Colder than a Stethoscope

Health Insurance Calling Card

The cold end of a doctor's stethoscope is a warm blanket compared to the health insurance industry's three D's.  

DENY - Judge, with or without medical justification, that a procedure is medically unnecessary.

DELAY - Slowly allow the medical team and the claimant to proceed through the appeals process so that the patient has to absorb more of the costs when the clock restarts the next year. Or, so that the high-cost patient chooses a different insurer next open season.

DEFEND - Extend the delay through insurance wording loopholes in hopes that the claimant gives up, pays out of pocket, or expires.

My business mind says, 

        "It makes sense. Insurance exchanges risk for a risk premium. 

        They don't profit from caring. They profit from reducing their liability."

Unfortunately, it only makes sense in the tactically (in the short run).  The model creates a literal death spiral.  

- Insurance firms increase the administrative burden of medical community.

- Medical community increases costs to cover the burden

- Patients get poorer medical care.

- Patients bring legal suits against medical communities and insurance companies.

- Patients pay higher costs for insurance.

- Patients stop having medical insurance and/or preventative medical care.

My wife and I got caught up in the Deny, Delay, and Defend cycle this year.

It all started three years ago when her health was deteriorating rapidly and after several misdiagnoses locally, we began seeking treatment at University of Alabama in Birmingham's (UAB) medical center. They had to run her through several series of tests to satisfy insurance demands. Then after far too much delay she had a mitral valve replaced in her heart. We went with a biological replacement - because mechanical introduced considerable life altering requirements, OCD-like monitoring, and "poisons" for medication.

The surgery was met with multiple complications.  First, her heart structure had been damaged from the long duration of mitral valve issues, untreated because of a lack of external symptoms. Second, she had a reaction to a medication in the surgical room. While she was in recovery -- the doctor said she is recovering, but he also said, "Do you have children?"  He followed with, "I think she is going to be ok, but..." These are not words you want to hear from a highly skilled surgeon.

A recovery that usually takes a few days before being sent home had her recovering and fighting for her life for six weeks in the hospital.  Even when they sent her home -- neither she nor I were convinced she was going to recover at home very quickly.  Even so, day by day her strength returned to the point that no one but those that knew would have suspected she had open heart surgery.

We traveled to the Ecuador in South America traveling by car to over 13,000 feet. We took a three-week trip through the Eastern United States. We celebrated our grandson's birthdays and big events. She resumed leading the Elementary and Pre-School Bible class program at church.

And then earlier this year we had a routine follow-up medical test that revealed something.  She endured three tests following it to confirm and define the problem.  Her valve that on average lasts ten years was wearing out at three. After multiple medical consults the doctors recommended a Valve in Valve procedure.  This would do two things.  One it would test whether the valve problem was a result of a bad valve or her difficult recovery, and it would provide her with a repair option that was minimally invasive.

Unfortunately, that recommendation is out of the norm in terms of insurance is concerned. (The reason you go to leading specialists is because they solve problems that are out of the norm -- but I digress.) Also, we are near October so even if they fail to perpetually deny the procedure, they can at least move it to next year where we will have to pay more of the bill. All the while, the problem with the valve is making the heart weaker over time.

There are of course options.  Appeal.  We are doing that.  Go out of pocket.  We might if the appeal is still denied into next year. Consider medical tourism where we can find equally qualified surgeons that have not had to raise their costs due to insurance demands. That isn't out of the question.  We have found at least to options in countries (and cities) where we know someone locally.

You often hear when lamenting about an insurance nightmare, "You need to have good insurance."  

I pay just over $10K per year for health insurance and my former employer pays an equivalent of $30K, bringing the value of my health insurance to $40K. When you consider that an average annual salary is $60K -- that is good insurance!

I am certainly not complaining about the risk that has been defrayed by my health insurance over the years.  My second child was born three months premature, I've had a couple of ER visits, and surgeries, and my wife has had several chronic medical costs.  All of which have greatly exceeded even current year insurance costs over the last forty plus years (that is $400K). I cannot say the same for other insurances that I have purchased (Life - fortunately, Homeowners, Auto).

We are, though, feeling the cold calculations of risk mitigation as it brushes up against the harsh realities of medical needs.