Halloween Horrors

Paul Gross

One October evening last year, I went to our local pharmacy to pick up a prescription for my daughter. I made sure to bring Cara's insurance card because my employer had switched us to a new health plan.

I wasn't sorry about the change. Our prior plan had been operated by incompetents--although they might only have been crooks, I couldn't be sure--who also managed our flexible spending accounts. These accounts, you may recall, collect pre-tax income from your pay and then return it to you to pay for out-of-pocket medical expenses.

With that plan, nothing ever worked as advertised. I would submit a dental bill for reimbursement and the company would review it for three months before sending me a denial notice, stating that my health plan had no dental coverage.

"I know that I have no dental coverage," I'd tell the representative on the phone. "That's why I put a big X in the box labeled Flexible Spending Account."

"You sure did!" she'd say cheerfully. "I don't know why they did that. You'll have to submit it again. This time, put my name on it...."

Or I'd submit a claim for a medical expense that was covered, then hear nothing for months and months.

"We've fallen behind," a weary-sounding representative would lament. I could picture the ceiling-high stacks of claim forms swaying on her desk. "You should be hearing shortly..."

No one ever said "I'm sorry." No one ever acknowledged the annoyance of the paperwork or the aggravation of waiting on hold for a representative. No one ever said, "Gee whiz! We hoped you wouldn't notice, because if you forget to contact us, we get to keep your money," although I suspected that this was one of their operating strategies.

So I was happy with the change in health plans. And there at the pharmacy, I optimistically produced my daughter's new plastic card.

The pharmacist punched something into a computer and stared impassively at a screen. After several minutes, I wandered off to look at vitamin capsules and cold remedies.

When I returned ten minutes later, the pharmacist was on the phone with my insurance company. Ten minutes after that, he was on hold for a different company, the one that manages the pharmacy plan.

While the pharmacist waited, I browsed the magazine rack. Then I made my way to the Halloween aisle, where I saw candy similar to the trick-or-treat leftovers desiccating in our freezer since the previous October.

The pharmacist finally beckoned and rendered a verdict: "Your daughter isn't covered under your pharmacy plan."

"What?"

"They've got you on their system, but no one else in your family."

"I can't believe..."

"They say you've got to talk to your benefits representative."

I thanked him for his thirty minutes of trouble. The next day I called my benefits representative, who reassured me that our entire family was in their system. Days later, my wife tried to fill a prescription--no luck.

The following pattern repeated itself over the next few weeks: (1) I'd call my benefits representative and receive assurances that the problem had been fixed; (2) we'd try to fill a prescription for my wife or daughter; and (3) the pharmacist would tell us that she wasn't in the system. Finally, weeks later, somebody somewhere flicked a switch and--voila--the pharmacy plan kicked into place.

Which brings me to the upcoming presidential election.

One of the candidates for our highest office is advocating new deregulations that would encourage Americans to comparison shop for health plans in all fifty states. This is nifty, if your idea of a simpler, more efficient health system is more health plans.

My first reaction was: who has time to spend evenings and weekends comparison shopping for health plans in all fifty states? And who wants to repeat the shopping trip in a year, when a plan's sticker price is sure to go up? Each change in plans, of course, means new cards, new forms, a new list of covered doctors....

The last medical comparison shopping I did was to hunt online for a Medicare Part D prescription drug plan for my 83-year-old mother. It was a nuisance. Years later, she's still using the same plan. Not because it's still the best for her--who knows?--but because it's just simpler that way.

The suggestion that some nimble shopping in a health-plan emporium is going to fix our health-care system would never occur to anyone who's wrangled with prior authorizations, changing doctors when one plan flips to another, or getting inappropriate bills because last year's insurance company was incorrectly charged for this year's blood tests.

Most people understand that each new plan--even a better plan--is a new bureaucracy. One more snarl in a tangled health-care web that already boasts hundreds of commercial health carriers and thousands upon thousands of different plans.

The only person I can imagine embracing a "more-plans-the-merrier" system, aside from insurance investors, is someone to whom it won't apply. Someone like our current presidential candidates--who as senators have a government-financed insurance menu that appears to suit them just fine.

For this Halloween season, the notion that we should flood the nation with more health plans seems like a horror-film plot rather than a long-term strategy for better health care.

Once Halloween is over and we put away the costumes and candy, I could go for fewer health plans. Fewer phone numbers. Less rigmarole. And an end to evenings spent wandering the pharmacy aisles, waiting for an okay from Health Plan Number 3,011.


About the author:

Paul Gross MD is founding editor of Pulse--voices from the heart of medicine.

Story editor:

Diane Guernsey

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