Fingernails and Insurance

She came into my office with the usual complaints-neck and arm pain, back and leg pain.  All started after the car accident more than 10 years ago.  As the story unfolded I took my notes but my attention was drawn to her fingernails.  What struck me was how perfect they looked-luciously long, groomed, and painted.  These were obviously well tended nails-the kind that take an hour to create-with the latest technology for fillers/lengtheners and the like.  I have sat next to women in various nail salons who were receiving such nails and was struck by both the time and cost associated with this-not to mention the frequency of required treatments to maintain.  For some reason, on this patient, these perfect nails struck me in an unpleasant way.
This was a woman who otherwise seemed to care little for herself.  She was sloppily dressed and not only overweight but clearly out of shape and unhealthy.  When she removed her shoes during the examination, her socks were more gray than their original white.  In addition, her history as she related included numerous times when she opted not to have insurance because she didn't want to pay her "portion" or when she opted out of recommended care because she couldn't afford the required co-payments.
Fast forward, and before me sat a woman now with a chronic pain syndrome-out of work for more than 6  years as a result and thus statistically unlikely to EVER return to gainful employment.
And yet her fingernails were perfect...
Hard as I try, I can't put myself in this woman's shoes.  I can't say for sure that she made poor choices about her limited funds.  It may be that the only thing she does for a "treat" just for herself is her nails.  Perhaps even this was a first-a special occasion and not something done regularly.  Undoubtedly there are many possibilities that perhaps I can't even imagine.
I just know I was struck by the dichotomy-the willingness to devote significant amounts of resources to her hands while neglecting a whole spectrum of healthy living activities, some of which require little or no money at all.  It did raise the question in my mind about the balance between societal and personal responsibility, especially when it comes to health and utilization of those precious resources.  In the coming years, perhaps these questions will be an increasing component of the discussions about health care insurance, Medicare, and reform.

My Oxford Challenge

My son is going to do volunteer work in Africa for 6 months and was prescribed malerone to protect him against malaria.  He obtained the prescription, took it to the pharmacy AND...we were told it would cost nearly $2000, even though my health insurance policy carries an expensive prescription drug benefit.  Thus began my odessey with Oxford.

First Call: (32 minutes): Informed it was not a covered medication because it was for travel.  They agreed that there was no such provision in my policy but that was "Oxford's general policy".  Informed I could ask for an APPEAL OF COVERAGE, expedited with an answer in 48 hours.  Great.

Wrote appeal, sent to provided address with registered mail.

Second Call: (48 minutes): Requested response on appeal, informed after some time that in fact medication was covered and what I needed was a QUANTITY LIMIT OVERRIDE APPEAL since he had 6 months of pills ordered and was only entitled to one.  Again told an expedited appeal would be answered in 48 hours.

Faxed appeal as instructed.

Third Call: (32 minutes) Couldn't find my appeal, couldn't find anyone who could tell status of appeal, tried to get through to a medical department and was told they weren't answering their phones I could continue to hold or call back later...as I had to go back into the operating room, I concluded the call.

Fourth Call: (36 minutes) Got lovely woman who apologized profusely for all the calls and trouble but after invetigating informed me in fact malerone was NOT a covered medication! After I got a little angry, she put me on hold, and ultimately agreed I needed a QUANTITY LIMIT OVERRIDE APPEAL and gave me a different fax number and instructions how to use the facesheet to prompt a definite response.

Re-faxed appeal as instructed.

Fifth Call: (49 minutes) Kind man said the pharmacy stated I could only get 2 months worth-I tried to remain calm and ask why the appeal had been rejected and who could I speak with as the whole point of the appeal was to OVERRIDE this limit and I though as he would be far from a real pharmacy and even a reliable postal service I had good grounds to request this.  I was put on hold again and when he returned he apologized profusely and said I was misinformed...what I needed was as VACATION OVERRIDE APPEAL-this process means I have to purchase the medication out of pocket and then after I complete 5 pages of paperwork (without leaving out a single crucial item), Oxford will decide if I am entitled to reimbursement that they can send me at their leisure.

And we wonder if our health insurance system is broken?

Bon Voyage!

Sad, So Sad

She was 78 with bones to thin I could see through them on xray

And a spine so crooked, she could challenge a pretzel

She had seen three world class surgeons who had said "No"

But here she was,hope in her eyes, asking for my help

She was 78 and in pain and her predicament so sad

Her problem was nature and the bad hand it had dealt

And no medicine nor surgery could outwit Mother Nature

So no one wanted to help, it just wasn't their job

She was 78 and her husband even older

No one wanted them to suffer but there was no easy answer

And together they refused to accept and so on they wandered

Wasting resources and time and getting less help than they should

She was 78 and in pain and the system conspired

So that she kept up her futility, remained in great pain

And once again, I shook my head and knew in my heart

She had failed the system and the system failed her.

George Harrison So Sad

My Job

Just a routine surgery
On a routine patient
All went well
Should be out in 3 days, BUT
Home not so good
Lovely lady
Not so lovely spouse
Surreptitious  arrangements made
Will get an extra 10 days
At rehab.