May 1, 2006 - It's Broke, So Why Not Fix It?

It’s May Day, and a beautiful one. After my noon physical-therapy appointment, it would be a great idea – and very therapeutic, besides, in these last days before my chemo treatment – to spend some time outdoors. Instead, I spend most of the afternoon wrestling with medical-insurance problems.

The first problem is the result of a couple of CT scans I had back in November – the initial round of scans Dr. Lerner used to determine the extent of my cancer. One was a scan of my abdomen, the other of my pelvic area. These scans were absolutely essential, medically speaking. They helped provide the basis for my entire program of treatment. Even so, my medical insurance (Highmark Blue Cross/Blue Shield) requires such scans to be pre-certified by Intracorp, a third-party agency they hire to act as a watchdog. Their rule is: no pre-certification, no insurance payment.

Dr. Lerner’s office duly applied for pre-certification, and – so they told me at the time – everything seemed to be in order. It now turns out that Highmark claims to have on file a pre-certification request only for the abdominal scan, not the pelvic one. Both tests were requested by the same doctor, for the same purpose, and performed on the same day – in fact, as far as I was concerned, they might as well have been the same test, because I never left the table between one and the other – but Highmark insists on splitting them. One they say they’ll pay for, the other they won’t.

After making phone calls to the hospital, the radiologist’s office and Highmark Blue Cross/Blue Shield, I phone Dr. Lerner’s office and ask them to apply for a retroactive pre-certification on the pelvic CT scan. The secretary says she’ll ask Dr. Lerner to dictate a special letter to Highmark, explaining the medical necessity of the pelvic scan.

Retroactive pre-certification: now there’s a term only a bureaucrat could love.

I consider the couple of hours I’ve spent running this problem down and making phone calls to be time absolutely wasted. I’ve produced nothing, and accomplished nothing. No one’s life will be improved as a result. All I’ve done is help my medical-insurance company comply with their own internal cost-control measures. I’m doing their paper-pushing work for them, and for my efforts I’ll receive nothing more than the payment I’ve been entitled to all along.

The second problem is related to that medical, legal, financial and emotional black hole that is our daughter Ania’s dental-implant treatments, following her auto accident almost a year ago (see the March 31, 2006 blog entry for background on this bizarre, Kafkaesque tale). The good news is, a check finally arrived today from Highmark for a significant portion of the remaining amount due, after our auto insurance had paid their share way back in October. The oral surgeon’s office had submitted and re-submitted the Blue Cross/Blue Shield claim several times. A few days ago, it finally made its way through the vast, multi-state, insurance bureaucracy to the right office. Now, I’ve got to decide whether to begin the process all over again with the third insurance company that’s supposed to be on the case: Geico, the insurer of the driver who hit Ania. The alternative would be to simply pay the remaining balance myself, out of pocket, and wait the months or even years it will take for our legal case to make its way through the courts, before I’m finally reimbursed.

I’ll probably go ahead and pay off the oral surgeon myself. He’s been sending me collection-agency notices for months, and has refused to proceed with the second stage of the dental-implant process until he’s been paid for the work completed so far (even though it’s very possibly his own staff’s fault that the claim has gotten lost – though we’ll probably never know for sure about that). The thing that most matters to me is that I’ve got a seventeen-year-old daughter who’s still missing three of her front teeth, fully a year after the accident in which she lost them – and the only reason for the unconscionable delay is the medical-insurance system in our country that’s so seriously broken, no one knows how to fix it.

An op-ed piece by Paul Krugman in today’s New York Times makes it clear how serious our health-care financing problem is. He calls his article “Death By Insurance.” Krugman cites the example of a doctor, Benjamin Brewer, who writes an online column for The Wall Street Journal. Dr. Brewer recently observed that his office staff has to deal with no fewer than 301 different medical-insurance plans. He currently employs two full-time staff members just to do the billing, and his other two secretaries spend fully half their time collecting insurance information. “I suspect,” the doctor writes, “I could go from four people in the paper chase to one with a single-payer system.”

We already have a single-payer system in this country, Krugman points out. It’s called Medicare, and it operates at about 98% efficiency (with only 2%, in other words, going for administrative overhead). For those of us who are under 65 and don’t yet qualify for Medicare, the efficiency rating drops to 80%. That’s twenty cents out of every health-care dollar that’s not being spent on health care at all, but is instead being frittered away on maintaining the world’s largest health-care financing bureaucracy.

I think Krugman’s 80% figure may be overly conservative. It doesn’t take into account the herculean efforts patients themselves must go through, checking and re-checking to be sure that every administrative “i” is dotted and every “t” crossed. There’s a huge, hidden cost – personal as well as financial – that never makes it into any medical cost-accounting figures.

All this would be fodder for some twisted, theater-of-the-absurd playwright, were it not for the fact that uninsured people are dying here in America, the richest and most powerful nation in the world: and only because they have no medical insurance. Krugman cites a report by The Institute of Medicine, part of the National Academy of Sciences, that estimates that lack of health insurance leads to 18,000 unnecessary American deaths – that’s the equivalent of six 9/11 terrorist attacks – every year.

It’s Krugman’s contention that we could simply extend Medicare to all Americans – not just those who are retired – and actually save money, even as we’re covering people who today have no medical insurance coverage. I think he may be right: and I think it’s time we told our elected representatives they’d better stop dithering at lobbyists’ lunches and figure out a way to fix this seriously broken system - or find a new job for themselves.