Diving into the dark water-Our State medical system (PEIA)


shark

I have always had a fear of swimming in dark water and think it may be a result of my childhood in Torrence, California where our family took trips to Long Beach to spend the day in the Pacific Ocean. Although I never witnessed a shark attack, I had heard many stories of them occurring right on the beach where we swam. This may seem totally unrelated to any discussion of medical care, but as I get older I have come to see the medical system as dark water that I am more than fearful to enter. It has become clear to me that my body is now much like my old Honda Accord, which is like me, beginning to break down. As a result of my aging, I have needed periodic medical attention, in contrast to my younger days of carefree living with infrequent trips to the doctor. As an aging American, I am one of many with the same scary feeling about a trip to the doctor. It is important to understand that doctors do amazing things to extend and enhance people’s lives, but it is also essential to remember that medicine is a very imperfect science, and at times creates more problems than it solves. Because we live in a capitalist society, the pure goal of treating and helping people is tainted by greed and too often the procedure that is best for a patient is passed over for a less expensive or more expedient procedure.
Recently my wife was in need of a hip replacement. We did the usual research and then talked to several orthopedic doctors. We came to the conclusion that the best way to have the operation done was with the relatively new ANTERIOR APPROACH. This is when the water darkened and the sharks began to circle. Our insurance company, Public Employees Insurance Agency (PEIA), was insistent that we stay in their network of doctors so as to help them economize. Although, when I asked for a doctor who performed the anterior approach in network, they said that they had no available information on which doctors did what procedures. Left to fend for ourselves, we found the closest doctor two hours from our home, who was considered one of the leading orthopedic doctors to use this technique. PEIA was of little help after numerous calls. The day before Sue’s surgery, as we were driving down to Washington, DC, PEIA called to inform me that they found a doctor who performed this procedure in their network. I asked where he was located and what his name was. It turns out that he practices in Huntington, WV, almost six hours from our home! I asked her if she thought that was a reasonable distance for us to drive. Since it was not her hip and she did not live six hours from the surgeon, her answer was predictably “yes.” Sue and I continued our trip to Sibley hospital in Washington, DC where the procedure performed. The results were amazing! After two months, Sue is living her life unhampered by pain or discomfort! Now we must face huge medical bills because we bucked the system and left the network.
What is truly incredible and depressing about this situation is the lack of information available to policyholders. We have learned since the operation that if we would have stayed in network and driven to Huntington, PEIA (so they say) would have helped us with gas and accommodations. Since the operation, we have written several letters to PEIA asking them to reconsider their decision of forcing us to pay out of network fees. After exhausting that option, I began to email our local politicians. Shortly after sending these e-mails, I received a phone call from a state representative. She was very empathetic and so agreed to call a person at PEIA to ask them to contact us. Well, shortly after talking to our representative, we received a call from PEIA. In short, her remarks focused on the fact that PEIA members do not pay a high enough premium to get top-of-the-line medical coverage. Therefore, according to her way of thinking, we should be happy with reduced service. To quote her, “If everyone wanted top-of-the-line medical treatment, then he or she should pay more for it.” I am not sure how my readers feel about the PEIA representative’s point of view, but I am infuriated over it! In other words, people insured by PEIA should not expect top quality care! Maybe we should consult the local vet to save even more money! The lady from PEIA also made the point that doctors in West Virginia get paid less than most doctors in other States! I am not suggesting that in order to attract good doctors, one has to pay more, but when a doctor graduates from college with a $300,000+ tuition bill, he might understandably go to the state that pays the best.
So here we are, in a situation where we are forced to make decisions about our health based on how much money we have. Said another way, the wealthy will continue to get the best medical treatment money can buy. I guess this is the way it has always been in our country. I think that the Affordable Care Act is trying to level the playing field so that this inequity does not is not so pervasive and prevalent. Maybe that is why the health industry and the wealthy are so against it. So, as many of my fellow Americans climb up the age ladder and need increased medical care, it is important to know how to swim in the murky waters of health care so as to avoid being eaten by sharks. An interesting statistic to throw out here is that senior Americans are some of the least healthy folk in the industrialized world and will need considerable medical care. It is a shame that, for Americans that most if not all of those decisions will be based on how well off they are. Live long and prosper!

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2 thoughts on “Diving into the dark water-Our State medical system (PEIA)

  1. This morning on Christmas instead of watching the usual onslaught of Christmas specials I watched Sicko, a Michael Moore documentary.
    It amazes me how certain elements of our society allow the sick, poor and powerless in our society to languish in medical limbo without a thought to remedy this situation. What’s even more astounding is in many cases the same people who rail against the Affordable Care Act are those who need it most, or are on Medicare..
    Now about PEIA. About five years ago I took a chainsaw to my left hand (no not intentionally, of course). Jan rushed me to Hampshire Hospital. The attending physician determined that I needed to be air medevac’d to Curtic Hand Center in Baltimore, or I would lose my thumb and most of the use of my index finger. Due to blood thinners I was also bleeding profusely.
    All went well they reattached my thumb, repaired the damage to my index finger, and set me up for months of physical therapy.
    Now the kicker. PEIA refused to pay the $25,000 for the flight to Baltimore. Their reasoning was ” a cut finger dose not justify air ambulance services”. Even though their policy manual stated clearly that when the need is clear and evident that air ambulance service is authorized ( they have since changed that policy).
    Well after one year, two Apelles, and a threat to go to court, they ultimately capitulated and paid the bill.
    When people complain that they don’t want government bureaucrats making medical decisions for them they fail to recognize that it is pencil pushers at the insurance companies making exactly those decisions for them. The only difference is the insurance company pencil pusher are getting bonuses for turning down your claim. The government bureaucrats would at least be salaried, and objective in their decisions.
    Good luck in you struggle with PEIA.

    1. I like what Rachel Maddow said, “Insurance companies are there to make money, do you want them deciding what treatment you need?”
      Thanks for responding with your story. I wish more would do the same so that people would see what is going on!

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