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Healthy Insurance: A Sick Odyssey – Part One

March 15, 2010

Like many people, I’m pretty appalled at the state of our Health Care system, especially insurance and pharmaceutical companies. My outrage, however, has always been pretty academic and philosophical, because I am about the healthiest person you’ll ever meet. The insurance industry spends no money on me because, at 40, I eat no processed food, I don’t smoke, I barely drink, I exercise daily, I weigh in at a whopping 116 pounds, sleep well, have no mental issues requiring treatment and am pretty much never sick. If this were grade school, I’d be the teacher’s pet.

Except that I got in a very bad car accident a year ago. Having recently been accused of being “dramatic” about it, I am just going to state the facts (which are incredibly dramatic, so there’s not much I can do about that.) Because what ensues, now, between my insurance company and me would be hysterical, if it weren’t horrifying and symptomatic of a very sick system.

My intent is to update this regularly to track my journey through a broken neck and an even more broken healthcare system.

  • I was in a car accident, in the front passenger seat, when another car (with an uninsured driver) hit us going about 35 MPH right at the crease where the front door connects to the front quarter panel. We spun and spun and stopped. Both the driver and I thought we were “fine,” just a little shaken up and sore.
  • Doctors visits, including X-Rays ensued. Very bad whiplash, but nothing more concrete than that, so off I went on my merry way to go about getting better.
  • I spent several months doing PT and massage for “soft tissue injuries” to my mid & upper back, and neck. My back got better. My neck seemed to be getting worse. This goes on for months.
  • A couple months ago I finally went to see a neck specialist because my neck was still getting worse. To the point that I was in near-constant pain, had headaches more often than not, and the occasional weird “symptom” like not being able to feel hands, feet and a few times having no sensation in my mouth.
  • After an MRI and Cat Scan, it turns out that the tip of my C2 vertebrae was broken off in the crash. The broken bit is floating perilously close to my brain stem. As a result of the injury, my spinal cord has formed a Synovial Cyst that is putting pressure on various nerves and is what’s causing most of the problems. The bone bit, however, has the potential to be life-threatening if it were to shift a bit and actually go into my brain stem. No reason to believe that it will or won’t do that.
  • They cannot do surgery to remove either the bone chip or the cyst because it is too close to my brain stem. There is nothing to do.
  • As a result, I will be wearing a neck brace for a year in the HOPES that I will build enough scar tissue, in the right places, to add support and stability in my neck. It is also hoped that said scar tissue will, essentially, entomb the bone chip so that it no longer poses a risk. Lastly, it is hoped that by keeping my neck in traction, my spinal cord will decompress and the cyst will drain.

That all pretty much sucks, but I’m up for it. I am making a fashion statement out of neck braces and doing my best to get on with my life.

But here’s the catch. I am in constant pain. It ranges from annoying to tear-inducing. Since there is nothing to do to actually fix the problem, the only thing that helps is massage.

After a year of treatment, the PIP insurance that was covering the injury is all used up and I am now thrown into the maze that is Premera Blue Cross to deal with this.

I have two goals. 1) be in less constant pain 2) not die. Simple. In order to do that, my needs are very simple: Massage once a week, Physical Therapy twice a week and MRI / Cat Scan every three months to check the status of the cyst and bone chip.

Premara Blue Cross in Seattle seems to have one goal. Make sure none of that happens. Or at least make it very hard and very expensive for me.

After a long talk with a very nice person at Premera Blue Cross  (really, she was great, none of this is her problem!), I have figured out the following:

  • Massage & PT are considered the same thing, along with any other sort of rehab treatment. I can have 30 appointments a year. (That’s less than 2 months, if you’re dealing with a broken neck.)
  • MRI and Cat Scans, which I need, are going to cost me, in addition to my deductible and huge copay for these because they are considered something along the lines of unnecessary, 20% of the cost of the test, which is about $2,000 out of pocket for me, each time.
  • The good news is that I can have all of the incredibly toxic and bad-for-me prescription drugs that I want. Unfortunately, I don’t want them because they are toxic for me and I don’t want to take them.

So here’s my beef.

My family pays about $600 a month for our health care coverage. We have asked very little in exchange. However, we are subsidizing, and we know it, the incredibly expensive health care of people who are obese smokers. Or people who are choosing to take tons of expensive medications instead of making lifestyle changes. Or people who are having dramatic surgeries to prolong lives that…. Well, you get the point.

I cannot even come close to being able to afford the most basic tests that I need. I have a severely broken neck, and cannot afford the test to find out if it is getting better or worse. I guess we’ll know if I drop dead, that would be a pretty conclusive test.

Nor can I afford the treatment that would allow me to not be in constant pain and to actually try to rehabilitate the muscles in my neck that would lessen the chances of jostling the bone chip into my brain stem.

With simple treatments, this should go away in a year.

As a result of Premera, it will go untreated. It just will. I have a broken neck, and basically, have to treat myself and hope it works.

So, today is a great example of why this is scary. For the last 48 hours or so, I have had tingling and numbness in my hands and feet. The chances are pretty good that it is directly related to either the bone chip or the cyst on my spinal cord – that something is changing. It would be good to know, for sure, but the only way to find out is to do those pesky scans. That means I have to come up with $2,000 right now. I can’t. So I won’t get the tests. Given the nature of the problem, that scares the crap out of me – but I don’t want to be dramatic.

Meanwhile, some person who is choosing to be 100 pounds overweight and smoking will spend tons of insurance money on prescriptions and other medical treatments to counteract the impact of their lifestyle choices.

They did say that I can appeal. She very cheerfully told me about the appeal process, and I will do it. I will spend hours trying to decode their codes and help them understand that my simple treatments would cost them far less than the bevy of pills they would happily pay for. (Hello! Any collusion between insurance companies and pharmaceutical companies?) And that treating this NOW will lessen the odds of more, and very expensive problems, in the future. (Like, for instance, shifting bone chip that doesn’t kill me but leaves me paralyzed to live the rest of my life in a wheel chair.)

Our next installment will be a journey through the appeal process and will include fun tricks like asking them to turn my “residential treatment allowance” into more rehab treatments instead (because I didn’t feel like wasting the time and money to check myself into the hospital, though I did appreciate the suggestion that I could access the simple tests I needed by admitting myself and incurring different costs instead.)

Now I really do have a headache, and this really is a pain in the neck. Is there a pill I can take for that?

____

What happens next? Read Part Two.

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9 Comments leave one →
  1. March 15, 2010 3:27 pm

    Health care essentially sums up the ideals of our ‘Grand Capitalist’ agenda among the U.S.A.: the freedom to become as bad as we want to be, so long as we can justify it by making people answer the right yes/no questions in a courtroom.

  2. Mike Copass permalink
    March 15, 2010 4:23 pm

    Alyssa,

    I saw this post on FB. Good grief Charlie Brown, a broken vertebrae chip embedded in nerve tissue, it sounds like a journey through hell.

    Sometimes the human person that works for the corporation can be helpful, but the actual “Corporate Person” (in your case, Blue Cross) seems to behave like a sociopath.

    Great writing, sorry the inspiration was through pain and suffering, keep me posted.

    Mike

  3. Susan Geist permalink
    March 15, 2010 5:17 pm

    What a nightmare. That bone chip is terrifying. I hope it stays put and doesn’t become a problem.

    You are paying a lot monthly and they should give you more in return in your time of need, especially since you are so healthy otherwise. Your story brings to mind a story of a very close friend who was also denied the proper physical therapy for her year long leg surgery recovery. Her only choice was to go on her own and do a very strict therapist-prescribed therapy regimen at home with weights, only seeing the therapist once every couple months.

    Tell the therapist that your insurance is cutting you off and I’m sure they can show you some exercises you can do at home to strengthen the muscles while you save your allotted appointments for the massages. They see it all the time and if they are a good caring therapist, they will do this for you.

    If all else fails, call the press. Amazing what gets covered with the threat of a televised “exposé.” You are basically a poster child example of how everyday people get destroyed by the current status quo health care system. Through no fault of your own, your life is at risk and Blue Cross is talking about their bottom line. It really does make a good pro health care reform story. Not to politicize it, just saying I think the news stations would find it interesting.

  4. March 15, 2010 5:26 pm

    A friend of mine, who’s husband is a doctor, left this comment on my Facebook wall…. Needless to say, this made my blood boil:

    Don’t forget the scooters the obese are prescribed and given for free! My husband refuses to give a prescription for one – he has had some pretty angry fat people when they were told walking would alleviate a lot of their issues. He takes terrible issue with the fat smokers who cost the system so very very much. He said that few ever take any of the diet suggestions and they almost never quit smoking. He is overwhelming to me how many people are denied real and needed medical coverage. Good luck with the fight!

  5. March 16, 2010 4:54 am

    What an f-d up system! So so sorry, Alyssa! I had no idea you were going through all of this. Insurance companies SUCK and are criminal. How do they sleep at night?! Arghhhhhh

  6. March 16, 2010 8:27 am

    Alyssa, you must appeal! I worked in medical billing for a few years and learned the tricks of the insurance denial trade. Insurance companies have targets for denials – yes, sounds arbitrary and capricious, and it is. They know that less than 5% of patients will appeal their denial, and they keep their denial bogeys up around 25%. Even if the denials are unfounded they know patients are not likely to appeal. That’s 20% pure profit for nothing! However, appeals succeed at least 25% of the time. Do the math… the insurers do!

    Play nice, fill out *all* of the paperwork, get your physicians to declare this problem a medical necessity. If your physician won’t assist you, call your state medical board and report your concern. But odds are fairly decent your appeal will result in approval of some if not all of the needed procedures.

    Good luck!

Trackbacks

  1. Healthy Insurance Part Two: Superheroes, Sugar, Smoke, and Scooters « Just Alyssa
  2. Healthy Insurance Part Three: Pain, Pills, Pot and Sleepless in Seattle « Just Alyssa
  3. Should I Get My CrossFit Level 1? | Just Alyssa

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