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Sunday, October 11, 2009

So presumably you can have blood pressure of 110/70 and low cholesterol, but if your BMI is over 25 you too can be denied health insurance
Posted by Jill | 3:17 PM
I have to admit, I'm kind of obsessed with the health insurance industry today. You see, I have Anthem Blue Cross/Blue Shield through my employer, and I am going for a colonoscopy tomorrow. (I wrote about my first one here.) I hate to be like that greeting card I have in my file waiting for my oldest and dearest friend to turn 50 which depicts an old man and his grandson on the front with the caption, "Let me tell you about my colonoscopy", and on the inside it reads "Welcome to the gross personal story years." But based on some anecdotal reading I've done, colonoscopy is one of the primary procedures where health insurers start to act up.

The facility where I have it done is an ambulatory surgical center. For a wuss like me, this place makes having this procedure tolerable. They wheel you in, they knock you out, and next thing you know, you're done. No pain, no fuss, no anxiety, no trauma. If colonoscopy is the best way to head off colon cancer at the pass by catching it early, or preventing it by snipping off benign polyps before they can turn cancerous, it's in everyone's, including insurance companies', best interest to make the procedure less traumatic. Instead, insurers are increasingly refusing to cover sedation for colonoscopy. Anthem is a subsidiary of Wellpoint, which has been denying coverage for colonoscopy anesthesia since 2005. Aetna, the other insurance-based option my employer offers, stopped covering it in 2007.

When I had my last colonoscopy, I was utterly batshit panicked about the procedure, including the sedation. I've never been a hospital patient, never so much as broken an arm. The reason I wrote that long piece after my last one was because I know there are many people like me who are terrified of this procedure. I know because I live with one, and have been unable to get him to go. Colon cancer is a lousy way to die. I remember a family friend dying of it in her 50s. She had a stomach ache for weeks, they opened her up and she was riddled with it. They closed her up, it spread to her brain and she died three weeks later. And it's relatively easy to prevent through screening. But just like outpatient mastectomies and drive-through caesarean section births, the insurance industry doesn't want to pay a penny now to save a dollar later. Perhaps it's because they know they aren't going to pay the dollar later.

Not so long ago, Rep. Alan Grayson said the Republican health care reform is "Don't get sick, and if you do, die quickly." It isn't just the Republicans; it's the entire insurance industry.

I'm lucky. I'm paid well and if the damn anesthesia costs, I can pay it...assuming they don't turn down the whole claim for some arcane reason that only they know. I pay $2800/year for this coverage, and my employer pays almost another $10,000.

I'm writing about this now because I'll be watching carefully to see what my insurer does with the bill for this. Stay tuned.

But that's not even the reason for this post. The reason is another example of how the fact that insurance companies can change the rules willy-nilly affects real people. And in this case, they want to put an infant on a diet:
Alex Lange is a chubby, dimpled, healthy and happy 4-month-old.

But in the cold, calculating numbered charts of insurance companies, he is fat. That's why he is being turned down for health insurance. And that's why he is a weighty symbol of a problem in the health care reform debate.

Insurance companies can turn down people with pre-existing conditions who aren't covered in a group health care plan.

Alex's pre-existing condition — "obesity" — makes him a financial risk. Health insurance reform measures are trying to do away with such denials that come from a process called "underwriting."

"If health care reform occurs, underwriting will go away. We do it because everybody else in the industry does it," said Dr. Doug Speedie, medical director at Rocky Mountain Health Plans, the company that turned down Alex.

By the numbers, Alex is in the 99th percentile for height and weight for babies his age. Insurers don't take babies above the 95th percentile, no matter how healthy they are otherwise.

"I could understand if we could control what he's eating. But he's 4 months old. He's breast-feeding. We can't put him on the Atkins diet or on a treadmill," joked his frustrated father, Bernie Lange, a part-time news anchor at KKCO-TV in Grand Junction. "There is just something absurd about denying an infant."

Bernie and Kelli Lange tried to get insurance for their growing family with Rocky Mountain Health Plans when their current insurer raised their rates 40 percent after Alex was born. They filled out the paperwork and awaited approval, figuring their family is young and healthy. But the broker who was helping them find new insurance called Thursday with news that shocked them.

" 'Your baby is too fat,' she told me," Bernie said.

Up until then, the Langes had been happy with Alex's healthy appetite and prodigious weight gain. His pediatrician had never mentioned any weight concerns about the baby they call their "happy little chunky monkey."

His 2-year-old brother, Vincent, had been a colicky baby who had trouble putting on pounds.

At birth, Alex weighed a normal 8 1/4 pounds. On a diet of strictly breast milk, his weight has more than doubled. He weighs about 17 pounds and is about 25 inches long.

"I'm not going to withhold food to get him down below that number of 95," Kelli Lange said. "I'm not going to have him screaming because he's hungry."

Speedie said not many people seeking individual health insurance are turned down because of weight. But it does happen. Some babies less hefty than Alex have had to get health endorsements from their pediatricians. Adults who have a body-mass index of 30 and above are turned down because they are considered obese.

The Langes, both slender, don't know where Alex's propensity for pounds came from. Their other child is thin. No one in their families has a weight problem.

This baby doesn't eat McDonalds. They can't put him on a treadmill. But this is where the utter lack of willingness to investigate environmental or other causes of obesity comes back to bite us. There's already evidence that widely-used chemicals contribute to obesity, but somehow I don't think there's going to be a whole lot of effort put into investigating this further. Too many industries might be hurt, and why look into real causes when you can talk the same old tired crap about fast food and laziness -- and then deny health coverage to an infant.

(UPDATE: Heh.)

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Blogger Sharon said...
For many many years --- in fact up until the last few decades -- a fat baby was the ideal. A thin baby (two words that honestly don't go together) was thought to be at risk of all sorts of maladies. When a baby was born, your first mission was to fatten up the little bugger. No one was concerned that fat babies would grow up to be fat adults. Now the insurance companies join the No Fatties Crusadeas an excuse to deny coverage. Ri-dick-o-lus.

Blogger Rhode Island Rules said...
The kid is going to be fine. My son weighed over 10 lbs at birth and by 6 months he weighed 25 lbs. We called him our little Buddha. He is now a very lean 24 year old.

Blogger TaraDharma said...
yet another reason we need meaningful health insurance reform. the execs who denied this baby coverage have sold their souls to the devil. shame on them!

Blogger SeDress said...
My dad just died from colon cancer: no doctor visits for him,ever, until it was too late. I'd been putting off the c-scope business: but scheduled one as soon as I was able to deal with things after his funeral. The prep was terrible: the actual scope was a breeze. But I had drugs to keep me calm. The thought of having to go through that without drugs? NOOOOOOO. How on earth can the insurance companies justify this?
[I did have a wondrous idea, while lying in the hospital bed waiting for the 'procedure'. Since there are so many baby boomers out there who are supposed to be having this procedure every 3 - 10 years: someone should create the "c-scope spa". Check in the morning before the procedure. Have a wonderful morning and afternoon of massages, aromatherapy, etc, and delightful 'meals' of chef-prepared consomme or gelatin. Then retire to your private room and bath for the purgative sessions, with aides on hand to remind you of what to take when. In the morning, instead of having to get out of bed at some awful time to get to the hospital, the nurse comes to your room, picks you up and wheels you off to the scope room. Then back to your room to sleep it off (because drugs will not be denied here). A light lunch brought to the room, more napping, then a cab takes you home. Wouldn't it be wonderful?]

Anonymous Georgette Orwell said...
SeDress, you have a entrepreneurial spirit, and I think you've hit on a fabulous concept! Now, if you just can invent a tolerable prep...

I'm sorry about your dad. An early c-scope saved my life, and I've become a proselytizer for the procedure.

Blogger Dr. Squid said...
I'd like to see the actuarial tables that says that an infant above the 95th %ile is more expensive to cover than a lighter infant. Seems that might be something that can be discovered in a lawsuit.

It's an important question because this could now be seen as a pre-existing condition that could follow my daughter around the rest of her life. (She's 14 months and is probably 29 pounds by now.) If they can use the presence of zits 20 years ago to deny breast cancer treatment, they would deny because of infant obesity as well, no matter how lean she is later.

Blogger Glen Tomkins said...
Wrong assumption

"If colonoscopy is the best way to head off colon cancer at the pass by catching it early, or preventing it by snipping off benign polyps before they can turn cancerous, it's in everyone's, including insurance companies', best interest to make the procedure less traumatic."

Screening colonoscopy can prevent, by our best estimate, roughly half of deaths from colon cancer, which would otherwise be the cause of death for 5-6% of Americans. So that assumption, that screening colonoscopy lowers both human and monetary overall costs, is correct.

What isn't correct is the idea that screening colonoscopy lowers the insurance companies' monetary costs. It would if the insurance companies were responsible for covering the lifetime medical costs generated by their beneficiaries, but their liability ends when folks turn 65, and Medicare takes over. We start doing screening colonoscopy at age 50 or 55 because there is a 10-15 year lag between the appearance of the pre-cancerous polyps whose removal is what creares all the preventive benefit of the procedure, and the developement of these polyps into colon cancer, and colon cancer doesn't really start appearing in any frequency until between age 60 and 65. Its incidence really takes off after age 65. Because of these demographics of colon cancer, the private insurers have a built-in burden shift of the expense of dealing with colon cancer onto the broad shoulders of Medicare. They have no economic interest whatever in preventing colon cancer, because someone else pays the costs, both human and monetary. They probably couldn't get away with just not offering screening colonoscopy, but eliminating the anesthesia, which isn't strictly medically necessary, not only saves money by itself, but has the added effect of making their beneficiaries less likely to agree to screening colonoscopy.

This sort of burden shifting onto Medicare is hardly limited to colon cancer. Most of the burden of most diseases is incurred in age range covered by Medicare, so private insurance lacks any motivation to prevent most of the preventable disease burden.

And the principle has even wider application than that. If we create a public option, it will function as the insurer of last resort. The industry won't even have to wait until its beneficiaries turn 65 to offload the burden of caring for them onto the public. It will have the public option there to take even those members of the under 65 crowd who have become a burden to them.

One of the chief benefits of single payer is that it, systematically and structurally, deals completely with the burden shifting problem.

Blogger Alex Arnet said...
I have stage 4 colon cancer and it could have been treated much earlier by an early enough screening. I now have an inoperable tumor that shouldn't have been given the chance to grow. I waited too long.

My situation is very different, since I live in Canada, but let me impress it upon everyone reading: get the test. It can save your life. There is no going back from my prognosis, but there was a heck of a lot I could have done in the area of prevention. No sermon here, just a simple statement. I may not survive, but you good folks can.

Blogger Batocchio said...
I heard about the baby story this morning on the radio. Crazy.

Best wishes to those in the thread dealing with colon cancer.

Blogger Interrobang said...
Funnily enough, I'd rather have a procedure like that done with the kind of fun drugs that leave you awake than be put under (again). (Get that IV away from me!) I guess that's the difference between never having had a real surgery and having had five.

When I had surgery on my sinuses last summer, I insisted that I be awake for the procedure, so my surgeon was poking around inside my face with a pair of long, thin forceps and I was flying along on five micrograms of Ativan. (That's the drug you want for any procedure like that, for what it's worth -- it relaxes you and makes you all happy, but doesn't make you totally loopy.)

Blogger SeDress said...
Jill: I hope everything went well with your procedure, and that the drugs were wonderful.
Alex: the best sermons are often 'just simple statements'. thank you.

Anonymous Astgtciv said...
By the numbers, Alex is in the 99th percentile for height and weight

Based on 25 inches and 17 lbs, I get a BMI of 19. He's not fat, just big for his age. Being in the 99th percentile in weight doesn't make the kid fat when he's also in the 99th percentile of height....

Anonymous Anonymous said...
The reporter got the description wrong. Going by the CDC charts, Alex is only in the 99th percentile on the weight-for-height chart (an expression the reporter appears to have misunderstood). His weight for *age* is 90th percentile or maybe a little under, with his height being about 50th percentile. Not that it should matter anyway, but it just makes the story even sillier that he does not even meet the "obesity" criterion stated in most of the articles.