Monday, October 14, 2013

why insurance in the U.S. sucks pt. 2

So great comments everyone! In fact, they are deserving of the Great Commenters award!!
I responded directly to your comments under the post but the comments were so good that I will bring some of what you said onto the main postings if you don't mind...Anyway, onward through the discussion. For those of you who want to catch up, the first post was here.

Having moved from a regular insurance provider to Kaiser Permanente, the kids and I found the first benefit to the managed care institution was that they had a pretty firm grasp on asthma. My 2 year old son had been hospitalized for five days with a severe asthma attack in April 99 and his sister had experienced some issues at school that the family doctor had not been taking seriously. In both cases I found our GP undereducated about asthma and, especially where my youngest was concerned, unable to help and worse seemingly unwilling to admit it. When we went to Kaiser, they were all about preventing asthma so they immediately tested both children for allergies and sent them to an allergist on a regular basis to get help get their asthma stabilized. All the pediatricians we saw were fairly well educated on what the specialists were doing so we never had to worry that the regular Doc would doubt the prescribed treatment. Kaiser was also partnering with National Jewish which is (or was) leading the nation on asthma treatment so they were doing their very best to keep my kids out of the hospital and in fact out of the doctor's office as much as possible.

At this point I think Ian's comment about healthcare being driven by profit is relevant here (I hope you don't mind if I quote you here, Ian!),
"The free market and entrepreneurship makes sense in many situations, but I think there are some things that define us as a society that should not be driven by profit. If we want a healthy and well-educated society, we should be measuring the health and education of our population rather than revenue, and behavior should be driven by that."      
The reason this becomes important is that part of the reason Kaiser is so good at treating Asthma is that it makes sense to treat a preventable disease such as asthma the way they do. If you keep the kids on the proper medication with a preventative that keeps the asthma in check you will keep them out of the hospital which is far cheaper (duh!). And Kaiser has also been out there pushing good nutrition and encouraging their customers to exercise which of course also saves them money. There are also other ways that seem logical for insurances to operate that (to the person on the outside) one would say, "It seems like it would be cheaper for the insurance to do... [this]" because in the long run the patient is treated more efficiently and given better care. So, profits are great if it's done to save sick costs and to raise the health and wellness of your patients. The problem was that those were not the only cost savings I witnessed at Kaiser and often the "savings" came at the expense of patient care.

First of all, I was working at Denver Public Schools and had by then gotten a divorce. I was getting my insurance through the school system (by the time the kids dad & I split the monthly cost was $1000) but I stayed with Kaiser because I wanted to keep the doctor I had and (more relevant) I couldn't afford the other plan they offered. The plan was almost the same as the one the kid's dad and I had- same co-pay, same emergency, same pharmaceutical pay-outs, etc. but my cost was $50 a month. The employer cost (as I recall) was $100 a month. The family plan was around $500 a month. As you see, paying as an individual/group is a great deal more expensive than paying in real "group".  But that aside, a couple of examples outline the problems with Kaiser.

A friend of mine went on a trip to France and came back with strep which she got on the plane. It was a freakish strain which caused a lot of complications and she had to go to the hospital to the emergency room. She also had Kaiser and it took a bit but they figured out what it was and sent her home with antibiotics. Unfortunately, they did not check her medical chart and see that the type of antibiotics she was on was of the same type that she was allergic to. So she went home and within a short period she had a severe allergic reaction. She was rushed back to the hospital. They switched her antibiotics, kept her for a couple of days and sent her home. The antibiotics were not working and she went back in having developed a staph infection from her first hospitalization and poor treatment. Her body was misshapen and bloated- almost 4 times her regular size! She was there for two weeks and she nearly died. All because they were in a rush to treat her and send her home. It was a frightening time for her and she wound up with scars on her forehead where they had to drain the fluids out. It's graphic and awful, I know. But poor medical treatment is never going to be pretty but at least this story ends with her being okay.

For my part, I was having migraines and they continued to get worse. I had a sympathetic doctor and she was prescribing me Maxalt and Imitrex for my pain. She said there were a couple of preventatives I should try, which I did. One did nothing but the other was a blood pressure lowering medication. My blood pressure is already low so as soon as I went on it, I felt my blood pressure just tank and I felt miserable. I told her and she immediately took me off but said that was it, there was nothing else she could do. They did a CT to make sure there was no brain injury but when I asked about any other doctors I could see, she said there was no one. That was it.

As the years passed, I was having 2-3 migraines a week and there seemed to be no end in sight. At one point I was sitting in the Kaiser pharmacy waiting on my prescription and the pharmacist was clearly working on my prescription, I heard him say, "She can't take this much of this medicine!" It was really loud and if I'd thought that everyone knew he was talking about me, I'd have walked out. A few years ago I was talking to a different and equally passionate pharmacist about my migraine medicine. He told me that Imitrex and Maxalt are triptans and essentially what they do is constrict the blood vessels (if you've ever had a migraine you will know that it feels as though every vessel in your head is going to explode- especially if it's a bad one) but that it can't, obviously, differentiate between the head (where the pain is) and the other vessels in the body. So if you take too much you could throw a clot and have a heart attack or stroke. Nice. That's why the Pharmacist had been so concerned about how medication I was taking but unfortunately it was going to be some years before I would get any preventative to help with my migraines. At my high point (or low- depending on how you look at it) I took 4 in a day (1 beyond what it said I should take- at least then I think it's lower now) but when you are in so much pain that you are throwing up and immobile because of the pain and dizziness in your head, unable to drive, get to work or... do anything for that matter, you will take that extra pill to get the pain to go away.

Another friend who was a teacher in a college also had Kaiser- had an 18 year old son who was still on her medical plan, He became ill his freshman year in college and they discovered he had a rare form of cancer. He came home expecting to be treated but Kaiser told her that the cancer he had had a high mortality rate and they did not support treatment. She had to sue to get Kaiser to get him the treatment he needed. To my knowledge he is still alive and well. That was in 2002 or so.

I don't mean to scare those of you who have Kaiser. If you have it and it's the only insurance you can afford, it's better than nothing but I think you should be aware of the realities. Kaiser is a business that does not like to spend money and like all big corporations wants to cut costs in order to make a profit. My daughter is an EMT and she hates dealing with Kaiser. She has only negative things to say about it and it's because they will not give their patience the care they need when there is an emergency.

I also don't want to sound like I am denigrating the doctors there. I was quite friendly with many of the doctors that I had while I was there but it seemed that they were quite stretched to the limit. They were caring and gentle for the most part- some good doctors! But they were mostly on overload and they did not seem to be very well paid for their trouble. That's why, when I got a new job and went to work for Denver Public Library which is a city agency, I switched insurances FAST.

But there are troubles coming my way with that and we'll get into that later...

So how will things change for those who have an insurance like Kaiser under the ACA in the future? It might get a little cheaper so people who want to opt for another healthcare company can afford to- at least for those states who are actively working to participate fully (like Colorado! YAY US!!!) with the entire population forced to find insurance, there will be more of a pool to even out the costs. I'm not entirely thrilled by that change. I think, like Ian that it would better to not have healthcare be a for profit institution but if the best we do for now is work in the system we have, then this is better than nothing.

So have you had any issues like that where the insurance companies have denied you coverage?


  1. I was in a sticky widget in the 90's with a work-related injury denied under workers comp. But since it was work related, it wasn't covered under my regular medical. To have any insurance at all is a boon these days.

  2. Hey, Danette, I have no problems with folks quoting me (as long as it's in the spirit of the original intent, and not out of context) - I take it as a compliment.

    And, to be honest, I see nothing inherently wrong with making profits from things like healthcare, as long as the rewards are tied to the right kinds of measures - such as overall population health. Problems come when everything gets fragmented and companies are chasing profits on a piece of the jigsaw, such as surgeries conducted, or drugs consumed, rather than the overall outcome. However, it would take drastic changes to the whole system to get anywhere near there.

    1. Good point Ian. Actually I amended what I said because it's not profit that is the problem as much as profit at the cost of patient care.

      And you're right, it would and should take a major overhaul. Too bad it wont' happen!

  3. I still don't understand what all the fuss is about. Health care should be available and affordable to everyone.


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