Sunday, January 20, 2008

Health Care?

Grace asked in a comment to yesterday's post, "Do we let insurance companies determine our treatment?" The answer to that is a resounding, YES!!!

In the natural medicine world, the low-carb world, and even before that in the women's health world, the onus for the sorry state of mainstream American health care has been placed on "Big Pharma." (For example, see Dr. Eades post for Friday.) It was the pharmaceutical companies that paid for the research to validate their products and then sell doctors on the benefits of the product which almost guaranteed that whenever you consulted your doctor with a problem, you went home with a prescription for some drug. Then they started going straight to the consumer and procured the legal right to advertise to further increase their sales. If you do any research on the web into any medical condition or treatment, you will find that the studies that have been done were done with a pill in mind. It seems that nobody can afford to do research just for the sake of finding out how things work. Melatonin is a case in point. Who is going to pay for research into the efficacy of a product you can buy at the grocery store?

But recently I read another book, Adrenal Fatigue, by James L. Wilson (which I will blog more about later. Yes, I'm off on another tangent.), in which he makes a very good point that our insurance companies are also shaping the medical world of today. You can't get diagnosed with a disease that isn't on their list of diseases and expect them to pay for the remedies. If a disease has no ICD code (International Classification of Disease), it simply does not exist. According to Wilson, adrenal fatigue is not on their list, only the more serious Addison's disease. If your tests show that you do not have Addison's, then doctors rule out an adrenal problem even though you may be presenting them with a classic case of adrenal fatigue which used to be treated quite commonly. (Ever describe your symptoms to your doctor and only gotten a blank stare in reply?)

Also, even if you have a bonafide medical condition (according to their way of thinking), they get to determine the therapies. They are now starting to refuse to pay for things they consider "not medically necessary." This morning's LA Times (in the Business section, it's all big business) has an article about a woman who after receiving therapy for carpal tunnel syndrome, was told it was not medically necessary and Blue Shield, her insurer, refused to pay for it. They are also refusing to pay for her annual MRI to make sure her breast cancer has not returned.

I myself was caught by this one recently. As part of the diagnosis procedures to determine what was going on with my digestive system, since my reflux symptoms were unusual, I had a routine colonoscopy and endoscopy. Colonoscopies are recommended for someone my age, but I had never had one due to the fact that 15 years ago I had a sigmoidoscopy at Kaiser Permanente without anesthesia and it was an excruciating experience. My gastro doctor said not to worry, I would be anesthetized this time. Doing the procedure without anesthesia was "barbaric" according to him. Now after the procedure has been done, my insurance has deemed the anesthesia "not medically necessary" on the advice of some doctor who was not there, has never seen me, and doesn't know my case personally. Hence, they have refused to pay the anesthesiologist's bill. And since this anesthesiologist is a Blue Cross provider (my insurance is Anthem Blue Cross), they say I do not have to pay any bill she sends me either.

I have been wondering what to do about this for several weeks. I feel like I am caught in a battle between the doctors and the insurance company. At least the doctor who did my second-guessing is an anesthesiologist himself, although it would have been better if he had been a gastroenterologist. The doctor who reviewed the lady's case in the Times article was a pulmonary specialist and not even in the AMA. But I wish I had been forewarned. Now I am afraid to have anything out of the ordinary done because my insurance, which does not come cheap, may decide afterwards that I didn't need it.

Is it any wonder Americans are turning to alternative means of health care?

1 comment:

  1. Don't hold the lack of membership in the AMA against any doctor. Half of all young doctors do not belong. A survey conducted by the AMA to find out why discovered that young doctors find the AMA to be irrelevant or perpetuators of a broken status quo. Thus, they don't bother to pay the $ to join it.

    The fact that this "doctor" working for the insurance company appears to make a living denying care to others in specialties other than his, that is a problem.