I've fought with insurance companies for treatment over the years. Treatment that is now, since Medicare covers it for breast cancer patients, finally recognized as the best option for patients. Still, it's not a complete guarantee. If you go the the National Lymphedema Network's page and click the the FAQ tab, one of the choices is insurance issues and there you will find an insurance appeal letter that you can copy, add your name, your doctor's name and the specifics of your case to send to your insurance company if you've been denied coverage for compresion bangages or garments.
Despite the fact that researchers dealing with this disorder will describe it as a chronic condition that requires daily maintenance, part of which is the aforementioned compression garments, insurance companies routinely cover only one or two garments in a calendar year. This is something that my daughter and I have to wear every single day. How long do you think a pair of socks would last that you wore every day, washed, dried and wore again? Think you could make the one pair last 6 months? It's absolutely unrealistic. But, it's something that insurance companies do all the time. Put it this way. If you or someone you know is diabetic, wouldn't you be raising all kinds of hell if they told you that they'd only cover enough diabetic supplies to see you through 3 months? You'd have to pay for the other 9 months.
My daughter was just fitted for a new garment. It cost us $254 and small change. That's our annual deductible. Actually, "our" is a misnomer. Every person in our household has a $250 annual deductible. So, even though I need a new garment as well, I'll be waiting until April. Imagine if you had to pay that amount out of pocket at minimum 4 times a year. In our house, it's actually 8 times a year. The manufacturer will tell you that to get the optimum use of your garment you should have two at a time. One worn, one hanging to dry. I've never been able to do this.
We are extremely fortunate that our insurance will allow us, once we met our deductible, to get as many garments as we need. This is the first time I've ever had this experience. It's still so new that I can't bring myself to use it for fear of being denied. Added to that is the fact that we have exactly one provider that will fit us for the custom garments we need. All the others will no longer provide custom garments.
This brings me to the crux of what I think the real problem is with American medicine. It's a business run by the insurance companies whose goal is to make the most money from your premiums they can while spending as little as possible on you the actual customer. The companies that have decided to stop providing custom garments are doing so because insurance companies are not covering them at anything near to their actual cost. They are in effect losing money every time they sell one. This is ridiculous. It's one of the reasons I believe that insurance companies were so reluctant to cover the therapy for lymphedema. It's labor intensive, requires the use of expensive materials and just plain doesn't meet the bottom line for their shareholders. Which is so completely wrong.
Chronic diseases are expensive. Improper treatment of chronic diseases is even more expensive. Take diabetes. A great deal of diabetes is completely preventable. But prevention is not something that brings in the bucks, so insurance companies ignore it. Once a person is diagnosed with diabetes, they have to learn an entirely new way of living. If it can be managed with diet and exercise, all well and good. But if it can't or a patient either can't afford the supplies to control the disease or won't control it, they end up with some really serious complications. Expensive complications. Amputations, blindness, and renal failure to name a few. I worked as a dialysis tech at one time and medicare provided the coverage for most of our patients. But Medicare had a set dollar amount they would cover. And it really wasn't enough to cover the expense of treating the patient. Where were those costs recouped? From the private insurance patient who insurance was billed substantially more than Medicare. It as also recouped by manipulating nurse and tech coverage so that we technically met the minimum state requirements but only just barely and often by counting the nurse as a tech to meet the proper ratios.
Another example of the business model gone wrong is prescription drug coverage. I have hypothyroidism. It means I have to take synthetic thyroid hormone every day. For the rest of my life. I've been on daily medication for almost two decades. In that time, I've been on several insurance plans. When I first started taking Synthroid, I paid $7 a month. That was my prescription co-pay for a non-generic drug. Gradually over the years, that co-pay has risen. Now, I pay $22 a month for a prescription that I could buy outright for $27. All because the standard drug to treat hypothyroidism has gone from a non-generic class to non-preferred name brand. Or as Blue Cross puts it, in the top tier of their three tier system. Yippee! This, my friends, is a crock. And Synthroid is a relatively inexpensive drug. There are others much more expensive out there that must be a real financial burden on their users. I don't want to argue the validity or efficacy of generic versus name-brand drugs. But it seems to me that drug companies are making an awful lot of money. Yes, they need that to research new drug therapies. But I find it hard to feel sorry for a pharmaceutical company that whines about generics undercutting their revenues when all they're using those monies for is to find a better pill for erectile dysfunction. And don't even get me started on insurance companies that cover Viagra and its brothers but not birth control. Do they not see the disconnect?
But seriously, how can we spend the most money on health care of any developed country and still have over 45 million Americans without health coverage? This makes no sense to me. Recently, I've heard Rep. Zach Wamp (R-TN) state that health care is a priveledge not a right. So says a man who has no health problems and a health plan provided by the government. And indeed those that can afford the best coverage or to pay out of pocket, get the best care. But it doesn't make it right. Doesn't the Declaration of Independence say something about life, liberty and the pursuit of happiness? Or to quote Mr. Jefferson:
We hold these Truths to be self-evident, that all Men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.
How can Rep. Wamp say that health care is a privilege when faced with these words? Moreover, how can he tell a patient who's doing their best to take care of themselves and remain productive (i.e. paying taxes) that what they need to do so is a privilege that they're going to have to a pay out the nose to maintain?
I don't know the answer to our broken health care system. You hear alot about how awful Canada and Great Britain's systems are and how anything that puts the government in charge of your health care will be just as bad. Seems to me if those systems don't work, why not look to ones that do instead? And is ours, as it stands now, really so superior that it doesn't need fixing? Tell that to the 45 million plus Americans who have no insurance and are only one catastrophic illness or accident away from bankruptcy. Better yet, tell that to the under-insured who are in the same position.
Frankly, anything that improves the current state of affairs is a win. But it must not overlook those of us with chronic or rare disorders. Every time I change insurance, I worry that some pencil pusher is going to label my lymphedema a preexisting condition. The whole idea of "preexisting" conditions being disallowable has got to be some sub-human's idea of cost saving. And again, it goes to the idea of medicine as business and health care as privilege.
I look forward to learning more about President Obama's health care reform plans. This reform is over due. Let's hope that the ideal of capitalism run amok goes the way to the dinosaur and we end up with a stable, fair and reasonable system that meets the needs of all Americans.