Patients feel that health care should be altruistic, but doctors and hospitals need to run a business. These are vastly different opinions, so what’s the solution?

As patients, we pay into a dysfunctional system. The health insurance business is about risk management and so how much will they cover for someone with a chronic condition? Apparently less and less each year regardless of health care reform. Insurance has bartered deals with doctors preventing them from doing a job well done, while insurance profits continue to rise (Aetna’s profit in the 4^th qtr of last year, a staggering 73%), and patients like me get abused in this dysfunctional system.

From the patient side, the belief is that insurance should pay for life saving medical treatments, because you are paying for that coverage.  Insurers know through medical records that people with conditions, like diabetes, often cost them way more than they are paying into health insurance. ::sigh::

This brings me back to my recent saga with my Dexcom and endocrinologist...

To quell my frustration and my badgering of the doctor's office, my endo offered me an appointment for the following week, and, as usual, she rocked as my doctor... then I brought up the Dexcom charge.

She said, “Insurance says we can charge for that.” 

My response was, “Yes, but when insurance covers only $13.00 of a $68.00 charge, you are discouraging patients from using something that could vastly improve their health.” 

Her reply, “The problem is that insurance reduces office visit reimbursement every year and the only way we can keep up is to hire SMART billers, who look for the changes in office visit reimbursements from an insurance company and automatically seek revenue from other places."

Ouch!

She also informed me that after covering Dexcom seven-day trials for the last few years, Blue Cross Blue Shield in DC has decided that seven-day trials with a continuous glucose monitoring (CGM) is still experimental and they will no longer cover the trial through a doctor's office.  For those who couldn’t make the financial commitment to buying a Dexcom, it gave the patient and their diabetes care team a vast amount of information about the blood sugar ranges, and it often leads to insulin adjustments that reduce an unchanging A1c.  This is something insurers should look at as preventive care, but no. This is another sign we are going backwards, not forward, in preventive health care for chronic conditions.

To add to the complexity of this for patients with diabetes, we face tough challenges:

• Not enough specialists to handle the patient population
• Not enough time for patient education.
• Not enough Certified Diabetes Educators

The comments that have been posted to my last blog echo this, saying that diabetes is such an intense management process and reimbursement is so low that no one wants to go into the field. Diabetes does require intensive management, but there are many reasons the patient population is failing to gain control and one of them rests squarely on cost.