How My HMO Makes Me Sicker


Many areas of the USA had a bad flu season this winter. There were numerous fatalities. Since I have asthma and several other health conditions that compromise my immune and respiratory systems, it’s heavily recommended I get the flu vaccine every year. Every pharmacy in my area offers it on a walk-in basis, and several of my specialists had the vaccine on-hand.

However, my cardiologist, my asthma/allergy specialist, the outpatient clinic at the hospital I attend and the local drugstore all were unable to administer it to me. My HMO will not cover vaccinations of any kind unless they are given by my primary care physician. Even the flu shot.

Don’t get me wrong: I’m extremely grateful to have insurance at all. I don’t say that facetiously. I live in a country where many people still don’t have coverage. Even those who have insurance often have trouble affording care due to the high costs of co-pays, co-insurance, prescriptions and deductibles. For many years I was severely underinsured, and what I have now is a vast improvement on the past. But it doesn’t mean I’m getting all the care I need.

If you live in a country that has universal healthcare and doesn’t treat medicine like a luxury, here’s a quick rundown on HMOs, or Health Management Organizations. As the name implies, they “manage” your health. You have a primary care doctor who is expected to provide most of your care. If you want to see a specialist, that PCP has to approve it and put an authorization request to the HMO. The HMO then approves or denies.

While you technically can choose a physician, and your PCP can request certain specialty providers, in reality the choice is restricted to doctors and hospitals who accept your plan. Complicating things further, you often have to choose a medical group or IPA – essentially, a sub-HMO – within your HMO’s plan, which narrows your choices further.

On my plan, there are a few doctors, such as a gynecologist, who can be seen without approval from your PCP. For the most part, though, every procedure, test or study has to be approved in advance. The medications you take may be restricted by your plan’s limitations, too. There’s a formulary – a list of approved drugs – but some of those may require prior authorization before the insurance will cover it.

When you have complex conditions, you quickly discover your HMO is not your friend. In numerous cases, my doctors have prefaced their recommendations with, “Here’s what I’d like to do, but insurance probably won’t cover it.” My providers seem sadly resigned to the fact that insurance companies will second-guess them and sometimes make it impossible to give their patients the treatments or medications that would do them the most good.

My HMO isn’t just turning down rare, unconventional procedures. Even getting them to pay for common medications can be a battle. One of my doctors requested a specific antibiotic because I had a lung infection for two months. Numerous courses of weaker medications had not worked, but a one-two punch of two antibiotics together seemed to be doing the trick. My insurance company refused to cover one of the antibiotics I need without prior authorization, and when my doctor submitted the paperwork, it was denied.

I’m allergic to several classes of antibiotics, and some of the “safe” ones hadn’t worked on this infection. My prescription fill list could confirm I’d already tried several weaker alternatives. I was regularly seeing both an immunologist and infectious disease specialist and clearly had a history of infections. That didn’t matter to my insurance company.

Even worse: when I asked if there were any list of antibiotics that required prior auths – so my doctors could avoid them – my HMO shrugged. I was directed to the formulary list, which did not indicate which drugs were PAs. So my doctors and I must operate with the knowledge that anything they prescribe might be roadblocked, and we have no way of ascertaining that in advance.

My immune condition was deemed too complicated for my regular immunologist, and he wanted me to see an expert at a local university. When he put in for the authorization, the supporting evidence included over 50 pages of laboratory results, a letter from my specialist and a supporting note from the researcher himself. My immunologist painstakingly explained that some of the labs he needed to run to develop a safe treatment plan for me were only available in university or research settings and could not be ordered at commercial labs.

My HMO still refused to allow me to see the expert. Instead, they sent me an authorization for a doctor with no training or credentials in immune deficiency who operated out of a dingy storefront, heavily pushed allergy shots, and had one-star reviews on almost every medical review site. I was told I would need to see this doctor before the expert would be considered. When I appealed the decision, they rejected it again without even requesting my medical records.

When I spoke to a patient advocacy group about it, I learned it’s par for the course for HMOs to require patients to burn through every single in-network specialist – even if they have no expertise in that rare condition — before approving an out-of-network referral to a doctor who can actually help them. Of course, all this doctor hopping reflects badly on you as a patient, even though it’s not your fault. It’s a practice that is penny-wise and pound-foolish and detrimental to everyone, including the insurance company that insists on it.

When I finally was able to see an expert – in desperation, my immunologist got me authorized to see someone at the local children’s hospital – they couldn’t even take my blood. Instead they had to work up a list of lab tests, arrange for some of them to be drawn at a commercial lab, and submit an authorization to conduct the ones that couldn’t be completed there. The result of this rigmarole: what could have been accomplished in 10 minutes on the day of my appointment ended up never being done.

Meanwhile, the “preventative health” department at my HMO has actually called to hector me about not having had what they feel is an “essential” screening test. My doctors and I have discussed it and deemed unnecessary for me. I have politely told the HMO’s nurses that if they were truly concerned about my health, they could try covering the things my doctors actually request for me.

I’ve also received letters offering me “disease management” for my asthma. I’ve had asthma since I was in high school, I’ve not been to an ER for it in more than a decade (knock on wood) and with the help of my meds, my PFTs are awesome. I’m therefore a bit perplexed to receive pamphlets telling me, “Asthma is a disease where you can’t breathe” with admonitions to “promise to take your medications every day!” Dude. I’ve got this one. Did you even look at my case history or medical records? No, of course you didn’t.

I’ve asked if the HMO has any “disease management” for people who have complex or rare illnesses and conditions. Nope. No such thing. They’re prepared to “manage” common conditions, but when someone sees 10 doctors and could really use help and advocacy to ensure they’re being properly treated, they shrug.

The HMO will pat themselves on the back for things like their “preventative care” services. They’ll send postcards and make phone calls and boast that they’re helping their members “stay healthy” while they’re simultaneously turning down requests from doctors for treatments that might keep their patients alive or give them a better quality of life.

It’s burned me out, truth be told. There have been weeks I’ve completely shut down because I’m so exhausted from trying to convince my HMO to give me care, checking with various doctors to ensure they’ve filled out the reams of paperwork required by the insurance company and sending lab results and progress notes hither and yon. I have enough battles to fight; wading through an ocean of red tape doesn’t help me in any way. The stress is not conducive to health, and in some cases it actually aggravates and exacerbates some of my conditions. It’s not hyperbole to say that struggling to obtain care this way makes me sicker.

I get it: I cost the HMO a lot of money, so they’re going to drag their heels as much as possible on covering things I need. What they fail to realize, or care about, is that by not covering my treatment or requiring me to jump through hoops to get decent care, it actually costs them far more in the long run.

Take the case of the out-of-network provider. They wanted me to see 10 different doctors who did not know about my problem before allowing me to see one who did. Ten doctors’ fees are a lot more expensive than one. It’s a lot cheaper to cover an antibiotic than it is to pay for a hospitalization when my infection spirals out of control. It’s less expensive to pay for the treatment my doctors want than it will be to pay for the multiple infections and massive organ damage that will result if I go untreated. But they don’t see it that way, and if they do, they don’t care.

And I’m hardly alone. I’m hardly experiencing the worst of it. I’ve heard story after story of people being denied lifesaving treatment for all sorts of conditions — of people forced to set up Go Fund Me accounts, sell their belongings or hold fundraisers to cover the costs of wheelchairs, hearing aids and treatments that have not been deemed “medically necessary” by their insurance companies. Of people who engage in long battles and appeals with HMOs to try to get the care that will help them live, only to be turned down again and again. Of people who simply can’t fight anymore.

People like me – who have complex medical needs, chronic illnesses or disabilities – are among those who most desperately need their insurance to facilitate access to adequate medical treatment. It can mean the difference between life and death; between having an acceptable quality of life and an untenable one; between heading complications off at the pass or being besieged by them.

Unfortunately, we’re also the people insurance seems most poorly equipped to help. And it could cost some of us dearly.

Getty image by yacobchuk


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