Insurance Madness


JULY 21, 2003

WASHINGTON - - Like most people in America, I have health insurance.

And while I am sympathetic to plans to provide health insurance to everyone in this country, millions of people like me face a different kind of problem:

The health care system we have currently does not operate in a rational way.

Here is a true-life example, one I bet most of you have experienced yourself.

You find a doctor you like and trust - - one whom your insurance company has approved, of course - - and you are prepared to follow his or her medical advice.

Recently, my doctor prescribed a drug for me for a common ailment. He did this after examining me and talking to me. He then called upon his years of training and expertise to prescribe exactly the right drug.

So I take his prescription to my pharmacy and hand it in.

After a wait, the pharmacist says to me, “Your insurance company won’t pay for this.”

Why not? I ask.

The pharmacist shrugs. “It’s on their list,” he says.

Their list of what? I say.

“Their list of drugs they won’t pay for,” the pharmacist says.

Why the insurance company won’t pay for the drug is something mere mortals - - you and me - - cannot find out.

They won’t pay because they won’t pay.

I call my doctor and tell him the insurance company won’t pay for it.

“I was afraid of that,” he said.

Is the drug no good? I ask.

“Oh, no,” he says. “It’s very good and it’s what you need. But the insurance companies don’t like to pay for it.”

The drug is neither exotic nor experimental; the insurance companies just don’t want to pay.

My doctor mentions another drug and I check it with the pharmacist who checks it on his computer. His computer, by the way, is not showing him information on the drug.

It is showing him what the insurance company will and won’t pay for, which is the most important decision in medicine today.

“They will make a partial payment,” the pharmacist says. “And your doctor has to call them.”

Why does my doctor have to call them? I ask.

“Because the insurance company says so,” the pharmacist says.

I tell my doctor he has to call the insurance company. My doctor is a hard-working, busy guy, but he will do it. “It usually takes about 10-15 minutes on the phone,” my doctor says.

Which is not a real lot of time, unless you have to do it for five or six patients a day.

My doctor calls me back and tells me he has called the insurance company and the company has agreed to make a partial payment on the drug. The insurance company almost always agrees, he tells me.

Why, then, does the insurance company make the doctor call? Because the insurance company knows that most doctors don’t want to waste their time calling, which means they will prescribe some other (cheaper) drug instead.

In other words, some insurance toad somewhere, who does not have any training in medicine and has never examined me, determines what kind of drugs I can take.

I pay for my health insurance. I also make co-payments on all drugs, doctor visits and treatments.

But the insurance company does not view this as my money. The insurance company views everyone as an enemy: It operates as if every patient, every physician, every healthcare provider is trying to cheat them out of their money.

Undoubtedly some do cheat them, but this has become an excuse for treating everyone as an adversary.

But I am an optimist. And I look forward to a day in America when doctors make medical decisions and not faceless bureaucrats who neither know nor care about us.

And if some presidential candidate could come up with a plan to do that, he or she might really be onto something.

Posted by roger simon at July 18, 2003 03:04 PM


Hallelujah. My husband just spent over 50 minutes on the phone with our insurance company listening to them dissemble on what is and is not considered pre-natal care. His blood pressure went up 50 points at least. Maybe they're just simply trying to kill us off.

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