WILLIAMSVILLE — My family of five is fortunate to have top-of-the-line health insurance. Even better, we're all healthy.
Nevertheless, we do use health care for routine screenings and the occasional illness or injury. I administer our two plans: one covers our high deductible; the other pays for everything else.
I'm not complaining about the coverage, but I'm furious about the untold hours I spend online, on hold, and on the phone as part of the paper chase called claims.
Because I worked in the industry, I know the lingo and how things are supposed to work. I'm also tenacious about collecting what's due.
But it comes with a cost of my time and sometimes my well-being. Following up on claims raises my blood pressure. Essentially, having good health insurance makes me sick.
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It gets worse. My oldest child completed college and is working for two nonprofits, patching together full time employment - but with no benefits. Thanks to the new national health care regulations in place, she's still covered by our deluxe policy. The catch is, she lives out of state.
Recently, this daughter became ill.
Because she knows how our insurance works, she put off seeking attention until she could call her primary care physician's office for a prior authorization, which they sent to the urgent care center where she had an appointment for the following day.
The urgent care center received the paperwork, but the receptionist couldn't put her hands on it when my daughter arrived for her appointment. The receptionist angrily handed my ailing daughter a stack of forms to fill out.
My daughter, who didn't feel well, called me from the waiting room in tears. She said she was just going to go to the hospital. I talked her down.
I found myself in the curious position of excusing the receptionist's rudeness.
The broken system of ours puts horrible pressure on people administering the delivery of health care to get all the paperwork right. In fact, entire jobs are devoted to the processing of claims so that the medical providers will be paid after they attend to the sick.
I told my daughter two simultaneous yet contradictory things: the receptionist is completely wrong to be rude, yet the receptionist is in an untenable position and must let off steam somehow. I coo into the phone, hoping my daughter will stick it out, see the doctor, and be treated.
She called me later to say that it wasn't just her asthma flaring up but bilateral ear infections as well. She said the doctor was really nice, and she went home to take her medicines, drink fluids, and go to bed. From there, she called her primary doctor's office, who kindly re-sent the information the urgent care center required.
She says she's going to write a letter to the center, to tell them of her experience there. She doesn't think someone having trouble breathing and in pain should have to fill in forms and suffer abuse to access care.
But this is the demoralizing nightmare of having insurance.
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I wish this were an isolated incident in my experience. Unfortunately, it's not.
This past fall, a different child had need of medical care after waking up with severe back pain. She lives in state but out of town, so she found an in-network provider and sought treatment, which helped.
But the chiropractor required my daughter to pay for her services up front, despite her in-network contract with our insurance company. The chiropractor then billed the insurer, who paid her as well.
I received both the credit card bills and the insurance company's explanation of benefits - better known as EOBs - and could see that this doctor was collecting twice for each visit.
I called the office and was put on hold - indefinitely. So I called the insurer, which, after all, had a contract with this doctor to work by its rules at its rates.
But the contracts that providers have with the insurers are just as bewildering as the coverage itself. And trying to run a primary care practice profitably is quite difficult. I once did it; I know [“Care package: How a doctor and his wife ran a 'mom-and-pop doc shop' in Townshend - and why they gave their business away,” Voices, Nov. 3, 2010].
So I can understand the doctor's business needs for cash flow and her frustrations with insurers.
Foremost, she's afraid she won't get paid for her service, and she has staff and rent and her own salary to cover. She probably also has substantial debt from her medical training. She's not in it for the money - there are better ways to get rich - but she both needs and deserves to be adequately compensated for her work.
Fortunately for me, the insurance company's customer service reps were mostly pleasant to work with, and when they offered to contact this doctor directly, I accepted. I figured that not only was it better for my health to let them do their job, but that part of the high cost of my premiums was allocated to doing just that.
Within a matter of weeks, I received a refund from the chiropractor.
Nevertheless, even dealing with pleasant customer service reps takes time - time away from the work I get paid for. Basically, I volunteer as an unpaid patient advocate in order to ensure that my family receives the insurance benefits it's entitled to.
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What's nearly been lost in all these shuffling papers is the face-to-face human encounter between the healer and the ill.
What is interfering with the patient-doctor interaction is the insurance industry, whose meddling and profits have both blossomed since the failed push for national health care during the Clinton years in the '90s. I suspect that it's the cost of insurance that's driving up medical costs even more than spiffy new treatments and tests.
Knowing that the system is broken in so many ways is a step toward getting it fixed. But it's complicated. That's why the fixes need to be simple - or at least flow from the simplest to the most complex.
The first thing to do is make the patient the center of whatever model we build. At one point or another, we will all consume medical care.
And as patients, we need providers. These used to be called doctors, but as medicine has increased in complexity, the number and types of people who treat us have also gone up.
Given our current model of health-care delivery, this multiplication of caregivers and division of responsibilities makes sense. In terms of providing consistent and effective care, it's a disaster.
Medicine is a science, but healing is an art, and a healer needs to know the person she treats, not just the disease.
We need to develop primary-care settings where this can take place: where patients feel comfortable and known, where caregivers have time to find out the gestalt of a person's lifestyle for both wellness care and treatment when ill.
We need to put people back at the center of health care, replacing money, which is currently its driving force.