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Susan Estrich
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May I (Not) Help You?

Comment

I got a call the other morning as I was racing to work from a woman who claimed to work for the "third-party administrator" of one of my health insurers. Yes, I'm one of the incredibly lucky people who actually have two health insurance plans, one for each of my full-time jobs. The woman wanted to know whether I would like the assistance of an RN on their staff in managing my health care. I knew what she really meant. I said no.

What she really meant, and what certainly triggered this call, was the two MRIs I have had in the past few weeks, the first of which was denied (and then reversed on appeal) and the second of which was pending (and did get approved). All of a sudden, I was costing a lot. Did she really think I would say, "Who needs the doctors and specialists who have been taking care of me for years and dealing with my family's history of heart issues when I can get advice from an RN who works for the insurance company?" But I was pleasant and just said no.

No, apparently, was not an acceptable answer. A few days later, I got an unctuous letter from the same woman. I'd say it was a form letter, but form letters generally have proper punctuation and sentences that include both nouns and verbs. This one had neither.

"I hope this letter finds your health improving," this person wrote to me. It gave me the creeps. Privacy, anyone? Who was she to be reviewing my records and telling me I was sick? She isn't a doctor or a nurse; she's a penny-pincher. "You have been identified as someone who may benefit from Case Management due to your complex health needs."

BS. You have been identified as someone who has good and dedicated doctors who are making decisions in your best interests, and not the insurers'. You have been identified as someone who is costing us money.

"Case Management is a personalized service that provides you with a Patient Advocate (Registered Nurse) to ensure that your care is being provided timely, appropriately, safely..." Do you see what I mean about the grammar? In fact, the only thing that has of late stood in the way of "timely, appropriately, safely" provided care is fighting with the insurance company to get medically necessary tests performed.

How dumb do they think I am? Do they think I would trust a nurse (I have great respect for registered nurses, except when they are being asked to trim health care costs.) on the payroll of an insurance company rather than the doctors who have taken care of me for decades? Why would I do that?

"Please contact me at your earliest convenience," wrote the woman I never intend to speak to again.

"I look forward to hearing from you and learning more about how ... our Nurses can help you." Grammar again. She looks forward to learning more about how her Nurses can help me? Maybe she's being honest and doesn't have a clue because there is no clue. Or maybe they're saving money by hiring people who can't write letters rather than just paying for the MRI in the first place.

This is not, I should add, Obamacare that I'm talking about. I have old-fashioned, pre-Obama, employer-provided insurance. This is the ugly underbelly of managed care, which was destroying the health care system long before Obama got his hands on it.

I discussed it with my doctor of 25 years. He just shook his head. I remember when it first became clear to me, and everyone else, that members of Congress were spending more time raising money than doing the people's business. Now, as every doctor I know who is still in private practice tells me, they work for the insurance companies and some days spend more time fighting with them than taking care of their patients.

I am truly lucky. Blessed. I have insurance. I have wonderful doctors. I know how to stand up for myself. I have problems that can be fixed by the best of modern medicine, and I am in a position to get the best. But I keep thinking of a time, many years ago, when my cousin Irwin was a big-shot doctor at Harvard. When I saw him, it usually was on "private patient" days, with well-to-do patients, no wait, etc. But one time, I had some rash, and my mother was nervous, and so I went in on clinic day. The place was packed. The wait was long. But we clinic patients, all of the poor people and me, got exactly the same care that the private patients did.

My cousin was so proud of that. It was a miracle. We just didn't know it.

To find out more about Susan Estrich and read features by other Creators Syndicate writers and cartoonists, visit the Creators Syndicate website at www.creators.com.

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Comments

6 Comments | Post Comment
Ms. Estrich started her Op-Ed by noting that: "Yes, I'm one of the incredibly lucky people who actually have two health insurance plans..."

She then goes on to state: "I got a call the other morning as I was racing to work from a woman... who wanted to know whether I would like the assistance of an RN on their staff in managing my health care. I knew what she really meant. I said no... In fact, the only thing that has of late stood in the way of "timely, appropriately, safely" provided care is fighting with the insurance company to get medically necessary tests..."

I'm a bit confused about what exactly Ms. Estrich is complaining about here. She admits up front that she is an unusual case. She has plenty of health insurance and apparently has found an extremely good MD who is looking out for her and who never ever makes mistakes or over prescribes meds or tests.

A lot of people are not so fortunate. Some have no healthcare at all. Others have doctors who order tests and prescripe medicines with at least one eye toward protecting themselves from potential/frivilous malpractice cases. The reason Ms. Estrich got the the attention she got is that the insurance company was treating her just like all the other peons out there (Her cousin would be so proud...). The company apparently doesn't understand that Ms. Estrich and her doctor know what they are doing when it comes to her health. They would never over prescipe or over test!

Well, welcome to the real world Ms. Estrich! Unfortunately, this kind of agressive cost control measure is just about the only thing keeping the lid on health insurance costs (N.B., Even with these types of measures, costs are increasing at a rate 9-10% /year above inflation). You had better get used to this kind of effort. Now that the government is even more involved in providing 'subsidies' for peoples health care, the scrutiny is going to get even tighter (Especially if Obama care ever really gets rolling and significantly adds to the deficit). We live in a world with limited funds. With the government 'helping' us, they are going to have to make every health care dollar count. Audits and oversight are going to become even more common and heavy handed.

Also, Ms. Estrich seems upset that an entity got between her and her doctor when it came to her health care. Just maybe this will create some empathy for all these people will have to change their doctors/ health insurance thanks to ObamaCare. But Ms. Estrich has good insurance so she won't have those worries. Those concerns are for the masses (At least for now).
Comment: #1
Posted by: Old Navy
Wed Oct 23, 2013 4:49 AM
I don't quite get the point of this article!
Comment: #2
Posted by: Oldtimer
Wed Oct 23, 2013 4:55 AM
I wish Ms Estrich had inquired about what the case manager would do for her vs what she think the CSM will deny her.
A case manager makes sure you have transportation to your appointments, makes sure that one doctor does not order the same test/procedure that another doctor already has you do. A CSM makes sure you have access to the medications that have been prescribed. A CSM will run your doctor to ground when he/she orders the wrong test or doesn't order a necessary one.
A CSM works for you, not against you.
Comment: #3
Posted by: capiscan
Wed Oct 23, 2013 2:00 PM
Poor Susan, so smart about legal issues, but so ignorant about healthcare and economics.

Obamacare is all about managed care - HMO style payment schemes alleged to increase patient outcomes, but merely a flat fee per head leaving it to the provider to figure out how to make a buck. This is what gave HMO's a bad name and it is definitely part of the reimbursement approach for PPACA. If you don't like it, the I'm sure a single-payer approach is going to make it so much better.

Insurance companies need to be on the look out for fraudulent charges and sometimes doctors do things that are not necessary but are done to please the patient and mitigate risk from malpractice actions. When charges increase suddenly for an insured customer, it is their fiduciary duty to look to see if this is correct or not.

However, the privacy matter is a very difficult one. Doctors can't give out information to anyone unless you okay it, but you've given the insurance company and their employees they designate, the right to access this information. Just think what it will be like in a single-payer world when it's HHS and IRS that start look into these things for fraud and you end up having to prove it's not fraud, instead of them proving that it is fraud.
Comment: #4
Posted by: pb1222
Wed Oct 23, 2013 2:31 PM
I agree with Ms. Estrich that the problems she experienced started long before Obamacare. The column is a personal reflection on a difficult and, to be honest, scary experience of interaction with her insurance company. I am curious to hear from Ms. Estrich if she believes Obamacare would solve or make worse the problems she experienced. I am also interested if she believes everyone should have health insurance, which is inferred in her appreciation for having health care, and if so, does she understand the cost being levied on American taxpayers to achieve that goal.
Comment: #5
Posted by: shortlink@gmal.com
Wed Oct 23, 2013 8:59 PM
Ms. Estrich,
I am unclear on the point you are trying to make in this article. All I gained from reading this is you seem to be looking for something to complain about in an attempt to identify with people that may be unsatisfied with their health coverage. I don't understand why you have or pay for two seperate health plans. I also think that you should report on the facts of why an RN wants to help you instead of your perceived ideas and hasty conclusions. You seems to have wonderful personalized health care. What a terrible thing indeed. Your very quick on negative assumptions. Perhaps your wasting your money to pay for two insurance plans, or perhaps your wasting time and money running around getting different MRIs and have been identified as someone who needs help making proper choices.

Also, I am one of those ""poor people"" that you had to sit with when you "had some rash." I hope they had some cure. I think you meant to say you had a rash. At any rate, thanks for the laugh. As one of those uninsured poor people that go to clinics, I have had no problem getting service from those providers. It is not some miracle. I think it is interesting that your whole impression of some aspects of health care come from one isolated visit to a clinic. It also has nothing to do with pre or post Obamacare.

Let me introduce a real problem with healthcare that I have, and this is a new problem or "post-obamacare" problem, not "a nurse called me to address my health needs problem." Obamacare will punish me now as I cannot afford one of the government plans and do not qualify for Medicaid. Now I am being held hostage to pay the government more of my money for not buying one of their expensive and poor coverage plans.

You, as someone who has two insurance providers and have the luxury of complaining about your care, have no right to comment on our health care crisis. You have no idea what it feels like to not have health insurance and then now be punished for it under law. Please spare the reader from your negative diatribes of perceived injustices. This column was absolute drivel and I want my minute back I spent reading it.

Sincerely,
J.D.M

P.S. Maybe you can get your insurance company to buy you a new voice box. Please share this endeavor with the reader in your sad little column.
Comment: #6
Posted by: John M.
Thu Oct 24, 2013 4:57 PM
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