Cancer Patient and Spouse Share Their Health Insurance Story

A 64-year old colleague has been diagnosed with cancer. While she is otherwise healthy, she has now started chemotherapy and radiation. Like other spouses who find themselves in similar positions, her husband is trying to be strong while taking on the caretaker role. On a cold but sunny spring day in Chicago, they recently shared their experience with her health care coverage:

What kind of coverage does she have? She is enrolled in a private insurance company’s Preferred Provider Organization (PPO) through her employer. (Her husband is on Medicare.) A major academic medical center and its oncology team (including nutritionists, psychologists, etc.) are in-network providers. They are also located nearby, which makes daily trips for radiation relatively easy.

How adequate is the plan design? The patient has already met her annual deductible and out-of-pocket maximum given the diagnostic process and treatment regimen. The PPO plan covers home health and mental health care, which has proven valuable. But recent changes to the formulary mean that the plan no longer covers some prescription drugs recommended by her oncologist.

Where does she go for help? The complexities of cancer treatment mean that the patient speaks almost daily to the insurance company’s care coordinator. Most calls have to do with bird-dogging the insurance company’s review process for those prescription drugs that her doctor recommends but the carrier declines to approve. She’s fortunately feeling well enough to do these calls herself, but “what if I didn’t?”

What happens when she turns 65? The patient will become eligible for Medicare in a few months. She knows that her provider accepts Medicare and she can afford a supplemental plan. But the thought of learning a new health insurance program makes her nervous. “I’m not looking forward to making such a major change in my coverage during the middle of treatment, but I will tackle that that hurdle when the time comes.”

What else? The health care provider recently implemented a new Electronic Health Record (EHR) system. The patient’s past medical history has not been uploaded into the new system, nor does it include current billing information and insurance records like it did the past. The new system and its capabilities may improve with time, but the transition has proven most inconvenient.

My colleague is grateful for her coverage, her medical team, her loving husband, and their family and friends. But cancer is hard. Insurance should be easy. Countries like Switzerland not only have one system for everyone, they spend less for the same if not better care. It could take ten years to make happen in the U.S., so it won’t help my colleague. In the meantime, she’s Mastering Health Insurance.