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OpEdNews Op Eds    H3'ed 5/12/09

Health Insurers' Bottom Line Defines 'Medical Necessity'

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Message Ed Tubbs
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I solemnly swear - and oh, how I damn sure do exactly that!

I solemnly swear the following italicized text is the truth, the whole truth, and nothing but the truth.

Wasn't going to be any "walk in the park surgery," the highly esteemed neurosurgeon said. He was looking at the numerous films and scans of the lower spine.

(The fellow might be forgiven for his use of hyperbole. Several surgeries had preceded what he had in mind, and each of them were several steps short of strolls anywhere.)

"You have a cyst at L1 and 2 that's pressing hard at the nerves, causing you the pain and the weakness in your legs and toes. That won't be too difficult. And if you want, we can just do that, and it'll probably give you some relief. But, as you can see here, the disk is completely gone between 4 and 5. Sooner or later, you're probably going to want that addressed as well. It would require fusing from 3 to 5."

The operation would take at least a couple hours. Recovery, total recovery, defined as normal movement with minimum, or at least only modest discomfort, might be two months to six. As the body reaches chronologically onward, it gets more and more difficult to predict how it's going to react and respond. All the systems become involved, though it might not always seem so to the individual. But that's the point precisely: we're all individuals. We enter the world with idiosyncratic predilections and we take them with us every step along the way.

There was the matter of age and the blood clot concern for which Coumadin had been a constant of daily life. "I'm going to have a cardiologist call, to make an appointment for a cardio-eval." The need was to take every precaution, determine whether the heart could handle the surgery.

The health insurance plan covered both the initial neurosurgical opinion . . . and the second. Regardless that the neurosurgeon, before proceeding with surgery, wanted some assurance of a better than even odds bet that the cardio system was sufficiently healthy to accept the stress of surgery, INSURANCE WOULD NOT cover a cardio workup exam! Checking to see whether the patient's heart could wither the storm of an approved surgery wasn't on the computerized "approved" list.

The full cost of that completely common sense examination came out of pocket.

Editorial, rhetorical question: What about the patient who was without the funds for such an examination, and who also happened to have a difficult to detect heart condition that posed a somewhat quantifiable risk? Doesn't the patient have an absolute right to that information? Doesn't the surgeon? (Editorial response: If the patient dies on the table, clearly that tragedy truncates all further medical expenses the insurance company would have to bear.)    

The cardiologist said the heart was healthy . . . But he was worried, very concerned about the chance of throwing a clot that might form in the legs. "A thrombosis, thrombophletitis." Progression of the clot from the legs, if it lodged near the heart, could be fatal! The cardiologist strongly recommended heparin injections, to be self-administered. He was stunned to learn that INSURANCE WOULD NOT cover them; only oral Coumadin.

In Washington, the lines on the healthcare delivery reform issue had been forming. I've watched many of the hearings, the witness panels seated in front of the committees. The committees seated on elevated seats, facing the witnesses. And to be honest, honesty doesn't seem to have been much in evidence; elevated or otherwise.

Click here and here and here.

To listen to the panelists, as if you were a disinterested observer from some other universe, you'd be tempted to believe that the insurance companies' mission, their raison d'être so to speak, was as it had always been: the welfare of the patient, that the insurance companies were as interested as anyone concerning reform. No! As you were: not "as interested," more interested than anyone else.

(Return to the sworn truth. Fifteen years ago, a young family member was perishing of a rare cancer. A team of oncologists had recommended a pharmacological therapy. The insurance company said "NO! They would not pay for it, it wasn't in the approved formulary." A year later the 23-year-old's ashes were presented to the parents.)

As a sidebar of sorts, no one can say with unequivocal, unqualified certainty what will and what will not prove the ultimate successful therapy when the malady is cancer. But that is not the point, is it?

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An "Old Army Vet" and liberal, qua liberal, with a passion for open inquiry in a neverending quest for truth unpoisoned by religious superstitions. Per Voltaire: "He who can lead you to believe an absurdity can lead you to commit an atrocity."
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