November 09, 2009
by Zaneb Khan Beams
It’s 4:45 PM on Friday. I’m covering a colleague’s phone calls while she’s out of the country, and there’s a newborn boy who needs phototherapy. This means he needs to be in the hospital in what looks like a miniature tanning bed for at least one night and one day. So, I call his parents and tell them the test results- their baby has a dangerously high bilirubin level.
Bilirubin is the by-product of red blood cells recycled through the liver and GI tract. Newborns’ livers are not efficient at recycling red blood cells, and the bilirubin by-products can accumulate in their bloodstream, cross their fragile blood-brain barrier, and cause kernicterus, ( serious permanent brain damage), or, in extreme cases, death. Neonatal Physiologic Hyperbilirubinemia represents a “bread and butter” pediatrics challenge. High bilirubin levels are easily and cheaply treated with UV light rays.
These parents knew their baby might have high bilirubin. Still, when I tell the baby’s mother he has to go to the hospital, she bursts into tears. I ask her why, and she describes a two year saga of problems with her health insurance provider, Blue Cross Blue Shield. Both parents in this family work in respectable jobs and receive health insurance “through their employer.” In other words, their employer negotiates a bulk rate for health insurance plans, and employees can buy insurance in bulk. Payment for the insurance comes out of their paychecks, and neither the employer nor the employee ends up paying income tax on dollars spent on health insurance. BCBS earns profits of about 30%. Win/ Win situation, right? Wrong. Blue Cross Blue Shield will pay for the medical care in the hospital, but not for being in the hospital. Room and board, at $600/ day, are not considered part of the baby’s treatment, and therefore not reimbursed.
Meanwhile, it’s almost close-of-business on a Friday, and I realize I need to get this baby home phototherapy equipment.
Their baby’s high blilirubin put this family in a position where the major issues in the Health Care Reform debate come into sharp focus. This baby’s parents struggle with challenges to affordability, and access. Likely, about one quarter of their income goes to costs associated with health insurance, with premiums increasing annually at a rate that exceeds the rate of inflation. They can not afford the cost of employer subsidized health insurance.
The online Health Care Reform poll, www.voicesofphysicians.org, gives us insight into what doctors know we need in Health Care Reform. Dr. Carey Vaughan of California states she is troubled by “ …the total lack of health care available to millions without insurance, but perhaps more importantly, the lack of health care access to those who are clearly UNDERinsured or covered by sub-quality plans that do not really provide the coverage needed for adequate prevention and treatment.” In other words, Americans with solid jobs, who pay for health insurance, cannot afford the care they need. Cheap, essential therapies become unavailable because of high cost and byzantine regulations aimed at withholding care from all but the most persistent and resourceful consumers.
Access refers to the average American’s ability to see an appropriate doctor and get the evaluation and treatment they need. Some Americans must spend an entire day travelling to get to the doctors they need. Some can not get preventive medication when pharmaceutical companies no longer see certain products as profitable, and stop producing them. Often, patients can not get evaluated in a reasonable time frame because insurance companies set up so many hurdles before evaluation as simple as a CT scan.
I saw a patient several weeks ago with findings suggestive of mastoiditis. This is a potentially serious infection of the temporal bone. It can extend to the brain, and must be treated with IV antibiotics. To conserve resources, instead of sending the patient straight to the hospital, I sent them to get a CT scan of the temporal bones- the most appropriate diagnostic imaging for mastoiditis. The parents’ request for prior authorization was rejected. So, in the meantime, if the patient had mastoiditis that had spread to the brain, the child’s life would be in danger. Two days later, after the patient had seen a specialist, and been started on empiric therapy with fingers and toes crossed in hopes that the infection would subside without IV therapy, the insurance company called to “re-deny” the CT scan. They said the patient had to be in-patient to get the CT scan. Hoping we’d give up before getting the CT scan, the insurance company presented absurd, illogical requirements that put patients’ lives and physicians’ livelihoods at risk.
As Dr. Peter Elias of Auburn, Maine, states in www.voicesofphysicians.org, health insurance is “not designed to provide health oriented care for patients. (It is) designed to provide and reimburse for episodic care and focuses on illness.” He describes an ideal system that “is not volume and profit driven, (and) uses evidence and effectiveness research.” My patient with the high bilirubin needed a very conventional therapy that is proven beyond a doubt to prevent serious long term complications. Based on excellent scientific data, we know that phototherapy for babies with hyperbilirubinemia prevents massive potential health problems. Yet, because of insurance company rules designed to protect their profit margins, I had to take a chance, and coordinate outpatient therapy, or ask the family to risk financial collapse. Dr. Elizabeth Peverall of Burnsville, North Carolina, states in www.voicesofphysicians.org “ I have patients whose lives have been put at risk due to inability to pay for hospitalization, medication, or a simple lab test.”
If a family who pays for health insurance can not obtain routine care for their child, health insurance, and health care, lack affordability and accessibility. Dr. Terry Vik, a pediatric oncologist in Indiana, states in www.voicesofphysicians.org that he is frustrated by “… dealing with insurance company bureaucracy to authorize care for children… (These) families… have so much more to worry about… They do not need the added burden of wondering if their insurance will cover… care.” Physicians are trained to methodically evaluate their patients’ complaints and physical findings, then forced to sublimate our expertise to insurance companies’ un-checked profit motives.
So how does Health Care Reform legislation solve the problems of affordability? Insurance reforms in the bill eliminate co-pays or deductibles for preventive care, rate increases, and coverage denials for pre-existing conditions, gender, or occupation. Bills currently under consideration also ensure guaranteed oral, vision, and hearing benefits for children.
Working Americans not receiving health insurance benefits will be able to purchase coverage at group rates through a health insurance exchange. Individuals and families with an income of up to four times the federal poverty level — an income of up to $88,000 for a family of four — will receive affordability credits to help cover the cost of coverage. The bill limits annual out of pocket costs at $5,000 for singles and $10,000 for families and eliminates lifetime limits on insurance coverage. Today, up to 60% of bankruptcies in the United States are the result of crippling health care expenses. The limits described here ensure that no citizen will face financial ruin because of high health care costs.
Currently proposed legislation further solidifies affordability and access by helping small businesses. Such enterprises, with up to 100 employees, will be able to join the health insurance exchange, benefitting from group rates and a greater choice of insurers. Additionally, small businesses with 25 employees or less and average wages of less than $40,000 qualify for tax credits of up to 50% of the costs of providing health insurance.
So, back to the office, it’s not quite 5pm on Friday afternoon, and I have secured the treatment my patient needs. I completed the paperwork according to Blue Cross Blue Shield’s specifications. Moderate medical and financial disasters averted.
As a result of currently proposed Health Care Reform, this infant’s family’s out of pocket costs would have stopped many thousands of dollars ago. Their monthly premiums might have been much lower, as a result of competitive prices created the health insurance exchange. The solutions being considered in Congress reduce deficit spending by $30 billion over the next decade, and fulfill the concept of “paygo”. In other words, they require no new funding beyond current budgeting. If we fail to enact robust Health Care Reform legislation this year, we risk spending 20% of the national budget on health care related costs within the next decade.
Doctors’ groups like the American Medical Association, the American College of Physicians, the American Cancer Society, the American Academy of Pediatrics, the American Academy of Family Physicians, and the grassroots organization, Doctors for America, support current legislative proposals. Doctors support reform because it makes sense. It improves our ability to care for our patients, and improves their ability to get the care they need. It makes sense, and it has to happen.
Dr. Zaneb Khan Beams is a board-certified pediatrician practicing in Maryland.
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