Wednesday, August 05, 2009

Treating the Cosmetic

I wrote a post about the hurdles one of my family members had getting insurance authorization for a medication for an infected nail. He surrendered and bought the medication at Walmart for $4 as the insurance company would not pay for the medication: the doctor had not indicated that the infection was causing pain or discomfort and so treatment was not approved-- of note, this doctor had never been denied this preauthorized medication for a patient before and was not aware he needed to specifically say the infection was causing pain or discomfort . Blog reader and physician Midwife With a Knife commented that onychomycosis (fungal nail infections) are really a cosmetic issue: should insurance even pay for such things?

It's an interesting question as to what constitutes distress and discomfort. ClinkShrink and I had a series of posts on the Worried Well and who deserves care-- we got close to bloodshed a few times, actually. Is one state of subjective distress more worthy of insurance-treated medications than another? Evidence-based medicine, FDA approvals for specific illnesses, and all that jazz, but as psychiatrists we sometimes see patients who don't do the best job of articulating their distress-- is it only real and worthy of certain treatments if you can articulate your torment in the right words (and perhaps the answer is yes)?
If your groddy toenails bother you, or leave you feeling self-conscious in your designer flip-flops, should insurance pay for your meds? Since there's a $4 Walmart option, maybe it shouldn't. And how does Walmart get all those meds so cheaply?

If you have a huge and ugly-- but benign-- lesion on your face, should insurance pay for its removal? And what constitutes "discomfort"? Many people suffer from psychiatric disorders where the result is subjective distress, but not dysfunction or impairment. If you're quietly having panic attacks, but they don't impair you, should your insurance pay for the treatment? What about a nose job if your nose is really ugly and attracts a lot of attention? How about breast or penile reconstruction for cancer survivors (or landmine victims, or the relatives of Ms. Bobbit?)? And what if you have pain, and repeatedly present to a doctor or the emergency room, and no anatomical cause can be found? Just thought I'd ramble about the lines of where we think about sticking our health care dollars...


Aqua said...

I think if you have insurance, and you are suffering, subjectively or objectively, your insurance should cover it. That is why we pay our insurance premiums.

Re: mental ilness, In Canada, the Canadian Medical association has said that Canadian Insurance Companies are bullying depressed people:

I believe it. I also have to wonder if they are just making things so arduous to request and get done that depressed people just give up trying.

A couple months ago my pdoc sent them a letter to My insurance company requesting they pay for a new medication (Cymbalta). The pharmascist told me they would not pay for it because it was "too new". Given they know I have tried every other medication available...this seemed pretty lame.

Then a couple weeks ago they sent the letter back to my pdoc saying they could not process the request because he did not put my claim number and insurance number on it. Note that he DID put my name, address, phone number, and all his information too.

They have been paying money into my account for a few years now.
Guaranteed if I sent them the same letter with a note saying you paid me too much this month...the extra would be processed out immediately. How hard would a phone call to myself or my doctor have been?

When I recently changed addresses I got the same runaround. It took me numerous Long distance calls and every dept. said they could not find me without my claim # (which I did not have)...I cannot believe that a huge organization like Manulife cannot look me up with my other vital statistics...You pay me $, but you don't know how to find me? Makes no sense.

ha, verification word is "scrumph"...just as annoyed as I feel

Sunny CA said...

The photo reminds me of a wedding I photographed which had an old lady who would tape her face up then cover the tape with a wig. A free face lift.

It's ridiculous to require suffering. An infection is an infection. Instead of creating national health insurance, I think the govt. needs to make rules for ins. companies and enforce the rules. I get so upset with my insurance company. If my doctor charges $400, the ins. company will say that the "reasonable and customary" fee for that service is $40, so they give me $40 credit towards my $2,500 deductible and I owe the physician, and pay $400. How is that even legal?

Zoe Brain said...

From a Financial viewpoint - it makes sense to treat some conditions where the need is not urgent, because if you let them worsen, you may end up paying Big Bucks to fix it.

There is a difference of interest between an insurance company and a government health system in one respect: a rational but inhuman insurance company will look at the initial cost, look at the maintenance cost without treatment, and make a decision based on the rate of return.
If the cost of maintenance without treatment would pay for an expensive procedure in, say, 5 years, it would be rational to pay upfront. 10 years, and it may not.

A government on the other hand is interested in tax revenue too. To have a taxpayer incapacitated for even 3 years, and being a liability rather than an asset, may far outweigh any medical costs.

I'm interested in this because of the situation in Alberta and Manitoba, Canada, regarding removal of financing of genital reconstruction for patients with transsexuality.

The up-front cost is about $20,000, with hormones for the rest of the life - say 40 years - at $300 a year.

Over 10 years, about $100,000 would be collected in taxes if the patient is functional.

The cost per year of not having surgery would be 10 psych visits a year at $200 ($2000), plus additional hormones ($500), plus anti-depressants ($4000) plus amortisation of hospital cost for 1 suicide attempt per 5 years ($2000). Call it $8500 per year.

Deduct 50% for the high proportion of completed suicides, and the consequent lack of need for aged care and lifetime hormone treatment, and it's about $4,000 a year.

So the break-even point is 5 years for an insurance company.

But for a Government, having $10,000 additional tax revenue, rather than -$20,000 in disability benefits, that's a payoff in less than a year.

From a financial viewpoint, providing surgery make sense. This is born out by the experience of the Californian government, where it found that an initial cost of 2c per taxpayer per year soon became revenue-neutral, and then a negative cost.

So the reason for stopping genital reconstruction cannot be financial. In fact, people are willing to divert healthcare costs from cancer patients just so more transsexual people die early.

Not that they realise that, consciously. They just don't want their hard-earned money to go to frivolities.

That is one example. There are many more, in particular spinal surgeries to remove spurs before they cause paralysis. Sometimes they never will, and the money is "wasted" on mere pain relief. Other times, the patient is first left permanently paraplegic, before surgery to relieve the agony and reduce the cost of expensive painkillers reaches the break-even point. From a governmental view, this is a financial disaster of course, a taxpaying cash-cow becomes a liability - but that's irrelevant to an insurance company.

Now can I wash my mind out please? Trying to think along these lines, removing any vestige of basic human decency and empathy is quite traumatic for me. These are people, often in significant distress, and I'm ignoring that completely.

We have to quantify, financially, quality of life. That will be somewhat subjective - one person may be in a cultural and social milieu that means a severe facial disfigurement causes no problems. For another, a minor one can cause them life-threatening danger from those who think "freaks should be exterminated".

Why do I put so much emphasis on finances? Because there is not enough money to pay for the best possible healthcare for everyone. It must be rationed, either by regulation, or by a market.

I don't trust regulations - they have an extremely poor record. Decisions are based on politics, rather than rational allocation of limited resources.

Anonymous said...


Sandy,PhD said...

So many varying opinions about where to draw the line in the sand, the sufferer having the strongest opinion of all.

But when it comes to a health care system that attempts to cast a wider net (more people covered), it seems we will need to become more discerning. Draw that line in the sand closer to necessity and farther away from subjective complaints.

It does get tricky when discussing chronic pain of unknown (un-detectable by tests) origin.

Sarebear said...

QUITE timely, as I've been thinking about my tendency to have skeletal deformities, and the facial surgery I had when I was 18, for what most laymen would say was just for an overbite, but my dad fought the insurance company over as far as medical necessity (I'll post the surgical drawing on my blog of what they had to do; I was a 9 on a scale of 1-10 of difficulty of surgery, as it turned out, on the table for quite a bit longer than expected).

All the emotional baggage I "buried" or left behind when I had that facial surgery at 19, has actually risen up to slap me in the, er, face, ha, or rather, across the hips, deformed from the normal though those hip bones may be (rotated back from the normal rotatation; took me all of August to figure out why the hell the diagnosis was bugging the hell out of me - making me dwell on the word and feeling of deformed, etc).

Duh. As soon as I had the thought "This isn't the first skeletal problem you've had, you had face surgery, and lived half your life with what your psychologist called a severe, when he saw a picture, overbite, and when such a life scarred me in many emotional ways, and when you KNEW when you walked away from that baggage as you recovered from the surgery, that someday it'd pop back up to haunt you, that you'd someday have to deal with it . . . . .

Well, I just never thought it'd be my HIPS that made it happen.

And there ARE medical reasons mis-aligned jaws and severely mis-aligned teeth need to be corrected, when orthodontics and surgery need to combine in tandem. I've got screws in both jaws to this day.

Anyway, some before and after pics and the drawing that shows what they were gonna do, sometime soon, on my blog.

My dad said he had to sell off the rest of his IBM stock back then to help pay for the surgery, but I rmemember them saying they fought w/the insurance and got them to pay some, too, convinced them of the medical necessity of it, but who knows.

This is oddly such a timely topic.

Even though I have to suck in my gut and find the courage to schedule the MRI that may reveal yet more wrong with me, on top of what's already wrong.

I'm having two total knee replacements next year, the chicken shots seem to be working nicely, the hip shot worked not at all (too much rounding on the top of the femurs, from well I'm not formed right so things grind wrong) Who'd thunk it wouldn't be the arthritis . . . .

Ah, and as I say, they may yet be more to reveal. If I can just get over this stupid fear, having never had an MRI before.

Anyway, sorry to go on. I AM tired of needles!!!! A;sp wondering if other skeletal bits may be mis-formed, and ticking time bombs, but hey, perhaps I can go as Frankenstein's Bride for Halloween. Ugh.