A sad story in Miami, Florida regarding health insurance was recently brought to my attention. It highlights the flaws inherent in both public and private health insurance plans, and is an example of why healthcare reform is so important. A friend of mine has an ailing grandfather, named Benito Jimenez. Benito’s daughter, Maria Conroy cares for him 24/7, and has taken charge of navigating the complexities of his insurance coverage. Her 85-year-old father has Medicare, but also has a Medicare Advantage administered by Humana. This would seem like an ideal compromise of the government and corporations, which would allow them to provide the best healthcare possible. Instead, it’s only brought Maria and her family one frustration after another.
Benito suffers from various conditions, but his health recently took a turn for the worse. He has developed anemia, which decreases the amount of healthy red blood cells. Severe anemia prevents your body from pumping oxygen everywhere it’s needed, so it’s obviously an urgent concern, especially for senior citizens. His doctors aren’t sure where his internal bleeding is coming from, though Maria suspects that it’s related to a previous stomach ulcer that was caused due to Benito taking a large combination of medications daily. The recommended test is an endoscopy, generally considered a simple and safe procedure (as opposed to a colonoscopy, which is more invasive). Unfortunately, possibly due to Benito’s age, his gastroenterologist–part of his primary care doctor’s “team”–refuses to perform it himself, despite being able and certified to do so–Maria feels that he is most likely scared of a malpractice lawsuit. Maria begged him to allow her to sign a waiver removing his liability, but he refused to take the risk of doing it on an outpatient basis. That gastroenterologist further explained that he would be obligated to do any and all tests necessary to save Benito’s life if he was in a hospital setting.
After the gastroenterologist told them to go to the hospital (where the procedure would be performed at a higher cost to them, as well as their health insurance), Maria and Benito were kicked back to their primary care physician. Despite Benito’s hemoglobin level being a very low 8.5, they were told that he wouldn’t be referred to a hospital until his hemoglobin level was 7. She is unclear as to whether the doctor or the insurance company establishes this arbitrary rule. If they had investigated his medical history, a hemoglobin level of 8 had previously sent Benito to the hospital in need of a blood transfusion. In the infinite wisdom of Medicare and Humana’s reimbursement rules, they would not offer preventative treatment until he was in critical condition and needed even more medical care. This runaround was costly for Maria, both financially and emotionally. Benito was prescribed an increasing number of medications to mask his symptoms, but they produced other side effects and exacerbated his main problem (while also resulting in higher co-pays). She felt that the doctors were condescending and were more focused on preventing health insurance fraud than providing care. While Medicare fraud is relatively common, the preventative measures may have backfired. Honest, ethical patients and their loved ones don’t receive the care they need, because they are unaware of the loopholes. For example, a previous cardiologist of Benito’s once referred him to Baptist Hospital in Miami, in order for another specialist to examine him; however, his insurance company wouldn’t pay for a visit to that particular hospital. The cardiologist suggested that he pretend to faint somewhere in close physical proximity to the hospital or in the hospital lobby, so they would be forced to admit him and later discover what he actually needed. This suggestion shocked and dismayed Maria.
For too many doctors, the health insurance bureaucracy has changed their caring vocation into an impersonal business. Ideally, healthcare reform would change this, even though this story shows an negative example of government involvement in health insurance. The saddest part of Maria’s story is that Benito was present when his primary care doctor shockingly informed Maria, as if he wasn’t capable of understanding or wasn’t listening, that further investigation would be pointless due to his frail condition–or at least, not enough of a sure thing to avoid the risk of lawsuits. They indirectly, but essentially told her, in front of him, that he should go home, medicate the symptoms and wait to die. Again, their fear of malpractice judgments and desire to bill Humana and the federal government (thereby making up for decreased funding that cut reimbursement rates) for as many procedures as possible overtook their oath to “do no harm”. It seems as though they prefer to wait until someone is in critical condition to provide preventative care, which results in their needing even more medical care. Meanwhile, Benito’s condition was far from terminal. A previous gastroenterologist agreed to perform an outpatient procedure, but his insurance was only willing to cover the specialist recommended by his primary care doctor. As opposed to working together for the benefit of the patient, that doctor steered them to the uncooperative gastroenterologist described above. Since the outcome was unsuccessful, Maria eventually managed to get her father’s initial gastroenterologist covered under his health insurance plan; however, the delay was detrimental to his care. Benito’s anemia is now critical: this lessens the chances of success of an outpatient endoscopy and might mean that he’ll need a hospital stay, after all.
In Maria’s own words, the health insurance industry has enacted its own “cash for clunkers” program. Only in this case, the so-called “clunkers” are older Americans being sent to the junkyard. There’s a lot of fault to go around: Medicare stretches its budget to the limit and has bureaucrats making coverage decisions, while for-profit insurers like Humana have CEOs and shareholders that also demand a reduction in costs. The patients themselves–our parents, grandparents, siblings, children, partners, and friends–are lost in the midst this battle, even though they should be the most important factor of all. Some opponents of the public option claim that it will lead to the forced euthanasia of seniors, while others believe those claims are overblown. Nevertheless, indirect euthanasia is already happening right now; this is a case in point. Healthcare reform is a complicated issue, and it’s deeper than greater availability of affordable health insurance. That won’t matter if, after paying premiums and/or taxes for decades, your insurance won’t give you the care you need most. I don’t claim to know what proposal will work best, but Maria says that the current system is broken and that we urgently need healthcare reform of some kind. “Everybody doesn’t have a family member to be an advocate,” she adds. “I worry about how many elderly people fall through the cracks without someone to find the loopholes to work the system for them.”