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co-pay, cost, Diagnoses, Doctors, Drugs, health, health-insurance, healthcare, Insurance, Medicare, Medication, Pharmacy, prescriptions, rejection, research
Doctor Says Yes… Insurance Says “We’ll Think About It”
Doctors, diagnoses, prescriptions, Medicare, insurance, and denial — those are words that seem to follow me around these days. Sometimes I think dealing with the medical system is almost a full-time job. If they paid by the appointment, I’d be drawing a salary by now.
One thing I’ve never quite understood is how a doctor can go to school for years, train for years more, examine you personally, and decide what medication you need — only for the insurance company to step in and say, “Nope, we don’t think so.”
Apparently, somewhere a person is sitting behind a desk who knows more about my condition than the doctor who actually saw me.
I worked for a health insurance company for 32 years before I retired. I was in the maintenance department, which meant I fixed things like doors and lights — not insurance claims. Still, people who knew where I worked would often ask me why their medication was denied even though their doctor prescribed it.
I always had to explain that just because I worked there didn’t mean I knew anything about insurance decisions.
Truth be told, I still don’t.
A good example is what happened recently with my son. He was prescribed medication for severe sleep deprivation. His previous insurance covered it, and he was happy because they had finally found something that actually worked.
Then he changed jobs.
His new insurance company now says the medication is “not medically necessary.” I guess sleeping is optional now.
The doctors now think he might have sleep apnea and ordered a sleep study. Before he even got scheduled, he got a phone call saying the test would cost over $2,000 because his insurance wouldn’t cover it.
He’s a young man with a mortgage, a car payment, and utility bills. In other words, he’s living in the real world — the one where people don’t just have $2,000 laying around for a test that might help them sleep at night.
Meanwhile, I realize I’m one of the fortunate ones. Because of my disabilities, I qualify for Medicare, and because I worked for an insurance company, I retired with a good supplemental plan. That combination gives me coverage that many people would love to have.
I don’t pay co-pays for doctor visits. I don’t pay for emergency room visits. Every time I leave the hospital, the bill says I owe exactly zero dollars, which is my favorite number.
I do pay for some medications, but not a lot.
One medication I take costs about $20,000 for a 30-day supply.
Yes, twenty thousand dollars.
For that price, I feel like it ought to come with a steak dinner and a weekend vacation.
Fortunately, the drug company offers a $0 co-pay card because they know insurance only pays part of the cost. Thanks to that program, I don’t pay a penny for a medication that costs more than some cars.
I consider myself blessed, because there are people who need this same drug and simply can’t get it because they don’t have the right insurance. That part isn’t funny at all.
When I ask why the drug costs so much, I’m told it’s because of all the research that went into developing it. I understand that research costs money, but sometimes I wonder if the scientists also built a few vacation homes along the way.
After being on this medication for a while, I feel like I’ve personally contributed a pretty fair share toward paying for that research — and I know some folks have been on it a lot longer than I have.
I don’t know what the answer is. Doctors are trying to help people. Insurance companies are trying to control costs. Drug companies are trying to recover research money.
And patients are just trying to stay alive without going broke in the process.
Maybe one day there will be a system where if your doctor says you need something, you can actually get it without filling out forms, making phone calls, and saying a small prayer first.
Until then, I guess we’ll just keep taking our prescriptions — and a healthy dose of patience right along with them.
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People sometimes try to make comparisons between the Canadian and American medical systems, which is impossible, it’s apples and oranges. Or maybe even more like apples and bananas, (because apples and oranges are still both round-ish).
But they are both fruit.
Needless to say, accountability to the insurance companies exists even north of the 49th parallel. One time my doctor said, “Why do you need that??” (It was about a referral). Not because she was being rude or dismissive of my health concerns, but because I suspect she was going to have to literally explain “why” to someone else…probably the auditory body of our government run insurance system, perhaps? Another time she said, “You don’t need a test for that, I can tell you your level, you don’t have any.” (It was about the lack of hormones post menopause, and I am sure she was correct about my lack, no blood test needed). These interactions just made me realize that she probably spends time behind the scenes justifying her referrals, the tests she orders, and maybe a certain amount of her prescriptions requests too. (Lots of prescriptions are out of pocket for Canadians unless they have a supplementary plan, but some coverage is there for seniors, and low income, which probably means oversight government oversight…)
Whether it’s the patient that has to spend the time advocating and appealing, or the doctor themselves, I think this is something that happens in both our systems, and it is truly unfortunate.
You make a very valid point. Healthcare in this country often seems to be a tug-of-war between politicians, providers, and insurance companies, and too often the patient is the one caught in the middle. It’s frustrating to see stories like this, and there is even a story in the news right now about a young lady who is appealing a decision from a major insurance company after being denied a procedure that her doctor believes is medically necessary. Situations like that put a bad light on insurance companies, and in many cases, rightly so.
When a doctor believes a treatment is medically necessary, it’s hard to understand how someone sitting behind a desk can override that decision.
Having spent many years working for a health insurance company myself, I understand that there are guidelines and policies that companies follow, but that knowledge doesn’t make situations like this any easier to accept. When you’re the patient — or the family member of a patient — the issue stops being about policies and starts being about pain, quality of life, and peace of mind.
Unfortunately, stories like this are becoming all too common, and they reinforce the feeling that the system can be slow and impersonal when people need help the most. My hope is that one day we find a better balance where medical decisions are guided more by patient needs and less by paperwork.