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My Best Friend gave me permission and even encouraged me to post this as a diary. This is a letter she sent to her Representative and Senators. ( by the way, her US Representative is a Republican, both of her Senators are Democrats who will vote for this bill and have voted for this bill, not so with the Republican House member, of course)

This is a case of someone whose husband is an experienced and well educated engineer who works for a company where the employer has not been able to afford to carry the quality insurance he once was able to offer. She is an award winning journalist and photographer. But the jobs available in her area limit her income potential considerably particularly in this economy with the job situation as it is.  Newspapers are laying off writers, photographer, editors and shutting down some newspapers entirely.

She and her husband both work but her part time job does not offer any health benefits so they and their child have no choice but to be covered under the husband's plan.

I did not want to list names so where you see a __ is in place of a specific name of a person  

Dear Rep. ___________

Imagine being sentenced to two weeks in enough pain that you could not sit comfortably at the dinner table.

I’m not talking about being sentenced for a crime – at least not one that I have committed. I am talking about being forced to endure pain needlessly because of my health insurance company’s greed.

On Sunday, Jan. 24, I experienced what I thought was muscle pain due to tightness or a muscle spasm. The following day it was worse. I took twice the recommended dosage of over-the-counter pain relievers just so I could function at my part-time job at a newspaper. By Tuesday, Jan. 26, I could not stand it and made an appointment with my family doctor, who said it appears I had either a pinched disc or perhaps a herniated disc on my cervical spine (that’s the neck area), probably between discs 6 and 7. He prescribed an MRI, which I scheduled for Fri., Jan. 29 at 2 p.m.

My insurance company, Aetna, requires a referral for any such procedure. I called my doctor’s office within 30 minutes of their opening on the morning of Wed., Jan. 27, to get the referral. They sent it through to Aetna that same morning, according to ___ who works in my doctor’s office.

Friday, I arrived for my appointment for the MRI only to be told there was a problem with my insurance. My MRI was not denied – but as of 1:30 p.m. – 30 minutes before my scheduled appointment – Aetna had not yet made up its mind whether it would authorize and cover the procedure.

A supervisor at the MRI place made several phone calls on my behalf, while I waited, wondering if I would get authorization for the procedure in time for my 2 p.m. appointment. Aetna told the MRI office supervisor that they had "until 8 p.m." to decide whether to authorize the procedure. I have no idea who decided they had until 8 p.m. but if common courtesy were their guideline, they would have had a decision before my appointment time. To make a long story somewhat shorter, I went home that afternoon without an MRI and proceeded to make phone calls to Aetna, who insisted they required 24 hours to review a request like mine. Aetna representative _______ insisted they did not receive the request until Thursday morning despite the fact that I requested the referral from my doctor on Wednesday and, according to my doctor’s office, it was processed immediately that morning. In other words, Aetna had more than 48 hours prior to the appointment to review the request.

They did not officially deny the request until Monday, Feb. 1. They told me the reason was that I had spent eight weeks under a doctor’s care trying alternative treatments such as physical therapy. What is most ridiculous about their so-called reason is I did, in fact, go to physical therapy! They paid the bill – or part of it anyway, as my copay was $440 – but not until after making various excuses in an attempt to avoid paying. They knew I had gone to physical therapy specifically for neck and shoulder pain and yet, they claimed I didn’t in an attempt to avoid paying for a portion of an MRI. I say "a portion" because my copay for an MRI is $100. Believe me, I won’t fork out $100 out of pocket for something that’s unnecessary.

I received notice of the denial at 8:30 a.m. Mon., Feb. 1, when I received a phone call at home from Med Solutions, a firm which contracts with Aetna to review claims. They told me they would fax the denial to my doctor’s office and the doctor could appeal if he wished. Interestingly, the doctor did not receive the denial for another two hours.

Meanwhile I was taking Darvocet, a mid-level prescription pain reliever. My job as a writer/editor requires extensive use of the computer, which is extremely difficult because the pain and numbness extends from the spinal column all the way down my right side and all the way down my right arm. To make matters worse, I am right handed.

However, I work part-time which means I don’t have any sick or vacation time. I cannot afford to take unpaid time off due in no small part to my medical bills. In addition to the $440 copay for physical therapy, $20 primary doctor visit copay, $40 specialist  visit copay and $80 copays for pain prescriptions, I will owe another $100 for an MRI – should Aetna decide to authorize it. That sum – which adds up to $680 – does not include any additional copays which will be required for the procedures needed to actually treat the condition. Nor does it take into consideration routine out-of-pocket medical costs including but not limited to the $250 a month I pay out of pocket for prescriptions and supplies to treat my diabetes and other long-term chronic but manageable (with treatment) conditions. And I pay that much out of pocket despite having prescription "coverage."

So I doped up and went to work. I had no choice.

That Monday – Feb. 1 – my doctor decided the best way to get me the treatment and testing I needed was to send me to a specialist, who prescribed Vicodin for pain. Although this drug is more potent than Darvocet, it does not take away the pain entirely. It simply dulls it to the point where I can function. If I want no pain, I would have to take something like Oxycodone, which would probably leave me unable to drive safely or function properly at work.

It comes as no surprise that the specialist said I have either a pinched nerve or a herniated disc and I need – get this – an MRI! In all probability, the treatment will be an epidural injection, which cannot be given until after an MRI is done.

I currently have an appointment for an MRI for Thurs., Feb. 11, assuming Aetna does not try to fight the specialist over his diagnosis. My doctor seems to think Aetna will be less prone to fight the specialist, but who knows. If I do get the MRI Feb. 11, it means my pain was drawn out needlessly for two weeks. If I don’t get the MRI, it will mean my pain will continue indefinitely.

This is not the first time Aetna has fought me or tried to block my access to basic health care. I suffer from allergies, which leads to a chronic cough which in turn aggravates the neck and muscle pain described above. My doctor prescribed Allegra. Aetna fought me, claiming I need to try over-the-counter alternatives first. When I said I did, they finally approved the prescription, though that approval means little. The full retail cost of the drug is $88 a month. I pay $78. Aetna pays a whole $10. I just learned I can get the prescription cheaper using a county sponsored discount program and not going through Aetna at all. The same is true for blood pressure medication I take. In these cases, it is cheaper to go as an uninsured party through this discount program than to use the insurance for which I pay $2600 a year out of pocket. (This figure does not count the additional premium paid by my husband’s employer). And I am sure that is just how Aetna likes it.

Incidentally, for the calendar year 2009, I paid $8600 out of pocket for health care. And although I have diabetes, I do not have any serious health conditions such as cancer or MS. I can only hope I never contract a serious illness because I am sure that would leave me bankrupt, assuming I don’t end up dead first.

I am sure you are aware that a health care reform debate is currently raging in this country. I urge you to work towards real reform that reins in the powerful insurance companies because what is happening to me and countless others across this country is absolutely criminal. Companies such as Aetna should not be allowed to put their profits above the health of their customers – the very people they are being paid to protect. And they are making a profit. A Feb. 7, 2008 press release issued by Aetna itself listed the health insurance company’s profits at $1.8 billion.

I realize the health care debate has caused lines to be drawn between the two major political parties. But this is not a Republican issue or a Democratic issue. It’s an issue of fairness and decency for the everyday American people – and by that I mean those of us not covered by the excellent health care insurance plan members of Congress enjoy, and those of us not benefitting from massive health insurance company profits. Americans are supposed to have the right to life, liberty and the pursuit of happiness. But we cannot live when we cannot afford basic health care. And we certainly cannot pursue happiness when we are in too much pain to even sit at the dinner table.

Originally posted to wishingwell on Tue Mar 16, 2010 at 09:21 AM PDT.

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Comment Preferences

    •  No diagnosis = no treatment (0+ / 0-)

      MRIs cost as little as $200 in Mexico or $98 in Japan.

      here, there seems to be a lot of pressure against doctors not to prescribe them because they show 3d - both bones and soft tissue and allow high detail. many kinds of injuries are invisible on X-Rays, also the literature on radiology is so old little of it is available on the net. That and the hurried work schedule of many radiologists works in the insurer's favor.

      Basically, my theory is that sometimes they dont want people with illnesses to get a diagnosis because then they don't have to treat you. Thats how the commercial system works, and if we trigger GATS in the Senate bill, there will be no escape, forever. The ratchet effect tightens like a noose around the unsuspecting naive American people. No public plans, ever. Even Medicare is a monopoly provider so eventually it has to go. (thats why we see the various moves towards privatization.)

      Another problem is price hikes.. Everybody is getting big ones, but your employer may get an extra big price hike this year to encourage them to lay you off. Please heed this warning, Ive seen this happen to many people. Thats why many working people go out of network and claim to be uninsured to get medical care. The insurance companies have been lobbying for a bill that makes that illegal. They want to know who is sick, because then they can avoid covering them.

      Remember, discrimination in PRICING is still legal for the 80-90% of all insured Americans who have group insurance. The kind of insurance "individual" insurance that gets new protections is so expensive VERY few Americans can afford to buy it.

      Do you live anywhere near Mexico, or are there cheap flights there from your city?

      Maybe you can go to a commercial storefront clinic, (the kind that mostly serve immigrants) pay in cash, TELL THEM YOU HAVE NO INSURANCE, and pay out of pocket, THEN you perhaps can get a diagnosis and then they wont be able to prevent treating you, then you can send them the bill and try to get reimbursed.

      The gag clauses make it so in-network doctors often cannot discuss anything related to things the insurance company is reluctant to pay for, even by sign language.

      So if your doctor is brave, you'll get honesty, but sometimes, you may get more honesty elsewhere.

      GATS trade agreement= the unseen hand behind the lies They are the REAL free market extremists! - GATS and healthcare don't mix

      by Andiamo on Thu Mar 18, 2010 at 12:53:20 PM PDT

      [ Parent ]

  •  Aftermath is that her insurance FINALLY (18+ / 0-)

    approved the MRI after she suffered for weeks and it showed there was significant damage to several disks in her spine and she would need some surgical treatments and injections.  It did not help that  her health insurance company delayed the diagnosis and treatment.

  •  Been there, done that (5+ / 0-)

    I know how painful that is...{{Best Friend}}

    "Ridicule may lawfully be employed where reason has no hope of success." -7.75/-6.05

    by QuestionAuthority on Tue Mar 16, 2010 at 09:25:46 AM PDT

  •  Some Americans are concerned that (7+ / 0-)

    if HCR passes, the government will be making medical decisions... but at least we have the opportunity to elect our governmental leaders.  When can we take a vote on which bureaucrats will be making medical decisions at Aetna?

    Barack Obama in the Oval Office: There's a black man who knows his place.

    by Greasy Grant on Tue Mar 16, 2010 at 09:30:56 AM PDT

    •  No, GATS says the government has to get out of (0+ / 0-)

      healthcare. Thats what the provisions that trigger GATS in the Senate bill will do. Everything will eventually be privatized, no barriers to trade. No monopoly service providers, no discrimination against corporations of any land. No public plans, obviously, but, of course, that was never on the table Wouldn't want to anger the WTO! They are our REAL masters!

      Isn't it depressing how much they lie to us?

      GATS trade agreement= the unseen hand behind the lies They are the REAL free market extremists! - GATS and healthcare don't mix

      by Andiamo on Thu Mar 18, 2010 at 01:00:13 PM PDT

      [ Parent ]

  •  Stories like this won't and wouldn't change (0+ / 0-)

    even with single payor which I support.  The model used by private health care is driven by profits.  Under government health care it's driven buy reducing spending.  Health care contracts would go to the lowest bidder.  Comforting thought.  

    Eat recycled food. It's good for the environment and OK for you.

    by thestructureguy on Tue Mar 16, 2010 at 09:33:11 AM PDT

    •  I don't agree with that. (1+ / 0-)
      Recommended by:
      wishingwell

      The CBO stated that the public option would have somewhat higher premiums because it would engage in less "management of utilization" and would attract less healthy enrollees.  Medicare has lower administrative costs than private insurance for much the same reason.

    •  Medicare rarely fights any Tests (2+ / 0-)
      Recommended by:
      wishingwell, slippytoad

      that my Dr. asks for so your opinion doesn't hold water. In the last yr I have had 7 epidurals, 2 MRIs, numerous X-rays, blood tests, a colon cancer test, a blood clot ultra-sound scan, not to mention my Pain Management Specialist and 7 daily meds plus a heavy duty pain med. My co-pay for all of this is about 6.00 a month for meds. What Medicare doesn't pay my State, Ca. pays the diff. except meds.

      "Maybe the American eagle should be replaced with the ostrich."

      by SmileySam on Tue Mar 16, 2010 at 11:51:18 AM PDT

      [ Parent ]

      •  Thats why public plans have to be replaced by pri (0+ / 0-)

        privatization under GATS. Its hard for public plans to say "no" in public health situations. Plus, single payer saves too much money and there's no opportunity for corporate profit. No insurers! Plus, they are unionized, and they are vulnerable to democracy, which the WTO seems to have deprecated.

        GATS trade agreement= the unseen hand behind the lies They are the REAL free market extremists! - GATS and healthcare don't mix

        by Andiamo on Thu Mar 18, 2010 at 01:05:18 PM PDT

        [ Parent ]

  •  Re: the Allegra problem (4+ / 0-)
    Recommended by:
    wishingwell, BachFan, beltane, DruidQueen

    I assume she is buying name-brand? The generic works fine for me, and it actually costs less than my $20 copay.

    I know generics are not always 100% equivalent to the name brand, and different people have different experiences. Just a thought since she is stuck with Aetna insurance.

    _Karl Rove is an outside agitator._

    by susanala on Tue Mar 16, 2010 at 09:43:09 AM PDT

  •  About the meds (2+ / 0-)
    Recommended by:
    Fabian, BachFan

    Vicodin contains the narcotic hydrocodone mixed with acetaminophen (Tylenol) in three strengths: 5 mgs, 7.5 mgs and 10 mgs. It is not time released.

    Oxycontin contains the (almost indistinguishable) narcotic oxycodone, without any acetaminophen at all. It is a time-released drug. The rationale behind providing a pain reliever in time released form is pretty sound because it keeps a relatively steady-state of the drug in your system for longer without the peaks and valleys that can occur with hydrocodone and tylenol. (You could always take tylenol with Oxycontin; they're not contraindicated. In fact Percocet is just that)

    Oxycontin is available in many more strength formulations than hydrocodone preparations. I believe they are 10 mgs, 20 mgs, 40 mgs and 80 mgs.

    There's no evidence that Oxycontin, when prescribed properly is more likely to cause problems with driving, working, etc. If anything, since the medication is released more slowly into the system, there's probably less of a "buzz" than with hydrocodone preparations - like Vicodin - which release all at once.

    Oxycodone got a (somewhat deserved) bad rap because people figured out they could bypass the time-released aspect of it by crushing and snorting or injecting it. If you don't do that, it might be a safer and more effective pain killer.

    One last thing though: Oxycontin/oxycodone is a Schedule II drug. That means it cannot be called in over the phone to your pharmacist. You must get a written prescripton for each refill and present it to your pharmacist. That's not the case with Hydrocodone preparations - like Vicodin - which is a Schedule III medication and can be called in over the phone and does not require you to present a written prescription to your doctor (at least in most states).

    You might want to talk to your physician about it. I certainly hope you find a way to be pain free! Good luck!

    This ain't no party. This ain't no disco. This ain't no foolin' around!

    by Snud on Tue Mar 16, 2010 at 09:47:36 AM PDT

  •  Nothing in the proposed legislation... (2+ / 0-)
    Recommended by:
    ybruti, Fabian

    ...would impact this situation except more Americans will pay for the same coverage.

    No such malpractice could happen at my insurer/provider because it is a staff model HMO where preauthorization does not exist and the salaried doctors make their own decisions. Where people have the choice and funds such a company is much more humane and efficient. And there are other kinds of models depending on location.  

    Not everyone has a choice, but purchasing a policy from Aetna, in particular, is simply neither a safe nor a good business decision.

    It's a general rule that, where there is choice, don't purchase private for-profit insurance.  

    HR 676 - Health care reform we can believe in - national single-payer NOW.

    by kck on Tue Mar 16, 2010 at 09:50:47 AM PDT

    •  Unfortunately that is the Only insurance the (1+ / 0-)
      Recommended by:
      kck

      employer offered and they have no choice but to switch jobs and that is not easy to do..it is very difficult right now.

      •  Understood (1+ / 0-)
        Recommended by:
        wishingwell

        Thus the need to decouple insurance from employment and eliminate the administrative interference with clinical care that real reform requires freeing the physician to do their job, reducing costs of the middle layer, providing consumers with service, choice, and portability. The procedural oversight can be done after the fact at the cost of overhead rather than patient health and comfort.

        HR 676 - Health care reform we can believe in - national single-payer NOW.

        by kck on Tue Mar 16, 2010 at 04:57:46 PM PDT

        [ Parent ]

  •  Aetna fucked me too (4+ / 0-)

    They refused AFTER a life-saving operation that they weren't going to pay for it, citing bullshit reasons (pre-existing conditions crap and other shit they pulled out of their ass). Thanks to Aetna, I was forced to declare bankruptcy recently.

    Aetna is the worst insurance company out there, and even though I am a peaceful Wiccan, I wouldn't shed a tear if someone "accidentally" left a bomb inside the office of the CEO and other head honchos at Aetna.

    Piece of shit company.

    This diary made me so angry all over again, because it brought back memories of my own Aetna experiences.

  •  aw yes those fucking referrals! (0+ / 0-)

    that's why i moved my insurance carrier to kaiser permanente.  having to deal with referrals as well as driving to hell and gone to see the doctors cigna wanted me to see nearly killed me a few years ago and kaiser seemed to be the logical choice as it's both the insurance company and the provider.

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