Boston Women's Journal - August/September 2008

Health Insurance or Cost Avoidance?

Recently I had an eye injury, an accidental chemical burn that in my doctor’s words looked like I “dodged a bullet” if I am lucky. This is unfortunate and fairly serious. But hey, I live in America with the best care in the world right? I waited almost two hours to be seen, and was later told most damage was done in the first five minutes after the injury. Parenthetically, I called right away and was told nothing about flushing out my eye, just told to come in in a couple of hours. Luckily my own training kicked in and I did flush my eye. I am not covered for the doctor visit (emergency, but to an office) because it was not a scheduled office visit, and am not covered for the tiny (1/8 oz) tube of medication that cost $100. Why? Because my insurance, required by Massachusetts state law, and the only one I could afford, only covers “essential medications”, and in those cases only partially. My sight is clearly not essential to me, or to them.

I am well aware that I am not unique. We all have horror stories, and mine will most likely have a happy ending, as so many others will not. But what are we paying for? I am fine with telling you that as a single person, with no major health history, for the least insurance I could get and stay within my state’s laws, I pay $400 per month. Without going into detail this requires massive deductibles, including only partially covered visits to the emergency room.

Several days ago I received a lovely brochure from my insurance company on very fancy paper. I probably wouldn’t have read it if I hadn’t had the injury, I would have just thrown it out. It was titled something like: “How to get the most out of your health plan.” A better title might have been “How we are giving you the least we can possible give you to meet state requirements, which by the way we are working on reducing so it costs us even less.” Each beautifully printed and graphically stylish page had pictures of different families all of different ethnicities romping on the beach, going camping or just laughing on a swing together. Clearly they weren't reading what the brochure actually said or they wouldn’t have been so happy.

As an educated consumer I began to read, and on the first page under “Updates” I was informed that the penalties increase in Massachusetts next year for not carrying health insurance. They may be as much as $912 per year. Great news!

Moving along, we have a pharmacy update page. More good news, as it lists drugs that will no longer be covered by the insurance company due to cost review. They reviewed the costs and decided these drugs are too expensive. What do you do if you need them? They didn’t say. What they do say is that if there is an over the counter “equivalent” for a drug it won’t be covered. What an exciting feature! We get to pay the whole price instead of the co-pay! Cheerfully oblivious people are pictured camping under this announcement.

And on we go the next page talking about “step therapy.” Your doctor can no longer choose what medication to give you based on knowing your body and history, they must work the steps, trying the cheapest drugs first and only giving you the more expensive one after the first ones have failed and you have jumped through their approval hoops. That’s a great new benefit, thanks. Cost savings? To who? Certainly not us!

We then move on to the next bit of good news. If a generic exists for your drug, you are now not covered at all for the non-generic. Where is your doctor in all this? Do they get a say in any of these changes? Do they get a chance to decide what is best for their patient? I am getting happier about my $400 a month every minute.

On to the next topic, “Utilization Review Requirements.” That doesn’t sound so bad, but what it means that you now need prior approval by this provider to get things you are already getting, such as chiropractic, infertility treatment, drugs injected in your doctor’s office or a hospital outpatient setting, and physical therapy. Are they kidding? These things probably save them millions each year and are among the few “alternative measures” they have covered. If you don’t get prior approval (method unspecified) you will have to pay the full amount.

YOU MAY HOWEVER BE ABLE TO GET CARE AT YOUR LOCAL PHARMACY, WITHOUT REFERRAL. I’m not sure if that is good or bad news.

The next page says out of network providers are no longer going to be paid. I am beyond incredulous at this point. Yikes!

There are so many things I want to say here. Especially about why more and more people are using alternative practitioners like me who are available almost all the time, take a long time to check into and understand your history, seek to find the most effective care, and monitor that care. What about all the wonderful doctors in this state that really try to help their patients? They are more and more boxed in. But let me step aside from all that ranting to tell a little story.

A young man I know went to England to study abroad for a semester. While he was there he injured his hand, perhaps broke it, but was hesitant to go to the doctor because he was concerned about the medical costs his insurance would cover and not cover overseas. His British dorm mates told him to go to hospital and not to worry, and not to use his U.S. insurance. He had urgent care within ten minutes, an x-ray within half an hour, a splint within ten more minutes, a discussion with the doctor about care and instructions to come back in a week, and pain medication to take for ten days. He asked about the cost and they laughed. “What do you think boy? This isn’t America, it is free. Now go home and make sure to be careful, and come back when scheduled so we can see how you are healing. Here is the number of the doctor on call if you have any problems.” Now that’s something to smile about.


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