Untangling the Dysfunction in Insurance Coverage

Ann Bartlett Health Guide
  • 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 4th qtr of last year, a staggering 73%), and patients like me get abused in this dysfunctional system.

    Add This Infographic to Your Website or Blog With This Code:


    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."




    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:

    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.


    Add This Infographic to Your Website or Blog With This Code:

    For a week, I mulled over the responses from the diabetes online community, private conversations with the people in the industry, and also with leading patient advocates. Those in the patient sector want more coverage from insurance, but patient advocates and those in the industry want to step back from insurer involvement... and I’m tending to agree with industry and patient advocates.


    In my case, insurance won’t pay for it all, but the problem is coupled with a poor business decision to not inform patients of additional charges. The more I thought about this problem of communication, the more I kept going back to thinking about how useful it would be to have a medical "menu of services."  If we treated health care like any other consumer-driven experience, we should be able to choose between options and cost. For instance, when I book an appointment for an alternative medical health care service, I know exactly what my cost will be and so I can budget for that service.


    What if we did away with the gloom and doom of finding out that my insurer only paid for $13.00 of a $68.00 Dexcom download, and instead charged a flat fee?  Why not have patients stop filling out the paperwork that asks, “Reason for visit” and “how many refills do you need?” and instead change it to a list of choices for additional services that we can have the option to pay for?  At the very least this gives me a sense of control over my money and health care. For example, it would look something like this:

    • Dexcom Download  $55.00*
    • Carb Loading Class/Meal Time Management Class $55.00*
    • Exercise & Insulin 101 Class  $55.00*
    • 30 minute private appointment with CDE/PA    $145.00*

                    (List topics that can be covered)

    • Traveling with Diabetes Class                          $55.00

    (The *asterisk indicates to the patient that he/she will have to self-submit paperwork to their insurance company if they would like to bill to their insurer for reimbursement of these particular services.)


    Further, added to this list should be “freebies” like access to programs that pharmaceutical companies offer, but patients never know about.  


    The bottom line is that health care will never be free and insurers will continue to show record-breaking profits.  The only way I see to change this dysfunction is to put the power in the hands of my doctor, and then I have the right to demand more of her. What are your ideas?

Published On: August 01, 2012