Thursday, August 25, 2005

So, Who Pays? A Lesson on Why healthcare in the U.S. Sucks

Here's been my day, so far:

7:15am-Alarm goes off. Slap the snooze button and move the cat away from my chest (Buddy does that sometimes-if he wants you up, he'll annoy you until you do it). Doze.

7:45am-Hit snooze for the 40th time. Watch husband come out of the shower (woot!) and get changed for work (boo). Move cat again and roll over.

7:56am-Hit snooze for the last time. Get up and pee, then smell the coffee wafting up the stairs. Realize, with dread, that I need to make a gazillion insurance phone calls today because of the fucking RhoGAM fiasco. Curse and swear. Grumpily go downstairs.

8:05 am-Called the prescription insurance company (my lovely district has a seperate carrier for prescription coverage) about this whole RhoGAM adventure. I found out that the medication is covered (it's normally $800-holy shit!), but it's a "non-preferred" medication, and I'm getting it at a "discounted" rate. Yeah, right. So, I calmly explained the situation (hey, she was nice, why ruin the rest of her day with me acting like a psycho-hose beast, right?) and she said that the RE's office could try to see if it would be covered under the copay, or to try to cover it under major medical insurance. Nice customer service rep told me that the situation "sucks" (her words, people), but to try to see if the RE's office would call to get an exception.

8:15am-Called Horizon Blue Cross and Blue Shield-they don't open on Thursdays until 9am. Gotta wait to call.

8:25am-Have a coffee, a Claritin (damn ragweed!) and a piece of toast. Try to patiently wait. Listen to husband tell me that I need to be "nice" on the phone and be patient. Give husband dirty look and mumble incoherently (coffee hasn't kicked in yet).

8:35am-I called Nursey P and told her what the prescription company said. She told me that she'd try to call, but to also try my regular gyn's office to see if they had it there-if they did, I can just go there as an emergency appointment and just pay the cost of administering the medication ($20) and the rest would be covered. If they didn't have it, then we could go from there. I need to call her back and let her know what's going on.

8:50am-I called my gyn's office-get the answering service. They don't open until 10am. More waiting.

9:08am-Call Blue Cross back. Get a very nice man named Brian on the phone. Explain situation yet again. He was very helpful and knowledgable-even before I finished the whole rigamarole, he knew what I was asking. He told me that since I don't have Blue Cross prescription coverage, their specialty pharmacy unit can't help (if I were covered, the specialty pharmacy would express mail the medication on my behalf to the RE's office, and it would be covered under the copay) because it needs to be under my seperate prescription card. Argh. BUT, he did say that if the gyn's office had the med in the office (which, he said, they usually don't, due to the cost of the medication and that it's not used often enough for them to keep it in stock) I'd just pay the administering fee (drug would be covered). And, if they didn't have it, but sent me to the hospital to have it done (they're right across the street from the hospital), again, the drug would be covered, I'd just pay an administering fee. He totally understood where I was coming from, which was nice-he said that he could understand that I wouldn't want to pay out for it if it's covered under major medical. Nice guy.

9:45 am-I'm waiting for 10am to come to call my gyn's office, where I conveniently have an annual on Tuesday. Of course, they probably still think that I'm pregnant, because Dr. Vest told me that, when I got my lovely 120.2 beta number, he sent a letter to my gyn about it and that I'd be released in 12 weeks to him. This phone call should be interesting, right? They'd better not congratulate me-I think that I might throw up if they did that.

10:04am-Called gyn's office. Wait on the phone and listen to the nice lady's voice on the prompt. Get someone on the phone, who tells me that they don't carry the medication (they never have), and that I'd need to get it through prescription and have the doctor administer it.

10:10am-Call Nursey P back, and give her the low-down. She told me to call Blue Cross back and see if, after I pay out the $$ for it, I could submit a claim under my medical insurance and be reimbursed. If that doesn't work, she'll call my prescription company to see if an exception can be made.

10:17am-Call Blue Cross back. Wait on hold. Get a woman named Paula on the phone. Explain situation yet again. Was told that she didn't know if it would be paid, I'd have to submit the claim and see if Blue Cross would pay for it (uh....and you get paid for......what, exactly?). Processing time is "currently" 30 days from the date of submission. Whoopee. That's, assuming, that they don't "lose" it or pend it for some ridiculous reason.

10:21am-Called Nursey P back. Explain what Blue Cross said. Commiserate with her as to why health insurance sucks ass. She told me that she's got 12 patient's charts in front of her, so she can't do it right this second, but that she will call them and let me know today what the prescription company tells her.

In other words, folks.......it looks like I'll probably be out $132.00 for the medication ($112 for the drug, plus $20 to have it injected). This is why I have health insurance, which I'm sure is expensive for my employer to pay for (I'm lucky that my employer pays 100% of the premium-teacher's benefits rule), so I can pay for medication that's MEDICALLY NECESSARY and should, in theory, be covered, but doctors office don't want to have it in their offices because it's too expensive to keep. Now, If the doctor's office had it, I wouldn't pay for it. If I had miscarried in a hospital instead of at home, it would have been covered. Now, I can understand why-it's not cost-effective to keep medications that are rarely used (90-95% of the American population is Rh positive) and will expire, but come on!? What's the trade-off.......that I don't get the shot and take a chance with any future pregnancies? To have more miscarriages (which happens because your body attacks the embryo), or, if by some miracle I do get pregnant, have a child with hemolytic disease (which, if you look up the information on it, is horrific), or have a stillbirth? Which is more cost effective, a shot that costs $800 that you get only once (or twice, if you have a lot of the antibodies in your blood), or hundreds of thousands of dollars in medical care for what would end up as a high-risk pregnancy and post-natal treatment.

The numbers don't add up, do they?

Yep, welcome to health insurance in the U.S. Thanks, Dubya. Maybe instead of touring across the country trying to placate the masses as to why we still need to have our soldiers stay and get blown to bits in Iraq, you should be going to doctor's offices, hospitals, and clinics instead to see just how privatized health insurance actually works in the real, average middle class world. Unfortunately, I'm not in the upper 5% of the population that can just shell out money for health coverage and not feel the pinch in my purse. And, I'm not in the lower end of the spectrum either-people on public assistance wouldn't have to pay out tons of cash because of Medicaid and welfare benefits. Benefits that I pay into with each paycheck. That I, hopefully, will never need to use.

So, I, as the middle-man, get screwed. This country is so fucked up.

4 comments:

Shelli said...

oh yeah, sister - I her ya, I hear ya.

That sucks ass.

there's no two ways aobut that.


Should we try to introduce sperm again, and since I'm on a new health care plan - I'm SCARED as to what I'll have to go through. let me go pull out 12 MONTHS of receipts to "prove" my infertility for ya.

And we can mail it together to dubya.


grrrrrrrr.

S said...

I think that we need to make Dubya physically collect the sperm sample. Wouldn't that be poetic justice?

**sigh**.....nothing can be easy, can it?

cat said...

Sigh, does this ever end? The same thing happened to me with this drug. They should give you a wallet size id card (just a piece of paper really) stating the date you got the shot and some other info. Our original OB did this the last time I got one.

My conspiracy theory brain feels that there is a darker reason for the meds not being covered fully.

Rhogam is also given to women who are Rh Negative if they have an elective abortion. My little id card says that the shot was given at termination of pregnancy, which bothers me since I didn't terminate or elect the d&c. *grumble*

Part of me thinks this is an issue for insurance companies who don't want to cover a medication for a woman if she elects to have an abortion. I know paranoid but perhaps true none the less.

Can we mail something else to Dubya like a steaming pile of shit?

Thinking of you and sending you love.

sue said...

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