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[cancer] The magical land of health insurance - Lakeshore
An author of no particular popularity

Jay Lake
Date: 2009-07-14 04:07
Subject: [cancer] The magical land of health insurance
Security: Public
Tags:cancer, conventions, health, personal, politics, travel
So let me start off by saying that my health insurance carrier has actually been quite supportive through the cancer experience thus far. Until the last few days, I've experience zero chain yanking and a great deal of positive, useful support from them, largely in the person of my cancer case manager.

However, last week I got a coverage letter telling me my oncologist is out of network for my PPO plan. This triggers an entirely separate deductible process, wherein I have to pay the first $2,500 for out of network coverage, after which I then pay 30% of charges instead of my usual flat co-pay. That would mean another $2-3,000 out of my pocket this fall, given where everything is going.

Finally got through to my case manager yesterday to discuss this. She verified they had no listing for my oncologist, and strongly advised me to find another oncologist. Long discussion about networks and coverage. My case manager was being as helpful as she could be within insurance company rules, but from my point of view, this whole thing is madness. They're already preparing to spend about $250,000 treating me, and they're barfing on $2,500 or so worth of doctor bills. Starting with the $279 sitting on my desk right now.

I called the clinic at my primary hospital after I got off the phone with my case manager, to explore it from their end. For example, could they rebill, etc. The medical administrator there was quite surprised to hear that my oncologist was out of network. According to her, all the doctors at the clinic are in network with my carrier under a master contract. Long discussion about networks and coverage. Much frustration on my part.

This gal is a Hero of the Revolution, so far as I am concerned, because she took my information and promised to call the health insurance company from the provider side and work through this. Still, what a mess.

Health insurance reform isn't just about access, it's about sanity. Or at least it better damned well be. With the exception of almost being killed by ER triage last year (literally), my experiences with the healthcare delivery system have ranged from good to admirable. My experiences with the healthcare finance system have ranged from adequate to surreal.

Also, in discussions with the case manager, we began reviewing the collateral medications associated with chemotherapy. I'm going to be a walking pharmacy before this is all over with. Anti-nausea, anti-inflammatory, anti-anxiety, et cetera, et cetera, ad nauseum. My biggest concern about the chemo trip is preserving mental acuity, so I'm very dubious about steroidal anti-nausea drugs, as well as anything psychoactive such as anti-anxiety drugs.

Upcoming I have another CT scan on 7/20. That's when we discover whether or not my lungs are a pair of tumor sacks. We'll also validate some of the other data and assumptions about liver and lymph. Unless something unexpected arises from that scan (or unless I have to switch oncologists for insurance reasons), I'll have my chemo prescribing appointment on 7/27. With luck, I can get the Harkonnen heart plug installed quickly enough to go to Worldcon while I'm recovering from that surgery, and begin the chemo when I get back.

I've decided to leave further documentation of my emotional freakouts for another day. Plenty of more-or-less objective detail here now. More as it develops.

Originally published at jlake.com.

Post A Comment | 27 Comments | | Link






ozarque
User: ozarque
Date: 2009-07-14 12:15 (UTC)
Subject: (no subject)
You are in my prayers.
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Jay Lake
User: jaylake
Date: 2009-07-14 12:16 (UTC)
Subject: (no subject)
Thank you.
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mondyboy
User: mondyboy
Date: 2009-07-14 12:17 (UTC)
Subject: (no subject)
Mate, the kast thing you need is this sort of bullshit anxiety.

I'm from Australia where we have a public healthcare system. Even though it's anything but perfect, there is a gap amount when you see a specialist - as in you may only get 70% of your money back, rather than the full amount But there would be a revolution in this country if the public health system was disbanded.

There's still private heath insurance (of which I have), and there are advantages to have private health care in this country, such as getting a room to yourself and skipping the line for elective surgery. But I simply cannot understand - in spite of seeing Sicko and reading a number of articles on the isue - how a country like the USA can still see a national healthcare system as the first step to communism.

If only the private health funds over in the US weren't so powerful. I can hope the Obama has the ability and the backing to do something about it.
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Jay Lake
User: jaylake
Date: 2009-07-14 12:25 (UTC)
Subject: (no subject)
Our political view of our healthcare system has been deliberately and cynically distorted by half a century of sharply confusing propaganda from the GOP, the AMA and the health insurance industry. Thanks to years of deliberate obfuscation over "socialized medicine", most Americans can't even define the difference between "single payer" and "single provider." Is it any wonder we have such a messy tangle trying to resolve this?

Because yes, I agree with you.
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mondyboy
User: mondyboy
Date: 2009-07-14 12:31 (UTC)
Subject: (no subject)
I'm really sorry to hear that.

Still, as an avid reader of your LJ I hope the health insurance side of things doesn't get in the way of your recovery.
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Danny Adams
User: madwriter
Date: 2009-07-14 18:08 (UTC)
Subject: (no subject)
Ironic that it may almost be cheaper for Jay to move to Australia than to continue with his current oncologist if the insurance company doesn't step up to the plate and behave sensibly.
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Jon Hansen
User: jonhansen
Date: 2009-07-14 12:38 (UTC)
Subject: (no subject)
Aw man. I'm glad you've got someone working the other end of the insurance nuttiness. Be strong.
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(no subject) - (Anonymous)
User: joycemocha
Date: 2009-07-14 14:57 (UTC)
Subject: (no subject)
I suspect that your oncologist had his/her private practice send the bill to the insurance company directly, instead of billing through the clinic. That private practice may not be a network provider, while the doctor-at-the-clinic is.

Thanks for bringing up this point--that's a good thing to know.

A savvy clinic biller is always a treasure. I didn't know I was getting ripped off by my old dentist until I changed to a smaller practice, where the secretary/bookkeeper is the dentist's wife. I was prepared to automatically pay a copay, but she told me not to bother. I have dual coverage through DH's work and mine, and everything was covered. The previous dental clinic didn't bother to tell me that at all.
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martyn44
User: martyn44
Date: 2009-07-14 12:55 (UTC)
Subject: (no subject)
You don't have to be ill to get involved in garbage like this, but you will be pdq.

Wishing and hoping and praying, etc etc. Be well soon.
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e_bourne
User: e_bourne
Date: 2009-07-14 13:11 (UTC)
Subject: (no subject)
Good luck and fight the good insurance fight. We did everything we could to insure everyone was in-network, as they say, including anestheiology, which is most often missed. Gods only know where we are now on this hell ride. I bought supplemental insurance,but they would only cover ICU for Mark because it's a pre existing condition. Hah! We totally got them! Hmmm. Maybe not so great. Insurance is the great satin.
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Kari Sperring
User: la_marquise_de_
Date: 2009-07-14 13:19 (UTC)
Subject: (no subject)
That must be horribly frustrating, and I am hoping that your Hero Lady can sort if out. The US medical system is just.... Well, it makes me glad I'm British. You should not have to deal with this kind of thing when your health is at stake.
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Autopope
User: autopope
Date: 2009-07-14 13:24 (UTC)
Subject: (no subject)
This.
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mcjulie
User: mcjulie
Date: 2009-07-14 13:37 (UTC)
Subject: (no subject)
With you all the way, man.
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User: barbhendee
Date: 2009-07-14 14:16 (UTC)
Subject: (no subject)

Oh, Jay, this is the last thing you need. I'm so sorry.

J.C. doesn't read live journals too often, and when I first told him what was happening with you--this was last year--the very first thing out of his mouth was, "Who is his health insurance carrier?"

It's so sad in our country that THIS is the first concern when someone becomes ill.

He was relieved when I told him that I believed your insurance comes through your day job. I'm correct, right? Strangely, that is a much more secure set up.

We have private health insurance. It's expensive and more tenuous.
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kyle cassidy
User: kylecassidy
Date: 2009-07-14 14:52 (UTC)
Subject: (no subject)
And your next book can be filled with pointless beaurocrats named after ... well, be sure to get the proper spelling of everybody's name just in case....

Hope to see you at Worldcon.
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Danny Adams
User: madwriter
Date: 2009-07-14 18:10 (UTC)
Subject: (no subject)
Maybe this could be his version of United Breaks Guitars . . .
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Elizabeth Coleman
User: criada
Date: 2009-07-14 14:52 (UTC)
Subject: (no subject)
Having seen all the strange things mental drugs can do to people, I totally understand your worries. They are valuable things, but there's definitely the occasional compromise to be made. Maybe you should look into yoga and other non-chemical methods of keeping your mind calm and focused. Certainly calendula_witch can help you with that, if she hasn't already, the sweet thing.
Ritual is like a computer programming language you use to get your mind to do what you want it to. It's choreographing a dance between the Rational and Irrational minds, keeping the Irrational busy and away from freaking you out.
That's how I look at it anyways.
Good luck. <3
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calendula_witch: arms
User: calendula_witch
Date: 2009-07-14 16:58 (UTC)
Subject: (no subject)
Keyword:arms
Aw, thanks! :-)

Yeah, sometimes I feel kinda helpless through this. But I do what I can...mostly a lot of listening and "I love you"s.
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scarlettina: DrWho: Welcome to Hell
User: scarlettina
Date: 2009-07-14 14:54 (UTC)
Subject: (no subject)
Keyword:DrWho: Welcome to Hell
Oh crap. Just what you need right now. Bleh! I'm so sorry.

The first thing I thought of when I read all of this was to wonder whether or not you had someone to be your advocate in all this once you're dealing with chemo and medication. As someone else here said, the last thing you want to worry about when you're ill is dealing with payment should such hell come up.

::hug::
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User: joycemocha
Date: 2009-07-14 15:02 (UTC)
Subject: (no subject)
Have you had a chance to talk to anyone who's been through chemo about handling the drugs? I know a couple of people--both have had breast cancer, but they've done the whole trip.

Also, talk to me about other possibilities for anti-nausea meds when you're back in town. I know a bit more about that stuff, and the possibilities aren't what most people think they are.
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kellymccullough
User: kellymccullough
Date: 2009-07-14 15:13 (UTC)
Subject: (no subject)
Off topic but I thought it might make you smile, and I figured you could always use another smile, especially at the moment. I had a status update come across my facebook feed from an old friend (paraphrasing): "A hot bath and a new Jay Lake novel, bliss." I know this is a person who doesn't know you from anything beyond reading your stuff and who wouldn't know that I know you, so it's pure reader pleasure on her part with no thought that it might ever get back to you.
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User: xjenavivex
Date: 2009-07-14 15:43 (UTC)
Subject: (no subject)
::hugs yo tight::

I hate the insurance bounce around. I am glad it was good up to this point. I hope it smooths back out.
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Kate Mulligan Wolfe
User: corasmama
Date: 2009-07-14 16:10 (UTC)
Subject: (no subject)
Health insurance reform isn't just about access, it's about sanity.

No kidding. I am lucky enough that my insurance company willingly coughs up for scans every six months just because my breast doc said I need it, even though I'm only 34. However, it chaps my hide that I have to get a mammogram in order to get the ultrasound and MRI (I'm alternating which one I get at each semiannual set of scans). I am one of a subset of women for whom it is well known amongst doctors (and I even got the information off the American Cancer Society website) that mammograms are practically useless, but ultrasound and MRI are useful, diagnostic-imaging-wise. While the MRI is expensive, it's beyond stupid that today, I have to get a mammogram, with the result of "gee, we can't see shit in here" result in order to get the ultrasound. A mammogram is, like, 3 times the cost of an ultrasound. So my insurance will, every year, pay 4 times more for my ultrasound appointment than they need to.

ok,

I hope they can bill through the clinic and that you don't have to switch oncologists. That's not what you need to have to do right now!

And you are in my prayers.
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martianmooncrab
User: martianmooncrab
Date: 2009-07-14 18:49 (UTC)
Subject: (no subject)
If you dont have a billing program to track your medical bills in place, do it.

Chemo affects everyone differently, the important things are to keep your routines, let your support group support you, and the people who you can call any time of the day or night on speed dial.

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User: (Anonymous)
Date: 2009-07-14 22:06 (UTC)
Subject: state vs. federal reform
Insurance reform + medical provider reform = health care reform, right? Utah health insurance reform has been center focus for the state, UAHU and private insurance carriers over the past 24 months. Mike Oliphant (UAHU board webmaster) runs a small Utah based health insurance website http://www.healthinsurancetexas.biz as well as http://www.DentalInsuranceUtah.net . Mike’s viewpoint provides a unique analysis which comes from being a “fly on the wall” observer in countless state session and insurance meetings. “Utah has been thrust into a state insurance reform pressure cooker which isn’t necessarily negative where I am an insurer, insured and patient”. Several interesting changes took place with H.B. 188 passage earlier this year which seems all too familiar to the ongoing federal health care reform attempt under Obama’s administration. The spirit of the bill allows private Utah market place remedies. It essentially guarantees a Utah health insurance carrier a "no loss" or "no gain" premise over competing carriers that operate within the “Utah Insurance Exchange portal”. On the surface it would seem unattractive to a carrier’s consideration (voluntary at this point). But you have to understand the carriers’ goal is to cover their administration fees and maintain a 3% profit. The Utah health insurance reform model claims this can be accomplished now by legislation and the watchful eye of the state’s risk adjuster board. The medical claim risks are essentially shared equally among the participating carriers. Therefore, the carriers can focus on administration efficiencies more so than competition over a fluctuating market share. Insurance carriers such as SelectHealth have efficiencies and risk management experience polished by long tested actuarial tables with health statistics and claim trends. Is it a bad idea to share that experience with a national carrier such as Humana? Would it surprise anyone to know that maternity NICU and anti-depressants represent the highest utilization in health insurance costs for medical and pharmacy in Utah? Compare this to Texas which suffers from abnormally high levels of diabetes and liver disease per capita.
The other half of the “health care reform equation” is medical provider and billing practices. The state claims this is on the agenda. It is popular belief among Utah legislators that reform stops with the insurance carrier. However, how can the insurance carrier continue to bear the risk and re-distribution of health insurance premiums back out the door in claims without provider billing reform? Add to this obstacle a continuing shrinkage of the insured populace. Obama’s administration proposes mandatory participation in a health insurance policy by employers of all sizes, self employed and unemployed populace. The logic being to shore up the unhealthy with healthy premium. When analyzing the Massachusetts’s system, you actually pay a penalty if you have no proof of coverage. The benefit level and health insurance price is nowhere close when you compare Utah health insurance quotes through HealthInsuranceSource.net or dental insurance quotes at DentalInsuranceUtah.net. Utah premium is easily half. This insight comes from a Utah health insurance agent whom often interacts with employers and residents looking for affordable coverage, making sure claims are paid correctly, implementation and explanation of the many policy procedures and putting a complex SelectHealth insurance language in understandable terms. Yet legislators claim agents to be of no value all in the name to save 3-4 off of Utah health%
With the latest announcement of hospitals agreeing to contribute $155 billion, where are the costs going to be shifted for this donation? In Utah, studies conducted by BenefitsManager.net revealed that cost shifting already exists in the ER. There is apparent lack of legislators in Utah and on the federal level proposing TORT REFORM. It is factual that a majority of US senators and representatives are lawyers. To push liability insurance premiums down that absorb as much as 15% in expenses with most medical providers is significant. Take 15% off total medical expenditures in US and you will see savings in the trillions.
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melissajm
User: melissajm
Date: 2009-07-14 23:01 (UTC)
Subject: (no subject)
Our health insurance system is nuts.
Keeping my fingers crossed for you.
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User: (Anonymous)
Date: 2009-07-31 11:23 (UTC)
Subject: Be strong
Hi Jay,

I appreciate the way you are in control of the situation. I shall add you in my prayers.

Jenny
http://www.caring.com/cancer
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