Death Panels? We Already Have Them

You've heard the rumors that proposed health care reforms would involve death panels that would make life and death decisions about your medical care.  What you probably haven't heard is that many insurers already use such tactics.  The opposition will not tell you that health care reform is the only hope to stop them.

Your insurance company may already be using strategies to reduce the cost of your health care that go well beyond what is reasonable and ethical.  This practice has the potential to affect your health, and even your life.  You may not realize that you, your parents, or your child is at risk for being denied critical care until it is too late.  Last year, it happened to me, and it can happen to you too.

My Health Insurance Nightmare

Last October, I developed extreme fatigue, shortness of breath, and pain in my abdomen.  My doctor ran an EKG in his office, and it was abnormal.  He drew blood and sent me to the hospital for a scan of my abdomen to determine the cause.  Unbelievably, he hospital turned me away.

My insurance company, Blue Cross and Blue Shield, refused to authorize the scan.  The insurance company "wanted to know more about my medical condition" before approving the scan.  Where is the logic in denying someone a test that will provide more information until you have more information?  At the time I was only frightened.  Now, I'm angry.  Clearly, this was a delay tactic.

I could not have imagined that I would have to use my years of disability advocacy skills to fight for my own right to appropriate health care.

Within an hour of my being turned away from the hospital, my doctor contacted me to say that I had a hemoglobin level was 5 and had to go immediately back.  At that point, the hospital had no choice but to admit me because it was an emergency.  I finally got the scan my doctor requested, and the test revealed I had a bleeding tumor.

I was given a transfusion to prepare for surgery and was taken to a cancer hospital  for surgery.  Thankfully, the tumor was benign.  Benign, but still deadly.   My surgeon told me that my tumor, which was in the small intestine, was extremely rare--so rare they wrote a white paper on me.  My jejunum is now famous.

Still Fighting

It is nearly a year later, and I am still having some symptoms and still fighting to get follow-up testing recommended by two of my doctors, which the insurance company has denied.  I appealed and asked the Blue Cross to expedite their decision because of the potential seriousness.  They responded with a form letter that told me the appeal would be processed within sixty days.  I'm still waiting.  As most cancer specialists will tell you, time is the enemy in treating the disease, but my insurance company insists on adhering to their timelines.  Another delay tactic.

Death Panels - Alive and Well

Despite my doctors' recommendations, Blue Cross and Blue Shield maintains that the followup testing is not medically necessary according to the Milliman Guidelines they use to make decisions. Naturally, I researched the Milliman Guidelines and found that this company is an actuarial agency whose purpose is to increase profits for their clients - - the insurance companies they serve. They produce software used by insurance agencies to make decisions on whether or not to approve or pay for medical care.

In effect, this group of actuaries have apparently decided that this 45 year old working mom (who could very well have died the last time they denied care) does not merit the followup recommended by her own doctors.  Their tactics include using lag time and delays in claims processing to increase profits as well.  They use demographic data such as age, gender, physical health, and mental health history to make decisions.  It is not unimaginable that disability, race, and socioeconomic status of the patient might be in that mix as well.

If you or your child have a chronic medical condition or developmental disability, you have reason for concern.  It is possible that these factors could be considered in denial of medical care.  If health care reform can prevent insurance companies and actuaries from denying care just to increase their profits, I am all for it.

What You Can Do

• You can bet that most insurance companies use similar actuarial services. If you're not sure what guidelines are used in controlling the care you receive, call your insurance company and ask.  Check it out before you have a medical crisis.  If you have better options, use them.  If not, join the fight with me.
• Take a moment now to read up on the health care debate, and think about what it can mean to you and your family.
• Look at your coverage in a new way with a critical eye.  Ask the hard questions about your insurance company's decision making process.  Don't settle for vague answers like those you'll read on the Milliman website.
• Find out exactly where you stand.  The health plan description book you received from your insurance company will not be helpful in your research.  For example, the booklet may say that medical testing is covered at 100% and that pre-approval is necessary.  The booklet will not tell you exactly how the company decides whether or not to approve the testing.
• When you've finished, consider calling your state representatives to let them know how you feel about this issue.  It is too important not to become involved in the decisions your representatives are making about health care.

More on Health Care Reform:

Health Care Reform 2009 - Separating Fact from Lies

Why the Health Care System Needs Reform

Understanding Health Care Reform