Posted tagged ‘insurance’

Child dying? Call your insurance company, first!

January 5, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

The action steps, in any health emergency, are: ABC. Airway, Breathing, Circulation. The airway has to be open, the patient has to be making an effort to breathe, and the heart has to pump blood. In any emergency, health care people are trained to address these, one by one, in order. Fix what you can before moving on, and concentrate on what’s going to kill the child first. Then, arrange transport for definitive care. That’s the core of life support, and how health care people are trained to respond to an emergency.

But in today’s enlightened times, health care isn’t run by people trained in health care. It’s run by bean-counting administrative flunkies who care only about saving costs.

Here’s this week’s true story: A child presented to my office in severe respiratory distress. He was not breathing well. In fact, he was barely breathing at all. We gave oxygen and supportive care, but he still needed more help—so we called an ambulance to transport him to the hospital. There, he was admitted to the ICU and received expert, life-saving care. He’s now doing fine.

Except his family now has to deal with a second nightmare. To get an ambulance to transport him, we called 911, and the county 911 service did what 911 services are supposed to do–they sent an ambulance over right away, with oxygen and trained people to get him quickly where he needed to be. But that specific ambulance company was “out-of-network”—that’s not the ambulance company that the family’s health insurance company wanted him to use. So the ambulance trip goes to “out-of-network” benefits, at a lower coverage rate with a separate deductible. And the family owes $1900 they can’t afford.

Bean-counting administrative flunky: Hello, sorry for the 30 minute wait, can I help you?

Mom: My child is blue and dying. Which ambulance company should I call for in-network benefits? Money is tight.

Bean-counting administrative flunky: Please enter your 15 digit member ID number, or say the numbers out loud.

(Etc, etc. After another 45 minutes Mom gets a straight answer to call Bob’s Ambulance Company. Bob and ambulance arrive 30 minutes later. The child is dead.)

Seriously: even if mom knew the name of the ambulance company that was “in-network”, she doesn’t get to choose what ambulance comes when she calls 911. They send whoever’s closest, whoever can help—that’s what a health provider is supposed to do. Help the patient. Unlike, obviously, the insurance company.

Bean-counting administrative flunky: Hello, sorry for the 30 minute wait, can I help you?

Mom: My child is dead. Which mortuary should I call for in-network benefits?

Bean-counting administrative flunky: Please enter your 15 digit member ID number, or say the numbers out loud.

The Affordable Care Act has helped many more people get health insurance. But the insurers are still in the business of making money, not in the business of providing health care or paying for health care. They don’t make their money by paying bills. They make their money by doing whatever they can not to pay the bills. If you want to get them to actually pay for your health care, you’ve got to know the ins and outs of the contract, and you’ve got to steer services to “in-network” providers– that includes hospitals, docs, pharmacies, and even ambulance companies.

Child dying? Forget the ABCs of airway, breathing, and circulation—your first call, now, is to your insurance company*. Do a crossword while waiting on hold. And maybe give your child a little oxygen, while he waits—just don’t expect the insurance company to pay for it.

*Though this post was 100% true, the advice in the last paragraph was “snark”, for comedic effect and narrative impact. If your child is very sick and you need an ambulance, call 911 right away. Do not call your insurance company. Later, you may have to straighten out some bills—but take care of your child, first, always.

Insurance tries to make it your doctor’s fault

January 6, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Little kids don’t like to accept blame. They’ll say “someone else did it,” or “it’s not my fault”, and they’ll look at the ground and shuffle their little feet. In their hearts, maybe they really think that someone else scribbled on the wall with lipstick.

Insurance companies know better. When they’re trying to deflect blame and obfuscate, you can bet that they know exactly what they’re doing.

Just one example: prescription drug “preauthorizations”. Even the word itself, “preauthorize” – what is that, getting permission before you get permission? Did Orwell himself make that up? I have a medical license, so, in the wisdom of the legal system, I can authorize a patient to get a prescription drug from a pharmacist. The “authorization” is the prescription, the piece of paper with cryptic scribbings and abbreviations and my unreadable signature.

Trouble is, just having an “authorization” from a medical doctor sometimes isn’t good enough. Sometimes, especially if the medication is expensive, you need a “pre-authorization,” too. And the insurance company tries to make it seem like that getting a preauth is the doctor’s job, too. If you don’t get a pre-auth, that’s the doctor’s fault. Honestly, Mom, I had nothing to do with the noodles in the clothes dryer.

No, a pre-auth has nothing to do with your doctor’s decisions. My job, my “authorization,” is based on my history and physical, the decision my patient and I made in the exam room. I already did that part, and I gave you the script. Now it’s up to your insurance company to pay for it, at whatever terms are spelled out in your insurance documents. If they don’t want to pay for it, that’s their decision. It is not mine.

Insurance companies have made up a new kind of authorization, the “pre-authorization”, that somehow has also become something your doctor is supposed to do. They’ll make it sound easy—just tell your doctor he has to fill out a form, or tell her she just has to call a “prereview specialist.” Of course, it’s never that easy. I don’t have the form, and it will take days to get it. The form itself may be complicated and many-paged, and will require me to pore over your old chart to see what other medications you’ve taken and on what dates. And a phone call? Please. We wait on hold just like you do. Me and my staff are supposed to be taking care of patients, not spending 45 minutes listening to “Muskrat Love.”

Any even when we do the form, the “pre-authorization” will often be denied. We won’t know it, but there are often “secret rules” that drug X won’t be paid for until the patient has tried drug Y and drug Z for at least 60 days. Documented, in the notes that we have to send and sign. You say those medications were tried by your last doctor, and didn’t work? That’s good enough for the doctor. It’s not good enough for the pre-authorization clerk or lackey with his red rubber stamp.

After all that, the patient gets a letter, which continues to blame the doctor: “Your request has been denied, based on the information supplied by your physician.” Needless to say, your doctor can appeal this, by spending a few more hours beating his head against a tree or contacting your insurance appeals department (those are approximately the same thing.) That won’t work either, but it will further reinforce the point of this entire adventure: it’s not your insurance company’s fault. Really. We’d love to pay for your medicine. It’s just that, between you and me, your doctor just isn’t very bright. He can’t fill out a simple form. We’d do it, sure, if only that doctor would get a preauth like he’s supposed to.

No. I’m not “supposed to.” Getting pre-auths was not part of my medical education, and it’s a huge waste of time. It’s a transparent way to make it difficult for people to get medications that they need, so the insurance company can spend less on your medical care.

That letter, the one that politely refused the preauth and blamed your doctor, it’s got one other truly Orwellian component. The letter will also tell you that the insurance company isn’t dictating treatment decisions. After all, they don’t have a medical degree. They can’t decide medical things. That’s up to the doctor. Yes sir. You can have any medicine you want. We’re just not going to pay for it. And we’ll do our best to make sure you think that’s your doctor’s fault, too. And so is the lipstick on your wall.

Inscos want to own your health care provider

May 23, 2011

The Pediatric Insider

© 2011 Roy Benaroch, MD

 We cut out the middleman to SAVE YOU MONEY!

It works with jewelers, car dealerships, discount chains—cut out that greedy middleman, and the buyer gets the goods, cheap!

Will it work for health care?

Here’s a new trend: insurance companies owning their own retail-based clinics. I’ve raised some red flags about retail clinics in drug stores and big box outlets before. One objection I have is the conflict-of-interest: if the drugstore will also make a profit when it sells you the drug, could it be that their salaried employee will want to prescribe the medicine that makes the most money for the drug store?

Take it one step further—what if the insurance company itself actually employs the health care provider? Every dollar spent on you is one less dollar of profit for the company. Do you think their provider is likely to order the best medicine, or the cheapest medicine? How about those blood tests or x-rays–you’d like to be sure that the person deciding whether to order them cares only for your well-being. What if the person who decides whether to order the test works for the company that has to pay for it?

Drug-store owned clinics are a huge conflict of interest, but at least the impact of their decisions is really limited only to medication choices. With insurance company-owned clinics, decisions aren’t just about who makes profit on the medicines. It’s about everything: how many specialist referrals there are, whether you’re told to go to the ER, whether you get an MRI on a knee or your brain. Every decision to offer anything past rudimentary, inexpensive care is less profit. Who do you want making these decisions?

The way health care is financed, “the middleman” is your doctor. Physicians are not beholden to the insurance company—we can pretty much order what we think is appropriate, without affecting how we’re paid for the encounter. (There are ill-defined “bonuses” to reward what’s considered “good care,” but those payments are minimal and unpredictable. And sometimes we have to jump through hoops to expensive things pre-approved, but whether they’re “approved” or not, we doctors still get paid.) Furthermore, I don’t actually make money on the stuff I order. You go get your MRI somewhere else, you go buy your medicine down the street. I decide what you need based on what I know about you and my best medical judgment. That’s the kind of middleman you need: a person squarely in your corner, looking out for only your interests.

Insurance companies are there to make money for their shareholders. Period. Who do you think will win when they alone decide what services you get?

Health Care Reform: The Good, The Bad, and The Ugly

July 21, 2009

The Pediatric Insider

© 2009 Roy Benaroch, MD

We can all agree that the current “system” needs a-fixin, and there is no shortage of good ideas that could be implemented quickly and fairly, and could dramatically improve access and costs. But there is also no shortage of truly bad ideas, and unfortunately, there is one Huge Ugly Problem that guarantees to muck up the whole process if left unchecked.

The Good

Allow people to shop for health insurance across state lines. Current laws allow a small number of huge plans to flourish in each state, stifling competition and choice. One tiny law with 15 words could immediately allow consumers access to hundreds of different plans.

Stop discriminating against individual plans. Currently, if your employer buys your health insurance, you don’t pay taxes on the premiums—but if you want to buy your own policy, you lose thousands of dollars back to Uncle Sam in increased taxes. That’s stupid, and unfair, and unreasonable. Stop it. Allow a personal income tax deduction to people who choose to buy individual plans.

Make it less easy to exclude pre-existing conditions. Current HIPAA laws forbid health insurance companies from excluding pre-existing conditions—but ONLY if you’re only covered by a group plan, and switch to a different group plan. If you’ve got individual insurance, the group plan or individual plan you’re considering switching to can exclude anything. Again, stupid; a loophole like this can be closed by legislation like *that* (that was me snapping my fingers).

Permit businesses to pool their employees and seek discounts for group insurance plans. Can you believe this is currently forbidden? Again, *snap*, the cost of group insurance for employers can drop dramatically if competition and group purchasing power is allowed.

Encourage the use of health savings accounts, so people can set aside money for health costs. Not those stupid “medical savings accounts” that are confusing, and allow money to disappear at the end of the year if you don’t use it—but real HSAs, controlled by individuals, where money can be used for any health reason, or rolled over from year to year.

Reform the medical malpractice litigation. There are many creative ideas here—“loser pays” or caps on punitive damages would be an excellent start. At the same time, make it easier for people who are genuinely harmed by medical errors to get quick compensation that doesn’t end up in lawyers’ hands. The goal of med-mal should be reducing errors and compensating the harmed—NOT to create a bonanza for lawyers, a nightmare for doctors, and an atmosphere where errors are hidden instead of studied.

The Bad

Creating a new federal “right” to health care. Sorry, health care isn’t like “freedom” or “the pursuit of happiness.” Health care has costs, and someone has to bear the costs. Remember elementary school civics? Your “rights” are only a “right” if they don’t interfere with my “rights”—and if I don’t want to pay for your health care, yet you’ve got a “right” to it, now the government has to take my money away from me. So much for my “rights.” You can’t pull a “right to health care” out of the air any more than you can invent a “right” to food or a “right” to housing or a “right” to high-speed internet access. A civilized society ought to have a mechanism in place for health care for all, as it should also provide for the infirm and the elderly and the meek. That doesn’t mean that all government social services are a “right.”

Pushing all costs into the future. Good Lord, we’re considering saddling our children with debt unimaginable, far far larger than even the made-up numbers in the newspapers. Do we want to be a generation that leaves a country entirely bankrupt for our children? We need to be honest about the costs of things, and we need to be honest about who will pay the bills and when. Our representatives in Washington, from both parties, have been profligate to the point of insanity.

Micromanagement of mandates. Health insurance should always cover certain basic services that could be outlined on a single sheet of paper. Beyond that, consumers should be allowed (but not mandated) to pick further coverage as they see fit. You want chiropractic coverage? You want prescription medications? How about brand-names? Do you want to be able to choose from a list of 100 participating hospitals, or is 3 enough? The law should stipulate that insurance plan information should be honest and easy-to-understand, so that what is and isn’t covered is clear. Beyond that, let the consumer decide if they want plain-vanilla, no-frills coverage, or if they want to pay extra for more-comprehensive coverage. States that have long lists of mandates end up with very expensive premiums that no one can afford—so few people actually benefit from the expanded coverage anyway. Who really thinks government bureaucrats  are in the best position to decide that A must be covered, but not B, for everyone?

The Ugly

President Obama says that health care legislation must be passed this summer, by August. Remember the Stimulus Bill, the one that was pushed through in the wee hours, the one that no congressman could possibly have read in its entirety? At least that was a one-time deal. Reforming health care is much bigger, and could shape the American economy for years to come. Let’s think about this, think about the ideas, allow time for congress to listen to their constituents, and come up with a plan that has been well-researched and well-discussed. The current rush-em’-through system benefits the Washington insiders, the lobbyists, and the cronies at your expense. Let’s take a breath and think this thing through, or we’ll end up with a huge ugly mess.

The Amish get hosed

July 19, 2008

I’m fuming over this story in the Wall Street Journal, from June 28, 2008. It’s a tale of Old Order Mennonite and Amish communities in the American northeast, and how their dependence on their own community rather than outside help may lead to bankruptcy. The story explains a lot about what’s wrong with American Medicine—and how well-intentioned policies can have vast and unjust consequences.

Many of these groups shun modern conveniences like electricity and cars. They believe their community should be self-sufficient. Every member of the community supports each other in times of health and sickness. They reject government aid, social security, government-subsidized healthcare, and health insurance. They do not reject modern health-care—in fact, it is a religious imperative to seek health care when someone is ill, and (contrary to propaganda from anti-vaccine sites) they do immunize their children and seek modern medical care when appropriate. And as with other goods and services, they expect to pay for it.
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