12/12/12 didn’t mark the end of the world, but it has marked the beginning of the end the great health insurance policy I have. Just as I figured, people with individual health insurance policies like mine get screwed by the Patient Protection and Affordable Care Act (PPACA). I’ve had my health care plan for over 10 years now, and It’s provided great coverage at a very affordable price, and, up until today, my insurance company had never denied a procedure.
My six month PET scan was scheduled for tomorrow, but the insurance denied covering the PET scan, and approved a CT scan instead. I got a letter from the insurance company yesterday authorizing the CT san, so I called the Cancer Center to see what was going on — it turned out the doctor who is standing in for my oncologist while she is on sabbatical hadn’t yet found out that the PET scan had been denied. So I was transferred to the receptionist in Radiology who explained that when the denial came in, the doctor on call cancelled the PET scan so I would not be liable for a $9000 procedure, and scheduled the CT scan. My new doctor was out of town, so he hadn’t learned about what happened.
Here’s the issue: if I did a CT scan it would show I have a bunch of tumors. The tumors are dead, killed by the chemotherapy I finished two years ago, but the CT scan will not show if there is any new, cancer-like activity; whereas a PET scan will show if there are any “hot spots” that could be cancerous. The doctor did say that the radiologist can use a CT scan to measure and compare lymph nodes from my previous PET scan, but he went on to say that I should have symptoms and the blood work would probably indicate if there were issues with lymph nodes having significant growth over the past six months. My blood work was normal, and I currently don’t have any symptoms to speak of.
The doctor called my insurance company this morning and argued for a PET scan, but they held firm in their denial. With the new rules that require insurance companies to use something like 80% of the premiums on patient care and other changes coming into effect from the PPACA, my insurance company changed its policy to only cover one PET scan a year, once a patient has gone two years from being diagnosed with cancer and successfully treated. But they will authorize CT scans since they are much cheaper than PET scans, and argue that CT scans are sufficient preventative procedures. In my case a CT scan is more of a problem than a preventative procedure, so we cancelled the CT scan, and we will see what the doctor can negotiate in January, since it’s a new calendar year.
The lead photo is one of the images from my PET scan done on this day last year. The second photo is the Rail Runner streaking by at the Alameda crossing, and the third photo is a car covered with Christmas lights speeding up Paseo Del Norte throwing off square roots of light.
Off Center & Not Even 
Wow, what a bunch of red tape. I am glad you will not be billed for the $9000. Your pics today are all very interesting and colorful. I like the third photo the best. Take care, Tim.
One of Tristan’s friends was with me and saw the car and said “get it” as it was zooming by. My camera was at 400 ISO, so the shutter speed was pretty slow, which ended up producing a cool photo.
Tim, you have laid out very clearly and succinctly in this example exactly what is wrong with the current state of health care in this country today: insurance companies with clerks not trained in medicine making medical decisions based on cost alone, and not what is best for the patient. Witness that they will pay for a CT, from which no useful information can be obtained, although potentially harmful information can be obtained. And, why? Because it saves a little money, and the person making the decision to deny the PET scan and approve the CT scan has no medical training to be able to understand this. In reality, to someone who understands, the CT is a waste of money, even though it costs less than the PET scan.
This is not new to the PPACA. My entire time in private practice, hours and hours were spent arguing with insurance companies. In the early 1990’s, a company no longer in New Mexico, refused to pay for medical treatment for a 21 year old with endometriosis, but would pay for a hysterectomy, because that company believed in the long run it would save them money. I did succeed ultimately in getting medical treatment paid for, but it took a lot of time and effort.
Over the years I have had patients with cancer diagnoses who ultimately were dropped by their insurance companies (often around 2 years out), who then could only get insurance through a state pool, and that depended upon whether the state pool had enough money to accept new patients at the time. Because of the PPACA, you cannot be dropped because of your medical history, but the company can cut back on what it is willing to spend on you. At least they cannot now drop you, which is a tiny step in the right direction.
When my COBRA ran out after my divorce, I was able to get insurance only because the Kennedy-Kassebaum bill (which many physicians hate because it is the source of the HIPAA regulations) had gone into effect, guaranteeing coverage if someone had had recent “creditable” coverage. In recent years, my premiums have run $600 – $700 per month, but I was glad to have any coverage at all.
Not too long ago, BC/BS of NM wanted a huge increase on individual premiums, but this was initially denied by the Insurance Commission. At the moment, BC/BS of California is asking for a huge increase on premiums for its individual policy holders.
The PPACA does not limit how much money insurance companies can spend on patient care. It requires the companies to spend no less than 80% of patient premiums on patient care. They can spend more. I actually got a $200.00 rebate just recently, because my insurance had not spent 80% of premiums on patient care. Your insurance company’s decision to deny a PET scan at this time was not determined by anything in the PPACA, as much as your insurance company might like for you to believe that.
As a physician, I and my staff spent hours arguing with insurance companies – again, mostly with clerks who were not trained to do anything but select and approve the least expensive treatment or test for any given diagnosis, whether it was good for the patient or not. As a patient, I have had to spend hours arguing with my insurance company to pay for services appropriately rendered by physicians. For the next-to-last surgery I had, I lost track of how many letters I wrote and how many phone calls I made, all to no avail. Finally, I had an attorney help me draft a letter, that stated exactly what I had stated before, but in legalese, and that got taken care of almost immediately. But it was a long, drawn out process, and most people do not have ready access to legal help for these kinds of issues.
Your issues with the PET scan indicate how really broken our current health care system is, and has been for some time. I do not have any answers. Dealing with insurance clerks who knew no medicine and whose job was to deny all but the least expensive treatment for a given diagnosis became less satisfying than photographing abandoned adobes, as much as I loved my patients and a wonderful staff.
For the moment, about all I can add is that I agree with Juanita that I am glad you are not going to be stuck with a $9,000.00 bill!
Medicare is cutting out PET scans and a whole lot of diagnostic procedures next year as well. Directly related to PPACA? I guess people can argue no, but I think it has a lot to do with it. In the case of my current insurance policy, an old, fairly generous plan, it does not meet the current standards or regulations, and has been grandfathered in under the new laws over the past three years, so I believe I’m not only going to see major changes in my plan, but very large increases in premiums. I’ve heard all policies will be going up 30% to 60% by 2014.
The system has been broken for a long time, but I don’t see the PPACA making it any better. Part of the problem is that HMOs and similar plans have made it so patients don’t really see the cost of the medical services they receive, and the cost games played between providers and insurers have made it so that no one really knows what the true cost of medical services are. PPACA just shifts the same process to the government, which has never shown great efficiency or the ability to reduce costs. Like PJ O’Rourke said “If you think health care is expensive now, wait until you see what it costs when it’s free.”
“Part of the problem is that HMOs and similar plans have made it so patients don’t really see the cost of the medical services they receive, and the cost games played between providers and insurers have made it so that no one really knows what the true cost of medical services are.”
Boy, do I totally agree with that! I don’t know if you remember the days when insurance was just getting established as “standard,” but the patients paid the doctor, and then the patients filed with their insurance. There was a little more openess with that. My father was in the hospital the day Medicare went into effect. The nuns came around and posted new room rates, which were exactly double what they had been the day before. On the other hand, for physicians to charge a patient with no insurance less than a patience with insurance is today called “insurance fraud.” In the olden days when I was growing up, doctors could provide free services to those who needed them, and charge people who could pay. Not today. . .
I know we have not yet hit bottom on how bad things have to become before a totally new system is constructed. This one with patches here and patches there simply will not hold up over the long term. However, I do not expect to see much improvement in my lifetime. 😦
I remember those days. I also remember the days when I had no health insurance and negotiated prices with doctors.