LifeAfterDx--Diabetes Uncensored

A internet journal from one of the first T1 Diabetics to use continuous glucose monitoring. Copyright 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014, 2015, 2016

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Location: New Mexico, United States

Hi! I’m William “Lee” Dubois (called either Wil or Lee, depending what part of the internet you’re on). I’m a diabetes columnist and the author of four books about diabetes that have collectively won 16 national and international book awards. (Hey, if you can’t brag about yourself on your own blog, where can you??) I have the great good fortune to pen the edgy Dear Abby-style advice column every Saturday at Diabetes Mine; write the Diabetes Simplified column for dLife; and am one of the ShareCare diabetes experts. My work also appears in Diabetic Living and Diabetes Self-Management magazines. In addition to writing, I’ve spent the last half-dozen years running the diabetes education program for a rural non-profit clinic in the mountains of New Mexico. Don’t worry, I’ll get some rest after the cure. LifeAfterDx is my personal home base, where I get to say what and how I feel about diabetes and… you know… life, free from the red pens of editors (all of whom I adore, of course!).

Wednesday, October 28, 2009


They are the best pimps on the block; but they are still pimps nonetheless.

And we’re going to turn national health care over to these people? And trust that they will do the right thing?

So top on my list of evil empires are the credit card companies. They change their terms whenever they feel like it. They play games. They work really hard at screwing over their customers.

And you know what?

There is no need to. You can make boatloads of money running an honest credit card company. But boatloads is not enough for Wall Street, is it?

If I had my way, the advertising of credit cards on TV would be banned just like cigarette ads were back in the 70s. I’d also ban the direct mail “you are pre-approved for a $10,000 credit card” mailings. And further more, I’d make them lock in the interest at the time of the “loan.” If you put 200 bucks on your card when your interest is 8% that rate should be locked to that balance.

Of course what really happens is folks rack up a balance at a low rate, the credit card company changes the due date, you are late paying, your rate doubles or triples, and the whole balance is affected. And then all your other cards are permitted to increase your rates because you were late paying the other guy. Wow. La Cosa Nostra would be proud.

This is why I use a debit card.

But back to the health care pimps.

Number two on my list of evil empires are not Wall Street banks, Big-Pharma, or the Iranians. Number two on my list of all-time most evil organizations are for-profit health insurance companies. And just this week I realized (late) that they use the same play book that the credit card companies use.

It started with a letter from my insurance company: Presbyterian, the best pimp on the block in New Mexico. We universally recognize that they suck, but they suck less than Lovelace or Blue Cross around here.

The letter starts by thanking me for being a member. And it states that their goal is “to improve the health of individuals, families, and communities.” Then the knife comes out of the scabbard. They have changed my Durable Medical Equipment (DME) coverage.

This is guaranteed to turn any T-1’s blood to ice. Although no sane person would consider a disposable device that is changed every three days in any way “durable,” the fact of the matter is that all insulin pump supplies have somehow found their way into the DME category of all health insurance. Simply put, how good your DME coverage is determines whether or not you can afford to run an insulin pump.

With sweat pouring down my sides I read on: “We have noticed that you are actually using your DME coverage, so we’ve decided to cancel it.”

OK, I might have paraphrased just a bit, but that is basically what the letter said. Effective November 15 Pres Pimps will not pay for any DME materials that are less than $200. Quoting the letter for real this time, supplies that are: “…less than $200 total will be denied as a non-covered benefit. Any charges for DME under $200 are the responsibility of the member.” This change is referred to as a “correction” in the letter.

So much for my 100% DME coverage.

So you are probably wondering why I’m whining about having to pay $200 bucks per month. Or maybe you’ve been deluded into thinking that infusion set supplies are more than two hundred clams anyway.

More dark secrets revealed: reviewing the packing slip from Edgepark Medical Supplies in Ohio, which oddly, is the preferred DME provider for my New Mexico health plan, which is heavily subsidized by my state; my Quick-Sets are $288.35 for a ten pack, and my Cozmo Insulin Cartridges are $205.00 for a box of twenty-five.

So I should be golden, right? Both are above the new $200 your-fucking-problem correction. Wrong.

Welcome to the totally fucked up world of American health care. What is billed has no relation to reality what-so-ever. It is an third-world market where the asking price is the first salvo in a bartering process. I was able to find an honest customer service rep at Edgepark (probably because I called from a clinic and used the health-care provider number); and got the low-down on the “allowable charges” for both items.

Allowable charges are how much Pres will actually pay. For the Quick-Sets the real price is $130; less than 50% of the “list price.” The cartridge allowable rate is set at $139, about sixty-percent of list.

So why is there even a list price, anyway? Well, if you are one of the millions of folks who have partial DME coverage, your share is calculated of off the list price, not the allowable charge.

Let us assume you have an 80% DME coverage. This means you pay 20% and your insurance company pays 80%. But they are double-dealing pimps, remember. You pay off of list. They pay off of allowable. Using my Quick-Sets as an example, if I had 80% DME coverage I would pay twenty percent of $288.35; in this example $57.67. My insurance company would pay the “balance.” But they really don’t. They pay the remaining portion of the allowable fee. They lead you to believe they have picked up the tab to the tune of $230.68 when they have really only paid $72.33. (Allowable minus your 20% of List.)

Guess what? Your 80% DME coverage is actually only a 56% coverage. You’ve been swindled by the pimps into footing 44% of the bill.

But it doesn’t end there. The pimps play the game both ways. For my new less-than-200-it’s-my-problem they won’t be using list price. They will be using allowable charges. Of course I don’t have a contract with Edgepark, so I’d be left paying list price out of pocket. For sets and cartridges this would work out to around 370 bucks per month.

Oh, except after all the bills are paid there isn’t 370 bucks left in my bank account.

For me, this means a return to multiple daily injection when my supply of pump supplies is exhausted. So much for Presbyterian’s goal of improving my health.

So for me this sucks, big time. But for the country, for our society, it foretells something much more sinister because the pimps are about to be given the keys to the city.

As of today, Congress’s health care reform is nothing more than a fancy subsidy package that will require virtually every American to buy insurance from the pimps.

Sure, a few new restrictions are supposed to help us. Pre-existing conditions are off the table. But do you really think the Pimps won’t find a way to keep their bottom lines intact? They will use sleight of hand, dirty tricks, and double speak. They will win, because they are what they are. Pimps are competing with pimps. They will all use the same play book if there is no mechanism to challenge them.

They only mechanism that could force change, by threatening profits, is the so-called public option, which is currently balanced on a razor blade. Maybe we will get it. Maybe we won’t. Maybe it will be a trigger. Maybe states will be able to opt out, resulting in health-care migrations between states.

It is a disaster in the making, for all of us.

Pres ends their evisceration letter to me by saying “We want you to get the most you can from your health plan.”

Yeah. Right.

Just so long as it doesn’t get in the way of their profits.


Blogger Crystal said...

Wow. Wil, total and major suckage yo. Hate to see you go back to MDI.

Insurance would be great for Doc appts and labs but not so much for supplies. Too many stories out there similar to this. Some days I'm happy to not have to deal with any pimps.

5:11 PM  
Blogger Bob Fenton said...

Very well stated! This is going to be the rule as more and more will be doing this to protect the bottom line. And our congress will do nothing to protect us from this and I believe they are purposely taking us in this direction.

Keep telling it like it is.


3:51 PM  
Blogger Scott K. Johnson said...

Oh wow. I didn't know they could just change stuff on the fly like that! Damn.

I feel so vulnerable when it comes to these kinds of things.

8:16 AM  

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