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Proactive vs. Reactive: Why Good Patients Are Broke.

My health management plan is both proactive and reactive.  I am proactive by taking steps every day to not only be healthy for 24 hours, but for decades to come.  I understand that monitoring, eating healthy, exercising, and seeing my medical team often helps keep my diabetes tuned up and keeps me tuned in.  I understand that efforts now will hopefully keep me healthier later. 

I'm reactive to my blood sugar bounces, testing as often as I can and responding with insulin, exercise, food, or some dizzingly varying combination of both.  I'm reactive to any aches and pains that pop up unexpectedly, like a wrist pain or an ocular migraine

It's good for me to be both proactive and reactive.  This mentality helps keep my health, though already slightly compromised by a diabetes diagnosis that was out of my control, at the best level I can achieve.

On paper, and in my mind, I'm a "good patient."  Trying to be, anyway.

So why are so many "good patients" broke?

Being proactive with healthcare isn't part of the natural American view of health.  American patients seem to be penalized for staying on top of their conditions.  For example, I had a dental cleaning on Monday.  My second one this year.  Both my dentist, my primary care physician, and my endocrinologist have told me that good dental health is crucial not only to my diabetes management but to my overall health.  So, on their recommendation, I have three - four cleanings a year.

Yet only two are covered by insurance.  So on Monday, I paid $105 out of pocket and unreimburseable to my dentist's office.  This doesn't make me frustrated with my dentist, but with the healthcare system that would be more inclined to have my teeth drilled than cleaned.  Yet, I'll keep doing this because it's what's best for my health.

And today, I went to the orthopedist to have my wrist examined.  And the doctor - very nice guy with a good bedside manner - examined my wrist and after about a minute with me, recommended a wrist brace, xrays, a cortisone shot, and surgery.  In that order.

"Even though I'm 99% sure I'm not pregnant, I am not on the pill and am only using barrier methods of birth control.  Can the xrays wait until I'm positive I'm not pregnant?"

"Sure.  We can wait for the shot for then, too.  And we can discuss surgery at that time as well.  You can come in really quickly next week once you're sure you aren't pregnant and we can do the xrays.  It will take three minutes and you'll be on your way."

"Okay.  Thanks.  So will I be charged for a copay next week, then?"

"Yes.  Of course."

"Wait, really?  Even though it should be part of this visit?  No one mentioned xrays to me over the phone, and even if it was something I should have anticipated, I didn't.  So now I'm being charged double for being proactively cautious and protective of a potential but highly unlikely pregnancy?"

"Well, yes.  Unfortunately.  I have to charge you for next week's visit, no matter how short.  Otherwise, it would be insurance fraud.  And we can discuss surgery, as well."

Great.  So now I'll be out $50 for what should have been one visit for only $25.  I'll be charged extra for xrays and potentially a cortisone shot, but the surgery would be 100% covered.  (Yes, I already called my insurance company to find out what's what.) 

Why, Insurance Company, are you so against proactive care?  Why do I need to pay more for a brace or a shot or an extra visit when you're more content paying for a several thousand dollar surgery instead?  Not enough bang for your buck?  Why do you fight me tooth and nail against coverage for a continuous glucose monitoring device?  Is my life not worth the investment to keep my legs on instead of paying 100% to amputate them in a few decades?  I know I'm expensive as a chronic disease patient, but I'm healthier than 85% of the people I know.  I eat well, I exercise regularly, and I am on top of my disease.  Yet you deny me life insurance, you won't let me purchase a private health insurance policy, and you would rather see me on an operating table than taking up a doctor's time in an office visit.  (And it's not like I'm taking up more than 5 - 7 minutes of a doctor's time, because that's about all we get, on average.  Pathetic.)

I am ashamed sometimes to admit that the reason I don't have the money to go out is because I spent it on a dental cleaning or a follow up visit to my doctor.  I'm embarrassed that proactive patients are the ones going broke.  I hate the healthcare system, and its backwards way of punishing me for thinking ahead and celebrating any decisions to let things deteriorate until I require more "procedures" than "maintenance."  Where's the love for the proactive patient?  Our reward is being charged double?

My checkbook will be $200 lighter next week, and I'm not even "sick."  I'm trying so hard to avoid becoming "sick."

What will my healthcare cost if I ever truly am?

Comments

kerri, i totally feel you! our health care system is a joke sometimes. i remember when i graduated from college, before i got a job, i couldn't get private health insurance because of my "pre-existing condition." it's ridiculous that the people who need health insurance the most are the ones who are getting denied.

I found this quote when I was up in arms about IBM's health care plan which allows me ONE education class. PER LIFETIME

"I can easily buy an amputation for a diabetic; I can’t buy comprehensive care to prevent that amputation." Paul Grundy, MPH, the director of healthcare technology and strategic initiatives at IBM

I completely understand! It just doesn't make any sense.

I had the same problem with my gyno. I went in because I had some concerns, and while I was there I was supposed to get my 2nd Gardisil vaccine shot. But my doctor and I both forgot, and I ended up leaving after my other tests were done. A few days later, I called and I asked if I could run in and get it done. The nurse said sure, but when I asked about the copay, she said I'd need to pay. ONE WEEK LATER. I was so mad! I was just there and they were supposed to give me the shot anyway. Now they're making me pay to go back?

Moral of the story: I ended up skipping out on the Gardisil injection because I couldn't afford and didn't want to pay for the shot. The risk of me getting HPV is very, very low, but still. However, this did clarify why they need me to pay anyway. Insurance fraud huh? That sounds serious. It also sounds ridiculous for a follow-up appointment. There should be some kind of exception, I think.

Kerri -

I completely know how you feel. I lived with Grave's Disease for years then finally had my thyroid out. I am constantly back and forth to the endo, and seeing the doc more than the average person because I have to work harder to keep my hormones in check. I am also forever spending money on copays, labs, ect. So, i can't get my MANDATORY bloodwork every three months covered, but they paid 24,000 when i had to have the whole organ removed? What a joke.

Nicole
- @TOTALeMEDICAL on Twitter.

I recently heard from Harvard business school professor specializing in health care that the fastest growing group of uninsured are people making around $75K.

Imagine a person makes $75K a year. We would consider that person well off, comfortable. However after taxes, that person brings home $37,500. In my state, if this person self pays for health insurance for a family, that costs around $14K - $18K. This leaves about $20K rest - to pay for everything else for the family. Not possible. So they don't buy health insurance.

They are pricing us out of our own health.

It's a total crock. When I was in the thick of Crohn's, I used to pay a couple hundred bucks every two months for IV infusions that would keep me from having another bowel resection. I used to quip to my friends that they'd better be enjoying their intestines because they got theirs for free, while mine came with a hefty price tag.

I don't think there's anything more I can say other than it's a total crock. And I'm sorry... it's unfair and uncool that in addition to managing a chronic disease, you have to pay to do it. But kudos to you for being willing to take great care of yourself in spite of the insurance company BS.

This is the core of my frustration with the current health care system. Very well expressed! And now I'm wondering if this is why my doc recommended I have my gall bladder removed after I had my first bought of bad pain rather than just treating the pain. It was much cheaper in the long run! (and who really needs a functional organ anyway?)

I have had incredible luck with problems like these by coordinating mine and Emma's care through my insurance company's care coordination nurses. Whenever there is an issue like the one you cited, one that is completed stupid, senseless, and wasteful, I bring it to their attention as well as to my benefits administrator at work. 99% of the time they cut through the red tape in no time and these problems are resolved. It's also a great way to let an insurance company know when a doctor or their office staff aren't providing a suitable level of service for the $25 I pay plus the $150 or so they pay.

As an example, my company has a %50,000 lifetime limit on DME. Well between Emma and I, I would have to quit my job because of the DME cap! I brought this to the attention of the benefits administrator and the large-case management nurse team, and the next day the cap was waived for us because it would be more expensive to deal with the complications than it would be to cover DME. Wow! An insurance company admitting that!

I haven't blogged about it yet because I am still debating how much to divulge of my illness and healthcare-related issues still, but let me tell you it gets FAR worse with Medicaid (and to a lesser extent, Medicare). You hear all the abuses of Medicaid about using the ED as a PCP office, for example, but there is actually DISincentive to managing things as an outpatient with RX limitations (using ONE example) whereas getting care/Rx as an inpatient/ED is covered 100% of the time.

I couldn't have physical therapy to improve my mobility/conditioning after my huge surgery last year, but should I have thrown a PE or fallen and broken God-knows-what, the sky's the limit for coverage. It's beyond absurd. I'm glad I'm done with that mess. I haven't tested out my new work insurance, but I'm sure there'll be some similar issues.

I agree with you. I think the American health care system is a joke! My son is 5 and insurance companies would rather see him get sick then pay for the right amount of supplies that he needs. They give the bare minimum.... but I think they forget that unpredictable things happen! It's pretty sad. I share your frustrations!

I whole-heartedly agree with you Kerri! I've come up against the double, triple, whatever co-pay problem on more than one occassion. I thought it soooo ironic that for all the co-pays I've paid for me and my family...when I was pregnant, I paid a $20 co-pay for the initial visit and not one dollar more all the way through to the birth of my kids! Talk about a system out of balance!!

Hi Kerri, I've been lurking on your blog and debating whether to share. I too have been going through the wrist pain thing since Christmas. I've had xrays, mri, ct scan, and a cortisone injection, as well as 2 weeks of physical therapy. Right now I'm waiting for the results of the ct scan to see if it's a bone spur. Since the first of the year i have paid a $1000 deductible + 20% of the xrays, ct scan, mri and cortisone. Physical therapy 3x a week is a $35 copay each time. And when they bill for the cortisone it is billed as surgery for some reason. So good luck with yours and I hope they find an answer soon.

Thanks, Kerri, for reminding me why I live in Canada (and why I'm staying here). It's been expensive for me to live with a chronic illness, but not nearly as expensive as it would be if I moved. Someday, the health care system will realize that covering proactive medicine (including less-traditional holistic therapy options) saves money in the long run by helping all of us stay as healthy as we can be, instead of just paying for pills and surgeries once the damage is done. Thanks for bringing our attention to this critical issue.

Oh, I SOOO understand! I had something similar last week. I've been having issues with my eyes for about 7 months. I had another eye apt. last week to discuss why another treatment did not work, when she actually realized what is going on. She asked me to come in during an active flare, because she she wanted to see it at it's worst. She told me that they would just squeeze me in, and it would just take a minute. So, just 2 days later, my eyes red, painful and blurry, I had someone drive me in so she could just look at it. Well, that's what she did, and then she said, "yep, definitely corneal infiltrates...follow up as scheduled" and charged me another $35. I was so mad. That was $105 in 2 days, and a real waste of my time!

Infuriating. I think about what a joke health insurance is almost every day. I'm in a battle right now with my insurance company for a CGMS. I recently heard of one health insurance company that won't cover birth control pills, but will cover male enhancement pills. Seriously backwards. I did nothing to cause my type 1 diabetes so why should I be at a financial disadvantage because I have to pay a co-pay everytime I pick up my insulin and test strips. Not to mention, my insurance will only cover a certain amount per month meaning I can't pay every 6 months...it has to be every month. Coincidence? I don't think so.

You caught me on a good day to rant about insurance. I was talking with my Medtronic rep today about appealing my CGMS denial and he said that BCBS likes to see 60 days of readings with several below 50mg/dl in order to approve the sensor. So I check the last 12 weeks of data on Carelink and my lowest reading was 50. I guess I'm not close enough to death or hospitalization for them to see any benefit to covering me. I know you and lots of other people have hypoglycemic unawareness problems, but luckily I don't. Still, I feel like the only way for me to get coverage is to intentionally let my numbers get "out of control" enough so the freaking insurance company thinks that I need this device. Uggh.

Great post. It makes no sense at all does it?

I hate our healthcare system too, but I absolutely love this post. Thanks for bringing attention to a huge problem a lot of us face, may it get better for us all someday!

I have really enjoyed reading your blog. My son was diagnosed Type 1 a litte more than a year ago at the age of 13. I am a nurse, so I recognized his symptoms before he went into DKA. He was never hospitalized. After meeting with the endo, we were set up for several education classes with our CDE. We attended these classes and learned how to manage his diabetes. We then received a notice from our ins. co. that they would not cover the classes. It is considered "self-help". Needless to say I was furious. We appealed with no luck. I did find out that the education would have been paid for as part of a hospital stay, had we not caught it when we did. I will never understand the logic.

I only began reading your blog a couple months ago and at that time I had no inclination for a pump and or a CGM. Now thats all I want. I have done the logging, the numerous Dr.'s appts. I started this at an A1C of 7.4 and last week it came back at 6.0. Good?!? Not really, this reminds me of all those sweaty nights and crashes in the morning, afternoon, etc. My endo stated my insurance won't cover a pump/CGM if I have numbers under 6.5, I'm doing to "well". ((SCREAM))

After two years withOut health insurance I decided I am better off, for now. In the long run, no, I'm not. 24 years with T1 and 2 withOut health insurance, first time, ever.

It was Never this bad, for as long as I can remember, never. The past two years have proven how bad things Really are here in America with our health care industry -- how Profit driven they are.

It is a sad state of affairs we live in. Doing the best we can with what we have and getting kicked in the ass in the meantime. Unfair - no doubt. Sad, sick, disgusting - absolutely.

I just wish I knew of an answer to all of this. I would love to be apart of the solution, help find one, offer one up.

Best to you Kerri. Hope things work out.

I never fully understood the American healthcare system and I still don't! We live in Finland and, apart from some small administrative costs, get essentially free health care, which includes all my son's insulin, blood glucose meters and strips, needles, insulin pens etc. How fortunate we are not to have long term financial worries whilst we manage his diabetes.

I couldn't have said it better myself. There are two reasons that things are the way they are. First and foremost, lobbyists run our health care system in Washington. Lobbying groups work for the hospitals and surgeons and they ensure that we patients end up getting the most costly treatment paid for so that they can all turn a profit. Preventative health care does not fit into this equation. In addition, because most Americans change health insurance policies fairly frequently throughout their lifetime, your health insurance company is pretty much assured that they will NOT be your health insurance company when it does come time for you to need some complicated surgery. They are gambling with the clock, hoping that they will come out ahead if they collect your premium and don't pay for the preventative stuff and that you will have a new insurance company once you need surgery.

The BOTTOM LINE is that America needs a nationalized system. The current private system DOES NOT take into account better health outcomes or quality because it's all profit-driven. If we had a nationalized system, the government would have good reason to ensure that we all get the preventative care we need, as we would have the same insurance company from cradle to grave.

AMEN!!!

AMEN to this post!

And just wait until you're pregnant. I go to the Dr every 2 weeks, I just paid $600 for an echo ultrasound to make sure her heart is healthy (totally worth is, but incredibly expensive)and soon they will want to see my twice a week for the last 2 1/2 months of my pregnancy.

Hey - I recently emailed Kerri with a question about the continuous glucose monitor.... our insurance will pay for the monitor, but the sensors go under DME, which is much higher than if they were paid under Rx, as ALL the rest of the pump supplies are paid....

Years ago, I humiliated our carrier with a letter reminding them that if they didn't approve and pay for the pump, they'd be paying for an ambulance ride and ER visit, and complications for my healthy diabetic hubby, who can no longer tell when he's low.

I also called them out for charging higher for certain ambulance companies in our town, citing the "out of network" argument. I asked them if someone in our plan is having chest pain, should they call the carrier's toll free customer service number to ask "which ambulance company" to call, rather than calling 911.

In both cases, the carrier changed the benefits, and this is a really big plan... but so far, I haven't had the inclination to fight for the coverage on the sensors... maybe I'm getting weak... I'm hoping the price goes down in time, and also that my husband doesn't have a low when no one's around.

We GOTTA get in charge of something around here!

Sorry for the rant, but what a great subject!!!!

Thanks Kerri...

Wow, that is frustrating.

My husband has hypoglycemic unawareness and tried to get approval for a CGM for two years. He was finally told that it would help his case if he had some emergency room visits in his medical records. They recommended the next time he went low (which happens often) that he go to the ER. He chose not to do that and instead proceeded forward filing a complaint with the Dept of Managed Care. He was immediately approved for a CGM.

After having type 1 diabetes for over 25 years with no complications, it seems that just wasn't enough for our healthcare system to consider him worth the preventive tools he needed.

Hi Kerri

I have been reading your blog for some time now and thought I would finally make a comment.
Living in South Africa as a Type 1 we have the same problems. The medical aids would rather pay hundreds and thousands of rand’s, (local currency here), for complications at a later stage than a few hundred rand’s now, to stop them occurring. I realize some people don’t look after themselves well but I wish the beaurocrats would look at us on an individual basis. But that would take the use of a brain.
If you look after yourself and you A1c’s are good, your health, fitness and overall results are good, then you should be able to visit the dentist, eye specialist or other 4 to 5 times a year. If not, well then let the medical aid’s save that money for the big operation these people are going to need.
I look after myself well, I gym most nights, I eat well, I check my levels 6 to 8 times a day, my last A1c was 5,5. I try my best. But I am constantly paying out for doctor’s appointments, extra test strips, (they think we should only test 3 times a day, its cheaper then), and for other bits and bobs to keep my level’s on an even keel. This above my monthly medical aid contribution.
Anyway’s enough whinging from here. The sun is out and I am still a picture of health. I just wanted to let you know, you are not alone. We too have idiots in the health care system on this continent.

Keep up the great blog.

Best wishes

Craig in SA.

amen, sister!

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