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!

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.

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.

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.

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.

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.

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

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”