Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, October 12, 2009

Just Saying "No" to Colonoscopy

Just when you thought you'd heard it all; just when you thought you'd heard every unbelievable, incomprehensible, illogical policy* imaginable; just when you thought it was safe to champion preventive care, comes the Darwin Award for the lowest an insurance company can go.

There's this patient whose father, sister and aunt all had colon cancer in their 40's, so you recommend a screening colonoscopy. The patient is perfectly willing to go (only about 1 in 10 patients right there!) but is told by her insurance company that they don't cover screening colonoscopies.

That sucks, especially since the company prides itself on its comprehensive preventive care that covers annual mammograms over 40 (shown to cause more harm than good, when anxiety from false positives is factored in) and PSAs for men over 50 (never shown to lengthen life). Still, patients often have symptoms like fatigue and changes in bowel habits, which allow the procedure to be coded as a diagnostic colonscopy instead of a screening one.

Ready for the kicker?

This company won't cover diagnostic colonoscopies either.

Epic WTF?

Let me get this straight: whatever the symptom, whatever the history, whatever the possible diagnoses, under no circumstances will this particular company ever cover the specific non-invasive procedure known as colonoscopy?

Yep.

How can they do this? By including this language in their "Plan Exclusions":
Colonscopy both screening and diagnostic is considered a non-covered service under this plan. This test may be appropriate for certain patients. This plan does not intend to recommend particular levels of care and if in consultation with their physician it is determined that this procedure is the most appropriate choice for their situation, they are encouraged to proceed with the procedure at their own expense.
Apparently, this is how the insurer transfers liability for non-coverage; it seems that this is permitted under the Supreme Court decision handed down in regards to insurer liability for non-coverage of an accepted level of care.

It turns out that this is considered purely a cost-containment measure.

What the hell next? There are plenty of other ways to save significant sums of money:
  • CT scanning is considered a non-covered service under this plan. This test may be appropriate for certain patients. This plan does not intend to recommend particular levels of care and if in consultation with their physician it is determined that this test is the most appropriate choice for their situation, they are encouraged to proceed with the test at their own expense.
  • Levaquin is considered a non-covered therapy under this plan. This drug may be appropriate for certain patients. This plan does not intend to recommend particular levels of care and if in consultation with their physician it is determined that this drug is the most appropriate choice for their situation, they are encouraged to receive this drug at their own expense. [Not all that bad an idea, actually. In addition to being hideously expensive, it's rarely the best choice.]
  • Chemotherapy is considered a non-covered treatment under this plan. This treatment may be appropriate for certain patients. This plan does not intend to recommend particular levels of care and if in consultation with their physician it is determined that this treatment is the most appropriate choice for their situation, they are encouraged to receive this treatment at their own expense.
It seems that in order to effectively contain costs, insurance companies are moving away from actually paying for medical care. And this is the private insurance that "most Americans are happy with"?

Un-fucking-believable.

h/t to BS


* Aside from Medicare paying for kidney transplants, but discontinuing coverage for anti-rejection drugs after three years.

13 Comments:

At Mon Oct 12, 07:48:00 AM, Blogger Rogue Medic said...

That is an interesting Medicare policy.

From Stanford -

Nowadays, kidney transplantation is quite successful in the short term, with a one-year transplant kidney survival rate at more than 90 percent in the United States. Improved success in short-term outcome during the last 10 years is due to advances in tissue compatibility testing, surgical technique, immunosuppressive medications, and specialized medical care by dedicated transplant nurses, physicians, and surgeons. However, there is attrition over ensuing years. The averagelife expectancy of a kidney from a deceased donor is approximately 10 years. The average life expectancy of a kidney from a living donor is longer, about 18 years. (Highlighting is mine.)

Is the conclusion that they want people to come to is that three times a week for dialysis treatment is cheaper out-of-pocket?

 
At Mon Oct 12, 11:14:00 AM, Blogger kg said...

And then we hear now familiar comments that we are to blame for: 1.) our illness, because all illness is caused obesity and/or smoking.
2.) not choosing the right health insurance policy. We should have known what our policy covered and does not cover even though that may change at any time.

My insurance company says it doesn't cover injectable medications.
Huh?!
After further questions and wrangling, they admitted that sometimes they do, somewhat, maybe...
And yah, that is about right.

I waver on whether I'd just be better off without it. I think they are hoping we will all just give them our money and go away.
My blood pressure is starting to shoot up...I'll have to stop and think of something calm and pleasant....

 
At Mon Oct 12, 12:22:00 PM, Anonymous Val said...

"It seems that in order to effectively contain costs, insurance companies are moving away from actually paying for medical care."

How else do you expect them to come up with the $$ for the outrageous administration salaries and bonuses?

 
At Mon Oct 12, 03:03:00 PM, Anonymous Anonymous said...

If you feel comfortable doing it, Dr. Dino, could you tell us how much this patient is paying monthly for this non-insurance, and what the name of the non-insurance company is?

Thanks.

 
At Mon Oct 12, 03:35:00 PM, Blogger Rogue Medic said...

Val,

The problem is not the dollar amount of the bonuses and salaries of the bosses. This is an insignificantly small part of the problem.

However, the ways that they are compensated can contribute to the problem. When the part of the CEO compensation is for short term stock price targets, the things the CEO do to attempt to raise the price of the stock in the short term, may be very bad for the company.

The board throwing a lot of money at potential CEOs, to get them to come to the company, is often misguided. Many of the CEOs not not have the talent that the exorbitant pay is supposed to be for.

If they did have the talent, it would be foolish to refuse to adequately compensate them. By adequately compensate I mean, to pay the person according to the amount of difference the person makes in the long term worth of the company. Otherwise, the good ones can just go start their own companies, where their long term influence will be rewarded.

I do not see how the Medicare rule, that Dr. Dino used, is an example that supports your claim.

 
At Tue Oct 13, 08:13:00 AM, Anonymous Anonymous said...

My favorite was when the insurance covered the colonoscopy, but oops - not the anethesiologist. Especially when I found out by getting a bill, ie, not before I entered the facility for the test and not even before I was discharged.

 
At Tue Oct 13, 08:29:00 AM, Anonymous galen said...

Here's one that MAY be worse, but in both cases, we're getting to the point of letting the insurance companies give us ample reasons for single-payer. I'll leave just the link and headline:

http://www.denverpost.com/ci_13530098

Heavy infant in Grand Junction denied health insurance

 
At Tue Oct 13, 11:22:00 AM, Anonymous Anonymous said...

I take the same meds used in Kidney transplants for autoimmune treatment.
Medicare has ceased paying for Cellcept for all non transplant patients.

The fact that immunosuppressants are, really ...when it gets down to brass tacks ..the main treatment for a lot of autoimmunity doesn't matter.
The fact that they now will cover Imuran, but not cellcept ...and Imuran is SIGNIFICANTLY riskier ...more risk of cancer, more risk of liver failure ...more risk of infections... it worked for what it was and when it was, but there are second generation drugs (like Cellcept) that may carry the SAME risks, but are significantly SAFTER ..LESS RISKY ...

I know 2 people who died, not from their AI disease, but from complications of Imuran. I know of no one who has died from Cellcept (although, theoretically, it can happen)

But medicare doesn't care that it's safer (and therefore may be cheaper!) they just don't want to cover it.

So that I can walk, dress, eat, chew, swallow breath and talk ... I take a drug that leaves me at risk. The alternative isn't pleasant and I remember all too well what it felt like before treatment ... so my choice is to take the risky drug.

 
At Tue Oct 13, 02:11:00 PM, Anonymous tom said...

The true value of one's insurance becomes known when a claim is submitted/treatment autorization is sought.

BTW what is up with having an anesthesiologist involved in a colonscopy?

 
At Tue Oct 13, 02:54:00 PM, Blogger Rogue Medic said...

tom,

BTW what is up with having an anesthesiologist involved in a colonscopy?


There was a big kerfuffle about this that is summed up at Movin' Meat in "Poachers and dabblers" It is only in the last 2 paragraphs that he describes the endoscopy aspects.

 
At Wed Oct 14, 09:25:00 AM, Anonymous Danimal said...

I'm curious -- is this a patient you came across in your practice, or an article that you read? If the former, in what state is this the policy? And, if the latter, do you have a link?

 
At Wed Dec 09, 03:16:00 PM, Anonymous Anonymous said...

I get a call from my doctor's office today letting me know that my insurer ( you know the one who won't pay for anything) is "requesting" that I get a screening colonoscopy. I say, "No thank you" as politely as I can and am told by the receptionist at the doctor's office that if I don't comply, my insurance rates can go up."
I thought this was still America and I had a say in my own medical decisions. Is the receptionist correct or just blowing smoke?

 
At Wed Dec 09, 04:01:00 PM, Blogger Rogue Medic said...

Anonymous,

That sounds like the kind of free market that America is supposed to have. If you make poor choices, your rates reflect those increased risks for the insurer. They aren't denying you coverage. They are stating that they will not encourage behaviors that lead to increased likelihood of a claim.

We're not discussing genetic disorders, or other things outside of your control. This is a voluntary decision by you that is figured into actuarial tables the same way that smoking, or heroin use, or not wearing a seat belt should be.

They aren't telling you that you must have the colonoscopy. They are just telling you what your choice will cost you.

 

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