February 09, 2011
The rotten US health care system-part 2
I have written before of the absurd levels of bureaucratic waste that runs through the US health care system. Here I would like to continue a report on one personal experience that illustrates this. I do this not because my medical history is interesting (it isn't in the slightest) but to document the appalling inefficiency of the system.
In part 1 of this series I wrote about my experience with a routine visit in May 2010 to a doctor for my regular check-up. As part of that process I had to get blood tests done and, as is common for people who have reached my age, a bone density scan. The blood test had to be done by a laboratory and the bone density scan by a hospital. All these things are supposed to be fully covered by my insurance. Since I know that the profit-seeking health industry has all manner of rules that can trip up the unwary, I made sure before I did anything that my doctor was part of the approved network, the laboratory was also approved, that routine bone density scans were covered, and that the hospital that did the scans was also approved.
Of course, a month after the procedures were completed I got bills for the blood test, the density scan, and for the radiologist who had read the scans, because my insurance company had turned down all of them. Only the doctor's visit had been approved. When I called the insurance company, they checked and found that the blood test had been turned down by mistake and said they would correct it but that the bone density scan and the radiologist's bill would not be paid because the hospital's billing office had coded my treatment as indicating that I had osteoporosis and thus my scan was not a routine check for that condition but part of treatment for it and thus not covered.
Let's pause for a moment to digest the absurdity of a health system in which a test to see if you may have a problem is covered but treatment for it is not. It reminds me of my previous saga involving a colonoscopy (part 1, part 2, part 3, and part 4), a procedure to see if one has colon cancer. According to the insurance company, they will pay for the colonoscopy unless, during that very same procedure, the doctor discovers any polyps. In other words, when I go for the procedure, I do not know whether it will be covered or not because that depends on the results of the very same procedure. What kind of system is that?
But the point here was that I had looked at my scan results and knew I did not have osteoporosis. Osteoporosis is a condition in which bone densities can become so low that people are at a high risk for fractures. I had at most something called 'osteopenia', which is not a medical condition that requires treatment, but merely a label for bone densities that are slightly above the cut-off for a diagnosis of osteoporosis. The story of the origins of osteopenia is a good example of how the drug industry exploits the fears of people in its drive for profits.
All adults start to slowly lose bone density after the age of 30 but it was not clear what level constitutes a danger for fracture and deserved the diagnosis of osteoporosis and thus require medical intervention of some kind. As the ability to determine bone densities more accurately improved, a group of osteoporosis experts convened by the WHO met in 1992 decided that they had to fix a numerical value of bone density below which they could assert that one had osteoporosis. The felt they had to draw a line somewhere in order to make an empirically-based diagnosis and did so. But as with all lines drawn to demarcate two regions for something that actually lies on a continuum, the question arose as to what to do with people who were just above the cut off. i.e., those who did not have osteoporosis but were near the line. The group decided to give the name 'osteopenia' for this region. So one way interpreting a diagnosis of 'osteopenia' is that it means you do not have osteoporosis.
For people of advancing years, osteopenia is common and not something to be unduly alarmed about. But when you pin a medical label on something, you immediately create the impression that it constitutes a problem. The ominous sounding label osteopenia can be used to frighten the unwary ("You will get osteoporosis unless you treat it!") and drug companies like Merck seized on this opportunity to frighten people and boost the sales of drugs that purport to treat this condition. They heavily pushed the sale of portable bone density measuring devices on doctors, lobbied the government to get Medicare to pay for bone density tests, and heavily marketed their drugs that allegedly increase bone density. As a result, large numbers of people suddenly started being told that they have osteopenia and to fear that it was a precursor to getting osteoporosis unless they took drugs to combat it.
In my particular case, since my bone density numbers were above the cut-off values for osteoporosis, what had happened was clearly a case of a mistake having occurred either in diagnosis or in communication and something that should be easily correctable. But I knew that nothing is simple in the rotten US health care system and predicted back in June of last year that fixing this would be complicated and that "I fully expect that there will be more glitches and more bills requiring more phone calls from me."
And I was right. But even cynical me underestimated the amount of effort it would take to correct a simple mistake.
Next: What happened in my case.