Monday, June 15, 2009

The Power of Medical Insurance Companies

As some of you are aware a friend of mine has been dealing with a wound on his big toe that will not heal. In the last four months his doctors have been using every antibiotic by mouth and IV to stop the spread of a bone infection likely gotten because of a stay in the hospital.

In the last couple of weeks they have begun to discuss amputation of at least the big toe and possibly to below the knee. In a last ditch effort to save parts of himself he made an appointment with another specialist in Santa Fe. That doctor wants to try one more round of antibiotics before hacking.

The cocktail of three antibiotics (Marc is way beyond the using one at a time stage) includes Zyvox which is used primarily on diabetics with infections. Here in the states it costs $2220 without shipping (it is so pricey none of the local pharmacies carry it).

That it needed to be shipped got Marc's wife looking on the Internet and she found Zyvox made by the same company and in the same dose as prescribed at a Canadian on-line pharmacy for $220. Overnight shipping brings it to $250 which is less than the co-pay would be here in the United States if Marc's insurance company would approve the drug. No it is too expensive.

The interesting part of their argument that it is too expensive is that they have already approved the amputation. Which got me interested on what that would cost. I found an interesting website on Below the Knee Amputations. I warn you that it can be a bit graphic.

The main surgery is likely to be in the $100,000 to $200,000 category. Artificial limb in the $12,000 to $20,000 range without bells and whistles. Then there is the after surgery wound care and physical therapy and pain management and emotional counselling, etc. Yearly medical treatment costs for an amputee in 2003 prices is around $100,000. I won't go into the rise in medical costs since 2003 in detail. One estimate said almost 200%.

I have a nurse acquaintence that believes medical costs are supported by the insurance companies. Nobody thinks that these insane prices will have to be paid by an individual but almost 40% of our population here in the United States is uninsured these days. And the rising cost of insurance premiums means that less and less employers provide health insurance. And health care costs for major manufacturing companies here is seen as the single reason they cannot compete with companies abroad.

And yet the Republicans are opposed to any reform of health care here. And so is the insurance lobby. They, and not the medical professionals and facilities, are what is really endangered with a reform of our current system. Some 70% of the citizens in the United States want a single payer plan. And the statistic is higher among doctors that have to have staff simply to deal with our complex insurance system.

Taking just the example of my friend Marc I am appalled. A clerk at this doctor's office has been in persistent back and forth communication with his insurance company to try and get this prescription approved. The insurance company (the ones without a medical degree in this debate) have proposed an alternative cheaper drug chosen just because he has not been on it before. And while the debate has gone on this last ditch effort to save his leg has been delayed as the infection progressed.

If you do things outside what the insurance company recommends they can disallow everything past that. In other words they can get out of paying for the amputation if Marc goes against their advice (but within medical advice) and takes the Zyvox. Another horrid statistic is that one out of three below knee amputees die within in three years. I cannot wonder if that is what the insurance company is hoping for.

Note: I don't think this is going to be my last article on insurance companies and the "best in the world" US health care system. While doing my research I found out that circulation impairment can be the number one cause of wounds that don't heal and unless that is fixed the chances of a successful healing of the amputation is doubtful. Marc has yet to have a circulation test.