What's The Matter With Health Insurance?

Doesn't "Health Insurance" Mean Equitable Distribution of Resources?

Why is it that people with diabetes (PWD) have a hard time getting enough glucose test strips per month covered by their medical insurance? Or insulin pens? Or Byetta? Or Symlin? And why is it next to impossible to get insurance coverage for a continuous glucose monitor (CGM)? Why is it that we have to beg, plead, appeal and fight for the FDA approved, and clinically proven drugs and devices, that will help us deal most effectively with this chronic condition and reduce, or eliminate our chances for end-stage, expensive and life threatening complications? Why is it that trying to get approval to see a dietitian, an exercise physiologist or a CDE is so difficult? I hate to be so cynical, but the answer is that insurance companies do not want to pay for these therapies because they take away from their bottom line.

The way money is spent by most insurance companies to take care of PWD is all backwards. Over 125 billion dollars is spent annually to care for PWD and the vast majority of that money goes into treating end-stage complications in hospitals (heart attacks, strokes, kidney failure and amputations). Only 13% is spent on medications and durable medical goods (e.g., syringes, strips, meters, insulin pumps, CGMs). The point is that insurance companies put up big restrictions on relatively inexpensive items that would save tons of money down the road. When a PWD comes to the hospital with a horrible infection on a neuropathic foot, health insurance seems to have no trouble paying the surgeon's hefty bill to have the foot amputated. On the other hand, a $30 visit to a dietitian for the same PWD to learn how to cook and eat foods that will help balance his blood sugar with his medications is commonly not covered or is denied because it is deemed "unnecessary" by the health care plan. This is infuriating to me as a physician and as a PWD.

I do not want you to think that all insurance companies are bad and evil 'Darth Vader' types. I know of several health care plans that are run by responsible and caring professionals who try to do the right thing for their clients. It's no secret that the cost of health care is skyrocketing and all insurance companies need to be smart about the dollars they spend. Pharmaco-economics is a term that refers to finding the most economic way to supply medications and other services to large groups of people. For example, there are multiple statin drugs available for people with high cholesterol. They all work very similarly and are a relatively homogenous group of drugs. It makes sense for an insurance company to bargain for the least expensive one and offer it to their customers. No one has a huge argument with this cost saving strategy.

However, there is a problem when a patient with type 1 diabetes suffering from a long history of hypoglycemia unawareness gets turned down for a life-saving, physician prescribed continuous glucose monitor. There is a problem when a newly diagnosed person with type 2 diabetes, who gets an average of 7 minutes with her doctor at each annual visit, is denied an appointment with a certified diabetes educator who could actually spend the time to truly help her deal with the disease. Insurance companies seem to have snuck into the position of making medical decisions for people--overruling both the physicians and individuals on aspects of health.

There are numerous roadblocks to ensuring that PWD are covered for the tools and medications they need. They all seem to be designed to discourage a physician from prescribing what is known to be the best for patients. Even when patients go through the appropriate steps with referrals and prescriptions and are armed with statements of medical necessity from their physicians, insurance companies still seem to delay any payment until PWD and their caregivers flood the insurance company with phone calls, letters and other appeal process requirements. These barriers to receiving the medications and services you (the PWD) need continually beat down an already harassed, busy and overloaded caregiver, and of course, you.

Caregivers and PWD who have been turned down for medications, devices and services that will help to provide a healthier life with diabetes need to voice the reality of our situation. Helping us get the tools we need today will likely help us avoid costly, end stage complications in the future.

Diabetes is not an uncommon condition, nor is it an inexpensive one. It is too bad that quality of life is never put into the pharmacoeconomic equation, because if it were, there would be no senseless arguments and stonewalling, and PWD would get what they need in order to take control of their diabetes. Education and access to good care, technologies and medications must improve.

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