September 26, 2009

Precertify this!

To: my so-called health plan

From: Alice

It has come to my attention that the word "insurance" does not appear anywhere near the word "health" anywhere in the opening pages of your 200-page book, the one you would prefer I not request as hard copy. "Curing the sick" is not even on your priority list.

Well, I read the damn thing, and the sum total is, if I am told I need a test more serious than blood, piss, a pap smear or a chest X-ray, my "health care provider" can neatly ignore what the radiologists, who specialize in reading films, have to say.

The buck did not stop at the doc-in-a-box office: she sent it flying off to the hands of the money-grubbers, those anonymous people whom I cannot telephone to argue for myself. My health is in their hands, whomever they may be, the "precertifiers."

If any of them has an M.D., I'm betting s/he works for the "insurance" company because no one would have him/her as a clinician or researcher. The guy who graduated last in his med school class, the one who is called M.D. nonetheless? That would be, should Cambridge (my nom de blog for the "health plan") actually employ someone with any medical training, the one who turns down my test.

This would be the idiot at the other end of the 800 line, paid to refuse to agree with the medical opinions offered by my first-line "health care providers." This leaves me either with large uncovered medical bills from the better doctors in this town, or it leave me being screwed, and possibly ill.

Notice the term "health care provider." Sounds like anyone from the clerk at the big-box drugstore chain to a kind stranger offering a Kleenex. Does not have that authoritative ring that an M.D. once implied. Apparently the health care (insurance?) provider has the last call.

Primary care means, I have discovered, if you can't diagnose based on years of experience, you will cover your ass by calling for expensive scary tests, then refuse to follow the advice of the radiologist, and blame it on my insurance. If you are a doctor employed by one of the mismanaged nightmare plans, you are not going to be my advocate.

An M.D. with experience and balls, however metaphorical, might fight for me to have what is deemed the next logical step in the flow chart per her outsourcing. But that's not how my health care plan works, and I'm betting yours is no better than mine.

Cambridge has decided it's not in the patient's (that would be me) best interest to follow through, on the grounds the next test is too expensive to bless. I wonder how the company will feel if, ultimately, I do get the damn test and it shows me lighting up like a Christmas tree. Will Cambridge then decide I don't need an oncologist?

That would be me, the patient, self-payer of $10,000 a year and rising for my health care. New discovery in the road to middle age: a "health care provider" is fine for, say, the chicken pox or the flu. If, however, you go in with a smoker's cough, you will find the PCP has never met a smoker in her practice.

Never heard of Nicotrol, the nicotine inhaler used to get smokers to stop and too scared to write the script on her own. Ever hear of a doctor NOT jump all over the smoker to help her stop? That's my "primary care provider." I should see a pulmonologist to confirm the need for medicinal nicotine.

Never mind that I control my own nicotine intake, and it's certainly got a lot more nasty chemicals in it than the prescription kind. Or that my lungs came out clear on the CAT scan. Where did the PCP get her M.D.? I'm afraid to ask. Her decision-making abilities, not to put too kind a description on them, suck.

When I asked her to act as my advocate, the go-between between Cambridge, which doesn't want to cover me when I may be sick, and her own medical opinion, she responded with a vote of no-confidence on pushing for what I need. I'm not sure she has her own opinions; her voice is never long on confidence.

Apparently it is my job to remind the doc that if she wants me to have a test, she may need to push for it with the precertification department. Not going to happen. Yea, that guy who was last in his class certainly knows more than someone who has seen the actual patient. Ha.

I doubt this doc-in-a-box would even prescribe an antibiotic for what could just as easily be bronchitis. And I don't need any degrees to know what bronchitis feels like.

But we are way beyond the chest X-ray. Went for the (preapproved) CAT scan, and independent radiologists offered up the PET scan as the next step in the testing process. Then Cambridge steps in, and says, not enough evidence.

Hmmm: I've seen the radiologist's report, and it is pretty damn clear what is supposed to follow.

Not from Cambridge, it's not. Who the hell makes the medical call of "sorry, too expensive. Wait until you feel like you're dying, and then we'll, say, send you to hospice"?

Who need a hospital when you can go straight from your own bed to the one that says, here's the last place you'll be on this earth? No, let's keep the costs down, and hope that one day, one of your Cambridge employees, needs this test. Then she will know how it feels, to be on the other end of test? You want a $5,200 test? Oh, no -- no precertification forthcoming. Not in the cards.

When the "health care" provider starts the bidding at four no-trump, the game is over before it begins. Cambridge has all the cards, and it specializes, it seems, in dealing its customers/consumers/suckers the hand without even one heart in it.

Our system is broken, clearly, but I don't have much faith in so-called reform, despite being a yellow-dog Democrat. Even with "insurance," we already have rationed health care, and I can't imagine the next round will cover my health needs any better than the crappy system in which I am enmeshed.

One of my closest friend's mother was diagnosed with lymphoma last week. This week, she's already gone for round one of chemo. She is 80, and recently she said, "old age is not for the faint-hearted." Her daughter, a veteran of the cancer wars, is a great advocate for her.

For the rest of us, however, her mom would say, 'It's a great life if you don't weaken."

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2 Comments:

Blogger the only daughter said...

DMOs are much better. Cover the exam but not the treatment. (Or, not all of it). Non-sensical.

8:15 PM  
Anonymous teresa said...

Will you precertify a long-distance hug? It may prove more healing in the long run.

(((Alice)))

2:10 AM  

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