A Different Perspective

The more I read about the health care debate the more my blood boils and I've just got to get this out there before my blood pressure goes through the roof.

Here's my basic opinion:  The health and welfare of me and my loved ones (And my loved ones loved ones.  And their loved ones.  And any other loved ones you might want to put onto the list) should NOT be determined by a profit motive.  Because then the decisions are going to be made based on what will earn the company money rather than what will help maintain your health and well-being.

Sweetie and I have insurance.  Damn good insurance.  When we moved to the 'couv we signed up for the Cadillac of insurance plans available to us.  We knew we'd be working on the hedgehog, and wanted to make sure we were covered for that.  We pay to get the Cadillac.  We consider it money well spent.

Not many people know this, but the Hedgehog is actually Hedgehog v3.0.  I suffered two miscarriages prior to this pregnancy.  That's part of the reason we signed up for the Cadillac of insurance plans, because we didn't know what type of care would be required in order to keep the Hedgehog in there for the duration.

When we arrived in Vancouver I went through tests.  Usually they don't want to start with the tests until you've suffered three miscarriages, but because I am old (by pregnancy standards) they let me cut in line and start with the tests after two miscarriages.

Thanks to the tests (all covered by our insurance without question) we came up with two potential issues that could have been causing the problems, and a plan of attack for both of them.  One of the issues is potentially low progesterone levels.  This is an easy treatment, you just take progesterone supplements from the moment you discover you are pregnant through the end of your first trimester.  (The other issue is not treated quite so easily as it requires a daily injection of blood thinners, but that's another story for another day).

So, I get myself knocked up with the Hedgehog and I get a prescription called in for the progesterone.  When I go to pick it up at the pharmacy I'm told that insurance isn't covering it at this time, that there's some paperwork that needs to be completed by my doctor's office before insurance will foot the bill.  Which I don't have a huge issue with, except it's Friday afternoon and the Doctor is gone for the weekend and so they won't be able to get the paperwork completed until Monday morning.  

And I'm sorry, but when you've been through two miscarriages and the drug that could prevent your third miscarriage is sitting on the other side of the pharmacist's counter from you but they won't let you have it for three days because a piece of paper needs to be filled out... yeah, that doesn't quite work.  So I called the insurance company to ask "Hey, if I pay out of pocket for the first batch of the drug will you reimburse me for it later, once we get all this paperwork sorted out?"

The answer was not only a resounding "NO" but "Don't bother with the paperwork, we will NEVER cover that drug for you.  Because it is a fertility drug."

The drug costs $400/month.  Money we don't necessarily have sitting around - in part because we are paying for the Cadillac of insurance plans.  And my insurance company doesn't want to pay for this drug because they won't pay for fertility treatments.  Except I'm not having fertility treatments.  Know why I'm not having fertility treatments?  Because I'm already knocked up.  I even have the test results (both at home and at the doctor's office) to prove it.

Want to give a pregnant woman a nervous breakdown? Throw that scenario in front of her.  Thankfully I have a saint of a husband who knows when to step in and take over the reins AND knows how to deal with customer service.  And he basically fought his way through the system until he found a person who agreed to cover the drug.  No need for the paperwork from the doctor now, by the time you get to the pharmacy everything should be taken care of.

The kicker?  The labeled use of the drug is for regulation of the menstrual cycle.

So, to quickly review:  My VERY GOOD insurance policy did not want to cover a drug that is manufactured to help women regulate their menstrual flow, that my doctor had prescribed to help preserve my pregnancy because there are women out there who use it as a fertility drug and my insurance policy does not cover fertility treatments.  And the only reason they DID cover the drug was because my husband works well with customer service AND does not like it when his wife is in near hysterics, so he just plowed his way through the system until he got someone to agree to cover it. 

I'm sorry, but vulnerable people should not have to fight for things they are entitled to because someone tries to find a loophole to get out of their obligations.  And as long as the insurance companies are out there trying to make a profit for their stockholders that's what they're going to do as long as they are permitted to do so.  Because for every person like me who fights until she gets what's appropriate there are probably scads of other people who just acquiesce and just pay the $400/month.

If I won the lottery and had the financial ability to sign up everyone in the nation for my very good, non-governmental insurance plan the system would still be broken because they would be more interested in all the profits those new subscribers were interested in rather than helping provide us with medical care.

THAT is why I support health care reform, and why I think you should support it, too.

Comments

[teacherrefpoet]

The husband's perspective...

When I called the insurance company after Swankette was in hysterics, I got the same woman she did. She tried to sound soothing, to say that she's understanding, that she wants to help us and the baby, but that she couldn't give us the drug because it was a fertility drug. I asked her...without losing my temper even once, even though I have never been angrier than I was at that moment...I asked her why a doctor would prescribe a fertility drug to a pregnant woman. She gave several different non-answers. I asked her if she believes pregnant women take fertility drugs. She gave more non-answers.

Only after I politely followed this line of questioning for 5-10 minutes did she agree to let me leave a voicemail for the insurance company pharmacist. He called back and gave approval.

A couple who is less savvy, less persistent, less knowledgeable, or less willing to navigate the Kafka novel that is the modern insurance company may well have lost their baby. And the insurance companies have no reason to give a damn.

Why?

Because, for the profit-margin reasons that Swankette gave above, it is the JOB of insurance companies to deny care.

I'll repeat that. It is the job of insurance companies to deny care to as many people as possible. The more people they treat, the less profit they make.

I try not to get angry at the woman. She's not evil. It is her job to help the company out by saying no to as many people as possible. It is the current system that is evil. It values profit over health.

So please, please don't tell me that a government plan will cause evils--unless you've got something better than the status quo--something not based on profit.

Because if someone with our Cadillac-level of care had to go through this, then there's a problem--and that's without even discussing the 45 million who don't have insurance.

(Want more evidence the system is evil? Listen to Act Three here (it starts around the 37 minute mark): http://www.thisamericanlife.org/Radio_Episode.aspx?sched=1308

It's impossible to listen to this without thinking of the word evil. But guess what? Under the current system, there but for the grace of God go any of us, insured or uninsured.

[Meem]

"A couple who is less savvy, less persistent, less knowledgeable, or less willing to navigate the Kafka novel that is the modern insurance company may well have lost their baby. And the insurance companies have no reason to give a damn."

Amen, brother!

In one of my audiology classes, a parent of a child with a cochlear implant came and spoke to our class. She told us that when filing a claim for the insurance company to pay for the implant (so that her child could HEAR, for Pete's sake), it was POLICY for the insurance company to deny the claim THREE TIMES before approval. Same goes with subsequent care needed after implantation.

I'm sorry. That's just plain wrong! A family is already caring for a child with hearing loss, shuttling them to audiologist and likely speech therapy appointments, and they're supposed to find the time to file claims THREE damn times? The insurance company is banking on the family giving up and not pursuing coverage. They figure learning sign language is a heck of a lot cheaper, and certainly not covered, no matter how many claims you file.

Rarrrrr.