Insuring Health Insecurity (2/16/15)
How Health Insurance Makes You Feel Unsafe
Insurance is supposed to give people a sense of safety from harm or threat. If there’s a car accident, someone will fix the car. If a fire wrecks my home, there is money to replace it. Yet the health insurance industry – with its varied “benefits” – has spent decades creating new insecurities. What’s left? That a real safety net exists only for the very, very few. Researchers measure the costs of this insecurity through lack of “access to care.” Yet the real costs – mentally, socially, and spiritually – are not counted – by bean counters or politicians. Instead they’re felt by by you and me.
How They Do It
As befits an industry which attains almost a fifth of the national economy, health insurers are ingenious. Here is just a very small sample of some of their innumerable and innovative tricks:
PreAuthorization: You need an expensive drug to treat your rheumatoid arthritis. You check out all the Medicare Part D insurers and find one who assures you – on the Bible – they will cover the medication. You buy their insurance.
But when the time comes the medication is refused.
Except you had the “guarantee” in writing.
If the insurer agrees to see the document – generally people accept the word of salesmen which is even more worthless – they are told to check the fine print. Their contract allows for “substitution” at the behest of the insurer, or disappearance of the medication from their formulary due to “market conditions” – or any reason they might care to make up.
You can get new insurance a year from now – if you’re still on the planet. In the meantime, you get your physician to fight for preauthorizion.
She will then talk on the phone to a representative who will move you to another representative who will put you on to a third, and so forth. My personal record so far is nine representatives, of whom five asked for the same information they could read on their screens – “just to check.”
After such ordeals medical personnel become wary of spending an hour on the phone to receive a fax they should have been given immediately. That fax will then ask for chart information over the last twenty or more years of treatment – demanding exact dates and results of the different medications you’ve had. At seven years many medical records are pulped – if you can get them sent from the now retired docs who filled them out. Impossible demands then lead to frequent “deauthorization.”
Variations of the preauthorization gambit include: agreeing to preauthorize, then not paying for months or years or forever; making health practitioner office staff spend hours to months resending “requested materials;” setting up arbitrary numerical allowances (‘you are allowed only one pill for day of this medication.’) There are many other ways to make the preauthorization fail.
Corruption breeds cynicism. People learn not to fight, because they will lose or spend so much time in frustrating battles that they think of little else in life. Many a parent with a sick child has quit their job to “work” full time at fighting insurance companies. Physicians learn to “go after the money,” targeting treatments and diagnostic tests that are readily paid for, not wasting time with “unpaid” actions like instructing patients or simpler, cheaper treatments that otherwise “eat into” physician work hours.
The Stall – You experience good fortune. You get preauthorized. Your treatment is considered within “standard clinical guidelines.”
They just won’t pay for it. One patient first required proof” of her retirement from her school job. None of the pieces of paper she sent were considered “satisfactory.” She kept on sending more, and never heard more for months – until she was turned down.
Her bills mounted up and up.
The Switcheroo – you think you have a practitioner lined up for your rare tumor, only to discover that they and their institution are no longer on your “provider list.”
A much more common arrangement is performed by pharmacy “benefit” companies. Often these benefits include changing generic drugs among manufacturers – without notifying you or your physicians.
When you find that the “orange pill” has become the “white pill” and then the “red pill” you are happily told that the “active ingredient” is the same.
This is technically true. However, the binding and delivery agents are different. Absorption changes. You discover this fact when your blood pressure skyrockets or you suddenly feel nauseous or your mood nosedives. The insurer blandly notes the medication is “the same.” You are told just as in TV advertisements to “ask your doctor” to change it. However when she’s on call this weekend she’s livid to discover that a standard medication has been changed repeatedly without her knowledge.
Fear of illness scares people – sometimes to death. So does fear of lack of effective insurance.
The health costs of this mess are indeed catastrophic. People spend their entire waking lives arguing with their insurance companies – often when they are dying. Believers that “the market” will fix things should consider negotiating immediately after their kid has had a car wreck, or their newly diagnosed cancer’s chemotherapy costs $60,000 per cycle – and the insurer demands a few months of paperwork before preauthorization.
The system is so broken that even truly rich people – the top .1% – tell me they need to “keep on working” to pay for the potentially staggering and unknown health care costs of the future.
What does this do to patients awaiting emergency treatments? To their families’ mental health? To the psychotherapist who must spend 40 minutes on the phone to “authorize” a 45 minute session? To the collective health of the nation?
The subject is not well studied. The health insurers – and the government – don’t readily pay for such research.
For now people continue to channel their effort into individual actions. How else do you explain that chief of the company that perpetrated the greatest (discovered) Medicare fraud in history was recently re-elected governor of Florida?
The simple explanation is fraud pays – economically and politically. A hundred million dollars buys effective political campaigns.
But fraud and fear of destitution does not buy health – economic, social, or psychological – for the people spending their time on the phone, fighting for preauthorization, for “benefits” they can no longer believe in.
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