Insurance Impediments!!!

What the hell— my insurance company has high jacked my chemotherapy treatment! I am so livid that I do not even know how to begin this blog. My gripe is regarding the insurance companies’ power. It is out of control.

In the 1980’s I was part of a group who lobbied in Albany NY to prevent the changes insurance companies wanted, that being special task forces that only deal with utilization and preview of all diseases and hospital stays originally designed to prevent unnecessary costs. This sounded like a good concept in theory but the fear was that people would be lumped into groups rather than receiving individualized care. The notion was saving costs for insurance companies meant passing on savings to the consumer. The reality is insurance, like Big Pharma is a money making endeavor so the bottom line is always their profit.

We lobbied against this because the fear was with predetermined health care coverages, those exceptions would receive inadequate care. Or, as in my case, the level of care prescribed by your specialist would be replaced with care that insurance company felt was more cost effective. We lost.

Insurance companies have adjustors, doctors and nurses and who knows how many other professional titles all gathering to go over aspects of a diagnosis and then determine the modus operandi they feel is adequate for that patient’s care. It may well be adequate but since it is not specifically tailored to that person’s total wellness or health issues, it may not be as effectual and may even cause harm. The least it might do is delay the proper medical care someone needs desperately, all in saving a buck.

Here are some of the definitions of what happens with your insurance company in determining approval of services. If your information crosses on even one desk who finds a loophole or something they feel can be used to deny a claim, it is denied!!! Otherwise, you are subjected to their conviction of what is best for your illness.

Utilization management/review  UM is the evaluation of the appropriateness and medical need of health care services procedures and facilities according to evidence-based criteria or guidelines, and under the provisions of an applicable health benefits plan.

Utilization review. : the critical examination (as by a physician or nurse) of health-care services provided to patients especially for the purpose of controlling costs (as by identifying unnecessary medical procedures) and monitoring the quality of care.

 Utilization Management (UM) Tasks. Consult and coordinate with health care team members to assess, plan, implement and evaluate patient care plans. Interview or correspond with physicians to correct errors or omissions and to investigate questionable claims.

I understand the need to keep medical costs down and the waste of hospital beds and equipment used unnecessarily. It was happening and needed to be changed. But this solution has its bad points and none are in the profit margin of that insurance company. And we are not hearing of any reductions in premiums as a result of this implementation are we? Only disclaimers and discouraging letters of denials. And do not get me started on Trump care because that can of worms is just too mind boggling for me to think about right now.

Here is why I am explicitly fuming right now. Six years ago I went to a specialist to get a breast reduction. This is a very complicated procedure and I do not mean the surgery. You have to have a couple doctors verify there is a medical reason for reduction, direct medical examples of how having large breast has adversely affected you (in my case I had years of spinal injections for the damage caused to my neck and spine from the weight of them) and there has to be deep ruts on your shoulders. The last obstacle was I had to have a rash between and under my breasts. I did not. As a result my claim was denied.

I was denied because I took appropriate measures to be clean and dry and used special creams and a man’s handkerchief to keep me dry. I share these intimate details because it is important to understand just how perverse insurance companies can be. After years of carrying these heavy boobs I finally got the nerve to go for reduction and was denied because I did not have a rash. Now because of my Rheumatoid infusions I have nothing but yeast infections but guess what, it is too late now because my breast cancer will take care of all that. Once I am done with chemo and radiation I will qualify automatically for reduction. But look what it took, what my cost was. That procedure coverage was based on reasonable criteria and documentation of medical necessity and it was decided I did not need it. And if a woman is heavy they use that as a reason for denial too, even though I had photos of having large breasts when I was slim too.

Fast forward 5 years. Last week I was given the protocol that would best help me in my battle against breast cancer. It is aggressive but it is also tailored for me specifically because of my myriad of other health issues. I got comfortable with the whys of it all and felt good about the inevitability. So yesterday imagine my shock when my Oncologist tells me the insurance company has decided they have a better course of action. Theirs is targeting the cancer but overlooking all the rest of ME. Dr. Benjamin argued with them on the phone but who holds the Power? Not us and not him.

This plan will take me longer and interfere with the chemo that was more specific to the HER2+. And I will still most likely go onto the chemo we first discussed but have to do this first. Does that even make sense to anyone else because it does not to me. Now I will begin rounds of Cytoxan and Adriamycin, the red devil cocktail. Both of these drugs are for the breast cancer but ignore some of my other medical concerns.

It was a long morning; so many other drugs come before the actual chemo all in preparation for those toxins meant to kill the cancer and save my life. But I was so focused on my anger about the insurance company I did not notice as much as I should have I am sure. I was fortunate, no symptoms as I received the drugs yesterday but it has hit me today with nausea and headache. They gave me the Neulasta patch for bone marrow stimulation which kicks in this evening and 2 other anti-nausea drugs: Ondansetron for vomiting and Prochlorperazine. I already began my #Youngliving Ningxia Reds and Digize and Peppermint capsules that support this fight.    

I want to clarify that I am so grateful to have insurance, I know what it is to be without. I was one of those people who had none and often times went untreated or paid off huge medical bills for so long. So I am thankful but also I am resentful at the blockades of high premiums, and low quality care disguised as cost effectiveness for the patients. It feels like being held captive at a crucial time when all I want to do is focus on beating this cancer and getting my life back.

So yes, today I am bitching about it because it ain’t all roses and sunshine and being positive does not make this quandary go away. Just sayin’.

Live Laugh Love                                                                   

Debbie

Tagged as: anger, Breast cancer, chemotherapy, cost effective, doctor, individualized, insurance companies, power, treatment, utilization management