sugars or taking mealtime insulin and were too busy texting their friends during their half hour dietitian visit to learn the carb counts of their 4 favorite foods. The pump really fixed that. I won;t do it,its a waste of time and money . Come back to this discussion when we have enough data to show that you have dawn phenom or hypo unawareness and you know your eyes are OK and won;t get wosre as we tune things up. The patient taking 4- 5 shots a day and checking 6 -8 times a day (BTW they have to pay out of pocket for the extra strips ) with an A1c of 6.9 , and is planning a pregancy gets NADA. I am sure if she had just been home schooled as a child so she did not get the viral infection or whatever it is that starts the cascade of autoimmune diabetes she could have avoided her disease. This happens over and over , I wait till they are sick or depressed and get an A1c then , which will be “too high” . [All you angry type 1's out there, I am on your side,. If this was an advanced country like the Czech republic, you would all have the best available technology because it saves money in the long run. I am merely saying those that try hard are punished by being denied access to those technologies.]

    While I am on type 1 diabetes let me say the limit on quantities of strips is insane. They are almost a dollar each retail, unless you get the cheap strips,”generic” and know that 30% of the time they don’t work . How the heck is anyone supposed to attain near normal blood sugars without knowing what the the glucose is? Its the great Karnak method for sure -put yor finger on your forehead and “see” the glucose value , by Gosh. Even though I routinely tell patients to check blood sugar before they drive especially if they have hypoglycemic unawareness , even the managers and attorneys and physicians I care for have trouble affording it .The indication here is clear -I am following conservative ADA guidelines. The benefit should be there just like the sexy MS drugs and the Remicade.

    The problem is there is a lot of diabetes, and it would cost a lot to care for it adequately and the parasitic insurnace companies can get away with it. Part of thie issue with saving money is that for the companies ther is no “long run” In two years it won’t be their problem any more. The other problem is the $100 heating pad and the $170 15 minute visit and the insanely expensive glucose monitor strips. Costs exist and they are shifted . I even have patients that want to get sensors (which are covered) just so they won;t have to buy as many strips out of pocket. There are lots of reasons you might want a sensor, shifting cost to the insurance company should not be one of them. The sysytem is broken. My opinion on the cure is skewed by 20 years in the trenches.

  • http://kalamazoopost.blogspot.com Tony61

    LynnB, you are officially my new hero. Scorchin’ rant! I think KevinMD should make this a post of its own.

    ($40/hr? No call? Do you have the number of that paper mill’s HR dep’t for me.)

  • R Watkins

    It’s not unusual for me to walk through my office in the late afternoon after the last patient has been seen. Every employee is glued to a telephone, deep in conversation. Checking up on a sick patient? Conveying lab results to a worried parent? Reminding someone they missed their diabetes follow-up? NO WAY. Every single person- receptionists, nurses, lab techs, billing clerks- is talking to an insurance company, trying to get a pre-auth, appealing a denial, questioning a wrong payment.

    It doesn’t make me angry: it MAKES ME SICK. What a worthless, deplorable, obscene waste of health care resources. Yes, we have to work with these protection rackets as best we can, but we also have to denounce them far more loudly and effectively than we have to this point.

    And, sadly, it is physicians and our ineffective professional organizations that I hold most responsible for allowing this situation to exist.

  • http://www.linkedin.com/in/achievementstrategies Marie C

    Lynn, I agree with Tony, you should write a separate post just on this. What you describe IS crazy. It DOES have to change.

    Just because I offered some ideas on how to cope with managed care does not mean I totally agree with or support it.

    Even though I am a nurse and a consultant, I do not see all the things you physicians see. Your stories need to be heard, especially the ones that are Kafkaesque in their horrifying absurdity.

    My tiny little well meaning article could not even begin to address the frustrations you all deal with. It would take multiple volumes. Please know I have nothing but respect for you and empathy for your anger.

    I just wish, more than anything, I had better answers for you practitioners and for our patients.

  • Paul MD

    LynnB,
    Very good posting. Your frustration (justified) seems to be pulsating through my monitor. Do you have suggestions to remedy or just venting? You really have captured the moment of futility and absurdity in your rant. Again, well done.

  • LynnB

    I am part of the “great unwashed” that sees patients for a living accounting for my low-class fury at the patients getting a raw deal . If I was really serious about helping patients I would quit practice , avoid patients altogether, get an MBA and become an administrator who talks nice.

    ……………….Ranting follows …………………………………..
    One thing that reallly bugs me. When a patient has shingles and is worked in promptly so we can start treatment and I prescribe acyclovir or famcyclovir or valcyclovir, the PA process takes 1 week. Its TOO LATE!!!! The emergency process takes 48 M-F hours . Its still too late .. The dose of the drug is unique. I would be willing to take one , not 15 but one, shingles quiz so I could have permission to prescribe withiout PA . I could prove I know it has to be started within 48 hours and that I know the adjustments for renal failure and that I can recognize the distinctive rash if I could just save patients ,who are usually old and often financially strapped partly because of their chronic illnesses , some of the inevitable suffering.

    . Forty electronic charts behind and my partner just called asked where were the antibiotics for another patients UTI –I e- prescribed at 11 am, asking the pharmacist to figure out the correction for her ESRD, but no meds . The outpatient pharmacies often question and refuse to fill because its “not the usual dose” when I correct for stage 4 or 5 (or 6) kidney disease. I thought I’d throw the ball into their court so she got it and they were happy , but they were so slow she didn’t get the meds . I should have done their job to the best of my ability, and let them pick at my calculation and tell the patient they saved her from an unsafe prescriber. Of course I could have just prescribed the usual dose, which is what my partner did , of a quinolone , rather than cephalexin which is cheaper, narrower spectrum, covered her Kleb, and doesn’t lengthen her INR which is currently at 3.2. He is smarter than me in so many ways –everything you do that creates more work for another provider will be classed as bad medicine
    …coherent again…………….

    Two things that are low hanging fruit in my small town. Not so easy in the city, I know
    1. If a patient with a chronic illness can die without the drug (insulin in a type 1 , Flolan, amio for Vtach/Vfib, anti-rejection drugs) within a week, they should get a weeks supply FREE while their case is in review . If the review isn’t done, the free drug and supplies (since many of these are injected )continues .These drugs, or one that adequately (slippery slope here, but we are talking only a few diseases ) treats the illness has to be tier 1. The list would be limited to maybe 10 or 20 universally agreed upon disease states . The ACP/AAFP/ACOG and AAP are the honest brokers here , not specialty societies. Psych is too hard I can’t comment on what makes sense there.
    2. If a patient has cognitive , or visual deficits we should get to use the safest drug, not the cheapest . We should not have to use the MMSE to establish that patients should not be giving themselves coumadin or drawing up and mixing NPH and regular, or measuring from a mutidose vial of Fragmin with their 20/60 vision and 15 year old glasses . What about -. They can’t see or can’t figure out where the 12 and the 38 are on the syringe without help. They don’t know who is president, or believe its Reagan or Kennedy. They will vote for the politician who will “keep the government out of Medicare”

  • http://kalamazoopost.blogspot.com Tony61

    I’ll play the cynic to LynnB’s voice of reason. The AAFP,ACOG, ,ACP and AAP are “the honest brokers.” True, at least I feel that way about my group (ACOG), that they make decisions based on science and patient welfare. BUT the minute they are put into a role of deciding which therapies will be covered, that objectivity is OVER. All the lobbyists who are currently on K street in Washington will inundate the professional societies with favors, cash and sex to get their drug on the formulary or their “Heating pad” on everyone’s in-home hospital bed.

    That is the one and only good thing about having insurance payers spread out over 200 companies instead of one governing body.

  • Anonymous

    LynnB- no one could explain it better than you, I thoroughly enjoy your posts.
    MarieC- sorry, but I was a little disappointed to hear you are a nurse and yet naive enough to say ‘don’t get angry-just deal with it’. I know you might be very young but many people have DIED because they didn’t get the care they needed and fought for. Do you know how many times I’ve heard a person got cancer and was dropped from their insurance? Like Watson said, it doesnt just make me angry, its makes me SICK. And thats just skimming the top. My family and I are essentially healthy and I still have issues getting meds my doctors prescribe, such as for migraines and acid reflux. Im not going to die without those, not anytime soon anyway- but its times like that that I wonder what other people must go through- and the endless calls to our private insurance co? I had to pay out of pocket for my daughters yearly visit $150 because of diagnosis codes the previous doc ofc billed that described a ‘shot only’ visit as rountine that counted as her having ‘exceeding allowance for routine care’. Neither office or insurance company could fix that for me. I know $150 isnt much but again, I thought, if they can get by with this, what about others with worse situations and more limited means? Its ridiculous what private insurance co’s get by with. To deal with that, my only choice was to take it up the tailpipe.
    I dont think insurance companies should even be involved in healthcare. Insure your house, your car but thats it. They should not have this power without accountability to make the decisions they do.

  • Paul MD

    LynnB,
    You may have lost me when you may have implied that my society (AAO) may not be an honest broker…but I see your point.

    That folks like you, where ever it is that you practice, wake up to the crap you take, makes the thought of the paper mill or the MBA administrator more appealing. I would lean more towards the paper mill position. It’s probably honest work that contributes more “good” to society albeit fewer catered “meetings” to declare yourselves “masters of the universe”

  • http://www.linkedin.com/in/achievementstrategies Marie C

    These comments contain so many important observations, so much crucial feeling and information, I would urge some of you to please write guest pieces for Kevin.

    You are the front lines. You are smart. You are caring. You are a powerful, powerful group. If only that power could be channeled into productive change! Think about it guys, please. Write and write and write some more and copy your legislators. Inundate them. In this electronic age it has never been easier.

    As for me, I will stick to topics that will generate less hate mail. My skin isn’t tough enough. Now that I know Tony is a member of ACOG, I may forgo that article I am writing about my home births. I wouldn’t want to lose my “seems very intelligent” status with someone I have come to like and respect in this short time. ;)

    Thank you so much everyone for sharing your experiences and your ideas!! While I admire you all, I am so relieved you do not know where I live. lol

  • R Watkins

    Tony61:

    I don’t quite understand your posting. I’m not aware of anyone proposing that the professional organizations you list be given authority over formularies and such. Which is a good thing, because, in my opinion, these organizations have done a miserable job of representing physicians and their patients. They have been so intimidated by the insurance companies that they refuse to address publicly any of the abuses Lynn so eloquently describes.

    Written after spending 30 minutes on the phone to get a pre-auth for Tamiflu (yes, Tamiflu!!!!!!) during a flu pandemic.

  • Charles W Patterson

    If we all had a Health Care Savings Account, we wouldn’t need an insurance company. Just a public option of some kind for those of us with catastrophicly poor health.

  • http://kalamazoopost.blogspot.com Tony61

    To R. Watkins, I was responding to LynnB’s comment: “These [preferred] drugs, or one that adequately… treats the illness has to be tier 1. The list would be limited to maybe 10 or 20 universally agreed upon disease states . The ACP/AAFP/ACOG and AAP are the honest brokers here…”

    And my inference is that the professional organizations would have some authority to decide on the Tier 1 therapies. I really don’t have a problem with that concept, but if you play that to the extreme, if we had single-payer or similar, then the professional organizations would wield a hefty power of the purse. “Let’s cover Yasmin for birth control, but not Ovcon,” and then the formulary is widely adopted. I’m not saying it would happen, just pointing out a possibility.

    To Charles Patterson, the only problem with HSA is that studies show that patients will neglect routine preventive care and screening tests if they have to pay the entire cost out of pocket. Information is asymmetric and the average person cannot put proper values on various tests and drugs. For instance, a college aged woman with multiple sex partners is at high risk of having HPV, but she is very much disinclined to get a Pap smear if she has to pay for it, and the Pap smear is VERY cost-effective. She might be unable to judge what is “worth it” and what isn’t. The perfect system would set guidelines for specific screening procedures that are fully covered, too.

    Marie C: Home births? This is 2009. You’re a nurse. Do you drive 70 mph on the highway without seatbelts, too? Just for the “wonderful experience” of it? Please.

    Good discussion.

  • http://www.linkedin.com/in/achievementstrategies Marie C

    Once everyone stopped calling me names, this did indeed become an excellent discussion.

    I have to chuckle a bit. Anonymous, you sweet thing you, in your comment you remarked I “might be very young”. Tony, you say “Home births? This is 2009″.

    Well, my home births, my daughters, were in 1985 and 1988. You know, when we were still painting on cave walls. My sons were both born in a hospital. In 1977 and 1978. I have a 3 year old grandson. The youngest thing about me will be the artificial shoulder joint I am receiving on Monday. In reality, I am older than dirt.

    I do drive 70 miles on the highway, usually blasting Bruce or Aerosmith. But I always wear my seatbelt. :)

  • Ring-Ring

    “She might be unable to judge what is “worth it” and what isn’t.”

    My ear has been ringing for 4 weeks. An internet search says it might be ear wax. Nurse recommends I come in and have it looked at. Pay $150 to get ear wax removed? It could be more serious. $150 to get a referral to a specialist? An expensive workup for something that can’t be cured or treated effectively. Too bad my HSA won’t pay for the bottle of hydrogen peroxide.

  • R Watkins

    Marie, I don’t think any of the comments were intended as personal hate mail!

    I think it was the phrase “deal with it” that made so many of us see red. That’s exactly what every doc has heard thousands of times over the last twenty years, while we have seen the insurance companies become more and more an obstacle preventing us from delivering quality health care. Reading Lynn’s truly Kafkaesque nightmare reports, it’s clear that “deal with it” is a completely inadequate response.

    Thanks for participating in what has turned into a very emotional discussion.

  • LynnB

    We are all working in a seriously flawed system, which I personally believe needs to be ripped out root and branch, but I have chosen to try to save the world retail, one patient at a time.

    Recall that in our current system the best course for a pregnant woman with pre-existing diabetes is often–quit your job, drop your insurance, get on the public plan. The reason :, the co-pays for several weekly visits, fetal ultrasounds and strips and pump supplies, and the very high amounts ofshort acting analog insulin (esp if there is also child care) is higher than her take home pay . Now we could use regular and with GDM we do, but then we won;t meet the goals with preexisting type 1 and type 2 , and there will be hypoglycemia. Who gets pregnant? YOUNG women, who don;t have 3 months salary in the bank and if they do they want that to cover their time off work. Some of whom are even married and employed , even some married to guys with decent jobs. The insurance companies would save a bundle in neonatal ICU care by covering medically complicated pregnancies better, but they save even more by NOT covering and shifting the cost to the taxpayers. I think a healthy baby is a good use of my tax money, but it isn’t a good system. Show me your company’s possibly unpopular patient HEALTH centered uses of money then I will just deal with your company and your DME minions.

    I don’t think for a moment a physician organization setting formularies would be perfectly ethical. I think that when death is predictably imminent , the companies should be forced to cover till the company gets its act together. had to put 2 weeks worth of anti rejection drugs on my Visa card for a young fool with a heart transplant 10 years ago awaiting approval, which came, I was reimbursed the next month , but –ouch! I have a patient with a BMT who wasn’t being covered for her re-vaccinations because they are a pediatric benefit. Was the university center that did the transplant or the hematologist fighting that battle? Hell, no , that’s an unpaid primary care job. Was she going to die tomorrow with diphtheria or chicken pox? No , so I just did those letters on the weekend. .

    Approval at tier 3 is equivalent to a rejection I have a few patients sending to Europe or Asia for drugs, because here in Oregon they are afraid to go to Mexico because of the perceived drug wars, and the swine flu . Too late for that second worry, but so typical of the health care debate . The adequate dose of Revatio for IPH looked like $900 monthly without insurance and $500 at tier 3 when my partners and I talked about the NEJM review at lunch yesterday. Kind of tough when you can’t work full time and need to hire a housekeeper because you are too SOB to cook.

    Instead of quarreling about any theoretical panel to rein in the life threatening abuses of the companies who keep the employees on the phone to THEM instead of the patiients (love that stray) , wonder why Humalog is still $100 a bottle and people need insurance to pay for it, 15 years after release . Wonder why insurance pays better for a non-fatal case of fibromylagia than lupus nephritis.

    I would suggest organized physician input in the case of “what are diseases in which a delay in pharmaceutical treatment for 48 hours or a week (or some other magic number) is likely to have severe or even fatal consequences?” . The list needs to be very short and if something new goes on, something old goes off. What is one adequate treatment? Our organizations vary in how closely they are aligned with insurance and pharma. At least docs , with patient experience, can join and have a vote as opposed to being completely shut out . That is the current situation, unless you give up patient care so you have adequate policy credentials to enter the inner courtyard.

    . . Marie is a well intentioned experienced nurse , who works with high ticket players –infusion centers getting $1000 for an infusion. Shoot, I’d be hiring someone to keep the coin coming also . She just doesn’t get it– my primary care world has no hidden profits. Those of us seeing patients don;t have time , money or energy to fight them, and the companies know it .The wolf is at the door and both my patients and I might get eaten!

  • TrenchDoc

    Organized medicine can’t do a thing to change this because we are not unionized. We can’t unionize because of antitrust laws that don’t apply to insurance companies.
    Focus your staff’s efforts on getting the patient what they need. Don’t waste your time on PAs. Prescribe generics whenever you can. Any info from insurance companies that are helpfull “hints” on patient care tear up and throw away. It is not worth you time to interceed. Get the insurance company to send you written guidelines on their screening criteria so you will know what to document in the patients record.
    Bottom line: we are at war the patient are the hostages being held by the Insurance Companies evil empire and we are the guerilla warriors trying to free the hostages. Take off your blindfolds and jump in the trenches.

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