The Paradox of Insurance

Towel not included… Neither is the toilet seat!

As I write this, we are being bombarded by ads for Medicare Advantage plans everywhere we look and listen. I don't know anyone who thinks it is a good idea to not have health insurance. According to various statistics, over 40 million individuals were uninsured in 2013, which was the last full year before the start of major Obama care coverage provisions. That number was so objectionable it became part of an ongoing national debate about how to extend coverage and how to pay for it. This article doesn't deal with that however, it talks about some of the silliness that takes place once you do have insurance.

According to the health care.gov site, "No one plans to get sick or hurt, but most people need medical care at some point. Health insurance covers these costs…" At least we hope it does, but often we don't really know until we find out the hard way. It is at that point why we may wonder what the point of insurance is anyway?

Say for example you have sustained an injury that does not allow you to get into the shower by yourself. After looking at your options, you decide to get a shower chair, a simple, plastic, inexpensive looking device that you will submit to your insurance company. Au contraire, you are wrong on two counts! What, you ask? How can you be wrong, what do you expect people to do – take bed baths? In a word, yes!

Medicare – and many insurance companies who take their lead from them – deny shower chairs on the basis that they are unnecessary "convenience items" which are "not primarily medical in nature." That's why it was so easy to find this classification under "Durable Medical Equipment" coverage! Oh well you say, no big deal. They can't be that expensive. Au contraire 2. Shower chairs can easily cost between $3000-$4000!

Pressure relief mattresses are another example. These mattresses are for individuals who cannot move and provide relief in the form of helping to avoid pressure ulcers. A pressure ulcer is defined as an injury to skin and underlying tissue resulting from prolonged pressure on the skin. While a regular mattress or even a pillow top mattress seams comfortable to you, it can be deadly for someone who cannot move such as one who is paralyzed. Once incurred, it may take well upward of a year to heal one of these. In addition to time, it can cost upwards of $125,000 according to the National Center for Biotechnology to treat an individual with a stage IV pressure ulcer and related complications. Left unchecked, a pressure ulcer can quickly deteriorate to the bone, introducing the possibility of infection and resultant sepsis which can in turn be fatal. So, suppose you have someone who cannot move or who is paralyzed. It certainly makes sense to get them on a pressure mattress in order to help prevent pressure ulcers, right? Insurance will most certainly pay for that! Au contraire 3. Going back to our trusted Medicare insurance coverage document, "the patient's medical record must contain sufficient documentation of the patient's condition to substantiate the necessity for the type of item and frequency of use". So, in other words, Medicare and most other insurances will not pay for the type of mattress which prevents a pressure ulcer, but they will pay on average $125,000 for the hospital cost to treat an individual who obtained a pressure ulcer because they were not on the type of mattress that would have prevented it. In addition, they will pay for the use of one of these types of mattresses on a rental basis until such time as the patient is healed, then the mattress must be taken away.

Are you seeing the Paradox yet? Good, as these aren't the only two items caught in this maelstrom of incomprehensibility. And don't even get me started on toilet seats! What, you consider this to be a convenience item? Where, uhm, how are they supposed to uhm… Oh, good grief!

Slice of Life series articles are those that share the special experiences of those living in a wheelchair in a way that is witty, informational, poignant and even inspirational. Do you have a story? Share it with us at info@unitedspinalusa.org