Private Insurance Already Pulls Trigger on Patients, Docs

This story is not unlike millions that play out in a similar fashion all over this nation. For-profit, private insurance companies practice medicine without apology - and without license to do so. Patients seek care; doctors assess medical needs; private insurance companies make the final choice. My insurance company - Blue Cross -- decided just yesterday that doctors at one of the finest medical facilities in this nation were wrong in what they prescribed for me.

Yet if we listen to the plans unfolding on the national political scene, we are supposed to trust that the private, for-profit insurers - like Blue Cross - will clean up their acts over the next few years rather than "trigger" the availability of a public health plan option for all Americans. As far as I am concerned, their decades of escalating abuses against patients and healthcare providers are trigger enough - they do not deserve five more years to decide if they'll do what it is right. We know they will not.

Even if they are given rules to follow - no pre-existing conditions excluded and they must issue policies to all - nothing will stop them from denying treatment and medications and payment for those medical services just as they do today. Private, for-profit insurers pull the trigger on us all in a very real way millions of times every year in this nation.

This weekend it was proven to me yet again. Private, for-profit insurance is a defective product. I purchase it so I can protect my health and protect my finances if I get sick. And that insurance product does not guarantee either issue for which it is promoted or for which I pay. I cannot believe that under a publicly funded and privately delivered system, my doctors would be second-guessed as they were and that I would have to suffer as a result.

And it's so interesting that California's attorney general is going to investigate the rate of insurance company denials following the release just this week of the Institute for Health and Social-Economic Policy (the research arm of the California Nurses Association) study that showed that insurance claim denials in the state often approach 40 percent. I am betting that denials like the one I had would make that rate soar even higher as thousands of these decisions unfold quietly at pharmacy counters and in private medical examination rooms all over the nation.

Last week, a pain that had been nagging but only occasional became more persistent. I tried, as most American patients I know do, to resolve the issues with over-the-counter medications and reading symptom-checkers on websites I trust. The problems continued, but I had no real desire to seek medical treatment because I almost always end up owing money I don't know exactly why I owe - as some service or some portion of some service is deemed as either unacceptable or uncovered by the insurance carrier.

But as a cancer survivor and as a woman who has some medical history in need of follow-up care, I wrote to a physician friend by email and asked what she thought about my symptoms. I knew what she'd say else I wouldn't have written the email of concern. I also called my primary care physician's office for their read of the situation, and I heard the same response. Sooner rather than later, go to the emergency room. Because of my history and symptoms, both felt I'd need a test that could not be done in an office setting and that the symptoms were troubling enough to warrant an immediate evaluation.

At the hospital at the start of the Labor Day weekend, I was given exquisite nursing care and doctors worked diligently to rule out immediately life-threatening causes for my symptoms. I was glad for the news on a couple of fronts but some troubling possibilities remained to be considered, and I felt awful. Sometimes when you are feeling badly enough, you just want someone to find the issue and fix it, stop it and stop the pain. This wasn't so easy.

The cardiologist said he wanted more follow-up within a few days but that could be done as an out-patient for now. But one of the other doctors was worried enough to try to urge me to stay a day or two longer in the hospital and have a more detailed gastric evaluation. I argued that since it was the holiday weekend perhaps I could do that testing on an out-patient basis as well. She didn't like that option but reluctantly agreed to send me home with a prescription for the oral medication they had been giving me intravenously in the hospital. I said I would fill the prescription and make the follow-up appointments.

So we stopped at my pharmacy on the way home. Mind you I had just saved my insurance company, Blue Cross, thousands of dollars by checking myself out of in-patient treatment, so I was feeling like I had been a responsible patient using resources prudently. So imagine my outrage when my pharmacist told me that Blue Cross issued their denial of my prescription as it was processed from the pharmacy. "They said no," said the pharmacist. "They said this medication needs prior authorization and then it may take three-to-five business days to get a decision."

"What?" I asked. The pharmacist had already noted that I looked like I felt awful. And so I did. I was in no mood and in no condition to launch into a fight with Blue Cross. I asked if there was any over-the-counter medication that would help. The pharmacist offered one suggestion but acknowledged it wouldn't be exactly as the doctor ordered. We drove home. I felt too sick to even cry. And too angry.

I called the 24/7 hotline Blue Cross has for asking a nurse. I told the story. I told Blue Cross' nurse that I have a history of cancer and gastric surgery that makes medications and their absorption sometimes problematic for me and that's why the doctors at a Johns Hopkins hospital facility ordered this medication for me. She acknowledged that it was "ridiculous" for the denial to happen but then said she could do nothing to help. "No one is in member services until Tuesday," she said.

Talk about audacity. There we have it. I will go without. I will go back to work. I will drug myself with whatever I can find to give relief - maybe wisely and maybe not. And I'll wait for my follow-up tests to see what's next for me.

And that is the crux of the matter for millions and millions of patients in these United States. Those of us who are insured are at the mercy of the private, for-profit business machine that is private health insurance. I would argue that many of the millions of folks who think they "like" their present insurance coverage haven't yet had it tested in a way that would show the true priorities.

Until we get the profit-mongers out of the examine rooms and hospitals, we are all at risk of being one Labor Day weekend illness away from tragedy. Blue Cross and all the others will pull their for-profit triggers whenever they deem it necessary.

I hope the President and Congress know that and do what it right for us all. We are better people than this, and healthcare is a basic human right not to be left in the hands of scoundrels.