Step Therapy Reality Check

WBZ’s I-Team recently broadcast a story of a 22-year-old college student’s experience with medical insurance that should be a cautionary tale for all. Reading Eitan Kling-Levine’s story and the subsequent price he paid with his personal health should shock you.

And in case you think this would never happen to you, let me share a personal experience with “step therapy”, albeit one with lesser consequences and a happier ending.

Several years ago, I was diagnosed with mild to moderate obstructive sleep apnea. Not only a relational inconvenience as the snoring kept my partner awake, it was a source of concern as I was continually exhausted from interrupted sleep. The standard protocol for this would be a CPAP, something I had familiarity with as my Dad had COPD and had attempted to use one.

Now I, the patient, know myself fairly well and, as an extremely light sleeper on a “good” day, I knew the noise of the CPAP would keep me awake as much as the sleep apnea did. And then there are the usual side-effects. So I did quite a bit of research and discovered that in my case a dental device called a mandibular advancement device (MAD), fashioned by a dentist with sleep apnea expertise, would be a more effective solution. And, to my great amazement, a renowned expert in this therapy had a practice in Worcester, MA – 40 minutes away. So I set about getting approvals and referrals.

My primary care doctor and the neurologist in that network, all submitted their paperwork. Everything was proceeding smoothly until a pinhead at the insurance company intervened and rejected the referrals. As I had not “failed” with a CPAP  (a $2,000-$3,000 expense), I was not approved for the MAD device ($1,400). In other words, I was not allowed the use of a less costly, more appropriate therapy unless I stepped through the CPAP therapy and failed.  Does that make any sense?

In the end, through the advocacy of a very skilled and persistent referral department in my health care provider’s practice, the MAD device was eventually approved. It took over 6 months; that was 6 months of loss of sleep, anxiety over a load of paperwork and frustration that a solution to a health problem was put on hold by an insurance company.  It could have been worse as you learn from reading Eitan Kling-Levine’s story.

Step Therapy is bad for the health of people, good for the health of someone’s bottom line. From what I can read, the Massachusetts bill correcting this insanity has been referred to committee.

Hopefully that isn’t “step therapy” for killing the measure.


Thank You SCOTUS

Thank goodness I reside in a state where it has been illegal to deny health care coverage for pre-existing conditions for some time (should I say “thanks” to Governor Romney?).  As of a few hours ago, the Supreme Court ruled that insurers cannot discriminate for pre-exisitng conditions nation-wide. For someone like me, that is truly good news.

It means that I don’t need to limit my retirement living options to Massachusetts – as much as I love the place.  As a cancer survivor, I have had coverage denied by a traditional insurer, who will remain nameless for this post. I had to carry my own coverage through COBRA and pay for coverage for anything else that might crop up “new” on the new insurance my husband’s company had switched to.  Trust me when I tell you that it was a financial hardship as well as a stressful situation.

As I understood the rule at that time – pre-Massachusetts healthcare reform – if I was treated in any way, shape or form for my pre-existing cancer diagnosis, I would have the start the clock all over again.  I don’t remember the time requirement any more, but whatever it was, the denial of coverage was wrong.

So I am celebrating today because no one should ever have to live in fear of wondering how to pay for treatment of an ongoing illness or condition. Treatment and medical factors should provide all the stress anyone ever needs in that regard.

Thank you Supreme Court. By not declaring these Health Care Reform unconstitutional, you’ve taken a step toward justice in health care.


Yet another foray into the medical labrynith

It’s a time of year that I dread and a time that is necessary. I am a breast cancer survivor. A yearly mammogram is not an option, it is a necessity. Some bean-counter in a medical or insurance facility, far far removed from real humans can designate my mammogram as a “screening” all they want. It is a stress-filled hour when I relive the moments 20 years ago when I first learned my body had betrayed me. For me, it is an hour of fear.

I rely on the reassurance of that first radiologist reading to quell the demons that cause my mind to race ahead with the what-ifs. What if they find something? What if it IS cancer again? What if I have to endure chemo again? What if I don’t make it? Maybe this is self-indulgent. It is what it is on mammogram day.

This year, the empathetic technologist offered that I could wait – even though I was “just” a screening – for the radiologist to read the mammogram. I understood that waiting would mean that there could be others ahead of me; I had a book, no problem. She even came into the waiting area about 15 minutes later to tell me that there were a couple of people ahead of me. “Not a problem” I responded.

Imagine my surprise 5 minutes later when another technician – who seemed to be overseeing the Friday afternoon events, asked me to step into a next door room. With her finger shaking at me, she told me I shouldn’t even be there, that I might have to wait another 45 minutes. There were people ahead of me. If you’ve ever been called into the principal’s office, you know exactly how I was feeling.

I explained I understood that, I had no intention of bumping other patients and I didn’t mind waiting. Apparently that was not satisfactory because the next thing I was told was that it was late, the facility was closing soon and that my mammogram may not even be read. I shouldn’t bother waiting. Has the medical world changed so drastically that even the doctor is “on the clock”?

This insensitive woman then went on to lecture me about making my appointments early in the week and early in the day. That did it.

I cannot come during the day, I teach. I also don’t care to have anyone outside of my family speculating about my personal health issues (already experienced that when I was on chemo) so I do NOT make medical appointments during the school day.

The fact is, my original mammogram – the one when the cancer was found – happened in June, right after school had gone on hiatus. Due to our crack medical system in this country – the one where yearly means 365 days + 1 and where diagnostic facilities are so overloaded that you cannot schedule appointments conveniently, my “yearly” mammogram has slipped from year to year until it is now 3 months later.

So when I get accused of princessing up because of the time of my appointment interferes with getting the weekend started, I take offense. Lucky for me, my internal medicine doctor is in the same building. I was able to walk up to the office and, reduced to tears and barely able to speak, told my story.

I hate that my one bout with serious illness has changed me so that every change in health, every “routine” diagnostic sends me into a panic.

Is it possible that our country’s medical system has become so insensitive that professionals on the front lines become so concerned about quitting times, that they don’t notice the human in front of them.

Has the US healthcare system been given the assembly-line, CEO, best business practices overhaul? I am afraid of the answer.

Waiting and Watching

Around 9:00 last night, I got sucked in to watching C-SPAN of all channels. And yes, I was watching the Health Care “Debate” — if you can call that circus a debate.

I am a supporter of national health care and, frankly, I think this particular round of legislation is a pale shadow of what health care should be in the wealthiest industrialized nation on this green earth.  But putting that aside, my great hope is that the minimal protection provided by the Bill will prevent such health insurance financial fiascoes as happened in my family being thrust on another.

My suspicions are that this debate was not so much about health care as it was about other changes that some factions — loud ones as it turns out — cannot tolerate.  I felt ashamed and mortified that grown adults lobbed disgusting epithets in the direction of Representative Lewis and Representative Frank. What is wrong with us that we can’t have a civilized disagreement? That once a vote has been taken, those of the opposing opinion cannot accept what the majority has decided.

Last night’s vote was mesmerizing. But now there is more to come with the Senate debate. Will there be less acrimony? Doubtful. And what happens from here, no one can know for certain.