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I have Crohn's disease, and I'm fairly certain dealing with health insurance's ineptitude directly led to multiple hospitalizations and a major surgery last yea

I have Crohn's disease, and I'm fairly certain dealing with health insurance's ineptitude directly led to multiple hospitalizations and a major surgery last year. Had it not been for their constant denials of a drug I had been on for over two years prior, I might still be taking that medication instead of having developed antibodies for the 6 months they denied. My doctors office gave me free samples as long as they were able, but in 2022 they were wiped out as all patients that were on that drug were being denied coverage. Worse still, insurance recommended "use drug X, which is similar"... but I couldn't because I was on drug X—until I had anaphylaxis from it!

magila 4y ago
I also have Crohn's and am going through this right now. Months of delays and denials for a new drug lead to two hospitalizations. I'm currently on TPN (IV nutrition) while I taper my Prednisone dose as low as possible prior to surgery. The funny/sad thing is: between my hospitalizations, TPN and related home health care, and surgery, this is all going to cost my insurance far more than the drug they were denying would have. One would hope this provides them with motivation to better judge the necessity of treatments, but I'm not holding my breath.
- geerlingguy 4y ago
  Exactly my thoughts. I can't believe the calculus here.
  - dreamcompiler 4y ago
    It's simple. Some executive gets a bonus soon if he saves the company money right now. Nobody gets a bonus for saving the company money over a 5-year period, and nobody gets punished for costing the company money over a long period either. The incentives are all about the next quarter.
    - magila 4y ago
      It still doesn't make sense. This whole ordeal has taken place over about 6 months. If anything, forcing me down the surgery route has pulled their costs forward in time, not pushed them back.
Centigonal 4y ago
Situations like this are infuriating to me. Our healthcare system needs to have some kind of provision for "this patient needs to be on treatment X probably for life. They are authorized for this treatment and subsequent claims will be approved unless there is a qualifying event (e.g. a recall, condition changes, patient and their doctor switch treatment, etc)." I have UC that's well-controlled with mesalamine, and I've had a few scares (my insurance rolls out a new prior auth every year, and I have to call my provider to have them sign it for some reason, or the new insurance only covers the name brand (not generics) because of PBM antics). The thought of having to come off of mesalamine for even a week is terrifying. I really feel for you because your condition seems much more severe/hard to control. Why do I need a new prior auth every year? My medication hasn't changed, and neither has my condition. It's a bureaucratic hoop, and if I don't jump through it I get to spend my whole day on top of a toilet. That's a terrible way to treat a human being. Even from a purely amoral capitalist perspective, I know the cost of my medication is a small fraction of the dollar value that doesn't get generated if I can't take it. I don't benefit and society doesn't benefit if I'm sick - the only group who benefits is the insurance company who gets to pocket my premiums and avoid paying out. It makes me furious.
- nine_zeros 4y ago
  Here's a simple solution. Insurance HAS to pay if a doctor recommends it. This is what premiums are for. If insurance cannot pay, they can go out of business.
  - ridgeguy 4y ago
    "For every complex problem there is an answer that is clear, simple, and wrong." - H. L. Mencken Even a moment's thought about the power disparity between an insurer and an individual facing medical problems leads me to conclude your "simple solution" has little to recommend it.
    - flangola7 4y ago
      I have no idea what you're trying to say.

magila 4y ago

I also have Crohn's and am going through this right now. Months of delays and denials for a new drug lead to two hospitalizations. I'm currently on TPN (IV nutrition) while I taper my Prednisone dose as low as possible prior to surgery. The funny/sad thing is: between my hospitalizations, TPN and related home health care, and surgery, this is all going to cost my insurance far more than the drug they were denying would have. One would hope this provides them with motivation to better judge the necessity of treatments, but I'm not holding my breath.

geerlingguy 4y ago
Exactly my thoughts. I can't believe the calculus here.
- dreamcompiler 4y ago
  It's simple. Some executive gets a bonus soon if he saves the company money right now. Nobody gets a bonus for saving the company money over a 5-year period, and nobody gets punished for costing the company money over a long period either. The incentives are all about the next quarter.
  - magila 4y ago
    It still doesn't make sense. This whole ordeal has taken place over about 6 months. If anything, forcing me down the surgery route has pulled their costs forward in time, not pushed them back.

Centigonal 4y ago

Situations like this are infuriating to me. Our healthcare system needs to have some kind of provision for "this patient needs to be on treatment X probably for life. They are authorized for this treatment and subsequent claims will be approved unless there is a qualifying event (e.g. a recall, condition changes, patient and their doctor switch treatment, etc)." I have UC that's well-controlled with mesalamine, and I've had a few scares (my insurance rolls out a new prior auth every year, and I have to call my provider to have them sign it for some reason, or the new insurance only covers the name brand (not generics) because of PBM antics). The thought of having to come off of mesalamine for even a week is terrifying. I really feel for you because your condition seems much more severe/hard to control. Why do I need a new prior auth every year? My medication hasn't changed, and neither has my condition. It's a bureaucratic hoop, and if I don't jump through it I get to spend my whole day on top of a toilet. That's a terrible way to treat a human being. Even from a purely amoral capitalist perspective, I know the cost of my medication is a small fraction of the dollar value that doesn't get generated if I can't take it. I don't benefit and society doesn't benefit if I'm sick - the only group who benefits is the insurance company who gets to pocket my premiums and avoid paying out. It makes me furious.

nine_zeros 4y ago
Here's a simple solution. Insurance HAS to pay if a doctor recommends it. This is what premiums are for. If insurance cannot pay, they can go out of business.
- ridgeguy 4y ago
  "For every complex problem there is an answer that is clear, simple, and wrong." - H. L. Mencken Even a moment's thought about the power disparity between an insurer and an individual facing medical problems leads me to conclude your "simple solution" has little to recommend it.
  - flangola7 4y ago
    I have no idea what you're trying to say.