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Christine Fife

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At Least Half of the Real Problem with Health Care

I would like to let you know upfront that this post is going to be a bit of rant about medical insurance and the health care “system”, but also customer/patient relations. Through the course of trying to treat a serious back problem, I have discovered what I believe is the problem with our health care “system” in the US. I use quotes around system because it isn’t a system at all. System implies that it is parts working together, but medical insurance, doctors, labs and treatment facilities don’t work together to help patients. They work independently to help themselves. It seems to me that this creates at least 50% of the the ridiculously high cost of health care and at least that much in debt for average Americans who find themselves in hot water because they didn’t realize how much they’d have to pay for by just doing what their doctor said.

Doctors’ offices, labs, medical treatment facilities, etc. do not make much (if any) of an effort to help patients understand that their medical insurance may not cover the treatment, test, procedure, etc. that they are prescribing or that the patient has an option to go to a different lab or facility where the treatment might be less expensive. That isn’t their job, right? Of course, a patient probably went to that doctor because he was listed on their insurance company network, but the labs and facilities that doctor tells his patients to go to, isn’t necessarily on the list of places that have a price deal with the patient’s insurance company. AND The insurance companies, make it as hard as possible, if not impossible altogether, to determine if a treatment or procedure is covered before you go have it done because they have hundreds of policy documents deciding that certain treatments are only covered under very specific conditions, but the insurance customer service rep doesn’t understand the documents, so they tell you to talk to your doctor or read the policies on their website.

The major problem with health care is that the doctors, insurance companies, medical labs and facilities do not work well together, and certainly don’t work as a cohesive “system” to help someone with an ailment. In fact, they each put up their own roadblocks and red tape so that patients can’t figure out what is or isn’t covered and how much it will cost. Of course, the patient is still in need of the medical care, so they move forward with the treatment only to find out they’ll be paying for it financially for the rest of their life.

Follow Along

23 years ago I had a horseback riding accident, after which I began having back pain. I was 15 at the time and after complaining a lot, I saw a whole host of different types of doctors until one of them in about 1988 told my parents and I to do a Magnetic Resonance Imaging (MRI) scan. The images showed a bulge in a disc in my lower back that was pushing against the spinal column and the nerves that extend down my left leg, thus the pain. Surgery was not recommended at the time as I was young and rest and anti-inflammatory medication might prove to relieve the pain. Unfortunately, it didn’t.

Over the years, I tried every conservative method of treatment to reduce the pain.

  • Physical therapy (at least 5 different times and continued to practice the stretches, exercises and methods of bending and lifting I learned throughout my life.)
  • Acupuncture (many times when my back would really flare up with pain due to bending wrong or exercising too strenuously)
  • Chiropractic treatments (about different times with multiple sessions each time)
  • Massage Therapy (all the time!)
  • Integrative Manual Therapy (What was I thinking?)
  • Yoga and Pilates (which I continue to incorporate into my weekly exercise routines.)
  • And one invasive treatment of a steroid injection into the spine in the late 1980s, which was the worst thing I’ve ever done in my life. It not only didn’t help the back pain, but it ended up giving me excruciating headaches with major sensitivity to light for about a month. Apparently, the way they used to do these injections (patient sitting on the side of the bed bending over while they stick the needle in your spin) wasn’t very full-proof and it was likely that they could nick or puncture something in there that would cause serious pain along the spine or headaches.

Nothing ever made all the pain go away, and for 23 years I’ve had tingling and numbness down my left leg. Many of these did ease the severe pain in times that it was especially aggravated, which the doctors seem to call “flare ups.” Essentially, a flare up means you’ve done something to get the disc and surrounding muscles, tendons or whatever to swell, causing more intense pushing on the nerves and spinal column.

Special Note: Many of these conservative treatments have not been covered by medical insurance policies I’ve held over the years so I had to pay out of pocket.

So, What Happened?

In about September of 2010 my back started feeling worse–a flare up was coming on and this was the worst I’d ever had. I decided to try some chiropractic treatments again. I heard good things about a practice that sounded like they were very modern and forward-thinking. After about 8 treatments of cracking my back and such, the pain, especially the shooting pain down my leg, was really starting to ease up. Another treatment (I had paid for a serious of 12 to get a price break) and suddenly the pain shifted more to my left hip and butt. I told the doctor that the pain was different and felt like something was happening in the muscles. But he continued on with the treatments. By mid-December I could hardly walk without wanting to cry.

I gave up on the chiropractor and found out at the end of December he had left the practice. I got a call from another doctor at the practice in early January who was calling to see if I wanted to schedule more appointments. I think they were checking to make sure the first doctor wasn’t trying to take his patients with him when he left because their’s is a corporate practice. I gave her an earful. She invited me in for free services to be treated by a new doctor. After a few treatments that did not include cracking my very tender back, I couldn’t stand from the pain. The chiropractor suggested I needed a new MRI as it had been so long and clearly there was a lot going on because I was in so much pain. An urgent care facility doctor I went to for some pain pills while I worked on figuring out what to do said the same thing.

The new MRI showed that there was a “broad-based bulge with central protrusion/extrusion and facet arthropathy resulting in moderate canal stenosis with moderate right and severe left neural foraminal narrowing.” The MRI also showed “Degenerative Disc Disease” in that particular disc. In English, that means, the disc was really basically dead and not being much help to cushion between the two vertebrae, and it was bulging out and  pushing on the spinal canal, especially pinching off the nerves to my left leg.

We Arrive At Today

I learned the results on February 4, 2011. I found a doctor, listed in my insurance company’s network, who seems great. He has recommended a steroid injection. I didn’t want to do that again, but he said that the way they perform the procedure is much different now and that what happened to me before couldn’t happen again. So, I decided I would like to try it.

Now I’m in insurance company hell! I’ve been burned by insurance companies before who said something would be covered and then it wasn’t, or by doctors who prescribed treatments or tests at labs or other locations that I later found out were 3 times as expensive as another location and I was stuck for my portion of the payment (what insurance didn’t cover). So I wanted to do my due diligence and get this right.

I have a PPO through Aetna with a $2500 deductible. After talking with the Orthopedic Doctor who recommended the injection, I started down the path to make sure it would be covered before I schedule the appointment. Here’s what’s happening:

  1. The doctor gave me the name of the procedure he is recommending.
  2. I called my insurance company who had no idea what that was and without the medical codes to look up they couldn’t help me.
  3. The doctor’s office is very busy (I live in San Francisco and every doctor here is always overbooked), so it takes a couple of days to get to the right person to get the codes for this procedure.
  4. Meanwhile, I’ve been on pain pills for a few weeks now and feel like a giant blob with a back and leg ache, laying around in bed with my knees propped up and feeling miserable.
  5. The very nice woman at the doctor’s office gives me the codes and I call the insurance company.
  6. The customer service rep at Aetna informs me that 2 of the 3 codes that make up the treatment my doctor recommends will be denied. Here’s where it really get’s good.
    • Through asking questions of the Aetna rep I find out that she says the 2 codes that will be denied are the same thing. Huh? She says they say the same thing and that they are either exploratory or experimental so it won’t be covered unless my doctor determines, and provide documentation after the procedure to the insurance company, that I fall within Aetna’s Clinical Policy Bulletin #725 ruling. Huh? The rep has no idea what that bulletin says or means.
    • So I take to the internet. I’m already laying in bed doing nothing but being on the computer (with a head full of pain killers). These 2 codes are CPT codes 64483 and 64484. Apparently, they both have to do with injections into the spine. I found this wonderful article, Understand the spine to code back procedures correctly, which shouldn’t be on me to understand–Isn’t that why I am paying for insurance and choosing a doctor and agreeing to pay for what the insurance doesn’t cover? I love the first paragraph of this article:

      Two problems that frequently surface when coding spinal procedures are inadequate physician documentation and lack of coder knowledge of the anatomy of the spine. Both can lead to a loss in reimbursement.

    • Clearly this article is meant for doctors’ office personnel and not for a patient to have to figure out. The doctor originally gave me a name for the procedure a “transforaminal epidural steroid injection.” Ok, but they only gave me 3 codes and the article goes on to say: “Whether a transforaminal epidural block is performed unilaterally or bilaterally at one vertebral level, use CPT code 64479 or 64483 for the first level injected. If a second level is injected unilaterally or bilaterally, use CPT code 64480 or 64484.” So I think I need injections at 2 disc levels, because the doctor’s office gave me 2 disc injection codes. But what are the other codes from 64479 to 64482?
  7. So I’ve already emailed the woman at the doctor’s office for additional assistance, explaining to her what the insurance company rep told me. Getting through the phone tree to talk with this woman takes forever and I’ve only been able to leave messages when I do get through, so no point in trying to call, email is much faster.
  8. But, I’m still in bed so I might as well keep digging. I wonder what Aetna’s Clinical Policy Bulletin #725 ruling is that is causing all the problem. I go to the Aetna website and do a search and find Clinical Policy Bulletin 725. What!!!??? The Bulletin heading is “Post-Herpetic Neuralgia”. What is that?! The first Google search results says it is pain associated with a herpes virus! Yes, my painkiller-confused brain is going crazy now!
  9. It’s a good thing I’m an intelligent person who understand how to do online research (how do people who don’t have a master’s degree in marketing and market research figure this out?) I move on to find out: “Neuralgia is severe pain along the course of a nerve. The pain occurs because of a change in neurological structure or function due to irritation or damage of a nerve. Postherpetic neuralgia is a painful condition which affects the nerve fibers and skin.” Apparently, commonly caused by shingles or herpes virus. Obviously, this is not the case for me.
  10. However, Aetna, in their great idiocy lumps many things together in their bulletins. The use of an Epidural corticosteroid, which is the injection the doctor recommends, is listed on this bulletin under treatments for nerve pain that are considered by Aetna to be “experimental and investigational because their effectiveness for this indication has not been established.” No where in the document does it say anything about the use of this injection for pain associated with a disc pushing on the damn nerves. So….? What?
  11. But, let’s not forget that the 3rd code will be covered. Code 77003 which covers Fluoroscopic Guidance in Pain Management Procedures. So the doctor can use a Fluoroscopy, a method that provides real-time X ray imaging, to guide the needle into my back near the disc, he just can’t actually inject anything there or it won’t be paid for! So, what the doctor described to me as “the way they do these injections now” being so much better than what I did before, is covered, but the steroid injection itself the insurance company now considered unproven. Lovely!

So, the next step, if this injection doesn’t work out, would be to have major surgery, called a lumbar discectomy where they drill in and cut off the part of the dead disc that is pushing on the nerves. Apparently, insurance will cover that.

In summary, what it looks like to me is that all of these entities that make up the overall “health care system” in the United States doesn’t really “care” about patients. They all either want to get paid or not pay what they think they don’t have to, regardless of the health of an actual person. The confusing mess these entities all make by not “playing better together” or, in other words, by not supporting one another for the ultimate good of the patient (aka. caring), both medically and financially is what is really causing insurance rates to go up, medical treatment to cost more and more Americans to be in debt from medical costs.

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As I drove off to college I never would have guessed I would end up here! But it’s been a fantastic journey. My career has been richly diverse giving me an advantage over marketers who are siloed into niche positions. I strive to be a true Renaissance person—I love to learn about everything and trying new things comes naturally. My career has been no different; I’ve successfully launched enterprise software and medical device development startups, improved communications processes for the regulatory department of a major financial exchange, increased client business and product development for several international exchange program companies and founded an international educational non-profit organization. My master’s degree in Integrated Marketing from Golden Gate University gave me a broad understanding of traditional marketing best-practices, but my BA in theater gave me the skills to understand how people communicate with one another and the importance of promoting a brand in a voice that is right for the audience.