Wednesday, January 13, 2010

Healthcare Crisis Part II: The "Benefits" of Health Insurance

On Thursday, St. Vincent’s who “accepts” both insurances requested Juliette bring the films as soon as possible. Since I work from home I volunteered. The UMDNJ is a typical hospital, white floors, white walls and white ceilings, however friendly medical staff dressed in blue pajamas smile at you and ask, “can I help you find something?” This is the same hospital I attended Physical and Occupational therapy for my hip and elbow. Memories. I picked up Juliette’s films from UMDNJ, paid a bored cashier and waited for the films. Directed to a waiting room, I sat and watched Rachel Ray as she made eggplant balls for Thanksgiving. “Do people actually watch this?” I said out loud. Seven pairs of eyes stared at me as my name was called. Clemency.

I arrived in the city at St. Vincent’s, a beautiful facility on the west side not far from the structure on Seventh Avenue. The first thing I noticed as I walked in was a cappuccino maker, various teas and thousands of magazines. Not bad I thought. I can wait here in peace. The walls were bright, the office neat, it felt like a children’s hospital. A beautiful young looking Chinese American woman, nervous stood before me, Juliette’s age, waiting to speak to a Secretary. We both hemmed and hawed for 10 minutes as they stood just outside our vision talking. Not a good sign, I thought. Though, quickly after we caught their attention, they attended to us and I was on my way back to Jersey City. They gave me a date of November 17th for an appointment. Everything we could possibly do done, we took a sigh of relief and settled in for the week’s wait.

Juliette and I spoke about the procedure, what this means. Everyone we spoke to seemed to know some relative, aunt, mother, sister who had a similar procedure. “It will be fine” we were told. Except sometimes it wasn’t fine, which scared us a bit and our luck ran with the Irish. Non-existent. We decided to not discuss it and muddle through until the 17th, after all this is something thousands of Americans are experiencing at the same time, right? We need to wait and see and breathe.

On the Saturday before the procedure we received a letter in the mail from St. Vincent’s. “No need to come in for an appointment.” Juliette continued to read. “Wait six months. Probably benign, come back for a new mammogram in six months,” with a bill for $50 tucked in for all the work the medical staff perfromed. “We’re still going to the appointment I announced to Juliette.” “What are you talking about? They just cancelled the appointment!” “They can’t do that” I argued. “Well, they just fucking did!” Juliette said angrily. We pumped ourselves up for the appointment and now it is not to be. “Fuck!” I yelled. “What do we do?” I asked. “Is this reliable? Is this a good thing?”

The fifty dollars was a bill for their services. Juliette called them and said her insurance should cover it. “Well, you didn’t meet your deductible.” “What deductible? I have insurance.” “Right, but this is 'an out of network' claim.” Perplexed Juliette asked them “what the fuck are you talking about. I thought you said you accept healthnet?” “Technically we do “accept” healthnet, but only out of network benefits.” She connivingly said. In "out of network benefits" she explained, “You pay.” So, basically as long as they get their money? No need to tell the patient they will be paying the first $500 or $1000 in deductible instead of simply a “co-pay,” or “in network benefits.” Thank god, we didn't have them perform the procedure, I said.

We weighed our options. Some told us to wait the six months. Juliette would receive another mammogram, and eventually have the biopsy anyway” was the advice. What is the point of that? Juliette asked her personal physician, “what should I do?” “If it were me,” she said. “I just don’t know.” Helpful. Juliette did not want to have her boobs shoved in a machine again, just to be told you need to have a biopsy, “what is the point of that?” she repeated. I agreed and encouraged her to seek a second opinion, though she was not happy about it.

Like controversy was made for us, new mammogram guidelines were released on November 17th, the day we were supposed to be attending an appointment with St. Vincent’s. These new guidelines sparked immediate controversy. A government advisory board made up of medical professionals said women should not be receiving mammograms until the age of 50. Our eyes perked. The guidelines written by a government panel essentially said that getting screened for breast cancerso early and so often leads to too many false alarms and unneeded biopsies without substantially improving women's odds of survival.” That sounds about right actually. They sparked outrageous controversy and fear, the media talked about them for a while especially the Rethuglicans who thought it was a good way to derail healthcare reform.

Still, what if? What if Juliette is in that category of women that have no warning signs, could she afford to wait until she was 50? We decided that because she was already screened we would receive a second opinion. We wanted to see what an actual surgeon who examined her would indicate.

We arrived at the doctor’s office at 5:00 PM, right on time. We needed to be buzzed in, "come on this is Hoboken, are we afraid of robberies now?" I said. Not a seat in the house as Juliette checked in with the receptionist. Also, not a white face in the room, all low-income, primarily Latino clientèle. “What is this guy doing,” I thought to myself and intimated to Juliette. "Scheduling everyone he can before healthcare reform passes?" Juliette rolled her eyes with abandon and scoffed the first seat available. After about an hour of waiting and several chapters read in “the Last of her kind” I looked at Juliette and said, “what the fuck?” He comes recommended Juliette said. Dr. B, her personal physician that operates as a community clinic recommended him.

We were called in, he was young, our age actually, he just turned 40. Is that still young? He was Latino, good looking and competent, and calming. He immediately told us “you should have the procedure done.” He explained the procedure and why he thought Juliette might benefit. "Most likely, in six months you will be right back here anyway." he said. "Plus, it is probably benign, but there is no way of telling unless the procedure is actually done." Juliette felt comfortable with him, so we scheduled the procedure for December 23rd. Done. The scheduler seemed nice, but she told us “I can’t schedule you at Hoboken Medical Center. I am having problems there and the Radiologist there is not on the schedule.” So, she scheduled us for an "ambulatory center" in North Bergen. Only two weeks to wait.

A week flashed by and we still hadn’t heard from the office, she informed us she would call to approve the procedure with Oxford, Juliette’s insurance company and then call us back. We started to worry. Five days before the procedure we started to panic. Juliette called her insurance company. “You are not covered at the ambulatory facility” she was told. "You will pay upwards of 2,000 dollars if the procedure is performed there." "You have not been approved, nor will you be approved.” "No one has called you from Dr. Costa’s office?” Nicole asked. “Nope.” And she intimated, "It sounds like they want you to use "out of network benefits."

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