I can't believe that I'm going to swallow my pride and admit this, but without this admission, the heart of what I'm trying to tell would be at best skimmed over and at worst, it would be purposefully inaccurate. With that in mind, I'm going to suck it up, let go of my hubris and just say it. My health insurance has managed to utterly confuse me.
This admission might seem unimportant or overblown in my mind, and maybe it's true, but there are two reasons I always felt that I would be impervious to this ever happening: 1) I have a health sciences education, and I've worked in health care, in big teaching hospitals, both government jobs, with a labyrinthine bureaucracies that one would expect and 2) I've lived more than half my life with chronic life-threatening disease. I've spent countless hours of my life in physician's offices, emergency rooms, on MRI tables, in invasive procedure rooms, and in surgical suites. I've been drained of probably gallons of blood over these 27 years for diagnostic testing and research studies, had biopsies taken of various and sundry tissues, head to toe. I've had ultrasounds, CT scans, MRI's, thallium treadmill tests, colonoscopies, endoscopies, angiograms, PET scans and X-rays. This is what I remember without even having to rack my brain, so imagine how long this list could be if I actually sat down, reviewed all my medical records and then made the list. I find the thought of that alone staggering, much less actually doing it.
But finally, I have to break down and fess up - my health insurance programs have me now utterly and completely confused and caught in a web of circular thinking and movement in trying to figure out what the heck is going on. I am exhausted from hours on the phone, frequently calling the same company and asking the same question multiple times, just because my gut was telling me that the person in the call center had absolutely no idea what they were talking about, or they were working with faulty or just downright bad (mis)information. The typical outcome has been that I get a different answer every time. As such, my new rule is that I have to hear the same information from three different people (and I take down their names) before I'll feel fairly comfortable that I have the right information and got an accurate answer. Even then, it's no guarantee that in the end, I'm working with accurate information. As an example of this, I'll describe something that actually happened yesterday morning (since it's now after midinght).
Today I went in to get pick up my new foot orthotics for my plantar fascitis in my left foot. Basically, they're outrageously overpriced custom insoles for my shoes that will support my feet in such a way that I'll minimize the discomfort in my left foot and hopefully, prevent if from happening in my right foot. This all started about a year ago, when I started having a problem putting weight on my foot in the morning when I first get out of bed; a classic symptom of PF. After my podiatrist ordered them, I called my insurance to find out what my out of pocket expense would be for these, before I decided to shell out any money.
Now I need to take a sidebar here, and first explain how my insurance works. I have 2 policies, one is Medicare, the other is Blue Cross. My Medicare is primary, which simply means that they get the bill first, pay out what they will reimburse for any care, and then the rest of the bill goes to Blue Cross and they decide what, if anything, they are going to cover that Medicare didn't. Now to make things even more complicated, my Blue Cross is divided into 3 different sub-plans. The first is called POS, which stands for point of service and to give a simplified explanation, means that I go to the doctor I want, it doesn't matter if they are in my network (more later on that, don't worry), but this has the lowest reimbursement rates and often doesn't cover what Medicare didn't.
Then there is my PPO, which stands for Preferred Provider Network. These are the doctors, hospitals, labs and allied health care service providers that are contracted with my Blue Cross, and they agree to accept the reimbursement rates that Blue Cross negotiates with them. This usually has lesser out-of-pocket (patient responsibility) charges than service reimbursed through the POS plan. Then finally, there is my HMO. This is the program that almost always ends up having the lowest out-of-pocket, but it is also the most restrictive of the three. I have to have a physician that is a member of one of the physician groups that contracts with Blue Cross, and that for what seems to be almost half of what my physician orders, they need to get a prior authorization for the treatment (or drug or device or whatever) before it is covered under the HMO reimbursement. The HMO seems to operate somewhat autonomously of Blue Cross, at least as far as I can tell, and the decisions as to what to authorize or not is made by the physician group. Then, and I almost forgot this, Blue Cross (my group policy anyway) now contracts out all their pharmacy services to a company called Wellpoint (or as I call them, Hellpoint), including prior authorizations and billing.
To further clarify the relevance of all this information to my experience yesterday at the orthotics company (contracted with my HMO, by the way), I need to take you back about a month ago when I decided to find out if my orthotics were covered by any of my insurance. I call the main number for BC, ask if orthotics are covered and what is my co-pay? I am told that they are covered at 100%. Any limitations? Nope. Thank you very much. I call back a few minutes later, just to confirm (this has become SOP as of late). I ask the question, and am told that there is a $500 deductible. Whaaa? I tell her that I had just spoken to another customer rep and was told that there was a $500 deductible. (Keyboard clicking) and she comes back and says "that is if you go through the HMO", nonchalantly, as if the discrepancy is just pennies.
"Well, first of all, what do you mean by my HMO? I have BC and Medicare, no other insurances". (Keyboard clicking) "No sir, your BC has an POS, PPO, and HMO cost tier". I swear to God, I have never heard that before. "I thought that this policy was a PPO". "Yes sir, but as I told you, there are three tiers, POS, PPO, and HMO" as if I'm either deaf or an idiot", but I keep my cool. I don't want a little black mark that means I'm going to get hassled and end up needing prior authorizations for them to pay for an aspirin." "I know what they all mean, I just had no idea that this was part of my policy". "Yes, it is sir, and for foot orthotics if you use a POS (non-network provider) the deductible is $500 (they cost $570 by the way). If you use a PPO provider the copay is 30%, and if you use your HMO, they are free to you, as long as your doctor get a pre-authorization. Me: "so my pre-auth goes to you guys?" "No sir, it goes to Brown & Toland". Holy cow, I think, I almost had one by that point.
So I call one more time, and get the same answer as last time, so I figure I'm good to go. I call the podiatrist, his office submits a pre-auth, and a week later, I get an approval letter, with a list of orthotics suppliers that are in my HMO. I call, make and appointment, go in, get fitted, wait 10 days, go back, get my new orthotics and the technician tweaks them, then says "ok, we're done. Just head up front and take care of your co-pay". Oh holy hell. So I get up to the desk, and the receptionist/billing clerk says "that will be $107.50 Mr. Tallmadge". Me: "umm, these were ordered through my HMO with a prior auth, there is no copay. " (keyboard clicking, as she goes to the BC website) "No sir, according to their website, with your policy you are only covered at 70%". I'm getting slightly irate: "you need to call Blue Cross then and figure this out" As I wait, she calls BC and ends up in phone tree hell for a while. Finally a person answers, she explains the issue "oh, that isn't us" she is told, "you need to talk to ____ I'll transfer you". Another hold, then again, she explains the situation. Lots of yakking back and forth, she keeps rolling her eyes at the person on the other end, tells them what information I got from the insurance company before I ordered these. Finally, she says "thank you", hangs up and goes back to the computer (keyboard clicking). She then tells me "you were right, Mr. Tallmadge. The problem is, BC's website doesn't show an HMO tier for your policy, so that is why the confusion happened".
This whole situation was minor compared to some of the bull that I've had to deal with lately with BC. Case in point: I call to order refills for my Interferon 2 weeks ago. I call the mail order pharmacy, and am told that I have no refills left, and they need to contact the Dr's office. Two days later I get a call from the pharmacy, telling me that my claim was denied. OK, that is it, I go off (but not at the poor customer service agent, it's not her fault. She is as much of a pawn to those bastards as I am). She then tells me that Wellpoint has supposedly called my physician's office 3 times in the last 2 days and they haven't gotten the required documentation to approve the claim. This has happened more than once before with Hellpoint already, so I know that was a flat-out lie. If nothing else, my physician's practice is very responsive with issues like this. I call the office and talk to the office guru that handles all this insurance company bull, and she tells me she is getting right on it. A few hours later I hear back from her, and she tells me that it was rejected, but she had requested an expedited re-auth, which they will do for life-sustaining therapies, and they have to respond within 72 hours (not business days, 72 hours from the time that they get the fax from my physician's office.
The following day Karen from the physician's office calls me back, as does my physician, telling me that they are still denying the claim. Supposedly my cirrhosis is too advanced and I'm not having an adequate enough of a response. I call BC and give them my "what the hell is going on" speech, they tell me that I can appeal again, and I have 60 days to do it. How nice. I tell her that this is a life-sustaining therapy, and unless the insurance company wants to take the blame for potentially screwing up a good response to treatment, it needs to be fixed NOW. She tells me to tell the physician's office to call and request another expedited appeal. I do, the following morning I hear back from the physician: "Parry, did you ever have a liver biopsy?" Me: "no, Marion Peters at UCSF said it was a wasted procedure since I was an acute infection, it hadn't been lingering in me for years". My physician then says "well I don't know where they are coming up with that, because that is what I told them was the case, and they didn't seem fazed; I told them that you were infected sometime after August, 2007, when you last were tested and was Hep C negative. They then tried to tell me that I hadn't sent in all the labwork, and there wasn't evidence that you were responding positively to the therapy. I told them to look in the file, everything was emailed over. I told them that you went from a viral load of 2.3 milion at onset of therapy, and by week 8 the viral load was undetectable, and had remained so. You can't ask for a better response than that. I also reminded them that standard of care, especially with HIV/Hep C co-infection, was 48 weeks of Interferon. I told them that they were risking compromising a so far robust SVR (sustained virilogical response) by truncating your therapy. They were jerking me around, I asked for a medical director. She got on the phone, I repeated everything to her, and all they said was "we will review it". The following day, my physician comes into the office in the morning to find an approval letter sitting in the fax machine. Egads. Oh, and btw, my physician told me in that final long conversation that we had that he had been told that he couldn't get request an expedited appeal over the phone. I told him "well call them back and rip them a new one, because that is the opposite of what I was just told.
Have you ever noticed that in all the insurance company's advertising, they always show robust, happy smiling (and usually white) people? They are probably smiling because they have never had to deal with their insurance company. Swear to God - these days, I think the way these crooks operate is so frustrating that they could probably get Mother Theresa to cuss like a sailor. I know know why there has been such a push for more anti-depressants to get to market. By the time people get their insurance company to pay for them, they are already past the point where the drug can be helpful and they now need a bigger and better one. If you haven't see Sicko, you really should. I've seen all of Micheal Moore's films. I respect him as an artist and as a humanitarian, but I'm not an apologist for him. He can be known to tinker with the facts to make his hypotheses work. He can be prone to hyperbole and to being fast and loose a bit with the truth now and then, as does any story-teller, of which he is one. I use that term in the most complimentary possible manner, by the way. But Sicko is a different story. In this movie, and I think I can speak from the perspective of someone who has a fair degree of sophistication with working the system, he really didn't have to stretch the truth, even if he had wanted to.
I've watched our health care system devolve over most of my adult life, both from the inside and the outside. Health care barely resembles what it was 25 years ago when I graduated from nursing school. We actually had a better system back then, and that is a pretty sad thing to observe. When Cuba, one of the poorest countries in The Americas, can provide free health care to their entire population, something that we so far haven't been able to do, that is downright embarrassing. That we are one of the most prosperous nations in the world, and are still the only country in the western world that doesn't have free universal health care is an abomination. I'm not very hopeful about any reform that is going to come through this year. I've not been watching the debate that much, but every time that I do, I see the same thing happening in Washington: finger-pointing, pandering to the whims of fellow legislators and giving every whiner a little pork in their pocket just so they can pass "something". To me, that is expediency at the expense of doing the task correctly.
What really scares me with the current "system" (what a misnomer that is) is knowing that if somebody like myself, who for the most part knows how to work the system better than most can still get dicked around, what is happening to people who don't know any better? Most people don't have the medical sophistication and education that I have been blessed to have. I can't tell you how many friends and loved ones I've walked through a fight with their insurance company. I have to know that for every one of them, there are thousands who don't have a voice or an advocate, and that is what the big business of rationed health care in our country depends upon. Their profit margin factors in and depends on a certain number: how many people will stay ignorant and uninformed? Then to go to the next step, how many of those people will then just roll over and take it when they get denied care by that insurance company? They want nothing to do with the government taking over the system; they stand to lose a lot, and they know it. Their little shell game of hiding the money and shuffling it around and burying it in a morass of paperwork will come to a screeching halt if the government takes over. Like Medicare already does, the reimbursements are set, the doctors don't spend half of their time and resources dealing with getting paid for their work. Ask 90% or more of doctors out there, and they will tell you how they love dealing with Medicare vs any private insurance company. The paperwork is less in volume and more efficiently handled, and the drug companies and hospitals are bound to take the reimbursement that the government will give. There is no negotiation, take it or leave it.
Our country is going to get sucked down the crapper unless we finally decide that every American has a right to free health care. Some crooked CEOs and their poorly-run companies will fail, and I think that is a good thing; we don't need to be trying to save all the AIGs and Enrons of the health care sector. If some of the bad apples fail, the sun will still come up every morning like it always has. The Ann Coulters and Glenn Becks will still be around, decrying the moral decay of our country as we slip into a socialist state, and I fully support their right to do so. I just hope that they are seen for the charlatans and crackpots they are. I'm just stunned that in our supposedly democratic country where the rights of all are sacred, that we still let so many among us fall through the cracks: no housing, not enough food, and the worst and most minimal health care that can possibly be doled out.
On Saturday, both the denial and subsequent approval on appeal letters for the continuation of Interferon therapy arrived - same day. The statements in one letter completely contradicted the statements in the other letter. It was a little funny, because in the approval letter, they went out of their way to make the point that the review and decision on appeal was made by a completely different person from the denial letter. Well duh! All you needed to do was read the letters, it was a perfect illustration of the right hand not knowing what the left hand isn't doing. Another gem in the approval letter was that they stated that I was approved for another 36 weeks, but if you count the dates that are covered by the letter (12/21/09 - 7/14/10), I get 29 weeks and 3 days by my count. Supposedly they only want to approve me for a total of 48 weeks, but with this approval, if it is honored, I would have enough drug to go for a total of 64 weeks. Whatever, I'm not complaining, I got the approval so I'm good to go in that regard.
On a lighter note, I made three more batches of peanut brittle this weekend, and if I can say so myself, it came out brilliantly. I had an interesting observation today. I don't know if you have actually taken note of this, but have you ever observed that most candy makers, chocolatiers and pastry chefs (as in professionals, and I said most, not all) are not obese? I think I've now figured out why. If you spend hour upon hour, day in and day out, smelling sugar syrup being cooked down, it becomes kind of gross, and rather quickly so. I have no interest in cookies or candies. I've eaten very little, but it's atill been seeping passively in my pores for weeks. My sweet tooth has been euthanized, and I am craving anything savory: meat, a salad, some dairy, something spicy, some vegetable, anything. I just don't want anything sweet right now, and all the sickening, sugary, sweetly smells have destroyed my appetite.
Since I've wandered back into a culinary topic again (actually it's a nice respite from talking about drugs, disease and insurance), I got an email from my niece yesterday. She is an adult, the only child of my sister Pam, and she is 33 yrs old. She had spoken to my Mom and was looking for a good cookie recipe. She was going to a party that a friend was having; it was a recipe sharing party, and this one's topic was cookies. Rachael doesn't bake a lot, so she was lost and asked me. Over the course of a few text messages, we narrowed the list down and finally came up with Chocolate Crinkles, when are easily my favorite chocolate cookie, and one of my top 5 favorite cookies. I emailed her the recipe and then sent her a text, telling her to check her email.
Later in the evening I got a reply from her, thanking me for the recipe, then out of the blue she says "I just saw Julie and Julia, and I'm wondering: what really inspires you in the kitchen?" I sat for a moment, thought it over, considered giving her a short and incomplete answer, since it was late and I was tired, but very early on into my response letter, I realized that she deserved better. That was a really insightful question, one that I have never been asked before, and not one that she obviously wanted me to just give lip service to with some perfunctory answer. So bleary-eyed and more than ready for bed I went for it.
What inspires me in the kitchen is the food. If I fail, I'm inspired to make it better. If I succeed, I'm inspired to try something else I never thought I could make. There used to be a long list of things I thought I couldn't do, mostly because I could never get them to turn out right. This last year, I've taken that list, and called it my challenge list. I told myself that there is nothing that I can't make. Cooking is part skill, part inspiration, part innate talent, and I have all three. But all those are meaningless without practice. Failures are inevitable, but that is how you learn. If I keep making the same mistake every time, I need to figure out why, all time reminding myself that I'm the problem, not these words printed on this page of a recipe book. If I make a new mistake every time, I'm learning. Cooking has a learning curve, even for the best of chefs.
Few things are as universally satisfying as good food, not even good sex, I reckon. Preparing good food is its own reward and creates new inspiration for me. I'll never get to a point where I can say I've peaked. If I do, then I'm delusional. I can, however, continue to set loftier goals, and I now approach these goals differently. Rather than thinking to myself that I hope I don't fail, I can instead set the expectation to succeed. It's semantics, but often those seemingly insignificant shifts in perspective can have far more monumental effects on one's expectations and outcomes. It's also interesting to me that as I have put into action these new ways of looking at my culinary path, I'm finding that what I used to perceive as flops and monumental failures seem to be very small. I think it's partly that as my skill has improved, I am at a stage of honing my skills rather than starting at square one. I also think that it's probably due in great measure to my generally new outlook on my life. I spin nearly everything differently when I'm analyzing data, which I do constantly. I don't see insurmountable odds or no-wins, I see challenges, I don't see illness, I see opportunities for both growth and also learning to adapt to the tools (my body) I have to work with, and the condition of those tools. I also have continued to get a deeper appreciation for the importance of honoring and respecting my mind and body. I'm getting a bit off-course here, but there is a point: in every endeavor that I've undertaken in my more recent life, especially with the even greater health challenges, the outlook with which I approach these challenges and the methods that I employ to meet the challenges are nearly identical, and nearly universally adaptable. I think I'm finally figuring out that the complicated solution is rarely the correct one. Thinking small can produce very big results.
It's funny, but the more that I write, the more that I realize that so much of our life is repeated experience, only altered enough to deceive our minds into thinking that we are seeing distinctly different occurrences. It seems to me that once you start distilling down your thought and decision making processes, you usually find that it's the same problem in a slightly different form. The same goes for the solution: same answer, slightly different form and content. Maybe life is really only one question asked and answered in an infinite number of slightly different ways. Personally that makes the most sense to me, and makes it easier to make sense of senseless situations. Again, this is another quantum shift I've experienced; there are no senseless happenings in life, there are only happenings that one may not necessarily understand at the moment. Eventually, all the puzzle pieces fit together, and in the end, the picture in the puzzle is the story of one's life.
Doggydad's Life Now: The Viral Monologues by Parry Tallmadge is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.
Based on a work at doggydad.blogspot.com.
Permissions beyond the scope of this license may be available at http://www.runnymedesilkys.com.
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