Followup on the Healthy Uninsurable Patient

As a quick follow up to The Healthy Uninsurable Patient, a few weeks after the blog was posted my daughter received her COBRA (Consolidated Omnibus Budget Reconciliation Act) papers. By this time she had obtained individual health insurance with a high deductible, but a reasonable cost. The COBRA quote came in at $569.04 per month. This is, by the way, more than I pay for my family plan that covered four people. This is also more than she makes in a month. How many 26 year olds can afford $569.04 monthly for health insurance? Of course I have a cadillac plan as an employed physician at a hospital but there are no other options offered. There is not even any information on how she might obtain other coverage included with the papers.

As a side note, it turns out that she was covered by my insurance when she had the CT scan done. Despite the fact that the letter received from Humana stated that her insurance would terminate when she turned 26, she actually was covered until the end of her birth month. She is a post-graduate student and I’m a doctor who deals with insurance issues every day and we still got it wrong. No one at the hospital where she had the tests, including the financial aid people, realized she was still covered. And this is where I work!!! Nor did the upper management in my office or the office staff at the surgeon’s office understand that she had continued coverage until June 30 (and the surgeon is employed by the same hospital I am).

Of course payment for the scans will be denied because pre-authorization was not obtained for them and we will have to appeal and cross our fingers. What a mess.

When she saw the premium amount on the COBRA papers my daughter asked, “How can they send this stuff out with a straight face?” Of course we don’t know that they do, since we don’t know the people at Ceridian in Florida who mailed the papers. More surprising to me is the number of patients in my office who keep a straight face when they say “But there is nothing wrong with our healthcare system. It’s the best in the world!” No. It’s not.

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What’s my Worry Today in Primary Care?

Worrying about patients is part of my job. In these last couple of weeks it’s been a long-time patient with a life-threatening illness, a pregnant woman who didn’t want to be pregnant, and a young person who thinks that a pill will fix her out-of-control life. (I get a lot of older folks who are looking for that magic pill as well but they don’t worry me as much). Mostly I leave those thoughts at the office but sometimes they come  home with me. Lately what’s followed me home are patients who are avoiding treatment or visits because they have a high deductible or no insurance at all. Last week was a middle-aged woman who just got insurance after being without for several years. She had several concerning issues but the most worrisome to me was the thickened area in her breast. She didn’t tell me about it but on physical exam there it was–it felt wrong. It didn’t belong there. It was a little hard, a little irregular. Classic sensation for a cancer.. She hadn’t had a mammogram or a physical in years because of the cost. Would it have made a difference if she’d had one last year? I don’t know. Maybe. And maybe this “area” will prove to be nothing, though I doubt it. 

The number of uninsured Americans has gone up a few percentage points in the last ten years. What I am seeing more of are underinsured individuals–people with high deductibles and high premiums. These are the people who skip needed care because they can’t afford it OR they have the perception that they cannot afford it. They are “non-adherent” with medications because they fear the cost of followup lab tests even when their medicines are on the $4 Kroger list. They don’t come see me because they don’t know we offer a 35% price cut for cash paying patients. They equate health care with health insurance. They are aware of the skyrocketing costs of hospitals, medicines and doctors and fear that if anything is found on exam that they’ll never get insurance (a reasonable fear to have these days since many people are outright rejected and others are quoted outrageous premiums based on what are often minor problems). Or the patient may obtain insurance without coverage for a pre-existing condition.

I await the mammogram report with trepidation and hope she doesn’t skip it. She was concerned about missing a couple of hours at her new job. God forbid she lose the job that is supplying her with health insurance. I am sure she can’t afford COBRA. And if the worst occurs will she lose her job anyway because she can no longer work while going through surgery, chemotherapy and radiation? And then what?

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