Insurance Caveat You Don't Hear About

As a health care consumer you really do need to wake up to the issues addressed in this article and also to the fact that Big Insurance has controlled the medical industry for a good three decades if not longer and it is the biggest cost driver there is.

RELATED ARTICLE: Six Lobbyists for Every Member of Congress

The "death panels" are already here
Sorry, Sarah Palin -- rationing of care? Private companies are already doing it, with sometimes fatal results
By Mike Madden, Aug. 11, 2009

The future of healthcare in America, according to Sarah Palin, might look something like this: A sick 17-year-old girl needs a liver transplant. Doctors find an available organ, and they're ready to operate, but the bureaucracy -- or as Palin would put it, the "death panel" -- steps in and says it won't pay for the surgery. Despite protests from the girl's family and her doctors, the heartless hacks hold their ground for a critical 10 days. Eventually, under massive public pressure, they relent -- but the patient dies before the operation can proceed.

It certainly sounds scary enough to make you want to go show up at a town hall meeting and yell about how misguided President Obama's healthcare reform plans are. Except that's not the future of healthcare -- it's the present. Long before anyone started talking about government "death panels" or warning that Obama would have the government ration care, 17-year-old Nataline Sarkisyan, a leukemia patient from Glendale, Calif., died in December 2007, after her parents battled their insurance company, Cigna, over the surgery. Cigna initially refused to pay for it because the company's analysis showed Sarkisyan was already too sick from her leukemia; the liver transplant wouldn't have saved her life.

That kind of utilitarian rationing, of course, is exactly what Palin and other opponents of the healthcare reform proposals pending before Congress say they want to protect the country from. "Such a system is downright evil," Palin wrote, in the same message posted on Facebook where she raised the "death panel" specter. "Health care by definition involves life and death decisions."

Coverage of Palin's remarks, and former House Speaker Newt Gingrich's defense of them, over the weekend did point out that the idea that the reform plans would encourage government-sponsored euthanasia is one of a handful of deliberate falsehoods being peddled by opponents of the legislation. But the idea that only if reform passes would the government start setting up rationing and interfering with care goes beyond just the bogus euthanasia claim.

Opponents of reform often seem to skip right past any problems with the current system -- but it's rife with them. A study by the American Medical Association found the biggest insurance companies in the country denied between 2 and 5 percent of claims put in by doctors last year (though the AMA noted that not all the denials were improper). There is no national database of insurance claim denials, though, because private insurance companies aren't required to disclose such stats. Meanwhile, a House Energy and Commerce Committee report in June found that just three insurance companies kicked at least 20,000 people off their rolls between 2003 and 2007 for such reasons as typos on their application paperwork, a preexisting condition or a family member's medical history. People who buy insurance under individual policies, about 6 percent of adults, may be especially vulnerable, but the 63 percent of adults covered by employer-provided insurance aren't immune to difficulty.

"You're asking us to decide that the government is to be trusted," Gingrich -- who may, like Palin, be running for the GOP's presidential nomination in 2012 -- told ABC's "This Week With George Stephanopoulos" on Sunday. But as even a quick glance through news coverage of the last few years shows, private insurers are already doing what reform opponents say they want to save us from. (The insurance industry, pushing back against charges that they're part of the problem, said last month that "healthcare reform is far too important to be dragged down by divisive political rhetoric." The industry has long maintained that its decisions on what to cover are the result of careful investigations of each claim.) Here is a look at a handful of healthcare horror stories, brought to you by the current system. It took Salon staff less than an hour to round these up -- which might indicate how many other such stories are out there.

-- In June 2008, Robin Beaton, a retired nurse from Waxahachie, Texas, found out she had breast cancer and needed a double mastectomy. Two days before her surgery, her insurance company, Blue Cross, flagged her chart and told the hospital they wouldn't allow the procedure to go forward until they finished an examination of five years of her medical history -- which could take three months. It turned out that a month before the cancer diagnosis, Beaton had gone to a dermatologist for acne treatment, and Blue Cross incorrectly interpreted a word on her chart to mean that the acne was precancerous.

Not long into the investigation, the insurer canceled her policy. Beaton, they said, had listed her weight incorrectly when she bought it, and had also failed to disclose that she'd once taken medicine for a heart condition -- which she hadn't been taking at the time she filled out the application. By October, thanks to an intervention from her member of Congress, Blue Cross reinstated Beaton's insurance coverage. But the tumor she had removed had grown 2 centimeters in the meantime, and she had to have her lymph nodes removed as well as her breasts amputated because of the delay.

-- In October 2008, Michael Napientak, a doorman from Clarendon Hills, Ill., went to the hospital for surgery to relieve agonizing back pain. His wife's employer's insurance provider, a subsidiary of UnitedHealthCare, had issued a pre-authorization for the operation. The operation went well. But in April, the insurer started sending notices that it wouldn't pay for the surgery, after all; the family, not the insurance provider, would be on the hook for the $148,000 the hospital charged for the procedure. Pre-authorization, the insurance company explained, didn't necessarily guarantee payment on a claim would be forthcoming. The company offered shifting explanations for why it wouldn't pay -- first, demanding proof that Napientak had tried less expensive measures to relieve his pain, and then, when he provided it, insisting that it lacked documentation for why the surgery was medically necessary. Napientak's wife, Sandie, asked her boss to help out, but with no luck. Fortunately for the Napientaks, they were able to attract the attention of a Chicago Tribune columnist before they had to figure out how to pay the six-figure bill -- once the newspaper started asking questions, the insurer suddenly decided, "based on additional information submitted," to cover the tab, after all.

-- David Denney was less than a year old when he was diagnosed in 1995 with glutaric acidemia Type 1, a rare blood disorder that left him severely brain damaged and unable to eat, walk or speak without assistance. For more than a decade, Blue Cross of California -- his parents' insurance company -- paid the $1,200 weekly cost to have a nurse care for him, giving him exercise and administering anti-seizure medication.

But in March 2006, Blue Cross told the Denney family their claims had exceeded the annual cost limit for his care. When they wrote back, objecting and pointing out that their annual limit was higher, the company changed its mind -- about the reason for the denial. The nurse's services weren't medically necessary, the insurers said. His family sued, and the case went to arbitration, as their policy allowed. California taxpayers, meanwhile, got stuck with the bill -- after years of paying their own premiums, the Denney family went on Medi-Cal, the state's Medicaid system.

-- Patricia Reilling opened an art gallery in Louisville, Ky., in 1987, and three years later took out an insurance policy for herself and her employees. Her insurance provider, Anthem Health Plans of Kentucky, wrote to her this June, telling her it was canceling her coverage -- a few days after it sent her a different letter detailing the rates to renew for another year and billing her for July.

Reilling thinks she knows the reason for the cutoff, though -- she was diagnosed with breast cancer in March 2008. That kicked off a year-long battle with Anthem. First the company refused to pay for an MRI to locate the tumors, saying her family medical history didn't indicate she was likely to have cancer. Eventually, it approved the MRI, but only after she'd undergone an additional, painful biopsy. Her doctor removed both of her breasts in April 2008. In December, she went in for reconstructive plastic surgery -- and contracted a case of MRSA, an invasive infection. In January of this year, Reilling underwent two more surgeries to deal with the MRSA infection, and she's likely to require another operation to help fix all the damage. The monthly bill for her prescription medicines -- which she says are mostly generics -- is $2,000; the doctors treating her for the MRSA infection want $280 for each appointment, now that she's lost her insurance coverage. When she appealed the decision to cancel her policy, asking if she could keep paying the premium and continue coverage until her current course of treatment ends, the insurers wrote back with yet another denial. But they did say they hoped her health improved.

-- Additional reporting by Tim Bella
-- By Mike Madden

Someone must be reading my writing

It was just a matter of time before coincidental thinking would start to surface in this current debacle amongst members of Congress.

Observing some of these discussion, along with the Sotomayor hearings, I'm amazed more people don't stand up to the idiots they've elected to office. Rarely are the people being represented.

But, along came Jones, aka Senator Tom Coburn, an Oklahoma physician who has hit the nail on the head.

Just yesterday I sent a missive to Rep. Jay Inslee, D-WA, in response to his boiler-plate email on the insurance issue. His canned information was so far off base it showed just what he and fellow D, Rick Larsen are up to. Senators Murray and Cantwell aren't far behind.

What we need are more members of Congress to really represent their constituents, turning a blind eye to payola from Big Insurance and Big Pharma.

NHN related articles -
Wrong Questions and Invalid Assumptions
Insurance Issues

Perhaps your representatives need to hear from YOU!

A Prescription for the Goose…
The Coburn amendment would force members of Congress to use ObamaCare.
Senator Tom Coburn is a physician who until recently still went home to Oklahoma to deliver babies. He believes Congress should weigh the dangers of a nationalized health system much more seriously than it has. In the tradition of someone using a 2x4 to win the attention of a mule, yesterday he successfully pressed the Senate Health Committee to approve his idea of requiring Members of Congress themselves to enroll in whatever "public plan" is passed to compete with private insurance companies.

"Let's demonstrate leadership -- and confidence in the system -- by requiring that every member of Congress go into it," Mr. Coburn told his colleagues as they were marking up the health care proposal championed by Senator Ted Kennedy. His idea wasn't exactly greeted warmly by many public plan supporters. Senator Jeff Bingaman, a New Mexico Democrat, responded: "I don't know why we should require ourselves to participate in a plan that no one else needs to participate in. This bill goes to great lengths to show that the choice is there for everybody."

But Mr. Coburn disagreed, saying his reading of the 1,000-page health care bill convinced him that everyone would end up being forced into the public plan as private insurance carriers were squeezed out of the market by mandates and regulations. Therefore, if Congress decides a government-run health plan is good enough for the American people, it should be willing to put itself under its care umbrella.

By a 12 to 11 margin, the Senate Health Committee agreed. Senator Chris Dodd, the committee's acting chairman, and Senator Kennedy were absent from the committee but sent in proxy votes in favor. Maryland Senator Barbara Mikulski was the only other Democrat to back the measure. Every Republican save for New Hampshire's Judd Gregg voted in favor of the Coburn mandate.

Obviously, many members of Congress -- who are used to a generous and flexible set of health benefits -- have no intention of letting the Coburn mandate become law. They will undoubtedly try to strip it from the bill at some point, in a conference committee between the two houses if necessary. But for now it is embedded in the bill and any overt attempt to remove it would be met with howls of public outrage.

--John Fund

Wrong Questions and Invalid Assumptions

This is where things are as far as the insurance coverage debate.

Even though I disagree often with Dr. McDermott, whom I have known since the late 1970s, especially on the Farm bill he recently supported, this is an excellent retort to Republicans who are intimately intertwined with Big Pharma and Big Insurance.

"If the private sector is so good ... why do we have 50 million people with no health insurance today?" Jim McDermott, MD, D-WA.

Will Health Care Reform Fall Short?

This morning I wrote the the House Ways & Means Committee with my comments on the medical insurance debate. This entire discussion is a fiasco because it is hanging on to the old paradigm. This is zero sum change folks!

By James Ridgeway | Tue June 16, 2009, Mother Jones

Confused about what's happening with health care reform? Join the club. After months of buildup, neither Congress nor the administration has produced a clear plan. Instead, the picture seems to get fuzzier every day. This doesn't bode well for President Barack Obama's commitment to create a "health care system that works for all of us."

At the American Medical Association convention in Chicago on Monday, Obama called health care expenditures a "ticking time bomb" and related eloquent—but familiar—stories of families, small businesses, and doctors crushed by spiraling costs. The rest of his speech catalogued the most uncontroversial elements of any potential health care fix—instituting electronic medical records, cutting down on junk food, encouraging more preventative care, promoting "best practices," eliminating waste. Who could possibly object to any of that, except maybe the manufacturers of potato chips and Wite-Out? Meanwhile, Obama offered only ambiguous clues about how he plans to resolve the most contentious and vital issues that will determine whether his attempt to overhaul health care succeeds or fails.

In fact, the White House's battle plan for passing legislation could best be described as one of calculated vagueness. Last Wednesday, Obama called together a group of key senators from both parties to hash out their differences. Afterward, the group touted the fact that nothing had been settled. Sen. Chuck Grassley (R-Iowa) told the Associated Press, "The president, I thought, was very flexible except on one thing, and that was getting it done. When the president is flexible on controversial things...I think that that's good news." Thanks to all of this flexibility, ranking Democrats and Republicans from the Finance Committee and the Health, Education, Labor, and Pension Committee agreed they could bring a bill to the Senate floor in July.

But what will the bill actually contain? So far, the administration's maneuvering suggests that its primary concern is not what kind of health care system we end up with, as long as we get something that looks like reform—preferably before the end of Obama's first year in office. Given the disaster that ensued last time Democrats tried to pass health care legislation, the administration's careful attention to the politics of the issue is understandable. But the danger of this approach is that it could ultimately produce a law that is uncontroversial, weak, and expensive.

One disturbing possibility is that health care could become a replay of the credit card legislation. The pattern goes something like this: First, we get a propaganda blitz heralding sweeping changes. But although the final legislation corrects some of the most egregious abuses, it doesn't change the system's underlying flaws. So, for example, insurance companies may be required to cover people with preexisting conditions—a need Obama illustrated vividly in his AMA speech with moving references to his mother's battle with cancer. We might see what the president called "more efficient purchasing of prescription drugs," which presumably means faster approval of generics and giving the government greater power to haggle with Big Pharma over drug costs. We will likely see incentives for health care providers to offer more cost-effective—and, hopefully, better—treatment. These things are not meaningless, and they will provide a modicum of relief to some struggling Americans. But they do virtually nothing to strike at the deeper problems of the for-profit health care system. And they offer only a fraction of the savings that a single-payer system would provide.

With no clear vision emanating from the White House and no bottom line, everything is up for grabs when it comes to the all-important details. It's no wonder, then, that new balls keep coming out of left field every day. As Obama prepared for his AMA speech, Washington scuttlebutt held that he would seek to reduce costs by accepting limitations on malpractice suits. In the speech, Obama said he was "not advocating caps on malpractice awards," but nevertheless wanted to "explore a range of ideas" to reduce the malpractice threat. As Mother Jones' Stephanie Mencimer has reported, the notion of crippling malpractice costs is essentially a conservative myth. But, according to the New York Times Obama sees addressing medical liability as "a 'credibility builder'—in effect, a bargaining chip that might keep doctors and, more important, Republicans, at the negotiating table."

Perhaps most important, Obama has not yet demonstrated how hard he's prepared to fight for the so-called "public option"—a government-run alternative to private insurance—or what such a reform might entail. At the AMA, Obama reiterated his position that one of the choices available to Americans "needs to be a public option." But could this position be a straw man, set up only to be knocked down? The public plan has certainly served as a panacea to single-payer advocates and other critics of medicine for profit, including important Democratic constituencies like labor unions. One health care advocate told me that the speculation around town was that the administration could eventually abandon the public option in order to win bigger concessions from its opponents.

For now, it seems increasingly likely that the "public option" could be access to the Federal Employee Health Benefits program. This is something Obama talked about on the campaign trail, and, according to Government Executive, his officials studied the plan closely earlier this year. Senate Finance chair Max Baucus (D-Mont.) has long hinted that the FEHB might provide the "compromise" that would allow bipartisan support.

However, while the FEHB covers millions of public employees, it is in no way a public plan. It simply allows federal workers to sort through dozens of different plans and pick one they want. Their employer, the government, then picks up around 70 percent of the tab, with the worker paying the rest. The coverage is generally good: It encompasses preexisting conditions, caps out-of-pocket expenses, and gives subscribers clear information to help them find the best plan for the needs. But it is not cheap. One hundred thousand federal workers don't participate because they can't afford the premiums.

Jim Jaffe, a former congressional staffer who worked on economic, tax, and health issues, and an FEHB subscriber, explained in a recent post Health Beat blog that the plans offered under the FEHB "differ little from insurance plans offered by other large employers." In particular, he writes, the plans "are not particularly user friendly or structured for efficiency," with enrollees facing many of the same complications and obstacles that they would encounter with private insurance. Jaffe concludes that the FEHB plan would be better than nothing, but "from an economic perspective, they are more problem than solution. Premiums regularly rise at a rate double inflation." Expanding access to the FEHB is far inferior to another incremental strategy for a public option, which is to open up Medicare or something like it to the wider population. Medicare, for all its flaws, is basically a single-payer system.

Obama has said that the public option must "inject competition into the health care market so that it forces waste out of the system and keeps the insurance companies honest." The FEHB wouldn't meet that standard. It might, however, be a victory for the Heritage Foundation, especially its chief of domestic policy, Stuart Butler, a Thatcherite Brit who advanced this idea back in the early days of the Reagan administration.

Sen. Kent Conrad, the North Dakota Democrat who chairs the Budget Committee, has advanced another compromise that he believes can win backing from Republicans and conservative Democrats where the public option cannot: health care co-ops. This proposal would establish a network of non-profit organizations that offer an alternative to private insurers. Instead of being controlled by the government, however, they would be run by boards of patients who are elected by fellow consumers. Again, it’s not clear that this scheme would bring about significant savings for patients or fix the inefficiencies that abound in the current system. In an interview with Kaiser Health News, Pam MacEwan, the executive vice president of a co-op called Group Health, admitted that its rates were similar to private insurers and its payment structures were also "pretty much" the same.

In other words, some of the leading public options under consideration may not be all that public. Will Obama allow his health care push to fall short by embracing such measures?
http://www.motherjones.com/print/24541

They Say "Follow the Money"

Yes, if you want to know what the covert story on something is, follow the money.

This seems to hold true in the medical insurance debate going on these days; anyone seeing that train wreck coming like I do?

Lawmakers Reveal Health-Care Investments: Key Players Have Stakes in Industry

Somehow this smacks of conflict of interest but MOCs don't seem to think it matters.

Medical Insurance Issue in SPIN: Obama's Way Off the Fulcrum

UPDATE: 10 June - Interesting to note that Aetna has been cited for loss of records for 450,000 people as reported by UPI.
If this is the case for one of the top medical insurance firms, just think of how secure your electronic health records AREN'T.
If you missed Ralph Nader's talk on the Politics of Health Care aired on public radio recently you can find out more about how he is saying exactly what we have said for decades.
Though we are not as famous as Nader we concur with the majority of his findings.
Yes, 60 + years since reform in the medical industry was proposed as was single payer. I'll be posting more information shortly but consider that the universal claim form would save billions and this has been ignored for at least 30 years.
There's more to consider.
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The SPIN cycle is in overdrive and it is clear that those in the US get wrung out in the wash one more time as this insurance issue debate begins picking speed.

For one, I'd say Barack is too close to insiders based on his wife's former job as a hospital executive.

I'd say he'll waffle on this one and once again people will be the losers, Big Insurance and SOS will be the winners. It's all in the politics of "as if consituents don't matter".

If you read the reports on what Kennedy and Baucus are up to you can see clearly through the smoke and mirrors and know exactly what's on the block to be spun out the other end of the sausage stuffing machine. Remember it's small intestine that's stuffed with you don't know know what, then gets sold as sausage.

I know the medical industry and I know the history of "reform" over about the last 50 years. It has never worked. I am pretty sure that what is coming form the pundit's high priced mouth spilling out of congressional and oval offices is about as close to real change as a dead skunk in the middle of the road.

All this talk about electronic medical records is not worth the $20+ million or more destined to be spent on failed software that we know the government gets taken for in almost every agency. The cost of implementing this fiasco is much more that what ever will be saved. Real economists know this.

And, did anyone ask the question about how many people will opt out because of privacy concerns if electronic records are a mandate? I know I would.

The there are those of us that know the medical system in the US is failed and we do not want MOS. We want right of choice and coverage for natural care not provided by the hybrid NDs that are wanna be docs and want to hang on the same old Newtonian mechanistic model based on insurance reimbursement. Aye, there's that Idaho law I helped revamp that is a voice in the wilderness.

No talk yet on prevention. Can't be because there's no money in prevention nor is there money in keeping people healthy and well.

And just what was the problem 20-30 years ago with implementing the UNIVERSAL CLAIM FORM?

Haven't heard a word on this huge money saver. Obama could put it in immediate effect with the swipe of his hand. Being a "lefty" too I'd like to push him along this path, pronto.

Big Insurance was against it, all those different forms let the different companies add on to time and money in their pocket, less care delivered and no monitoring of real outcome.

Stay tuned for the next SPIN cycle. And in the interim, contact those idiots you elected to "represent "you and demand Universal Claim Forms NOW!