Just a small example of how the health care system sucks

I have rheumatoid arthritis. If I’ve got to have this nasty chronic ailment, I certainly can’t complain — I have an extremely mild case. In fact, my RA seems to have been in remission for the past 3-4 years. And apparently, that’s a huge problem.

About a month ago, my left ring finger started swelling badly at the first knuckle [the one where your finger connects to your palm]. Quickly, the swelling moved up toward the second joint, making it impossible to remove my wedding and engagement rings. I started taking significant quantities of Advil, hoping it would jolt my finger back into submission the way it did my knee last year. [More on that below.]

I did recently manage to get my engagement ring off, but apparently, my finger so disliked that that I haven’t been able to budge the wedding ring since [and the wedding ring is even a tiny bit bigger]. A couple of mornings this week, I’ve awakened to a finger so swollen that my ring is really painful. So this is not a good situation.

Reluctantly, I’ve finally admitted I need to get back to my rheumatologist. When I say reluctant, I’m serious — last year I lived through a month-long episode where I could barely walk, convincing myself [apparently correctly, as it turned out] that the problem with my knee a. did not require the steroids my primary care provider prescribed and b. was related to residual damage from my several-year bout of active RA, instead of being a “flare” — what you call it when the disease is active. Because going to the rheumatologist means you might actually be sick, you know? And nothing good comes of being sick with RA.

So at any rate, I struck out right away this morning when I found out that my rheumatologist’s practice has disbanded in the past few years. I Googled him to no avail [some advice, medical industry? SEO. You need this so badly. Data mining/spam/SEO content farms have totally sucked up all your Google juice. It wouldn't be hard to claim it, but you seem to be asleep to this basic marketing principle.], and then I sought recommendations for another rheumatologist on Facebook.

Within 2 hours, I had several good personal recommendations, so I tried one, at the Vanderbilt Medical Group. They pull up “my file” [how?? haven't been there -- apparently I've seen SOME Vanderbilt doctor], but when they see I don’t have an active relationship with one of their doctors, they tell me I have to go to primary care first. But then I notice on their web page — there’s my missing doctor! He’s joined the Vanderbilt practice! But he’s at the Cool Springs office instead of in town. So I say, hey, Dr. Douglas is my doctor, but can’t I see someone at the hospital office instead?

Well, no. It takes a voice mail and a message back [they were all very nice and very prompt], but because it’s been more than 3 years since I’ve seen Dr. Douglas, they don’t have my records [they're not electronic]; only he does. So I have to go there, see him, and get him to refer me back to someone at the hospital.

That’s dumb, but fine. So I call his office in Cool Springs. And again, I get nice people, but no help. Even worse, they tell me I can’t even see Dr. Douglas, because it’s been more than 3 years. Have to go to a PCP first. The first guy explains the 3-year policy. And I said, I totally get it, but who can help me make an exception to your policy? Because Dr. Douglas is my doctor. And it seems awfully silly to waste time and money seeing a primary care provider who is not an RA expert when I already know I need an RA expert. So he has the nurse call me.

Here’s the annoying part: The nurse explains that it is not a Vanderbilt policy that I need to see primary care first — it’s an insurance rule. [I'll get to how stupid this is in a minute....] Now, why didn’t the FIRST Vanderbilt person I spoke to, 4 phone calls ago, explain that? So I said, ah, while that is dumb, I get it. It’s a gate we have to go through for the insurance company to pay for my doctor visit. Yes. So if my primary care provider will refer me without seeing me, then we’re good? Yes.

Right now I have a call in to my primary care practice to see if this is possible. Something tells me it’s going to be illegal or insurance fraud for them to do this…what do you think?

The upshot is, it’s going to cost me not just the extra time [hello!! trying to make sure I keep my finger here!!] but also oh, say, an extra $100. I have high-deductible insurance with no copays, because I own a small business and that’s pretty affordable as far as insurance goes. But the catch is, when you go to the doctor, you pay every penny, until you hit your deductible. So, to see my PCP just to get the referral will cost me the price of an office visit…and then I’ll get to pay the whole amount of whatever it costs to see my rheumatologist, too. Because, like I said — I’m healthy, so I’ve probably just hit my deductible 4-5 times in my life.

So let’s recap:
I am so healthy that I can’t go see a rheumatologist. But I’m so sick that I don’t qualify for individual insurance. That’s right…I got turned down for individual insurance a couple of years ago when we were contemplating going that route. A few years of epilepsy and RA make you pretty damn uninsurable…but apparently, not qualified to go to the doctor.

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3 Comments

  1. Theron
    April 21, 2011 #

    A ridiculous and all too typical story. My insurance company makes me see the PCP before I do anything. So if, say, I don’t know, I wind up in the OR with an intubation tube down my throat because a piece of food is stuck half way down my esophagus after years of problems swallowing, I still have to visit my PCP before the G-I specialist who treated me can then do tests to see if I need surgery or some other treatment. A waste of everyone’s time and the insurance company’s money. On the other hand, when I needed medical care in evil socialist France, I got it immediately, and no one ever asked me if my insurance company approved.

  2. Linda
    April 22, 2011 #

    FWIW, I also have high-deductible insurance with no copays and I don’t work for a small business. I miss the days when companies offered decent benefits.

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