The huge envelope sat outside my front door, glaring discontentedly like an alien kept away from a protected compound. In actual fact, the envelope, labeled “Important Benefits Booklet,” contained my new 2012 Evidence of Coverage with Partial 2012 Drug Formulary.
At 350+ pages, this could scarcely be called a booklet. It had been awaiting my arrival because our mailman had been unable to wedge it through the mail slot.
As I flipped through my new booklet, encountering phrases like “you must,” “you should,” “if you miss your deadline,” “restrictions,” and “you can appeal,” I couldn’t help but think again of Franz Kafka’s chilling novel The Trial, to which I’ve referred in the past when discussing our health care system.
Kafka’s everyman Josef K is arrested on an unspecified charge, and most of the book revolves around his difficulties appealing his case even though he never learns the nature of his crime or even if he did anything wrong at all. In the end, he is murdered by representatives of “the system.”
Two weeks earlier, I’d received what I thought was the same thick envelope and now felt a glimmer of shame. I hadn’t even opened it. And yet the new package, which out of guilt I did open, began with a curious command: Your 2012 Evidence of Coverage (EOC) has changed. Please destroy the previous 2012 Evidence of Coverage package.
“Changed?” I asked myself. In just two weeks? And the directive wasn’t to discard or recycle, but to destroy. Sounded very John le Carré to me. Very Tinker, Tailor, Soldier, Spy. My guess was that the suits in charge of my health insurance plan must have discovered some wildly dangerous sentence inadvertently inserted by a rogue employee, something like “We hereby agree to pay for all your expenses when you become ill.” I’ll bet some poor editor lost a job over that one. If I were CEO, I too would be ordering all evidence destroyed. And while I was destroying things, I’d get that editor as well.
As I glanced through my 350+ page booklet, printed on paper so cheap it made the phone book look upscale, I kept encountering phrases that could only be described as good cop/bad cop. You know the lingo from TV. Translated from its legal healthcare language, it goes something like this: “You can go to an emergency room, pal, but it better be a real emergency, and the emergency room doc had better say ‘this was an actual emergency’ or you, my fine friend, better have your checkbook ready. Is this clear?”
They don’t say it exactly like that in my oversized booklet, but it’s close enough.
Reading a few more “benefits booklets”
I decided to give myself the truly unpleasant task of reading several of these euphemistically titled “benefits booklets” to see if this self-serving misuse of our language was the norm. Each insurer’s booklet is available online. From the onset, they look very similar, written in a style best described as stilted.
The booklets are subdivided into sections and then into sub-sections, with lots of bullet points and an occasional reminder that “this is a legal document.” Because all these booklets sound so much alike, it did cross my mind that the whole booklet-preparation industry might have been outsourced to a single huge English-as-a-second-language country, perhaps a company in downtown Calcutta employing hundreds of otherwise unemployable attorneys, MBAs, and English majors.
I once did ask an attorney, “Who actually reads entire documents like these?” He answered too promptly for my liking, “Really only two people. The attorney in charge of writing it and the federal or class-action attorney preparing a lawsuit against it.”
At this point, I remind you of a mantra that should be engraved on your cerebral cortex. Repeat after me: Insurance companies exist to make a profit for their shareholders. They achieve this by collecting your money and doing everything in their power to legally (and sometimes illegally) keep it for themselves. Any time you find yourself writing a check for your healthcare (or your storm-damaged roof or stolen bicycle) and muttering “But I thought I had insurance,” just recite your mantra. Your life will be easier.
Health insurance companies scrutinize every possible aspect of health care, from brain surgery to the set of crutches you received for your broken ankle. Then they create rules (remember, “this is a legal document”) so that you, and not they, pay for as much as possible (out-of-pocket expenses). They also want to accomplish all this without any of their senior management going to jail. As a preventive measure to avoid penitentiary time, the health insurance industry is one of the largest lobbying groups in Washington.
The appeals process: Josef K incarnate
An astonishing number of pages in each booklet are devoted to the appeals process if you feel you’ve been wronged. You’re protesting a bill you’ve received from your healthcare provider which, for reasons you don’t understand, your insurance company hasn’t paid and you seem stuck with. You resubmit the bill to your insurance company, with a note that reads, “Hey, you guys, pay this.” But the bill comes back marked “denied.” “Denied!” you bluster. “Denied!!” you expostulate. You call your health insurer, steam pouring out of your ears. “Well, ma’am,” you hear. “You can always appeal.”
The appeals pages review the ways that you can, step by pitiful step, attempt to plead your case. If you lose, such as in the case of a huge hospital bill that’s not covered, you lose big. Family homesteads have been known to disappear down the health care maw, these types of losses representing an enormous percentage of bankruptcies in the US. Most of the time, you’ll find you’ve been nickel-and-dimed by your insurance company until you realize you’ve spent a fecal-load of money on healthcare.
Whenever, in fact, your health insurer denies you a benefit, I (your doctor) receive a thick letter from your insurance company, small print on both sides of four pages. This format isn’t intended to save trees, but rather to discourage me from reading it. I get one or two such appeal letters daily.
They’re all about you and the struggle you face trying to get reimbursed for something that in all likelihood you do deserve. Some line item on your hospitalization, some treatment by your physical therapist, or some prescription that works just fine for you has shifted in a retooling of their legal document to “uncovered benefit” status and is now your financial responsibility.
The letter describes how I can participate in your appeal, hopefully by discouraging you from pursuing it, as doing so will involve me. If you want to move forward I’ll have to read the whole dreary letter, review your chart, and compose something in your defense. Basically, they want me to encourage you to suck it up and do nothing.
The final paragraph of these four-pagers (eight sides of written material) is always the same, providing the address of your state’s department of insurance to file a complaint. Given the number of government layoffs in Illinois, best not hold your breath when choosing that route. Click here to see photo of where your letter will likely go.
Drug formulary bonus booklet
Usually arriving in the same envelope as your “benefits booklet,” but as a separate booklet unto itself, is your 50-page Drug Formulary. This is meant to explain (but rarely manages to) why so many of your prescriptions are being denied when you go to a pharmacy and why so many require something called “prior authorization” from your doctor.
As I flip through it, I see endless incomprehensible tables and charts, with drugs subdivided into something called tiers, each with some footnote or another. The footnotes relate to quantity limits (the X number of pills per month I can prescribe, with you maintaining coverage), prior authorization requirements, step therapy (in which you are forced to try three crappy drugs before they’ll allow you the one your doctor thinks will work), and so forth.
The drugs themselves are loosely divided into “old” (generic, off patent, inexpensive, lower-case print) and “new” (brand name, expensive, lots of capital letters). As I scanned the drug formulary, I noted some of the allowable generic medications were so old I was surprised anyone was still prescribing them. These are medications your grandparents might have taken and although many of them are still quite useful, others are just sort of outdated. For example, paroxetine (Paxil) and amitriptyline (Elavil) are generic, have been around for decades, and are reasonably good antidepressants. It’s just that newer ones, like Lexapro and Viibryd, with more reliable clinical benefits and fewer side effects, are better.
With drug plans like these, most of the new drugs you see on TV will either be completely unavailable to you without a lengthy appeal or will require a substantial co-payment. If you’re financially well-off, shrugging your shoulders at a $75 co-pay because it’s less than you paid for wine at dinner last night, then you’re just fine. The med is yours. On the other hand, if you’re like most people your jaw will drop when you hear the cost of the co-pay and you’ll leave the drug with the pharmacist, hoping for the best with your ancient generic.
Of course you could always buy your meds, brand name or generic, from Canadian pharmacies, which (because the pharmaceutical industry is another lobbying behemoth) our government does its best to prevent. Not surprisingly, most US users of Canadian pharmacies have health insurance. In fact, they also have drug coverage–just not enough to cover the high co-pay for what they need. Interestingly, paying full price for a drug in Canada often comes to less money than using your health insurance with a high co-pay here in the US.
Patients occasionally ask why some brand-name drugs are covered by their insurance, albeit with a high co-pay, while other drugs for the same condition (basically the same type of drug) are not covered with any co-pay.
Please refer to the back page of your formulary, where the answer lies hidden. I quote: “Aetna (or Humana, or Cigna) receives rebates from drug manufacturers that may be taken into account in determining the Preferred Drug List.”
That this rebate largesse is strictly for their pleasure–not shared with you–appears in the next sentence. “Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions.”
In Chicago, aldermen go to jail for taking these types of “rebates” unless they’re willing to share them with ward committeemen.
I discovered that the very final sentence in virtually all these booklets sums it up, a great coda of US health care. Here it is: “Aetna (or Humana, or Blue Cross, or whoever) does not provide care or guarantee access to health care services.”
Instead, they build skyscrapers and fill them with employees working day and night to block you from getting well…and from getting reimbursed. And people wonder why I think so highly of the French healthcare system.
Let me end with Aetna’s very cryptic, ambiguous, elliptical, and Orwellian big-brotherly motto:
We want you to know.™
Read this slowly aloud, dropping your voice several octaves. Add three more periods at the end and it’s even spookier.
So for God’s sake, stay well,
David Edelberg, MD