Healthcare: “Reform”

True Healthcare “Reform”

Over the past year we watched as both houses of the United States congress worked feverishly to “pass” a program that would make  “promises” of Healthcare Reform come to fruition.  Even with the majority of Americans rejecting  this particular package* of  Healthcare Reform the bill was passed and signed into law by the president.  *I’m not arguing that point. Most Americans agree that some reform is necessary,)

Personally,  I am totally against government intrusion into the private sector of business.  I do believe that some sort of reform needs to be initiated within healthcare, but not so much in medical care.  I would have preferred the industry police itself, but I am not naive enough to believe that that would ever happen…. that is, within the insurance industry of healthcare.  That would be the proverbial “shooting yourself in the foot” to them.

A Case In Point: Over the years  John (named changed to protect identity) has  needed a certain medication to sustain life.  Unfortunately, this medication is not cheap.  Since 1996 he has taken this type of medication either in tablet form or injection.  During that time he has been hospitalized approximately 16 times because of his body’s rejection of some of these medications.  On two occasions his family was informed that he would not make it out of the hospital (but the Good Lord knew better).  It has now come to the point of needing the medication to stay alive.

The current medication prescribed for John is to be given twice a day, meaning 60 doses a month.   His insurance company informed him that they will cover only 30 doses per month (15 days worth) at his current copay.  (The cost to John for the other 30 doses being over three thousand dollars a month – There is no generic and this is the only medication left for treatment.)  While in the hospital the doctor informed the insurance company that John must have the 60 total doses per month.  She emphasized that going without one single dose would mean further irreversible damage leading to death.  The insurance company still declined the extra doses.

To aggravate things more the insurance company faxed a letter to the doctor stating that at her request they would consider approving the extra doses.  The letter stated, “Before initiating a request for additional coverage, please note the following information:  Additional quantity can be obtained through additional member co-payment.  The plan is not denying access to additional quantity.” John informed his doctor that the additional copay was not a problem.  She informed the insurance company.

His doctor faxed the completed form back to the insurance company after answering all the questions and supplying the pertinent information.  The insurance company denied the request again.  Their reasoning: John was not suffering from cancer and he was not pregnant. “The information provided by your prescriber indicates that your use of this drug does not meet the requirements for additional coverage.”

Two other doctors besides the hospital doctor have informed the insurance company that, “if they did not allow John the other 30 prescribed doses (even with the additional copay), he (John) would be required to re-enter the hospital every month for the last 15 days of each month to be placed on IV therapy.”  Amazingly the insurance company did not balk about that.  Seems that they would rather cover approximately 25 thousand a month over 3 thousand a month!  Makes a lot of sense to this writer!

As of this writing, John has two days of medication left.  If his situation is not resolved, he is to call his specialist handling his treatment, and the specialist will then call the hospital to have him admitted for IV therapy.  We will keep you updated as to John’s case.

This is not a “rare” case.  This happens all to frequently.  The horror stories of dealing with insurance companies would make a superb Hollywood thriller.  Jason and Freddie would both seem like childhood bad dreams compared to the horrors of “The Insurance Company” (Roll eeerrrriiieee music!)

The type of reformation that the healthcare industry needs should require that doctors, not insurance companies, dictate what a patient needs.  I realize that insurance companies are in the business of making money…as we all are.  But most doctors are not in the business of treating their patients without a need for treatment.  I’m sure there are some unscrupulous doctors out there who are in it for the money… and there are some that one could consider as “drug pushers”… But, if there is going to be “True Healthcare Reform” then let “pruning” be a part of the package.