Now a days when you watch TV, we see several advertisements that are for replacement policies for Medicare recipients, that promise everything and more. The usual Medicare does not cover vision, dentistry and over the counter medications. But theses policies cover everything and they also 'give you money in pocket'. If one thinks about this with some intelligence, they will realize that one has to cut the cost somewhere.. Theses Insurance companies get money from Medicare and then they spend it for health care . But they have to have some overhead expense and also they need to show some profit for their share holders. So how can they do all that and promise things that are not covered by Medicare? The obvious answer is they MUST BE CUTTING SOME SEVICES OR PAYMNETS. Most of the patients do not think about this. This brings me to story for today. There are 2 such stories that I came across recently. Both are similar.
I have known this patient for many years. She has been seen by me for last few years with shortness of breath and has been obese. She has Asthma /COPD and has been on medications. She had done sleep study and she has sleep apnea, the treatment for that is CPAP - pressurized mask for sleep. She has refused to use the CPAP. She also has heart problem and she has not lost any weight . She has atrial fibrillation and the heart rate has not been controlled. The cardiologist had suggested ablasion, but it was never done and she was not sure if she wanted that. So she needs oxygen and CPAP or BIPAP and also needs to lose weight . She has oxygen and recently she was in hospital. When I talked to her I asked her if she was using oxygen and she told me she does not as the oxygen cylinder is 'dangerous' to carry as it can explode if she has car accident and she is not going to put her and her grand kid's life in danger if she has car accident. So she does not take oxygen with her and so he has not done any exercise and she has not lost any weight.. Just as aside note - walking or the amount of exercise that she or patient like her can do will not add much to weight loss as the calories spent will be minimal. The main thing for weight loss is diet. e.g. 16 French fries consumption is equal to doing 31 minutes of bike riding or 52 peanuts is equal to 90 minutes of house work. So there is no dietary change and no exercise. I also asked her if she will be willing to use PAP as that has been shown to reduce the atrial fibrillation problem. She told me that she can use only minimal pressure -which will not do any good as that pressure is ineffective to control her sleep apnea . So I asked her as to what does she want me to do / The answer was she wanted PORTABLE OXYGEN CONCENTRATER -the one that she has seen on TV and she knows that Medicare covers it . The problem is that Medicare covers oxygen but does not cover all portable oxygen concentrator and when a patient has one home oxygen concentrator ,then Medicare will not pay for second. We had tried to get her the portable oxygen concentrator in past and the company that has contract with her Advantage policy had refused it. Simply stated I can tell that patient needs oxygen and the company will provide oxygen .But what device they will cover is up to them and when there is cost reduction by these plans they may not get what patients want.
So, then there is conflict The plans tell everyone on TV that they cover everything and MORE and in reality they have to cut cost to cover MORE and that is cut for every service - physicians , labs , radiology and also for DME that provides such equipment . The patients are told that if a physician writes a letter that 'it is medically necessary' then they will cover it. But reality is they WILL PROVIDE oxygen but not what patient wants .Patients watch TV have misconception and then don't do what is more important than just the equipment
