Insurance Rant

As the vice president of a small company, I see how hard it is to pay for insurance. We want to do right by our people. It gets harder every year to make certain we all have insurance. Both the company and our people pay thousands of dollars every year. For what? So that the insurance company can treat us like we are trying to rob them every time we make a claim? If your doctor doesn’t play the game right, you are screwed. I’m not advocating any side in the current debate over healthcare. All I know is that the current system is broken. If you don’t think so, then you have been a very lucky person indeed.

Speaking of health insurance. In 2008, 43.8 million persons of all ages (14.7%) were uninsured, (http://www.cdc.gov/nchs/nhis/released200906.htm). That’s right, 43.8 MILLION people! Check out some of those other stats on the Centers for Disease Control and Prevention site, (http://www.cdc.gov/).

I have two wonderful friends who have agreed to let me post their thoughts on this blog. They are two of the most intelligent people I know. They have worked in the trenches of medicine. These are real people who know first-hand what it is like to deal with insurance.

Dr. John Cmarr
My own perspective on the current status of healthcare is colored by two things: the how insurance companies fail in helping me to do my job, and my time in the VA system.

My biggest frustration with insurance companies stems from the fact that they are companies, and so profit is a primary objective. As such, they have huge incentive to deny payment for claims, tests, and medication, which leads to policies designed to encourage that to happen.

One example of when insurance compnies fail, which I run into on a frequent basis is in the denial of certain medications or tests. At least once a week, I am faced with a patient who is unable to get a specific medicine that I prescribed for them because it either is denied by the company, or needs “prior authorization” because the company wants me to give them a different but similar medication from their formulary, because it costs them less. Sometimes it’s not a big deal that I substitute one medication for another, but in many cases there are specific medical reasons I am prescribing the drug in question. The appeals process involves long phone calls and paperwork that can eat hours of my time, and is no guarantee that the company will ultimately agree to cover the medication. Sometimes it feels like a war of attrition, in that I decide that the time and energy I waste, and the delay in getting the patient needed care, is just too much, and so I just go with what the company will cover.

There have been several occasions where companies have denied paying for a CT scan on a patient when it is urgent and necessary, in which case I’ve had to send the patient to an emergency room to get it done—an obvious waste of time and resources.

My time at the VA hospital system during my training was very illuminating. I concur with a oft-quoted opinion that the most successful and biggest socialized medicine organization in the world is the US Veterans Affairs system. In terms of services and access, it’s excellent, with the biggest issue being long waits for patients to get some services. It’s electronic medical records system is awesome in terms of functionality, if sparse in interface. Overall, it’s more functional and reliable in many ways than the standard US healthcare paradigm, and if I had my choice, I’d transfer my care to the VA system in a heartbeat.

About Dr. John Cmarr
John Cmar, MD, has been long enthralled with horrible infections that could spell doom for humankind, as well as sanity and skepticism in the practice of medicine. He is currently an Instructor of Medicine at The Johns Hopkins University School of Medicine and an Infectious Diseases specialist at Sinai Hospital of Baltimore, Maryland. In his role as Associate Program Director for The Johns Hopkins Internal Medicine residency program at Sinai, he teaches an annual course series in evidence-based medicine, among many other duties. He also does Infectious Diseases outreach in Baltimore television and print media. John is also a science fiction and fantasy fan, avid gamer, and podcast enthusiast. He has made contributions to several podcast projects, and can be currently heard in Mur Lafferty‘s audio drama The Takeover (zombinc.net).

This article was originally printed in the Traverse City Record-Eagle on August 25, 2009. (http://www.record-eagle.com/archivesearch/local_story_237071143.html/resources_printstory)

Medicine is trust, not money
By EMMY LOU CHOLAK
August 25, 2009 07:10 am

—
As a physician, I have worked long hours in the emergency room—seen, felt the calamity. I will never forget one little boy. The nursery school brought him, saying he did not play that day. He was quiet. All tests returned negative. Since the family had no insurance, we sent him home with strict instructions to call or return if a fever or cough developed.

About five hours later he returned, dead on arrival. He had meningococcal meningitis, a very contagious, quick-acting killer. Everyone exposed to him received preventive medication. If he could have stayed the night, he would have received the medication he needed and hopefully would have recovered.

A woman was admitted with a mass in her left breast, larger than a grapefruit. She told us a truck hit her. We all knew better just from seeing it. Her cancer was too advanced. She died within the year. She was young, in her 30s, had three children. Both she and husband worked, but they had no health insurance.

The case histories could fill a hospital with many untold stories of sorrow, pain, death. How do the uninsured get treatment? They wait until they can’t function anymore, then go to the emergency room. Their cost of care is 40 percent greater than preventative care. They are sicker. The outcome of death is more likely. With these facts, how can we not afford reform?

We pay more now, through our general taxes, for the uninsured person’s care through the emergency room than we would under any reform package offered. It is estimated that 52 million Americans will be uninsured by 2010. The lack of health insurance coverage causes 22,000 deaths each year. We are 45th in the world’s ranking for quality health care. We spend more, get less.

The lack of health care insurance is everyone’s loss. We pay for it through our taxes, loss of jobs, the weakening of our economy.
We pay for it with decreases in our own health care. Hospitals have to lay off nurses due to lack of funds. Our fees for hospital care have risen in an attempt to offset these losses.

We also pay for it in the loss of qualified physicians. The zeal to become a doctor for humanitarian reasons has been lost due to insurance companies’ demands to account for time and fill out forms, rather than account for patients helped and cured.

This is especially true for those practices where individual care and listening go a long way. Many doctors get discouraged or choose to work part time. The passion has been driven from them or has no opportunity to blossom.

Medicine is that trust in the doctor-patient relationship. That relationship hastens recovery, leads to cooperation with treatment, consoles. That relationship is being eroded by our health care system today.

I have provided my patients with the best care possible. But today, with the constraints the present health care system places on all physicians, it seems almost impossible.

It’s time to make things better.

About the author: Emmy Lou Cholak, MD, was a pediatrician in a public clinic in a large inner city, taught sensitive interviewing to medical students and residents of medicine, taught in the psychiatric emergency room and ran a ward for abusive families and abused adolescents during the eating disorders epidemic.

Copyright © 1999-2008 cnhi, inc.

Healthcare links:
Centers for Disease Control and Prevention
(http://www.cdc.gov/)

Myths and falsehoods about health care reform
(http://mediamatters.org/print/research/200908200002)

Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2008
(http://www.cdc.gov/nchs/nhis/released200906.htm)

Thank you for reading this blog. I’d love to know what your experiences have been.

Oh, and one more thing… why aren’t eye and dental care just part of health care? Is there anyone out there who can give me a good reason for that?