March 29, 2014

From Gerald R. Lucas

When your doctor and your insurance company disagree, guess who gets harmed?

When a system only benefits a few, that system is broken.

There seems to be a disagreement between my health care provider and my insurance company for which I must suffer. Doesn’t that just seem to be the way of things these days? For those of you interested in my sordid and very banal story, read on. For those not interested, I can it sum up this way: my story just adds to the ostensible FUBAR that is the American health care system.

Let me step back and give a bit of my health history. I used to be overweight and out-of-shape. In fact, most of my life was spent relatively sedentary; just the idea of exercise would make me sweat, but I likely got what I needed waiting tables for thirty hours a week.

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When I waited tables, I had some sort of health insurance through the corporate power hat owned the chain. Since I was in my late-teens and early-twenties at the time, I didn’t use it once. Not for anything. When I quit the company to go to graduate school, I lost my insurance and, I’m sure as a karmic consequence, I almost immediately ended up in the hospital with appendicitis. It was my senior year as an undergraduate. With the help of the awesome folks at the University Community Hospital and my father, I was able to pay the surgeon and the hospital every penny of my operation and my week-long hospital stay.

Fortunately, I was able to make it through grad school without any medical incidents. It seems I already sacrificed my appendix to the cruel gods of medical insurance.

When I got my job out of graduate school, I also was able to get medical coverage once again though the University System of Georgia’s Board of Regents. After a few years of not really using it, I decided to start getting an annual preventative checkup: being married and turning forty have a way of broadening one’s perspective. Also, I lost over fifty pounds recently, and I’m probably going to run my first marathon this year. I’m almost forty-five, and I’m in the best shape of my life. My wife calls me a “model patient,” and she’s soon to be a nurse practitioner.

I began to see this young doctor (probably about my age) working with a medical group out of the Coliseum Medical Center.[1] I liked him; when he was with me, I felt important — as if I was the only patient he had to see that day. He took time to listen, address each of my questions and concerns, and treated me like an intelligent human being. At my first visit, he shook my hand and said he would be honored if I would consider seeing him regularly. This I began to do.

About two years ago, there was a change in the insurance coverage offered by the BOR. I was on a high-deductible plan that covered preventative visits. This served me fine for a number of years, but when “POS” began to appear on my BCBS insurance card, I started to have issues (I’m not sure what that abbreviation stands for, but I can guess). Apparently, my insurance had changed, and Dr. — was now “out-of-network.” At first, I was a bit irritated, but since my new coverage came with a health insurance savings account and a Visa card, the “extra” I had to pay was not really a problem. It all seemed to work out in the end, at least for 2012 and 2013.

Since my last visit to my GP, he moved his practice. Apparently, he now works under a group called Internal Medicine Associates PC (their blood-red web page speaks volumes), and when I called today to confirm my annual appointment, I was told that just to walk into the office would cost me $800. I guess they’re way out-of-network now. When the receptionist told me that, I wasn’t sure how to respond, so I just said “thank you” and hung up. That, it seems, was that.

Well, I just couldn’t let it go. With the American health care system on everyone’s mind these days, I couldn’t just accept this new situation without at least finding out why it was this way. Besides, I have an intimate relationship with my GP. He can’t just break up with me this way. So I called back and spoke to “Debbie.”

I introduced myself and explained my situation. I asked for an explanation about the current situation, in writing. Surely, I thought, this has to affect many more people than me, so they would have some sort of PR response to a decision of such magnitude. “No,” stated “DebbieDebbie” (I put her name in quotation marks because she would not give me her last name), “no one has said anything, as the doctors are still negotiating with BCBS. I guess any who might be having issues will just sit tight to see the outcome of those negotiations.” The “as you should” was heavily implied.

She explained that the Internal Medicine Associates PC providers have their own lab that they want to use, and that Blue Cross Blue Shield wants them to use LabCorp. The latter, a BCBS representative later explained to me, must be used for certain tests, but providers are free to use an internal lab for other tests — specifics did not follow. If an internal lab is used for these verboten tests and then BCBS billed for them, the claim would be denied. So, apparently, the Internal Medical Associates PC providers decided not to renew their contracts with BCBS. That’ll show them.

Now this seems to be about as petty as the current US Congress. I can imagine that dealing with health insurance providers has got to be a monumental task for a doctor. I bet an excessive amount of their staff’s time and energy goes to dealing with the capricious nature of multiple insurance providers. Health care providers likely have an army of full-time professionals just to get compensated for one patient’s procedures. I’m sure that because of the Kafkaesque bureaucracy that is the current health care system in this country, the providers get fed up with insurance companies. This is likely what happened here with my GP’s group and BCBS. I am sympathetic. Goodness knows I have no patience for pointless bureaucracy.

However, it seems that the only ones suffering from the inability of the providers to reconcile with the insurance company are the patients. Let me try to draw an analogy.

Suppose that a student wanted to study with me, Dr. Lucas, at the University of Central Georgia (there’s no such place, but we’re being all hypothetical). She decides to get a student loan from the largest supplier of student loans — really the only bank lending money for college in this economy — and she goes to sign up for classes with her new credit card. When she attempts to pay for her classes with her loan card at UCG, they tell her, “Sorry, we won’t take money from that bank because they insist we use their bookstore and our professors want to use their own campus bookstore, so we don’t have a contract with that bank. You can still study here, but you’re going to have to pay out-of-state tuition.” Who suffers the most here?

OK, this might be a totally false analogy, but the bottom line is the same: the individual is hurt because of the arbitrary rules and desires of faceless entities that won’t even acknowledge their complicity. I’m sure if I could talk to my GP — you know, person to person — he and I could come to an agreement, but do you think that’s possible? “Debbie” was having none of it.

“You can try talking to the business office; these decisions come from them, really,” she kept saying to get me off the phone. I knew this was untrue, but “Debbie” had lost patience with me. I apologized for frustrating her — “oh, no, you didn’t, really” — and she gave me the number for the “business office.”

I spoke with a very fatigued-sounding Pam at the “business office,” who informed me that the doctors make those decisions, and hers in an external company, so they have nothing to do with the group’s dealings with insurance providers. I think I heard her chuckle — not at me, but at the recommendation I call her for an explanation. Yeah, I saw that coming.

Next, I spoke with Kiara at BCBS — after negotiating their automated system that really wanted me not to bother any humans there. Seriously, corporations, stop it with the dumb automated systems; nothing communicates “we can’t be bothered with your issues” more than one of those stupid systems that have never been able to help me. Also, quit telling me about your awful web site: yes, I know I can go there to equally not find the answers to my questions. Seriously. Enough already.

When I did get to speak with a real human, she was very nice. I explained my situation and she asked for some particulars. She put me on hold for a minute and came back to say “Dr. — could renew his contract with us at any time.” Good news, but it didn’t really answer my questions about why the contract was not renewed in the first place. She had no information, but confirmed that “Debbie’s” explanation about the labs could be the catalyst.

Finally, I chatted with our HR representative at the college. She was sympathetic and told me that often doctors and insurance companies just aren’t able to work out their differences, so contracts aren’t renewed and patients suffer. Often, she explained, the doctors are in a position where they don’t really need the patients they will lose because a lapsed contract. In her experience, most providers are “on-board” with BCBS; only a few decide they don’t need the hassle or that their issues are irreconcilable.

Besides her advice to “sit tight,” “Debbie” told me that in the interim the doctors would give a 65% discount on visits for patients who are out-of-network. Wow, if $800 is 65%-off a visit, they charge about $2000!? (Am I mathing that right?) That’s about what I get paid to teach a course overload. This just makes the Internal Medical Associates’ decision look even more petty. Add an additional layer of disgusting.

Should doctors have the ability to see who they want to see? I would generally say yes. I guess what bothers me is that what should be an individual, personal decision between a doctor and patient — an admittedly intimate relationship — should not take a corporate and arbitrary face. Are these doctors hiding behind an institutional façade so as to obfuscate the humanity of the situation? Shouldn’t decisions like this be more personal? Why can’t I decide which students I teach in a similar way? Perhaps the institution removes that burden from both of us. Which institution is to blame? The medical PC? The insurance company? The health care system?[2] Corporate ’Merica?

Whose fault is this situation? I’m not sure. What I am sure about is that I seem to be the loser in it. So, there you have it. I might have gotten some facts incorrect or misrepresented others, but I couldn’t get anything in writing from any of the parties involved. If you’re reading this and know better, please set me straight. I would love for this situation to be resolved. I would also urge Dr. — to put a human face on this situation by writing a letter to his (former) patients. Would that be so difficult? Perhaps his hands really are tied. A few paragraphs might just do the job. It certainly could do no more harm.

Can anyone recommend a good health care provider on the BCBS network in central Georgia?

Notes

  1. I don’t want to name him. I do, but I won’t.
  2. Maybe I should just give up health insurance all together. See how we’re punished for trying to do the right thing? Yeah, ’Merica! You once again prove that you’re the best in the world at dicking people over, and the Affordable Care Act does not seem to address this particular systemic issue! It requires that we be a part in a broken system that only really privileges the corporation.