Coverage is Not Care: A Case Study

I have health insurance. For one of my medications, I cannot take the generic form, so I must have the name brand. With my job I started 2 years ago, came new insurance. I'd always paid more for my name brand drug (maybe $45 or so). But suddenly that price jumped to $400 per month with my new insurance. This is opposed to the $5 copay if I could take the generic. You see, it's "non-formulary". I was denied coverage, even though I could not take the generic. It's just not an option. I appealed it to the very top of the parent company. I was denied regardless of medical necessity. They officially didn't care. (Irony Alert: I was helping my employer fight medical necessity denials from Medicare)

Fast forward to 2015. I figured the price would go up with a new year. To our shock and dismay, my medication I depend upon every day was now $1,000 per month. Wow. Just because they can. And they still officially don't care.

Fortunately, my husband now qualifies for health insurance benefits with his part time teaching job. With this new insurance, it will now cost us a grand total $40 per month for my name brand medication. Why? Just because they can. They perhaps care a little more for their customers.

MY POINT: Coverage is not care. In both examples, I have health insurance. One insurer has decided to cover my name brand prescription (for a slightly higher price), and the other chooses to not cover the name brand at all, regardless of outrageous expense or needs of the patient.

Addendum: My son's medication, for which there is no generic, is also not covered under the first insurance plan. For my medication they denied me because there is a generic available, but I "choose" not to take it. In my son's case, there is no alternative, but they still choose not to cover his medication. Just because they can......

Coverage is not care

Health insurance coverage is not the same as healthcare.

Health insurance is a risk-adjusted bet as to whether or not you will need to access the healthcare system:

• You're betting you'll need healthcare
• They're betting you won't

But the insurance companies hold all the cards. It's their job to make sure you get as little healthcare as possible. The less they spend on your health, the better. Insurance companies do NOT have your best interest (or your health) in mind. They're looking after their pocket books.

This is just one reason why focusing U.S. healthcare "reform" on insurance coverage is the wrong direction. It only ensures more business for the insurance companies.

Each of us will need access to healthcare at some point, with nearly 100% certainty. We're all human, we're all mortal. We all need medical attention from time to time, whether for illness, injury, or just health screening and maintenance. So why are insurance companies who are in business to make money the gatekeepers of healthcare?

Medicare and its Complexities

Medicare rules the healthcare industry in the United States. They write all the rules. Literally.

I've learned that the coding rules are so complex, there are entire industries dedicated to helping healthcare institutions manage and navigate those rules. The medical coders who put codes to every diagnosis and every procedure, go through all the notes, lab results, and operative reports to enter the proper codes for billing.

If the healthcare providers (Doctors, Physicians Assistants, and Nurse Practitioners) don't state things just right, then a diagnosis cannot be coded, or is given a non-specific code. These codes, in turn, are what drive the DRG's (Diagnosis Related Groups). This is what is billed out to Medicare and other insurers. Although DRG's were developed for billing on Medicare patients, wherever Medicare goes, most insurers follow. Most insurers pay according to the DRG.

The codes also drive Severity of Illness (SOI) and Risk of Mortality (ROM) scores. These are derived from a more advanced version of DRG's, called APR-DRG's. They (supposedly) take into account how many co-morbid conditions the patient has, and the complexity of care required. These SOI/ROM scores, along with the billing codes and DRG's, are what many of the publicly-reported quality scores are based upon.

All these rules are written by the nice folks at the Centers for Medicare and Medicaid (CMS).

New Beginnings

I've ignored my blog for several years now, thinking no one was listening. I'm going to give this another try.

Now that I'm employed in the revenue cycle of healthcare, my passion for Health Policy is higher than ever. The direction we are headed in US health policy is a disaster. My 2 main lines of thought:

1. Coverage is not care
2. Medicare is killing our healthcare system

I will be composing thoughts on each of these topics very soon. Stay tuned for new posts!!

Thanks,

Elaine

New Legislation

Although I don't approve of the insurance mandates and the enormous cost, the newly signed Healthcare legislation has some good aspects to it. I like the fact that it places further restrictions on the Insurance Companies, especially to end denial of coverage for people with pre-existing conditions. But that leads me to a bigger question: why are we having to legislate restrictions on free-market entities? Why do we need to spend so much energy to regulate an industry that controls such a vital (literally) part of our lives? This tells me that maybe they have much more power than they should have.

I'm starting to think that we do need to move away from the free-market approach to healthcare. Why are we allowing several industries to become filthy rich off of our basic medical needs? There are legitimate arguments for not making healthcare a "right". But Constitutionally, we DO have the RIGHT to life. To me, that includes the right to protect our own lives, and to have access to the medical care necessary to maintain our GOD-GIVEN mortal bodies. My health is not a commodity for others to profit from!!!

Coverage is not care

Insurance coverage does NOT equal healthcare!!

Insurance Industry Takeover

We are apparently going to hand the keys to our medical care to the sole gatekeeper, the Insurance Industry. Shouldn't it be the medical community that runs healthcare? Instead we are putting the for-profit insurers as the only way to access medical care for our bodies. They restrict healthcare providers in what they can do, and dictate to them how to do their jobs. We are not cars that might get into an accident. We are human beings who need the help of doctors and nurses to maintain our health, and sometimes to save our very lives. Does this Insurance Industry takeover of the Healthcare system bother anyone else??!!