A Minor Health Care Travesty, a Personal Story with a Larger Meaning

I'm in the midst of a dispute with my health care insurer, which, although it is over a fairly minor amount for a blood test, is indicative of a much larger problem, and is one of the very many reasons why sweeping health care reimbursement reform is absolutely necessary in this country.

I have a family history of prostate cancer and am over 50. Thus, by almost all reasonable medical standards, the PSA test (Prostate Specific Antigen, info here), is indicated annually, to test for signs of the disease. My doctor has told me of patients of his whose potentially life threatening cancer was detected by this test. I have had this test every year since I was 50, and have had the same health insurance all that time. The insurance has always paid for it.

Now, all of a sudden, I get a confusing "Explanation of Benefits" with a code that when you look up the fine print means "Denied due to lack of medical necessity." That's all. The same day, a bill from the lab arrives for the full, "Cadillac", uninsured-patient price of $115, just for this one test. If the insurer had paid it, they would have paid $30 or so, and the lab would have taken that, because that's their negotiated price, but if the insurer denies payment, they expect you to pay the "gouge" price, which is actually about 130% of the market price for the test if you walk into an independent lab and pay for it out of pocket (I checked).

I truly believe this practice is racketeering, pure and simple. I would so love it if a State AG or the US AG would prosecute (or sue) some of these people under RICO, but I guess that's a vain hope.

I won't go into all the hoops you have to jump through just to get the insurer to deign to reconsider (no guarantee they'll pay even then). They lie to you and say they told the doctor they need more documentation and a letter of why it's necessary, but it isn't true, they just deny it and it's up to the patient to initiate and follow through with all the convoluted steps in the process to try to get the bill paid.

Meanwhile, the option of negotiating with the lab gets you nowhere. They stonewall: "We don't negotiate." Bullshit. They negotiate all the time, with those who have leverage. But as a mere patient, you have none, and they threaten you, on the very first call, with sending their bill to collections to ruin your credit.

You have to be extremely proactive to get affordable health care in America, and not get cheated, even if you have (supposedly) decent employer-based health insurance.

Check out T. R. Reid's The Healing of America, the Quest for Better, Fairer and Cheaper Health Care. I'd send my copy to everyone I know if I could afford it. It's already spoken for by about five people.

Reid happens to mention the very test that I'm disputing, PSA. The truth is, the National Health Service in Britain, as an example of an alternative system, doesn't pay for this test. They pay for a lot of preventive care but they've concluded this one isn't reliable enough. (Most countries' health systems do pay for it). But the difference is, when you go to the doctor in Britain and say, "I seem to remember there's a blood test for prostate cancer," the doctor will tell you, "sure, mate, but the NHS won't pay. You can pay for it yourself, for £10." (Because the doctors depend on this kind of uninsured service to make extra income, and they compete fairly for it).

Here, you and your doctor think it's covered, till you find out it isn't, then you find out you've agreed in the fine print of the lab form, sight unseen, to an outrageous gouging amount (undisclosed in advance, of course), which if you don't pay in full you're officially a deadbeat, even though the amount may in some cases be as much as ten times what the insurer would have paid for the same item. And these kinds of discrepancies in what insurance will pay and what health vendors expect uninsured and underinsured patients to pay out of pocket don't just apply to labs. These problems exist across the board in American health care. No wonder Americans more and more hate health insurance and everything about it!

As I said, this particular personal instance is a minor matter. The $115, if I just paid it, wouldn't kill me. They count on that. Most people just pay, to avoid the hassle. But what if it were a $100,000 surgery? Because don't think it doesn't happen. And the scenario unfolds in much the same way. Employer Health Care Advocates (now there's a job that shouldn't be necessary. I'd rather see people employed as elevator operators to push the buttons for you). Countless letters, phone calls, and faxes back and forth, all a tremendous waste of time and mental energy. And then, like as not, they deny it anyway. And if you can't afford it, it ruins your credit. Some file bankruptcy. Some lose their homes.

This stinks. It really, really stinks, and it's time to put an end to it. 45,000 people die every year in this country because they can't afford medical care or insurance. That's the worst. But another 700,000 file bankruptcy, which doesn't happen in any other advanced country. Can't. In countries with private health insurers, the cost of everything, and what's covered and what's not, is public record. No one has to just pray their insurance carrier will pay for something and that the medical bills they get stuck with won't .... literally.... bankrupt them. It's illegal not to pay claims in every other country that has private insurance. Health cost related bankruptcies are unheard of. (Because, of course, no one is uninsured, even in advanced countries with purely private systems, like Switzerland and Germany). But not here. In America, our health care delivery is very good, overall, if you have insurance (not so good on preventive care), but our system of paying for health care just plain sucks and must, must be changed.

Please join with me in making our politicians make that happen, for real, and soon.