This is What You are Demanding

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

a reply to: TheRedneck

This is in no way an endorsement but since I work in the medical field I have found that elderly and folks like yourself use a pill splitter and ration their meds because of the federal bureaucracy.

They do it because they have no choice.

my mom's going through similar BS over one of her meds right now... you have my sympathy. our entire healthcare system in this country is badly broken, whether it's medicare or private insurance. it's all a mess.

Isn't medicare like...socialism?

I have no insurance, my doctor has been trying to dial in what works for me. She gave me some samples of Trulicity for 2 months it worked better and gave me less side effects. So I got a prescription it was over $1000 a month try this, I got my prescription for 25 bucks.

Yes our medical and health insurance system is screwed up, doubt universal is the answer, but as it is isn't working either.

Try here I was desperate and it saved on some other meds too.

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a reply to: TXRabbit

Actually, Medicare is insurance. Forced insurance. No one ever asked me if I wanted to pay into Medicare; the money was taken from my wages whether I wanted to pay it or not, by law. If I had been asked if I wanted to pay into Medicare, I would have turned down the offer.

However, I was forced into buying into Medicare insurance, so I plan on using that Medicare insurance.

If, as you say, Medicare is socialism, then all insurance is socialism. Somehow I am having a very hard time coming up with a rebuttal to that.


TheRedneck

a reply to: DBCowboy

That is horrible, although I understand why some people would have to do so.

Crazy thing: whenever I am waiting to see my doctor in the exam room, there's one of these revolving ads hanging on the wall giving medical advice... how to read consumer labels, what vaccinations people should get, that kind of thing. One of the ads is saying how important it is to take medicine as directed and quotes an enormously high percentage of patients who don't.

If you want someone to take medicine as prescribed, then it would seem the first step in that is to make sure they can get it, as prescribed. Of course, in my case, it's a little difficult to split a pre-dosed injection pen in half...

TheRedneck

a reply to: putnam6

My wife is on Trulicity. Unlike me, she can't get on Medicare so we're having to go the charity route for her care and meds. The maker of Trulicity has a program for low-income uninsured where they get their medication free.

I don't have a link, but I'm sure someone who wants to find it can do so.

TheRedneck

I am sorry your going through this and by no means feel the need to reply to me but I do have a few questions.

Do you believe your diet and/or life style played a roll in your health problems? Or did you eat a balanced low sugar diet your your whole life with proper exercise and due to genetics this somehow still happened and was totally unavoidable by any realistic means or perhaps a modicum of self care?

Again not trying to bash just trying to understand the logic at play. You don’t sound like a healthy person and I am just wondering to what extent if any you feel your actions played on your health.


a reply to: TheRedneck

a reply to: TheRedneck

Wow, that sucks. Five hundred on Triglicerides is way too high, that will cause problems in anyone. I am concerned about the seventy seven though, that seems awfully low. Too low is no good either. Problems start with too low when you get under fifty if I remember right.

When Triglycerides get over three hundred, medicine is most often necessary. Diet cannot take care of it when it hits like five hundred, I know a person who is going downstate for a trial because her triglycerides are between eight hundred and a thousand, the Statins were not working for her. She did get them down into the hundred something range with the trial. She has the actual rare disease. Her trials ended in December and I won't be seeing her until spring again. She was not overweight, in fact she was a little too small and eats a real lot of veggies all the time. Did she start eating mostly veggies because she sensed the problem or did the chemistry in some of the veggies cause a degradation of the enzymes needed to properly use triglycerides.

The government has never been fast about anything, but they require us to be fast and punctual or they deny things. I used to do government paperwork years ago and it has not got better, in fact it has gotten worse. The high triglycerides are probably directly related to your condition. Most people never would get that high, you must not make an enzyme or make too much of an enzyme used to metabolize them. It sounds like that med is working for you, too bad the heart is already damaged. Too bad that medicine is so expensive, it probably is cheap to produce but lots of profits are made from some meds.

Hopefully there is no side effect of coming off the med too fast. It would suck to lose a good moderator.

originally posted by: DBCowboy
a reply to: TheRedneck

This is in no way an endorsement but since I work in the medical field I have found that elderly and folks like yourself use a pill splitter and ration their meds because of the federal bureaucracy.

They do it because they have no choice.

Not trying to be argumentative but it's worth checking they aren't slow release tablets first.
There can be problems if you bypass the coatings or layers or however these things work.
I was on several different painkillers for my back and warned about certain ones and not to do that.


Although it's only a half dose, the absorption rate can make quite a difference.

a reply to: Athetos

I'd say no more than with any other average person. Since the medication in question works so well, it appears it was a chemical imbalance in my body chemistry that made me so susceptible to ridiculously high cholesterol.

As for being "healthy"... aside from the one heart issue, I happen to be quite healthy. Liver functions are perfect, despite desperately trying to drown myself in my youth with alcohol on many, many occasions. Kidneys work fine. Thyroid function normal, as is pituitary function. My lungs, despite being a life-long smoker, still have the capacity of a 20-year old (thank God or I would be in real trouble!). I have the immunity system from hell... if anyone is immune to HIV/Ebola/whatever, I am. I could eat poison ivy.

But I can't walk more than a few minutes at a time, even pacing myself. I can't wear a face mask (or anything that lowers my SpO2) for longer than I could hold my breath before. The legs won't keep working, and everything else starts going out if I push too far for too long... I will even eventually become disoriented as there won't be enough oxygen for my brain. My blood flow is just too slow.

Health is not a binary thing, nor do we even know everything about it yet. I was blessed with exceptional health and vigor, but also cursed with a tendency for my blood cholesterol to run amok. Based on the mechanism of action in that medication (yes, I researched it before trying it, as I do every medication), I have too much of a chemical that destroys the cellular receptors in the liver that absorb and convert cholesterol. The medicine inhibits that chemical and lets the liver do what a liver is supposed to do.

I still fix my own car, take care of the lawn, make my own repairs... just now I have to do it slower (MUCH slower!) and I have to let machinery do most of the heavy lifting. I can't walk around my place any more (at least not without several rest breaks en route), and certainly can't carry heavy materials or tools that far, so I use my riding mower and a trailer. Patience and leverage, leverage and patience.

When a person is young and vibrant, it is easy to make that binary classification of either "healthy" or "unhealthy." I know; I've been there. When things start breaking down, however, one quickly learns how to deal with the issues at hand and realizes that there's an infinite number of shades of grey when it comes to health.

TheRedneck

a reply to: rickymouse

That is exactly what the problem seems to be: too much of a chemical, or too little of the chemical that controls it.

Check out my last reply; it pretty much covers what's happening.

One more interesting thing... I'm a firm believer in satisfying cravings; they are the body's way of telling you what it needs. Here the last week or two I have been craving vegetables... not even cooked, but raw vegetables. Cabbage (cole slaw), raw carrots, raw tomatoes, raw taters, raw cucumbers, fresh lettuce, that kind of thing. I am literally skipping cooked meals for raw veggies. The last time I had a craving this strong and long-lasting it was for mushrooms, and I was becoming known at the local salad bars for cleaning them out.

I know you're big into nutrition. Any idea what this is, what my body is trying to get?

TheRedneck

originally posted by: TheRedneck
a reply to: rickymouse

That is exactly what the problem seems to be: too much of a chemical, or too little of the chemical that controls it.

Check out my last reply; it pretty much covers what's happening.

One more interesting thing... I'm a firm believer in satisfying cravings; they are the body's way of telling you what it needs. Here the last week or two I have been craving vegetables... not even cooked, but raw vegetables. Cabbage (cole slaw), raw carrots, raw tomatoes, raw taters, raw cucumbers, fresh lettuce, that kind of thing. I am literally skipping cooked meals for raw veggies. The last time I had a craving this strong and long-lasting it was for mushrooms, and I was becoming known at the local salad bars for cleaning them out.

I know you're big into nutrition. Any idea what this is, what my body is trying to get?

TheRedneck

Yeah, paying attention to cravings is important, and trying to figure out why you are having them is hard. I break them down to possible nutrients or companion food chemicals. It takes a lot of research and often the super complex research leads to such a simple answer you would have never believed it if someone told you. But most people studying this stuff don't go down the rabbit hole nearly as much as I do....you need time and also a lot of comparison to come up with the proper answer.

But, I have been eating chef salads quite a bit the last three weeks, this time of year I always start to crave them when the snow goes. I also tend to eat a lot of cooked green beans and some other veggies.....way more than in the winter. I miss the all you can eat salad bars we used to go around Easter every year. I crave fruits and carb veggies in the late fall and green veggies mostly in the spring. Been that way most of my life, no used changing now. In the midwinter I like potatoes and carrots more, they provide energy to keep warm outside when doing stuff.

I get a craving for mushrooms sometimes....I have never worked on identifying how come I get that craving. Then the craving just shuts down and I sometimes have to toss out some of the last package or try to eat them up even though I don't feel I need them anymore. They have to be an antidote or medicine for something.

I do know that the oyster mushroom and some others contain lots of statin chemistry to them. I think it was levastatin in mushrooms. link.springer.com...

So, it is no coincidence that you wanted to eat all the mushrooms at the salad bar.

Naturally thank you for your time and reply.

So it’s all stemming from your liver being unable to function properly. Has this been the case your entire life?
Do you still smoke?


a reply to: TheRedneck

a reply to: rickymouse

Lovastatin in mushrooms? Wow, that does explain a lot!

I'm wondering about something... the craving for raw veggies roughly coincides with the weather breaking and thus me getting outside to do something there every day. In other words, my exercise (such as it is now) has increased many fold. Can you think of a correlation there?

TheRedneck

originally posted by: TXRabbit
Isn't medicare like...socialism?

NO!
we[working Americans] funded this program since we entered the workforce

A55#0l3

a reply to: Athetos

Probably has been the case my entire life. It just took this long to build to critical levels. I've always had high cholesterol, just not that high.

Yes, I still smoke. Apparently I have one of those metabolisms that allows me to do so with few if any negative effects. As I said, my lung capacity is exceptional, and moreso considering my age. Every doctor who has treated me for the heart failure has told me two things: "I want you to stop smoking" and "smoking didn't put you here."

Interestingly enough, a while back I had a doctor, a cardiologist, and a neurologist all playing scavenger hunt in my body to try and find anything and everything they could wrong with me. Result: I have at some time in the past had at least two strokes, best anyone can tell from when I was an infant. I have a 2.3 cm abdominal aneurysm... my cardiologist saw it, shrugged, and said they would be monitoring it and if it got to 5 cm they'd just fix it. He's not worried. I have abut 60% blockage in my carotid arteries on the left side... again, monitor and maybe stick a stent in if it gets a lot worse.

But the one thing that hasn't been verified is the possibility of myathenia gravis, an autoimmune disease that attacks the nicotinic receptors on the striated muscles. They're named that because they were discovered by a researcher who was investigating the effects of nicotine on the body. They are normally triggered by acetylcholine, but nicotine also acts as a trigger. If that is an issue, that would explain the cigarette addiction.

The blood test simply isn't back yet (or if it is, no one has informed me).

I have switched, for many years now, to home-rolled cigarettes using pipe tobacco. The difference is astonishing, both in price and side effects. Most of the health problems with smoking, I have convinced myself, center around people being forced outside into inclement weather to smoke (my home and my car are designated smoking areas, by order of the owner), and tobacco companies use a lot of pretty nasty chemicals in cigarette tobacco to speed up the curing process. Pipe tobacco is cured more naturally because pipe smokers buy based on flavor, not nicotine levels.

Are you aware of the regulation that says all commercial cigarettes must now be "fire-safe"? How do they make a cigarette "fire-safe"? They paint little rings of carpet glue on the inside of the paper! The government has mandated that all smokers must smoke burning carpet glue!

Let that sink in for a moment... all cigarettes now contain flame-retardant carpet glue by Federal mandate.

Except mine.

TheRedneck

Makes sense to me. I am very aware of the fire safe cigarettes and their implications, when I smoked I rolled my own often and would only buy a pack for the ease of use while at a bar or party. I quit the habit fortunately after only 14 years of smoking. As for the last part justifying your smokes each their own, but with the plethora of issues that seem to plague you one might come to the conclusion inhalation of any burnt matter might not be in one best interest sans glue or not, but I believe in personal freedom and having creature comforts can go a long way.


Looks to me like you have made peace with your reality which is the most important thing in my opinion. Thank you for your detailed replies.
a reply to: TheRedneck

I feel like if I was able to keep the money that's being taken out of my paycheck for taxes I wouldn't have to worry about insurance.

Another #ty aspect of insurance is that apparently you can max out your insurance.

Outside of the military I spent most of my life without insurance. If I couldn't get it taken care of by the VA, or couldn't fix it or cut it out myself I just dealt with it.

Fast forward to this year I finally started using insurance. I used the dental insurance to get a root canal and three crowns. I was supposed to also have a full on dental cleaning, but they told me that my insurance was maxed out, and that I would have to pay the whole price out of pocket, which is like $250.

I'm not paying $250 for that. I can do that myself lol.