A Few Thoughts on Our Healthcare System

I entered medical school in the fall of 1989 and have been intimately involved in the United States' healthcare system in one way or another ever since. And the financial part of it still makes no sense to me so I cannot imagine how confusing and frustrating it must be for folks who do not interact with the system on a daily basis.

In our family, we have two persons with the same diagnosis which has required treatment since early infancy to prevent permanent brain damage. The variations in how this has been covered or not covered through the years seem mostly like an exercise in randomness, even though we have always been fortunate enough to have insurance. There have been times when their treatment was completely covered and free to us. At most other times, it has not been covered and we have often paid more than $10,000 a year for the same treatment.

We recently had a situation in which these two people with the exact same diagnosis and the exact same insurance were prescribed the exact same thing. For one of them, it was considered a covered service by our insurance and cost $27 per month. For the other, it was denied by insurance and the same amount was going to cost more than $1400 per month from the same supplier. After many phone calls and letters by our healthcare providers, the insurance company agreed that it was a covered service for both of them.

The second confusing piece of this is that the insurance company does not actually pay the supplier anything for the prescription. Because it is a covered service, we get the contract price of $27 and the rest of the cost is written off by the supplier. So why are they willing to accept $27 if we have insurance but would charge us $1400 if we didn’t?

We never know from one year to the next whether we are going to get prescriptions filled cheaply or need to pay thousands of dollars for them.

I once participated in a General Assembly committee hearing in Richmond addressing the issue of insurance coverage for treatments for genetic metabolic disorders. After I had spoken, an executive of an insurance company stood at the lectern and assured everyone that his company provided coverage for treatment for a certain disorder. Since we had coverage through his company at the time and were being denied coverage for the disorder in question, I knew this was not true. I do not think he was intentionally lying. I think he just didn’t know. But since the hearing rules said that once a person spoke they were not permitted to speak again, I could not point out this inaccuracy.

I think the helplessness I felt as I sat in my seat in that hearing room probably is shared by many folks as they encounter the illogical behemoth that is the American medical system.