A little bit on what we pay for.
Jul. 22nd, 2007 10:12 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
pecuniumIn my guest stint at Majikthise, I spent my time on healthcare.
Because it seems to me we get a whole lot less than we pay for, and for what we pay, a whole lot of gaps are created.
Grisham's novel, "The Rainmaker" is about a crooked healthcare company. The problem, it seems, isn't really one of kind, but degree.
Take a look at this, from CNN.
(BEGIN VIDEOTAPE)
COHEN (voice-over): Karin Perry and her son Andrew have faced so much together. Andrew was born with a severe birth defect. He's had 21 surgeries. But Perry says she's now facing one of her biggest challenges yet. 13-year-old Andrew was born without adult teeth buds. He'll soon have no teeth in his lower jaw.
When Andrew loses that bottom row of teeth, how is he going to eat?
KARIN PERRY, PARENT: I'm not sure. I'm really not sure.
COHEN: Perry's a kindergarten teacher and doesn't have the $60,000 for teeth for her son. But wait. Perry has health insurance. Won't that pay for it? She says they told her no, that it's a dental expense. Her dental insurance has a $500 cap.
PERRY: It makes me want to scream. Why can't you just see that this is medically necessary?
COHEN: Karin Perry isn't alone, far from it. One out of four Americans says they've had what they consider a legitimate health insurance claim denied, according to PNC Financial Services Group. The insurance industry says that survey is wrong and that only a tiny percentage of claims are denied.
MOHIT GHOSE, AMERICA'S HEALTH INSURANCE PLANS: This industry pays billions of dollars in healthcare services, routinely covers millions of claims every month, and makes sure that people are getting the care they need.
COHEN: Perry says insurance has paid for a lot.
PERRY: All of his surgeries have been covered by insurance. For that, I'm very grateful because we're looking at, you know, probably a $1 million kid at this point.
COHEN: But she says she had to pay $10,000 for medical expenses insurance wouldn't pay for. Her friends held a fundraiser.
PERRY: I'm a school teacher, and I'm a single mom. And so $10,000 is a lot of money for me. It's a real lot of money for me.
COHEN: Mohit Ghose, who represents an insurance industry trade group, says people like Perry should appeal insurance decisions if they think they're wrong.
GHOSE: It's important to note that consumers do have options.
COHEN: Perry says she did appeal once and failed. And she's never tried again.
PERRY: I'm probably the exact kind of person they're hoping comes into the insurance appeals process, because it's exhausting. And it's time consuming. That's what they count on. They want you to give up.
COHEN: Ghose says that's not true. And they try to make the process as easy as possible. Perry says she's thankful for the insurance she has, but she wishes it were easier.
(END VIDEOTAPE)
COHEN: Now we called Ms. Perry's insurance company, HMO Blue, for comment. And they immediately called Ms. Perry to say they would pay for Andrew's new teeth. Their spokesman told me, "Typically, we don't cover dental implants. But if there's a unique clinical circumstance, that's considered in making medical coverage decisions..."
Now Karin Perry's situation ended well because of our story, but what about other people? What do they do when they get denied? A group called the Patient Advocate Foundation helps people with insurance problems. And they've agreed to specially staff their phones this morning just for our viewers. The founder and CEO of this foundation is Nancy Davenport-Ennis. And she's here with us this morning. Welcome, Nancy.
So they go into a couple of claims.
COHEN: The first one is from Debbie in Virginia, who writes, "My son was born at 32 weeks and went straight into the NICU. The hospital was in network, but none of the doctors in the NICU were. Our insurance refuses to pay the doctor's bills, and he would have died without immediate care. What can we do? We have medical bills of $150,000."
Nancy, what do you recommend for this family?
DAVENPORT-ENNIS: Elizabeth, the first thing that I would say to the family is please understand that what is happening to you may the first time for you, but many other consumers have faced a very similar denial.
I think it's very important for them to understand that, when you have a child that is born and needs to go into a neonatal intensive care unit, that the child was actually delivered in an in network hospital that was part of their health plan and an approved provider. When the child needed to be moved into the intensive care unit and required physicians with specialty care backgrounds, certainly, the parents assumed that those were approved providers.
When finding out that they were not, we advise that she immediately let the insurance company know she will be filing an appeal, and go to the hospital and collaborate with the hospital in this appeal. Because ultimately, the parents were not asked to make a decision of who was going to provide care to this child. The decision was made by the hospital.
COHEN: Nancy, do you think this family can work this out?
DAVENPORT-ENNIS: I do. And I think this is happening more and more in the United States. And what we find is that you have to engage the hospital in getting the resolution. And you may have to actually engage a caseworker from the hospital or caseworker from the health plan.
COHEN: Now we should point out this claim sounds legitimate. But to be fair, some claims aren't legitimate. Some things just aren't a part of your healthcare coverage.
DAVENPORT-ENNIS: Indeed, that is true. And so, one of the things that any parent has to do, if they're looking at a denial of a benefit for a child, is to look at the language of your health plan and see indeed what it provides for. In the case of this child, the child was born in an in-network hospital. And certainly the benefits that that child needed, needed to accrue to the child. That family was not aware that the doctors providing the care were not in-network providers. And that information had not been provided to them.
COHEN: Nancy, that's good guidance for this family.
How much is it worth to 1: not have to deal with this crap, and 2: see to it that everyone is covered?
Because there's an awful lot of money tied up in this. How many man-hours? How much paperwork? How many people required to chase down the right billing codes, examine the policies, pore over the medical records? And for what?
To deny people the coverage the paid for. We are paying for the profits. Spend a little less (each) and about the same, total, and no one goes without what they need.
Karin Perry hit it on the head. How many people have the means, time, and willpower, to fight this sort of thng to a win?
Is anyone willing to cover bets that, absent CNN getting involved, that kid would be looking at a liquid diet, and a shortened lifespan?
I'm not.
Because it seems to me we get a whole lot less than we pay for, and for what we pay, a whole lot of gaps are created.
Grisham's novel, "The Rainmaker" is about a crooked healthcare company. The problem, it seems, isn't really one of kind, but degree.
Take a look at this, from CNN.
(BEGIN VIDEOTAPE)
COHEN (voice-over): Karin Perry and her son Andrew have faced so much together. Andrew was born with a severe birth defect. He's had 21 surgeries. But Perry says she's now facing one of her biggest challenges yet. 13-year-old Andrew was born without adult teeth buds. He'll soon have no teeth in his lower jaw.
When Andrew loses that bottom row of teeth, how is he going to eat?
KARIN PERRY, PARENT: I'm not sure. I'm really not sure.
COHEN: Perry's a kindergarten teacher and doesn't have the $60,000 for teeth for her son. But wait. Perry has health insurance. Won't that pay for it? She says they told her no, that it's a dental expense. Her dental insurance has a $500 cap.
PERRY: It makes me want to scream. Why can't you just see that this is medically necessary?
COHEN: Karin Perry isn't alone, far from it. One out of four Americans says they've had what they consider a legitimate health insurance claim denied, according to PNC Financial Services Group. The insurance industry says that survey is wrong and that only a tiny percentage of claims are denied.
MOHIT GHOSE, AMERICA'S HEALTH INSURANCE PLANS: This industry pays billions of dollars in healthcare services, routinely covers millions of claims every month, and makes sure that people are getting the care they need.
COHEN: Perry says insurance has paid for a lot.
PERRY: All of his surgeries have been covered by insurance. For that, I'm very grateful because we're looking at, you know, probably a $1 million kid at this point.
COHEN: But she says she had to pay $10,000 for medical expenses insurance wouldn't pay for. Her friends held a fundraiser.
PERRY: I'm a school teacher, and I'm a single mom. And so $10,000 is a lot of money for me. It's a real lot of money for me.
COHEN: Mohit Ghose, who represents an insurance industry trade group, says people like Perry should appeal insurance decisions if they think they're wrong.
GHOSE: It's important to note that consumers do have options.
COHEN: Perry says she did appeal once and failed. And she's never tried again.
PERRY: I'm probably the exact kind of person they're hoping comes into the insurance appeals process, because it's exhausting. And it's time consuming. That's what they count on. They want you to give up.
COHEN: Ghose says that's not true. And they try to make the process as easy as possible. Perry says she's thankful for the insurance she has, but she wishes it were easier.
(END VIDEOTAPE)
COHEN: Now we called Ms. Perry's insurance company, HMO Blue, for comment. And they immediately called Ms. Perry to say they would pay for Andrew's new teeth. Their spokesman told me, "Typically, we don't cover dental implants. But if there's a unique clinical circumstance, that's considered in making medical coverage decisions..."
Now Karin Perry's situation ended well because of our story, but what about other people? What do they do when they get denied? A group called the Patient Advocate Foundation helps people with insurance problems. And they've agreed to specially staff their phones this morning just for our viewers. The founder and CEO of this foundation is Nancy Davenport-Ennis. And she's here with us this morning. Welcome, Nancy.
So they go into a couple of claims.
COHEN: The first one is from Debbie in Virginia, who writes, "My son was born at 32 weeks and went straight into the NICU. The hospital was in network, but none of the doctors in the NICU were. Our insurance refuses to pay the doctor's bills, and he would have died without immediate care. What can we do? We have medical bills of $150,000."
Nancy, what do you recommend for this family?
DAVENPORT-ENNIS: Elizabeth, the first thing that I would say to the family is please understand that what is happening to you may the first time for you, but many other consumers have faced a very similar denial.
I think it's very important for them to understand that, when you have a child that is born and needs to go into a neonatal intensive care unit, that the child was actually delivered in an in network hospital that was part of their health plan and an approved provider. When the child needed to be moved into the intensive care unit and required physicians with specialty care backgrounds, certainly, the parents assumed that those were approved providers.
When finding out that they were not, we advise that she immediately let the insurance company know she will be filing an appeal, and go to the hospital and collaborate with the hospital in this appeal. Because ultimately, the parents were not asked to make a decision of who was going to provide care to this child. The decision was made by the hospital.
COHEN: Nancy, do you think this family can work this out?
DAVENPORT-ENNIS: I do. And I think this is happening more and more in the United States. And what we find is that you have to engage the hospital in getting the resolution. And you may have to actually engage a caseworker from the hospital or caseworker from the health plan.
COHEN: Now we should point out this claim sounds legitimate. But to be fair, some claims aren't legitimate. Some things just aren't a part of your healthcare coverage.
DAVENPORT-ENNIS: Indeed, that is true. And so, one of the things that any parent has to do, if they're looking at a denial of a benefit for a child, is to look at the language of your health plan and see indeed what it provides for. In the case of this child, the child was born in an in-network hospital. And certainly the benefits that that child needed, needed to accrue to the child. That family was not aware that the doctors providing the care were not in-network providers. And that information had not been provided to them.
COHEN: Nancy, that's good guidance for this family.
How much is it worth to 1: not have to deal with this crap, and 2: see to it that everyone is covered?
Because there's an awful lot of money tied up in this. How many man-hours? How much paperwork? How many people required to chase down the right billing codes, examine the policies, pore over the medical records? And for what?
To deny people the coverage the paid for. We are paying for the profits. Spend a little less (each) and about the same, total, and no one goes without what they need.
Karin Perry hit it on the head. How many people have the means, time, and willpower, to fight this sort of thng to a win?
Is anyone willing to cover bets that, absent CNN getting involved, that kid would be looking at a liquid diet, and a shortened lifespan?
I'm not.
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no subject
Date: 2007-07-23 11:18 am (UTC)no subject
Date: 2007-07-23 02:55 pm (UTC)More to the point, this is a medical issue, not a dental one (yes, it's his teeth, but the second-order effects are severe.
It's also possible that he can't use them. I'm not a dentist, and going on what I know, from reading) the bones of the jaw are odd. Without the pressure of eating, they disolve (which is why old people, who've lost teeth have those hollow faces).
The problem is, this isn't rare. One of the things I've found is that while the horror stories about elective surgeries taking a long time to get in places like Germany get the press; the waits for simple things like a visit to the doctor are longer here.
And the number of people in this country who just flat-out can't afford a doctor's visit is the highest in the First world, almost half of respondents said they forwent a visit, when they ought to have gone.
I don't think that's what we mean when we say we are number one.
TK
I
no subject
Date: 2007-07-23 03:05 pm (UTC)no subject
Date: 2007-07-23 02:32 pm (UTC)no subject
Date: 2007-07-23 02:48 pm (UTC):)
no subject
Date: 2007-07-23 03:01 pm (UTC)no subject
Date: 2007-07-23 04:20 pm (UTC)I also have several clients on workman's comp, and boy, is THAT a place you don't want to end up. It's a nightmare. There are so many people who end up having to hire an attorney and go to court it's next to impossible to find an attorney.
And then there are people like me, the uninsured. I'm self-employed, work 10 or 11 hours a day, the government takes a third of what I make. At almost 60, insurance premiums are financially prohibitive unless I move to Carmel and start charging $120/hour. The good news is that every doctor I've seen has been happy to give me a cash discount, roughly the same as what they eventually get from the insurance companies. As long as I keep the diagnostic tests to a reasonable level, don't have a major health problem or accident, I can handle it. To qualify for an Health Savings account, (for the self-employed), you already have health insurance - it works like a Flex Fund.
no subject
Date: 2007-07-23 04:27 pm (UTC)I know that this sounds mercenary and awful, but resources have to come from somewhere and it seems like the argument for more and better medical care isn't taking into consideration where the resources will come from.
no subject
Date: 2007-07-23 04:38 pm (UTC)Resources have to be allocated, no argument. Right now the allocation, in the US, is based on how much money one has. If you are well off, you can afford to get insurance which covers diagnostics, and then treats the problems.
If you aren't well off, you don't get the diagnostics, and then get denied for the more expensive treatments that come of putting things off (polyps are lot less trouble to deal with then colon cancer).
I don't know where I'd be if my kid was in this camp. My nephew isn't right, and I think, had it been us, we'd have let him die when he was born (three months premie, and not as developed as he ought have been).
If, however, the effort to keep him alive is going to be made (vis-a-vis my nephew, or this kid) then to go to all this effort, and then quibble over something as minor (in the grand scheme of things) is wrong.
TK
no subject
Date: 2007-07-24 05:36 am (UTC)no subject
Date: 2007-07-24 06:26 pm (UTC)no subject
Date: 2007-07-24 06:34 pm (UTC)There is no affirmative duty to save someone. There are some implicit responsibilities for those who are guardians of others (and while the law doesn't favor children over adults, public opinion does).
But a no extreme measures/DNR covers it.
I hope, God forbid, I'm ever in that position we can come to a decision, and not hate each other from guilt.
Definitely something to get counselling after.
TK
no subject
Date: 2007-07-23 04:43 pm (UTC)no subject
Date: 2007-07-23 11:21 pm (UTC)There are no words really.