Because insurance pays for a portion of your treatment, rarely 100% of it, and the moment you start racking up bigger bills, insurance starts looking for ways to not pay your claims. They’ll put a hold on payment until you call them and broker a deal or they go back and forth with your doctor demanding that you receive some treatment other than what that doctor recommends.
I have Crohn’s Disease, an autoimmune disorder that is often treated with immunosuppressants. First, they did not want to pay for my initial “loading dose” because it has to be done by infusion. That’s a ~$25,000 procedure (3-4 hours on an IV). I talked them into it by telling them that only the first dose would be by infusion and the rest by self injection.
But when my company decided to pay for a less expensive insurance plan that started at the beginning of the year, they suddenly didn’t want to pay for the injections either. Now I owe 30% of the cost of my injections. That’s almost $4,000 a dose that I take every 8 weeks, about $25,000/year.
So now I use a coupon program through a separate company, and they bill the remainder of the balance to the company who produces the medicine who give me a $21,000 annual credit toward paying the remainder. So now to get my medicine I must coordinate between my doctor, a specialty pharmacy, my insurance provider, a company that runs the coupon program, and the company that produces the medicine… Just to get a syringe delivered to me on a schedule. And the credit probably won’t last until the end of the year; I’ll probably end up shelling out a few thousand for my meds around Christmas time this year.
If any of the complicated web of companies that collectively get me these meds doesn’t have everything lined up in their system, I don’t get my meds. My last dose was almost three weeks late to me because of all the calling around I had to do. Because we don’t have a central health care authority, that means each company maintains their own system of record. Each phone call involves working through a phone tree to get to a human agent, working through the same set of identity verification steps with them, explaining the situation over again to a different person every time…
It’s a real pain in the ass, and they do it on purpose to get you to give up. Having insurance doesn’t mean your health care is paid for, and you pay a premium (hundreds of dollars) on every paycheck to keep the insurance that still doesn’t pay for your medical costs. Having health insurance does not mean you don’t still pay through the teeth for your health care. Having health insurance does not mean that health care is accessible to you. Having insurance that makes health care accessible today does not mean they won’t change the rules behind your back, and that you will still have access to health care tomorrow.
All things considered, their situation is not as bad as it could be. I had a job where one of my duties was to get prior authorizations for every procedure we did in an oncology-focused plastic surgery clinic. The vast majority of the procedures were breast reconstruction following mastectomy and skin cancer excisions. I had an insurance company demand documentation and evidence of medical need to close the incision site after excising the melanoma. They were gracious enough to allow the excision without requiring a prior authorization, but in order for the surgeon to close that incision (or in this particular case, fill in the area with a skin graft because the amount of skin to be removed precluded a simple closure), we had to file a mountain of paperwork on a tight deadline because the procedure couldn’t wait more than a week or so.
I’ve also worked in hospitals, and every hospital I’ve worked in has social workers on staff to help patients line up emergency insurance coverage or financial assistance for emergency medical care. I never actually saw the bills for it, but we treated a kiddo that was a bystander in a drive-by shooting that was transferred to our hospital from another ER so that they could have the pediatric trauma surgeons try to fix his femur. So that’s two top-level ER visits, an ambulance ride, an ICU stay, and probably a bunch of surgeries and associated hospitalizations…because this 2 year old got hit in the leg with a stray bullet. The total almost certainly topped 7 digits. Shit’s fucked, yo.
It’s always a consideration, but the question is where would we move to (and how much am I willing to uproot my family)? Canada is a nice place with a better healthcare system, so maybe there? But that’s expensive all on its own, and I have to consider that I have two autistic kiddos who are currently receiving their education at the best school in the state for special ed kiddos. Is it worth it? Maybe not. For now, I think we should stay where we are. I love it here, except for the high cost of my own care. Think I’d rather stick it out and fight for a better system here. Maybe we can improve things for everyone instead of jumping ship.
Because insurance pays for a portion of your treatment, rarely 100% of it, and the moment you start racking up bigger bills, insurance starts looking for ways to not pay your claims. They’ll put a hold on payment until you call them and broker a deal or they go back and forth with your doctor demanding that you receive some treatment other than what that doctor recommends.
I have Crohn’s Disease, an autoimmune disorder that is often treated with immunosuppressants. First, they did not want to pay for my initial “loading dose” because it has to be done by infusion. That’s a ~$25,000 procedure (3-4 hours on an IV). I talked them into it by telling them that only the first dose would be by infusion and the rest by self injection.
But when my company decided to pay for a less expensive insurance plan that started at the beginning of the year, they suddenly didn’t want to pay for the injections either. Now I owe 30% of the cost of my injections. That’s almost $4,000 a dose that I take every 8 weeks, about $25,000/year.
So now I use a coupon program through a separate company, and they bill the remainder of the balance to the company who produces the medicine who give me a $21,000 annual credit toward paying the remainder. So now to get my medicine I must coordinate between my doctor, a specialty pharmacy, my insurance provider, a company that runs the coupon program, and the company that produces the medicine… Just to get a syringe delivered to me on a schedule. And the credit probably won’t last until the end of the year; I’ll probably end up shelling out a few thousand for my meds around Christmas time this year.
If any of the complicated web of companies that collectively get me these meds doesn’t have everything lined up in their system, I don’t get my meds. My last dose was almost three weeks late to me because of all the calling around I had to do. Because we don’t have a central health care authority, that means each company maintains their own system of record. Each phone call involves working through a phone tree to get to a human agent, working through the same set of identity verification steps with them, explaining the situation over again to a different person every time…
It’s a real pain in the ass, and they do it on purpose to get you to give up. Having insurance doesn’t mean your health care is paid for, and you pay a premium (hundreds of dollars) on every paycheck to keep the insurance that still doesn’t pay for your medical costs. Having health insurance does not mean you don’t still pay through the teeth for your health care. Having health insurance does not mean that health care is accessible to you. Having insurance that makes health care accessible today does not mean they won’t change the rules behind your back, and that you will still have access to health care tomorrow.
what the actual fuck… thanks for sharing your story and I wish you courage. Have you considered moving ? given the severity of your condition ?
All things considered, their situation is not as bad as it could be. I had a job where one of my duties was to get prior authorizations for every procedure we did in an oncology-focused plastic surgery clinic. The vast majority of the procedures were breast reconstruction following mastectomy and skin cancer excisions. I had an insurance company demand documentation and evidence of medical need to close the incision site after excising the melanoma. They were gracious enough to allow the excision without requiring a prior authorization, but in order for the surgeon to close that incision (or in this particular case, fill in the area with a skin graft because the amount of skin to be removed precluded a simple closure), we had to file a mountain of paperwork on a tight deadline because the procedure couldn’t wait more than a week or so.
I’ve also worked in hospitals, and every hospital I’ve worked in has social workers on staff to help patients line up emergency insurance coverage or financial assistance for emergency medical care. I never actually saw the bills for it, but we treated a kiddo that was a bystander in a drive-by shooting that was transferred to our hospital from another ER so that they could have the pediatric trauma surgeons try to fix his femur. So that’s two top-level ER visits, an ambulance ride, an ICU stay, and probably a bunch of surgeries and associated hospitalizations…because this 2 year old got hit in the leg with a stray bullet. The total almost certainly topped 7 digits. Shit’s fucked, yo.
It’s always a consideration, but the question is where would we move to (and how much am I willing to uproot my family)? Canada is a nice place with a better healthcare system, so maybe there? But that’s expensive all on its own, and I have to consider that I have two autistic kiddos who are currently receiving their education at the best school in the state for special ed kiddos. Is it worth it? Maybe not. For now, I think we should stay where we are. I love it here, except for the high cost of my own care. Think I’d rather stick it out and fight for a better system here. Maybe we can improve things for everyone instead of jumping ship.
Yea, I can certainly understand the choice of staying and fighting for change