A day in my life (health care thoughts)

Yesterday was a sick day. I needed a root canal.

I’ve always thought dental insurance is better visualized as a buyer’s discount club with some minimal insurance features instead of an insurance product with some buyer’s discount club features.  I estimate that my dental insurance has an actuarial value of about 50%.  The rest is out of pocket.

My endodontist started the procedure and about twenty minutes after I had been numbed up and the drill started to go through the crown of my tooth, she stopped and we had the following conversation:

“This is a little different than what’s on the X-ray”

“Is it a problem?”

“No, but I would like to do a scan to confirm the diagnosis, you okay with that?”

“How much would the scan cost and what does it get me?”

“$300 after your insurance pays, and it slightly decreases the chance you are in pain on Saturday”

“What are my baseline odds of pain?”

“Pretty low, I’m good at what I do…”

“Then no scan”

“Okay”

Twenty minutes later, the temporary crown was on and I was walking out the door.  As a health policy researcher and insurance geek, I was impressed with the radical price transparency and the discussion of value as my mouth was being worked on.  As a patient, this is something that I appreciated that I was not surprised with an unexpected $300 charge for minimal gain but it is not a decision that I was particularly able to make well.  I was operating at massive information asymmetry.  I had no way to evaluate whether or not my dentist was telling me the truth on how good she was and whether or not the baseline odds were accurate.

Once I got home, I checked the mail. And joy of joys, I received a revised bill from my son’s pediatrician.  We had taken him for his annual well child/vaccination update visit last July to an in-network provider.  The doctor’s office did not believe he was insured that day.  OOPS!

The HR office made an error on the special enrollment period membership file to the insurer.  He was initially deemed not covered so we got billed for the entire charged amount.  I fought and it took four rounds of phone calls to get everything straightened out.  Now we owe the standard co-pay and I dropped that check in the mail this morning on the way to the kids’ bus stop.

On one side there is radical price transparency fueled by low actuarial value coverage.  On the other hand, high actuarial value coverage required the paper work to work right.  One system worked as designed, I was a hyper informed consumer who decided to not get marginal care and the other took over six months to resolve to everyone’s satisfaction.  This is where we are probably going for health coverage where the insurer is more of a buyer’s discount club but the moment of decision felt like I was still operating under intense informational asymmetry and a power imbalance.  Getting the billing right for my son was a pain in the ass but I had allies from the insurer who do this multiple times a day so information and power were closer to symmetrical.

 

62 replies
  1. 1
    chopper says:

    He was initially deemed not covered so we got billed for the entire charged amount

    that sounds fun. why are there so many zeroes on this number?

  2. 2
    MattF says:

    Did your employer pay you for the time and effort it took to fix the billing issue? I’m guessing ‘NOOOO’.

  3. 3
    beth says:

    Here’s my day in my life healthcare thoughts. I recently went for my annual mammogram. Just received a referral from my gyn, no discussion involved. As I’m standing at the machine the tech asks if I want a 3D mammogram. Tells me that if my insurance won’t cover it (some don’t) I’ll be billed $160 that I’ll have to cover. I ask her why I would need it and she says “it’s better”. I asked in what way was it better and was told it was just simply “better”. I was pretty pissed off – why wouldn’t my doctor discuss this option with me, allowing me to make an informed decision and checking with insurance to see if it was covered before I was standing half naked in front of the mammogram machine wondering if “it’s better” was worth the extra $160? I waited two months for this appointment and already took time off from work for it – I wasn’t about to reschedule. How can you be an informed patient when shit like this happens. Called my doc to discuss it and was told they’d be happy to make an appointment for me – in 6 weeks and I’d probably have to pay for it. This is what makes people crazy about healthcare in this country.

  4. 4
    ARoomWithAMoose says:

    “Operating at massive information asymmetry”. Every proponent of radical free market style solutions to everything kinda glosses over that part.

  5. 5
    Ohio Mom says:

    I suppose it’s heartening that even insurance experts have to spend months trying to get bills corrected.

    I often wonder what the value of all that time and effort is. It isn’t so common anymore but I remember seeing magazine articles on what it would take to replace all the unpaid labor of stay-at-home moms: you’d need to pay a maid, a cook, a child care worker, a chauffeur, a decorator, a gardener, a nurse, a psychologist, etc. The point being that there is a lot of very productive work that isn’t captured by the usual economic calculations.

    How much unpaid labor goes into shoring up our crazy patchwork of a health care system? It has to be significant, added all together. It is both an externality and a waste of resources.

  6. 6
    Walker says:

    I have had similar conversations with a vet. I know vets don’t make as much money as other doctors, but man is the experience so much different than human health.

  7. 7
    Crashman says:

    @beth: This is such a great point. The time you took off from work to get the appointment and the time it took to get one scheduled in the first place just makes the whole process more frustrating.

  8. 8
    Amir Khalid says:

    @Walker:
    I guess the difference is that if you turn a pet animal upside down, you can’t shake as much money out of its pockets.

  9. 9
    frosty says:

    I got charged more than the insurance company markdown price by a provider so I called the insurance company up. To my surprise, CIGNA went to bat for me and for about 3 months whenever I got a letter threatening a collection agency, they said don’t worry, we’ll follow up. The last letter had the reduced price and I paid it. For me the system worked without a lot of effort on my part. This time, anyway.

  10. 10
    different-church-lady says:

    I am going to ask you a very blunt question, and I am not going to spend any time defending it, because it is clearly and patently legitimate:

    Why is incompetence baked in to medical administration culture?

  11. 11
    Bostonian says:

    Re the temporary crown, I recommend switching to a dentist that uses cad/cam for crowns. You can get a root canal and permanent crown in a single visit, and no weird gummy wads in your mouth or temporary crowns. It’s much better, takes less of your time.

  12. 12
    Ohio Mom says:

    @beth: I had breast cancer five years ago, and the first couple of years after my surgery, I automatically had “diagnostic” mammograms on my remaining breast, that is, the more expensive, 3D version (plus the radiologist came out immediately after with the results). The insurance paid.

    Then, since I was getting negative results, I was downgraded back to the regular, cheaper mammogram.

    My internist said it was just as well, less radiation. Last year I brought the topic up with my oncologist and she said I should spring for the 3D. But she wasn’t going to prescribe it, which would make it covered.

    The truth is, the main thing mammograms have going for them is that they are dirt cheap. But they aren’t very detailed.

    They are the medical equivalent of driving in heavy fog. You will *probably* be able to see that there is a car in front of you but you certainly won’t be able to tell the make or model, or even the color. 3D ones provide a sharper image but I don’t know how that is quantified.

    Fun fact: most tumors are eight to ten years old before they are large enough to show up on a mammogram.

    Didn’t I just make you feel better? My favorite part of mammograms is when they offer you the opportunity to buy a five dollar piece of foam rubber to make the squish hurt less.

  13. 13

    @different-church-lady: Cynically, because they don’t have to be that good to get paid

  14. 14
    Bostonian says:

    @different-church-lady: Incompetence is baked in because the fundamental job of medical administration is waste.

  15. 15
    beth says:

    @Ohio Mom: And you just gave me more useful information than either my doctor or the mammogram tech did. It’s maddening.

  16. 16
    Ohio Mom says:

    @different-church-lady: I have also questioned this. The answer I came to is that the entire medical administration system is completely corrupt.

    It is the equivalent of the small town cop operating a speed trap who is willing to skip writing the ticket for a little personal consideration, but writ very, very large.

  17. 17
    Humdog says:

    I fought with my medical provider for 16 months over them not properly crediting both a copay and two insurance payments on my bill. Each time I wrangled with them by phone, I was told they saw their error and would fix it. Then I’d get a collection notice in 30 days. I’d call again, they’d admit error then send the same damn bill. They finally sent the bill to a collection agency at the same time I was trying to refinance my mortgage, so I paid them their extortion fees. Grumble. Glad I could scrape the $ together but supremely ticked about it still today.

  18. 18
    Fake Irishman says:

    Wait: Why did you end up owing a co-pay for a well-child visit and immunizations? Wouldn’t those be zero-dollar under the HHS definition of “preventive care”?

  19. 19
    Nicole says:

    Oh, the billing mistakes… I had a double mastectomy and reconstruction in 2016, with a surgeon in-network, and, I assume, due to an error in code or who knows what, got a $23,000 bill in the mail a year later. Over the next nine months, numerous calls were made by me, my husband (insurance is through his work), the lovely person at his work who works full time dealing with claims, and the doctor’s office, and increasingly threatening notices about this bill arrived in the mail for me, until, in July, they removed the charge, leaving me with an outstanding $40 copay for something or other, which I paid. Then, this December, what should reappear, like a bad penny, but this charge, minus the $40 co pay. Cue Round Two of calls from me, my husband, the lovely person at my husband’s work, and the doctor’s office. Not to mention, the invoices ALWAYS, ALWAYS arrived on a Friday afternoon, so that the entire weekend could be spent worrying about it.

    Add to that the fact that the company that manages the health savings account always, always, always rejects EVERY SINGLE CHARGE (I mean, “Oncology?” How do they KNOW that’s for an appropriate medical reason? Maybe I’m buying DVDs!) until we send in paperwork (months later, when we find out they’ve rejected the charge because we’re getting invoices from the medical offices).. oh, man.

    And yet, I’m grateful that the insurance we have covers most of what we need. And I’ve learned how folk deeply in debt start to ignore it, because after awhile I started getting numb to all the invoices for a bill we couldn’t afford.

  20. 20
    Droppy says:

    I fought and it took four rounds of phone calls to get everything straightened out.

    You are in the top .00001% of people who know stuff about medical insurance. And still, 4 rounds of phone calls. I have one kid with a mental health condition and one recovering from a car accident. I am swimming in claims and out-of-pocket this and not-in-network that and bills and collection agencies. I’m not stupid, and I try to keep up with it all, but the complications and the relentless unhelpfulness built into the system are going to kill me (well, first they are going to bankrupt me, and then kill me.) So, the next time Paul Ryan wants to tell me about the socialist nightmare of European-style medical care, I am going to give him a wedgie.

  21. 21
    guachi says:

    Every story I read makes me glad I’m in the military. They can screw up, but at least billing is never an issue.

  22. 22
    Gin & Tonic says:

    @Droppy: My son lived in Canada for a few years, first on a student visa, then on a working visa. One year he got very seriously ill, and spent 10 days in a major teaching hospital. He got excellent care, and everything worked out well in the end, although as part of his treatment he was getting infusions of something called, IIRC, rituximab. Which costs many thousands per infusion. He was getting them for a few months.

    I never even saw a bill. Paul Ryan can DIAF.

  23. 23
    Ohio Mom says:

    @beth: Glad to be of help.

    As a breast cancer veteran, I think Dr. Susan Love’s advice remains the best: know your breasts. She doesn’t mean, be religiously rigid about doing a self exam on the exact same day every month, grimly conducting military-like reconnoissance. Your breasts are not enemy territory.

    Learn what they — and the rest of your body — is like throughout time. Make yourself comfortable with yourself. You will be better able to notice when something is off.

  24. 24
    WereBear says:

    @Walker: We should all start going to the vet. They use the same drugs and procedures a lot of the time :)

    The number and complexity of hoops I jumped through to get an official diagnosis was incredible. After encouraging me to get it, the insurance company then turned around and wouldn’t pay for it. But most astonishing was the astonishing difficulties in using my Health Savings Account to pay for it instead. Stunning levels of complete incompetence. And this is after 20-40 minutes of just getting to someone, much less the right person.

    If I charged my normal consultation fee for all this, they would owe me money, of course.

  25. 25

    Sigh. None of this is ok and the fact we walk around thinking it is ok to pay the amounts we pay in insurance and copays and still go through all this is remarkable.

  26. 26
    oldster says:

    “I was a hyper informed consumer”

    It’s very rare that a statement including “hyper” can also be a gross understatement, but this is one.

  27. 27
    Monala says:

    Dave, I know several people whose health insurance policies have been unexpectedly cancelled recently, without any apparent reason. Have you heard about this trend?

  28. 28
    Leto says:

    As someone who just got out of the military a year ago, after 20 years in, and now having to figure out which insurance company to go with, who’s “in-network”, copays, is this covered???… it honestly makes me and my wife’s desire to head back to Europe a hell of a lot stronger. I’m a gov employee now and my introduction to market based health care was basically a few power point slides on how to sign up. Not really too much education/information past that. Went with BC/BS because it seemed like the best option of the choices I had (I guess?), and because most of the people in the office had it too.

    I’m thankful we haven’t had to deal with anything for the past seven months, but we’re also a bit worried when the time comes because we understand how much we don’t know. I honestly miss my “soshulized” medical system. The mil system has it’s flaws, but it’s so much easier.

    Edit: @guachi: Know exactly where you’re coming from; how long until retirement?

  29. 29
    beth says:

    @Gin & Tonic: My spouse is battling cancer. He’s generated over $400,000 in medical claims since November alone and this has been going on for five years. I refer to the 2-3 hours per month I spend dealing with insurance companies and collection services as my “part time job”. While I don’t wish harm on anyone, I would be tempted to toast a marshmallow in that Ryan fire.

  30. 30
    Leto says:

    @guachi: Know exactly where you’re coming from; how long until retirement?

  31. 31
    Monala says:

    @Ohio Mom: it took years of asking doctors this question about breast self-exams before I got an answer: “My breasts are lumpy anyway. What am I supposed to feel?”

    Their answer generally was, “You’ll know it when you feel it,” which is not an answer at all.

    It was finally a nurse who told me, “Squishy lumps are fine. If you feel a hard lump that doesn’t give when you press it, that’s when you should be concerned.”

  32. 32
    opiejeanne says:

    @Ohio Mom:

    they offer you the opportunity to buy a five dollar piece of foam rubber to make the squish hurt less.

    What? I’ve never been offered anything like that.

    I truly hate having to go in for a mammogram, and not just because it usually hurts so much but at least Medicare picks up the ridiculous bill now; our insurance didn’t cover much of it.. I know that they are an inefficient method of detection because a tumor could become visible the next day and spend a year growing before the next mammogram. I self-examine but I’m not sure if that is more likely to detect a tumor.

  33. 33
    WereBear says:

    At least there is abundant information and patient advocates out there on the Web. The horror would be worse if we were all trying to wrestle with such challenges without at least some knowledge to guide us.

    Like the way medical professionals tend to not brief anyone on possible side effects if we go with this drug or that procedure. Informed choice is a joke in such cases. I have run across many people whose condition cleared up, no thanks to the medical intervention that is now the item causing them health problems.

  34. 34
    Nicole says:

    @opiejeanne:

    I truly hate having to go in for a mammogram, and not just because it usually hurts so much but at least Medicare picks up the ridiculous bill now; our insurance didn’t cover much of it.. I know that they are an inefficient method of detection because a tumor could become visible the next day and spend a year growing before the next mammogram. I self-examine but I’m not sure if that is more likely to detect a tumor.

    Yeah, that’s the rub. Tumors come in all kinds, and some are really fast growing and some are so slow that even after being detected in a mammogram, they likely would not ever turn into anything serious, but women go through aggressive treatment anyway. At this point, mammograms are the best we have for a very confusing disease. Twenty or thirty years from now, cancer detection and treatment is liable to look very different, because gene therapy is, I hope, going to be farther along, and science will also, I hope, be able to make better predictions about which tumors are going to do what.

    In my case, cancer was found after a mammogram in one breast, but gene testing results showed I had a pathogenic gene that came with a high chance of cancer eventually showing up in the other one, so I made the decision to get a double. Which sucked, but I’m glad for gene testing because it helped me feel I was making the most informed decision I could at the time.

    I’m also glad for the WHCRA, passed in 1998, which requires most insurance to cover the cost of reconstruction afterwards, including making sure both sides look symmetrical. I am absolutely sure that is a benefit that insurance would cheerfully jettison if they could.

  35. 35
    dr. bloor says:

    @different-church-lady:

    Why is incompetence baked in to medical administration culture?

    The key word here is “administration,” not “medical,” because you can fill in the blank with any word other than “medical” and it will be as true. This is particularly true in large, multiparty interactions (patient, insurer, professional) where a noodnik in front of a screen might be at as big an information disadvantage as any other party.

    You’re understandably more anxious about and sensitive to it when your health is involved, but it’s ubiquitous.

  36. 36
    Ohio Mom says:

    @dr. bloor: No, I think this is different. I’ve had my go-arounds with many bureaucracies, I’m in one now with the state voc rehab agency on behalf of my son.

    But they do not have the financial incentives health insurers have when it comes to minimizing and denying coverage. No voc rehab caseworker is going to ever get a bonus for turning down the most cases, as happened a while back with one of the big health insurance companies.

  37. 37
    CarolPW says:

    @opiejeanne: I found each of my tumors (20 years apart) and even though they knew where the things were they could find neither on the mammograms. And when I felt the first one, I knew it was A Very Bad Thing. Since the second felt like the first, it was obviously Bad Thing #2. Two mastectomies so no more mammograms and no more self-exams, which is a relief.

  38. 38
    Cermet says:

    I understand the pain a little better for woman who get mammograms. As a male, who works out and has little body fat, I discovered a large cyst under my left nipple (not really surprised – a really nasty poisonous spider wound on my lower back was the ultimate cause – long story.) The doctor freaked thinking it was cancer and so, ordered a mammogram (I, instead, suggested cutting it out – that idea didn’t fly.) After the test, the doctor agreed it was a cyst. Decided against removal but a antibiotic did the trick. All I can say is, those mammograms hurt and you ladies go through hell for them.

  39. 39
    mozzerb says:

    Well, I can certainly see why British conservatives want to replace the NHS with a US-style system.

    Seriously, this stuff sounds like a nightmare. How is anyone supposed to navigate their way through it?

  40. 40
    WereBear says:

    @mozzerb: How is anyone supposed to navigate their way through it?

    That’s the thing; if you are sick and give up, they make more money.

  41. 41
    opiejeanne says:

    @Nicole: I didn’t know insurance did or didn’t cover reconstructive surgery. That’s a good thing, and you’re right, insurance companies wouldn’t cover it if they didn’t have to.
    I had a friend who opted for reconstruction after her treatment was successful. That was in the late 80s. A lot of her friends were angry that she was doing this, felt that she’d bee through enough pain and surgery and didn’t need to do this to herself. They blamed her husband but I thought she did it for herself. Me? I’d probably not opt for reconstruction or at least go for daintier ones on a rebuild. My blouses would fit better either way.

  42. 42
    opiejeanne says:

    @CarolPW: My mother had benign cysts which scared the pee-waddin’ out of us when she was treated for the first. Dad was picking her up at the hospital after she recovered from surgery on November 22,1963. To say I was already distracted that day would be an understatement.

  43. 43
    opiejeanne says:

    @mozzerb: When we had Kaiser Permanente it was never an issue. Second and sometimes third opinions were automatic, all labs, surgeries, treatment programs were covered and the only thing out of pocket ever was your very minimal co-pay, $10 when we left. All the prescriptions were around $5 except for the very expensive drugs I needed when I was treated for Hepatitis C in 2005, and the pharmacist was very apologetic that I would have to pay $30 for them. I saw the invoice for the wholesale cost of these drugs, Interferon and Ribavirin, and it was several thousands for a single month.
    We didn’t leave willingly, they figured out that we now live too far from their nearest clinic.
    Now that Kaiser is moving into the Seattle area we are waiting for our insurer (through our retirement) to allow us to return to their care but they haven’t yet added the expanded territory. We have Blue Cross/Blue Shield Anthem and I can say that they truly suck, but probably not as bad as other systems. I see that Aetna has themselves in a jam right now in California.

  44. 44
    gvg says:

    the other problem is when you are sick for a long time such as 6 months of chemo, you can’t deal with anything complicated or requiring endurance. Too much info can just confuse. drugs can confuse the mind, so can pain. this is the real reason many of us would like a national health care. we just don’t see the point in this confusing inefficient mess of billing and always changing rules. All we want is to go to the doctor and the pain to stop. Not a medical degree, not a run around in paper and never bankruptcy.

  45. 45
    VeniceRiley says:

    I understand what you mean in re “discount club” feeling of Dental. But the real discount club is VISION. Amirite?
    I am in the fortunate position of working for a large FQHC that I am allowed to pick for (Assurant HMO) primary care. I use PPO for Dental.
    But I have no copay for anything. We have medical, dental, and pharmacy; and I have an army of coworkers whose job it is to get any specialist referrals covered, etc. I feel very lucky.

    Anyway, back to vision. Exams covered, but good luck getting an amount that would cover a whole pair of glasses with the Rx. Maybe enough to cover a simple rx single vision plastic ugly frame pair with no coatings. Boo!

    Another story from my consulting days: I was uninsured and had a growing marble sized growth on my finger. Paid for my own hand surgeon … and they had me call the hospital billing mgr ahead of time to negotiate in advance. For cash, I think I got 30 days net 60% off or something like that. On the entire bill right down to the drugs-to-go. Anesthesiologist paid separately with check in hand before surgery started, of course. Geez, those guys!
    So, if you’re uninsured or not covered and not in an emergency situation, some places will cut you a break in advance. You just have to have the ALL cash for it within a month. This was at Torrance Memorial. Maybe they do that because they’re so close to Little Company of Mary and all the docs have privileges both places? It was a long time ago … maybe 2003? It was a huge wallet help for sure.

    PS – Got my mammo and need to note there was only a slight discomfort. NO PAIN. In and out in a half hour! Don’t be scared, ladies. Just get it. It’s no biggie.

  46. 46
    CarolPW says:

    @opiejeanne: Wow – talk about bad omens. I hope the surgery was all over before she heard the news because you don’t need to be having an operation on a day you know is already totally fucked.

  47. 47
    dr. bloor says:

    @Ohio Mom: We don’t know about Richard’s four calls, although this wasn’t a case of an insurer denying clearly covered services. He stated himself that his HR department initially screwed up, so the widgets in front of the terminal most likely had incorrect information, at least at the outset.

    I spent 75 minutes on the phone a little while back trying to get a preauthorization for a patient across state lines, and for procedures that spanned the 2017 and 2018 calendar years. I got kicked around between four or five different people until I finally hit the one with sufficient info, who cheerfully told me that it would be no problem at all. My patient gets 10 hours of my time for a $15 copay, the insurer pays a covered service without any malice or recalcitrance, and I’m out 75 minutes of unbillable time. This sort of Rube Goldberg nonsense happens far more often than incentivized denials for procedures that are explicitly deemed to be payable in an insured’s contract.

  48. 48
    opiejeanne says:

    @CarolPW: The surgery was the day before and we were all relieved but there was that remaining fog of worry that doesn’t always just evaporate right away. I think they were in the car when they heard but I don’t remember.

  49. 49
    gene108 says:

    @Droppy:

    So, the next time Paul Ryan wants to tell me about the socialist nightmare of European-style medical care, I am going to give him a wedgie.

    Sad thing for us is, is guys like Ryan never slogged through working in the private sector. He has no clue what it’s like to not have good government insurance, and he wants to dictate what he thinks is good for us. I hate him.

    *******************************************************

    My mom officially retired last month. She worked as an electrical engineer for the last 40 years.

    She moved from NC to NJ to be closer to me and my brother, who lives in NYC. She fixed an appointment with a PCP for a routine check-up. The PCP works out of an office park, which is linked to a local hospital. I think they are all part of the same building. The PCP referred my mom to the in-house radiology lab at the hospital for a mammogram. My mom went to the lab and fixed an appointment for some time later.

    We were talking about her appointment during lunch. She told me the hospital and physician are in-network. The name of the radiology outfit was different than the hospital. She figured, since it was all under one roof, they are all part of the same organization and thus in-network.

    Having been the person at my employer, who helped get other people’s claims resolved with the insurance, I realized the radiology outfit is different than the hospital, because the names are different (I had to resolve issues with hospitals being in-network and doctors/surgeons being out-of-network and angry employees wondering WTF was going on with their claims).

    I told her to double check with the insurance, if the radiology outfit is in-network. She did. They are out-of-network. It never occurred to her that such a thing is possible.

    My mom is a well educated woman, who is very capable. She has also been healthy (she takes really, really, really good care of herself) and not had much interaction with dealing with medical issues, and their subsequent bills, and insurance screw ups.

    She was blindsided by the fact outfits operating in hospitals, which are in-network, are just renting space there and maybe out of network for her.

    The level of information asymmetry is not just about evaluating the value of procedures, but even in determining what is and isn’t covered by the insurance.

  50. 50
    Ohio Mom says:

    @opiejeanne: Thankfuuly, medical science has advanced. In the 1960’s, biopsies were done on the operating table, and if the results weren’t good, the doctors did a mastectomy right then and there. Women didn’t know if they would come out with two breasts or one. It *was* scary.

    Nowadays it is a multi-step process, involving various types of scans such as sonograms and MRIs, and out-patient biopsies done with only local anesthesia, all to determine if it is indeed malignant, as well as other details, before the various surgical options are discussed. All that technology did not exist in your mom’s day.

    @opiejeanne: It is something of a quirk that there is a law covering breast reconstruction m. A nice quirk, but a quirk nonetheless.

    If you opt for a prosthesis, as I did — which was about $300 — or develop lymphedema as I did, and need to spend hundreds of dollars every year on compression garments and other supplies, then there is no law with teeth.

    Supposedly insurance should pay for foobs but they conveniently have very few network contracts with prothesis shops. So you buy them out-of-network, and it is only covered if you have already maxed out that deductible. Which I suspect most of us do not, ever.

    Lymphedema activists have been trying for years to get Congress to require Medicare to pay for compression garments to no avail. The idea is that if Medicare pays, private insurers will have to as well — I don’t know if it works like that or not. I just know that Congress has yet to budge.

    Anyway, I can’t help but think this quirk has more to do with American culture than compassion or ethics.

  51. 51
    SC54HI says:

    Re: root canals. All portions of the procedure are covered by our dental insurance, with our co-pay at about $250. I’ve had two — one with a diagnostic xray at the endodontist’s, the other without — and they had the same co-pay. Both my regular dentist & the endodontist prefer a temporary crown & recommend waiting at least a week to be sure all infection is gone before having a permanent replacement crown or restoration.

    Re: enhanced digital tomography for mammograms. After a scare with “something” seen on an xray over 10 years ago (turned out to be nothing after biopsy) + dense breast tissue, I’ve chosen to have the enhanced scan for annual mammograms once it became available. The additional charge is $36.00, which I pay, while the cost of the standard mammogram (listed as the “retail cost” in the insurance company’s statement) is $373 and completely covered. There is an additional cost from the radiologist who reads the results. It is also covered completely by our insurance & is said to be $123.

    I am insured through the spouse who is a union member. Our insurance is a BC/BS affiliate. We had Kaiser for many years (and were happy with it) until DS went to college. He was in a location where Kaiser doesn’t have a presence so they would only pay 75% or so of emergency costs, nothing for check ups or preventive care, so we switched to BC/BS to be sure he had access to non-emergency care.

  52. 52
    bobbo says:

    The best my dentist can tell me is “this crown will cost $750 if insurance decides to cover it; $2000 if they decide not to.”
    They don’t seem to know ahead of time if insurance will cover it.

  53. 53
    ProfDamatu says:

    @opiejeanne: Oh, that would have pissed me off royally if anyone had suggested that I had my reconstruction for anyone other than myself! It’s funny how some people, even other women, don’t realize how much a part of your self-image breasts can be. I think the fact that having the mastectomy is usually not truly optional plays into it as well – having cancer (or a BRCA mutation) is out of your control, but you *can* control how you look afterward to some extent. Having said that, I also realize that I had a much easier reconstruction road than most; my cancer was very small, and its location allowed me to have a skin-sparing, nipple-sparing procedure on the cancer side as well as the normal side, enabling me to have immediate reconstruction with implants. (I was kind of amused that right around the time I had my procedure, there was a story on the Today show about this awesome new immediate reconstruction option…my surgeons had been doing it for about a decade at that point, and I’m in a small city! Just goes to show how contingent and random care can be; sometimes, even out in the boonies you can get advanced procedures if the right providers happen to be in the area.)

    My two cents (not that anyone asked, lol) on the self-exam/mammogram discussion from above…like others have said, I think the key is knowing what’s normal *for you* in terms of the self-exams. My breasts were always lumpy, but I knew them very well, so when the tumor showed up, it was lumpy in a new, different way. Like many patients, I found my tumor in the shower rather than during a self-exam, but all those semi-monthly exams enabled me to immediately tell that something was wrong. Oddly, the tumor wasn’t visible on the mammogram I had a few days after finding the lump, despite being easily palpable (very obvious on the follow-up ultrasound, though). Conversely, my baseline mammogram back in 2012 revealed a fibroadenoma that I hadn’t felt at all…and it was larger than the 2016 tumor. (Interestingly, my breast cancer was completely contained within a fibroadenoma. The radiologist who did the biopsy was convinced the lesion was a fibroadenoma, and was super-apologetic that he had to go back in a few days later to put in a clip when it turned out to be cancer…but then the full pathology showed that he wasn’t entirely wrong! Only the second such case my surgeon had encountered in like 20 years.)

    There’s a lot of somewhat controversial research out there about the value of mammography, especially in terms of the age at which screening should start as well as screening frequency. Whatever changes in practice end up getting made, if any, my first-hand perspective is that probably the most important thing you can do for yourself is to know your body, know your breasts, starting at a young age, because not everything shows up on a mammogram. I think it can also potentially give you the confidence to advocate for yourself more strongly.

  54. 54
    J R in WV says:

    @beth:

    Regarding your mammogram, here in prehistoric West Virginia both my wife and I are able to walk in to the Imaging Center associated with the hospital where our family Doctor practices same day or any day it is convenient for us for chest xray, mammogram, joint diagnostic, whatever.

    MRI takes a little longer, like next Tuesday. Would explore other options if it took more than tomorrow, personally, we’re talking cancer with mammograms where days can count.

    Hope your was clean!

  55. 55
    J R in WV says:

    @Ohio Mom:

    …..My favorite part of mammograms is when they offer you the opportunity to buy a five dollar piece of foam rubber to make the squish hurt less.

    Never offered one to me when they needed to squeeze as much as they could. I didn’t have much to work with but they managed. Negative results, negative needle biopsy, which really stung when the local wore off….. yes, guys get them too.

  56. 56
    ProfDamatu says:

    @J R in WV: First, if there’s something going on with you or your wife, I hope all turns out well! But I did want to note, as someone who’s had cancer twice and had to be talked down from the ledge both times…outside of a small handful of cases (which, for breast cancer, are usually rather apparent), delays of a few days here and there are generally unlikely to make much, if any, difference. I’m a major health worrier, so I am emphatically NOT trying to downplay or dismiss anyone else’s worry (I just about went nuts waiting the two weeks between lymphoma diagnosis and the surgical biopsy needed to retrieve sufficient tissue to ascertain the lymphoma type). However, if you do get that diagnosis…of course you don’t want to drag your feet, but it’s really important to take enough time to process what’s happening and carefully consider your options. I was “lucky” in that my mutation status and body type all but made my surgical decisions for me; other women may want to take a few days to weigh lumpectomy vs. mastectomy; type of reconstruction if any; and so on. Having said that, when it’s not just screening it’s worth pushing a little to get the diagnostics done as quickly as possible, if only to cut down the amount of time you have to be anxious!

    “…prehistoric West Virginia…” lol! I’m in the Shenandoah Valley over the mountain from WV, and in my town we actually have similarly speedy imaging services. I’ve speculated that we’re in kind of a sweet spot here – although there are only about 50,000 people in my town, there’s enough population in the county (and neighboring counties, including a couple in WV for whom this is the closest hospital…and now you can probably guess my location!) to support having the full range of medical services available. Enough population to have almost everything you need…but not so much population that there are delays in getting appointments. Just about the only thing that I’ve encountered that’s involved substantial delays is a dermatology appointment; I think we only have maybe 2 or 3 derms in town.

  57. 57
    Capri says:

    @WereBear: Veterinarians are notorious for treating themselves, I’ve heard of one who did his own vasectomy.

  58. 58
    J R in WV says:

    @ProfDamatu:

    No worries about me or Wife, in the long ago I had pain and tenderness, a mammogram AND a needle biopsy, no downside but the pain after the local wore off. Wife gets standard occasional mammograms, cancer doesn’t run in her family, little cancer in either of our families. Arthritis, on the other hand, is wearing me out!

    Charleston has a branch of WVU med school at one of the main medical campuses, is one of the three major medical centers in the state so serves many counties of rural state. Our family doctor is a bit of a character, also a musician, has been our doctor for 40 odd years, some of them very odd. He’s from a very rural location, where people who knew him as a kid come from to see him. I have seen people carrying crates of farm produce, canning jars mostly, back into his private office, gifts I assume, or perhaps payments. Atypical but sweet.

  59. 59
    J R in WV says:

    David,

    I hope your mouth is comfortable today. I’ve never had a root canal, have had some extractions, some crowns, but I understand the root canal is the evil king of dental procedures.

    Best of luck with the temporary, hope the new tooth stays put well and good.

  60. 60
    EthylEster says:

    I just got back from the dentist. I had a great one for over 20 years and then she decided to merge with another practice so she could work 2 days a week. The office staff of the “new” practice cannot determine accurately costs of proposed future work so I’m given one figured beforehand and then get a bill for significantly more. The folks at the “old” practice never made an error in this regard. Also, too, the new practice tries to upsell…sort of like Mr. Anderson’s story. And don’t get me started on all the cosmetic stuff they market. I just want my own teeth til death. Having the whitest ones is pretty much irrelevant to me.

  61. 61
    Daddio7 says:

    @bobbo: Where are you? I live in north Florida near St. Augustine. I do not have dental insurance. Last year I had to replace three crowns. They had decay under them and were so well fastened they had to be cut off. New ones were $900 each. One tooth needed a root canal when the decay proved to be too much. The endodontist drilled through the new crown to do it. He put in a temporary filling, that was $1000. A month latter my regular dentist put in a permanent one, $120. I guess dentist work cheap here.

  62. 62
    Daddio7 says:

    @J R in WV: I will chime in again, I have had eight or nine root canals. As long as the Novocain doesn’t wear off no problem. They just take so long it wears off. I had one endodontist who hooked up a miniature IV to the site. Unfortunately for me I have developed a choking phobia and need oral sedation. One and a half Halcion takes away the fear and makes you continuously forget what he just did. Valium does nothing for me but with the Halcion no problem, Also the last endodontist was highly skilled and worked (at least it seemed to me) very fast. When done I was able to carefully walk to the car. My wife drove.
    I have had two teeth with root canals and crowns get infected and have to be extracted. These were done when I was in my late thirty’s and lasted about twenty years. I do know if any of my teeth need a root canal and a crown now I am just getting an implant instead.

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