+6 more
posted on Apr, 14 2021 @ 01:47 PM
A tale of how great insurance works under government control... specifically Medicare. Now, don't anyone get me wrong; I am thankful to have
Medicare. Without it, I would have absolutely zero insurance of any kind and probably wouldn't last much longer. I feel, however, with the promise of
"Medicare for all" hanging over our heads, this little tale might be of interest to those who think it fixes all the healthcare problems.
A little background (without being too specific in accordance with ATS policy): Most here already know I have heart issues. That is true; to date I
have had 8 heart attacks, one stent, numerous exploratory cath surgeries, and a quintuple bypass (open heart). Yes, that's 5 bypasses installed. The
last heart attack came two weeks after the open heart surgery and I feel it was that one that damaged my heart so badly. My expulsion ration is down
near 40%, and the accompanying fatigue caused by the resulting low blood flow is the reason I am on disability.
On the other hand, the extended recouperation period notwithstanding, all my other bodily functions, including my immunity, are still strong.
The reason for all the heart attacks was atherosclerosis, aka "hardening of the arteries," brought on by a rather outlandish cholesterol level.
Before the stent was installed, my triglycerides were well over 500... the doctor told me at the time that they could not get an accurate reading on
LDL, HDL, or total cholesterol because the triglycerides were so high. The hospital brought them down with statins and a strict diet, and sent me back
home.
Thanks to Medicare, I have been seeing a doctor for about a year now. I like the guy... rough, gruff, with a dark sense of humor. He's a lot like me,
so we understand each other. When I started going to him, he switched my statin... again... and about 6 months later my total cholesterol was again
coming in at the 500 range. He then explained that he never expected the new statin to work, but in order to get the medicine I needed, he had to
provide proof that the statins alone were insufficient. He then wrote me a prescription for a new drug, a pen that I take once every other week. After
a few months of that, we checked my cholesterol again. This time it was 77.
That is not a typo... in just a few months, it dropped from 500 to 77. The new drug works, and thus far has had no side effects for me.
Now here's the issue... it's pricey! Pricey as in, over $550 a month. I am of course on a fixed income now, so while it's sufficient for my needs
it simply cannot cover that cost. Now here comes Medicare! They drop my monthly cost to under $10. Great, right?
Well, it's great as long as they cover it.
You see, my Part C provider does a "prior authorization" for such drugs. That means they, like my doc explained they would, specially verify that
patient's needs with the doctor before approving it. Special procedure. OK, no problem, just go through the paperwork to get it approved, which
should be done by the insurer and the doctor.
But it doesn't work that way.
I get this thing in 2 months supply. My prior authorization ran out in February, just after I had it filled. So it comes time for a new batch and I go
to pick it up... but the pharmacy tells me I need a prior authorization and they have already sent the paperwork to the doctor to be filled out and
turned in to the insurer. That's how it's supposed to work, anyway. But now Medicare steps in. You see, they're so excited about making sure people
get their medicine, they only give the insurers 72 hours to make a decision (24 if it is "urgent"). Sounds great, right? What they forgot was that
doctors keep office hours. They're not there on weekends, and mine is also closed on Wednesday. On top of that, the doctor's office has one person
working the medication paperwork, and she is handling requests for a few hundred patients. It takes time, especially when she also has other duties.
So what happens? The patient needs their medicine; the patient calls the insurance company to find out how to get their medicine; the insurer allows
them to start the prior authorization, making sure they know that they'll get an answer within 72 hours, or if they are in a hurry, say it's urgent
and make that 24 hours.
What they don't emphasize is that within that 72/24 hour time, the doctor has to respond with the needed information or the claim will be denied.
That means if you start a prior authorization at Friday noon, the doctor's office has less than one business day to receive the information request,
check the patient's records to verify they need that medicine, fill out the forms, and return the request. If the patient said it was urgent, they
have a few hours at most, because doctors are simply not open on Saturday.
The result is that, in order to make sure patients don't have to wait on their medicine, Medicare has made it much more likely that they'll never
get their medicine.
Understand, this 72/24 hour time clock is not coming from the insurer or the doctor... this is a Federal Medicare mandate for anyone who is covered by
a Medicare plan. It isn't even coming from Medicare itself, at least not at the level individuals interact with Medicare... this is coming from
politicians who have no earthly idea how the industry they are regulating works.
So now you who like the idea of Medicare for all, sit down and think a moment. You now know someone who will be missing their bi-weekly medicine dose
tomorrow (there is now no way I can get it by then, even if the President himself drove down here and demanded that it would happen... the logistics
will take longer than that) because of Medicare restrictions. Is this what you want for yourself and your loved ones? Those regulations will only get
worse the larger Medicare becomes. That has been the way of government programs since the first Pony Express rider saddled up.
(I will likely get the medication eventually, for those who might be inclined to offer condolences. I will likely also miss a couple doses, but I
don't think my cholesterol levels will hit 500 in that time. It's just a strain trying to stay on track with the dosages, and my real worry is that
some medications can have potentially fatal side effects if stopped suddenly. Luckily, this isn't one of them. I also worry because most Medicare
recipients are even older than me; I broke my body early. They often don't have the comprehension and/or memory ability to take on a fight like this.
They are at the mercy of those idiot politicians with their grand ideas that only work in the few functioning neurons they have left.)
TheRedneck