I just checked my certificate of insurance with HealthNet online and lo and behold! there is now an attachment which is new and which we never received (and subsequent to my and others' appeals) entitled "Evaluating New Technology."
They claim they depend on the Hayes Technology Assessment Manual to determine whether or not a device is investigational and depending on Hayes' rating, may use other sources. I googled Hayes and found that this is the equivalent of an "independent medical examiner"
staffed by master's and doctoral level employees and nurses. The closest thing to a medical doctor on their staff is a veterinarian.

Aren't insurance company shams grand?

What a joke...sorry you were screwed and insulted at the same time.

Sorry to hear this B. The way you write makes this sound both funny and horrible..

Best, Allan

Thanks, Justin and ans. Just to clarify, this is an amendment to our certificate of insurance which has appeared subsequent to my appeal. They have also expanded the written policy regarding artificial disk replacement which they still consider investigational and which now includes some of the incomplete and erroneous wording that appeared in the "independent review" of my appeal. My one consolation is that my appeal may have caused some anxiety (because it was very, very good and thorough) and someone at HealthNet decided they had to cover their a***s--although those a***s look pretty bare to me!

I can only hope that the party that claims they are Pro-Life realizes what life means. It is not just being alive that counts. It means life sustained.

I am always amazed at the talking out of both sides of one's mouth that politicians engage in and I blame them for the mess the health care industry is in. When I hear that a party want's government small, so that States and individuals can have more rights, it reeks of another motive entirely. Let's keep government small, so as to have no oversight and, business can thrive at the expense of people.

As long as profit is king, people will suffer.

I am sorry for the nonsense you've gone through to get your health cared for. Really pays to have insurance when they seem so opposed to your general well being.

Terry Newton

It's a shame what level politics has degenerated to in this country, but there are different views to every problem. In my mind, small government means less expensive so I get to keep more of the money I earn rather than have it taken to be given to someone else. Unfortunately, neither major party is the least bit interested in small government.

As for insurance companies, they can be fired. I changed jobs to see if a new insurance company would mean approval. I realize not every can do that but some simply don't WANT to do it. My new insurance company claims they cover the procedure, we'll find out for certain in a couple of months. I would like to see employees be more proactive in trying to get their employers to move to better insurance companies.

The profit motivator does seem to be hurting the insurance industry. But there are good companies out there that have managed to make money and provide good coverage. But the problem is more than just the insurance companies. Too many people still go to the ER for everything. Everything. That's expensive and wasted money for the insurance company and wasted time for the ER. People do it though because they don't want the inconvenience of making a Dr's appointment or trying to find a walk-in clinic. That or they just don't know better. Ignorance is bliss I suppose. This country also needs malpractice reform. We have a friend who's an anasteatheoligist(sp?) and his malpractice insurance, paid for by the hospital, is several times his salary. That's insane. We also have a friend who was successfully prosecuted on a malpractice claim when the patient died because the patient didn't follow the Dr's advice. The claim was that the advice was not clear and/or forceful enough. People are even suing OB's for malpractice because they unexpectedly had a baby born with down syndrome.

The problem is multi-faceted and there is no single solution to the mess. We can't simply point to insurance companies and scream they're the problem(not saying you are Terry, I just know some people who do). There are problems with Dr's, insurance companies, and patients. I'd be more in favor of a plan that lets us, as consumers, pick and choose our insurance company rather than our employer picking it for us. For instance, states could mandate that any insurance company offering insurance in said state would have to offer insurance as a group plan to the entire state. Employers could still offer an insurance allowance as part of their benefits package, and consumers could pick the company and plan offering that fits their needs. If we could enable that plan(more detailed to be certain) it would allow the better insurance companies to thrive and give us the opportunity to fire them when they suck.

Ok, sorry for the long post and rant off :).

Many who go to the emergency rooms in our area do so because they have no health care coverage at all. Hospitals have to give away a certain amount of charitable care to keep their non-profit status. Patients know this and go to the Emergency room as they know they cannot be turned away. As the economy worsens this situation will get worse. This is a catastrophe in the making. Here's one article I found to verify my story:

http://www.commondreams.org/headlines01/0509-07.htm

I also have worked in the health care field for years. I understand about medical malpractice as I have been sued before under my professional liability plan. Even though no one won in the case it was still traumatic for all involved.

I support tort reform with reason. I believe there are some frivolous lawsuits though, there are many with merit as well. That is why I believe in a trial with a jury hearing the facts, supporting arguments, and, award settlement. I would hate to see a system where companies, physicians, other entities could practice with impunity. In the State of Michigan; John Engler, past governor ensured that the pharmaceutical companies cannot be sued in our state. This can only occur in Federal court where the client is assured of losing. So the people hurt in the Viox cases throughout the country could collect due to negligence but, not in Michigan. I hate to see the little guy get squashed and big business gets away with whatever they want with immunity. It's a lousy system when the little guy gets victimized over and over again.

I have also made my case very well known on the forum here. A dog ran in to my bicycle as it was not on a leash. I went end-over-end and shattered my clavicle and destroyed my spine. You can only sue someone for their policy limits and nothing more. The stories you hear about people getting rich are ones where big businesses are liable. The homeowner had $100,000 policy. My settlement was still not enough to cover my expenses. I shelled out $74,000 out of pocket to cover all of my medical costs, bicycle and clothing reimbursement, physical therapy, medications, etc.

Tort reform will benefit insurance companies, who are already wealthy, and corporations who have probably been proven at fault in court or, settled out of court to take care of the case.

The homeowner's insurance company was State Farm and they refused to talk to us in any way, shape or form. They forced us to sue and played hard ball every step of the way.

Most believe in all of the hype about the McDonald's coffee suit. When you get injured it's another story entirely. All I wanted was money, that taken out of my retirement plan, to get me back whole, to be replaced. Without the money being replaced I would never be able to retire.

Terry Newton

I see and agree to some of your points. I never advocated a complete absence of liability, but think reasonable limits should be set.

It's good that you brought up pharm companies. They seem to be a favorite target of people because they're, generally, making a good profit. People scream about them making money but then demand the latest drugs for free. Pharm companies invest billions in R&D looking for the next wonder drug. There's a reson life expectancy has been rising and drugs are part of the reason. Viagra seems to grab the headlines but there have been a boon of new drugs offering hope for many people afflicted with different conditions.

Would those discoveries have been made by not-for-profit drug companies? Highly doubtful. And for every amazing discovery, how many R&D projects end up as busts? Walmart can make all the money in the world but God forbid a company in the medical industry make a profit.

Also, insurance companies would not be the only people to benefit from tort reform. Our anasteatheoligist friends mal insurance is 400k/year. 400k! It should probably only be 25% of that at most. That's 300k the hospital would save on a single doctor's benefits alone. That means they don't have to charge as much for their services; the insurance companies, the uninsured, and those with out of pocket requirements then don't have to pay as much. This leads to lower health insurance premiums.

The insurance companies will still make their money, the hospital will have an easier time making theirs, and the consumers save as well. In our current system some smaller towns can't even attract a doctor because the mal insurance is so high the doctor couldn't stay in business.

Yes, many uninsured go to the ER for all medical care. However, many ignorant insured people go there as well. And if we bring down the general cost of health care, more people would be able to afford it.

For isntance, take my plan regarding states requiring insurance companies to treat all state citizens as a group. That makes it more accessible as group rates do tend to be lower. Also, with multiple insurance companies competing in the state, prices will be driven lower.

Is it as simple as that? Of course not. But it isn't much more complicated either. Meanwhile, if you go with socialized medicine you are stuck with the one option. What are we to do if we socialize medicine and now you're told that fusion is the standard and that's all that is available to you? Are you willing to trust the government to treat you fairly? Do you trust the government to do what's in your best interest or what's in their best interest? What has the government done to deserve this level of trust?

I truly do understand the frustration with our health system in its current form. Remember that I was denied ADR by my first company. It sucked. But I had options and I exercised them. I do not want to be stuck with the government as my only option. I've heard to many horror stories from coworkers who either are or lived overseas where socialized medicine just isn't getting the job done and they didn't have any other viable option.

Again, if we want to test government health care, beyond the VA anyway, then let a state test it and run with it. Then, keep it on the state level where it's more manageable. The federal government has ruined every benefit program it has been entrusted with no matter which party was in power.

Insightful Post, But...
 

Jason, well said. Umm, well said, because I agree with many of your points. ;)

Can you relate your ideas back to the orginal post -- about the IRO process that some spine patients must endure? More specifically: is NAIRO "owned" by the insurance companies? Yes, or course they are! I've studied this travesty for years in many ways. The system is corrupt. But the need for specificity in this weird diagnosis is important! Out of all the problems in the "system," which one is the most obvious? The most addressible? The "low hanging fruit?"

So the real question is: why do insurance companies own the independent review process? What can we do to change the process to make it legit, fair and HONEST? That's my rant.

As the editor, I try to steer people back to the intent and needs of the orginal post author. Hence, this post.

I second this. I finally settled my case against the 18 wheeler who hit me. First of all, do to liability laws, they were only liable for 6 months of my care, since I was a passenger in another wreck 6 months after they hit me. So all, the following figures are for 6 months of my care (from Jan 06-July 06). My medical for those 6 months was $40,000. I got a settlement of $75,000, which sounds like a lot; but here is the true breakdown. Attorney fees $35,000 (who I was forced into hiring, since the other company was not willing to work with me, they wanted to give me 30K, which would have left me in the hole), Money owed to health insurance for payments they made, $14,000, money owed to automobile insurance for medical payments they made on me $5,000, money I paid out of pocket for medical $15,000, and money I paid for childcare and house cleaning (I had a 2 week old baby and a 2 year old when this happened and I was on strict restrictions, so I had to hire help) $4,000. That totals $73,000 owed out of $75,000; so I get $2,000 for pain and suffering. It makes me sick that someone can destroy your life as you know it, take away your livelihood and I get a lousy 2k.

On the McDonald's suit, I was talking to my attorney and I said something about frivolous lawsuits and I brought that up. He said in fact, that that McDonalds had been cited over 30 times by the health department for their coffee being too hot, they had had other people get burned and still did not turn down the coffee. So in fact, they knew the coffee was too hot, had initinally left it too hot and ignored numerous warnings to turn it down. The lady who was burned, also had 3rd degree burns from the coffee, hence the suing. I'm not saying the suit was right or wrong, just pointing out how the media just does the headline to shock and never gives the facts behind the case.