Mrs Cad has major problems with inflammation. Has for quite a while now and it is really starting to affect her health. So with an inflammation problem she should speak to a rhumatologist right? Thing is that requires a referral.
Her PCP refuses to give her a referral since she doesn’t know what is causing the inflammation.
According to the PCP, the refusal is because rhumatology refuses to accept patients with non-specific inflammation.
So Mrs. Cad can’t find out why she has such highly elevated inflammation.
So how the f**k is she supposed to get any answers? Kaiser’s business model is “Give us your money and F off if you need any real treatment.”
Kaiser is most likely the doctor and the insurance company in this case. Basically it’s a HMO where the doctors are employed by the insurance company. They’ve always freaked me out because of that and I’ve avoided them like the plague.
OMG, my sister will agree with you in spades! She’s got a major hernia in her gut likely related to her hysterectomy some eons back. She is in constant agony, has ended up in the ER a couple of times, and Kaiser says it’s too soon to consider surgery. She’s in the state insurance exchange and as soon as she’s allowed to change plans, she intends to.
Why hasn’t her PCP ordered a battery of tests that will cost far more than an initial rheumatologist visit in order to discover the cause of the inflammation?
You need to start documenting this, send them emails and letters telling them your wife is not being treated for her inflammation.
Do they have one of those online patient portals? Use that to communicate with them if you can, you may have a better chance getting through to some medical personnel who will do something instead of just administrators.
But I agree about pushing her primary care physician to do some additional diagnostics, particularly since you can’t get her in to be seen by rheumatology.
IANAD, but … just a f’rinstance:
If her CRP is elevated … here’s a family practice/primary care web page to help guide physicians:
If it’s her ESR …
Her PCP shouldn’t be at a standstill because Rheumy won’t see her.
Kaiser Permanente, an integrated medical services consortium that primarily serves the Pacific Northwest, California, and Hawaii (although I see they do have networks in Colorado and Georgia as well). It is essentially a hospital system, pharmacy network, and insurance company combined together. Unlike independent medical insurance, you cannot ‘opt out’ of network (at least, not easily) and they are particularly notable for a lack of transparency about medical costs despite the fact that their integrated nature should make them able to control all aspects of cost.
I heartily endorse this pitting. I am still dealing with massive overbilling for services I did not receive and could not conceivably require (e.g. pregnancy and neonatal care) and refusing to resolve the issue until legal action required them to, and even now the billing department sends me periodic notices of payment to which I respond with the letter from their billing department admitting their error and CC:ing my lawyer. Its mental health services are notably overpriced and poorly managed but because of our constantly shifting health plan options through work I had to use Kaiser for a couple of years during which I went through grief-induced depression, and the ‘services’ I received were well beyond casual indifference and approached gross malpractice, all provided at the cost of nearly $300/billing hour, which actually translated to 30-40 minute ‘sessions’ of a therapist mostly fucking around with his computer or making himself tea.
People often have the mistaken impression that non-profit organizations (NPO) do not make profits, but this is not strictly true; rather, what it means is that the company does not have shareholders or distribute its profits externally, but rather ‘reinvests’ its earnings back into the company, although what constitutes as ‘re-investment’ can be subjected to a lot of creative accounting. Kaiser is actually a collection of both non-profit and for-profit companies under one umbrella, and its corporate compensation is well above norm for NPOs.
Something I have seen recommended is to tell her primary doctor you would like her to put in the chart the reason she is not sending a referral to rheumatology. If they chart it, it makes them more liable if there are problems that could have been addressed by the specialist.
I don’t really know why she wouldn’t make the referral. Elevated labs would be reason enough. Unless she thinks that another specialty is a better choice. But if that was the case, she should have made the alternate referral already.
Kaiser is fine for ‘doc-in-a-box’ stuff, or if you have easily managed medical issues that don’t require expertise that they don’t have in-house. Their hospital facilities are better than average, and they’ve got as good of a reputation in oncology that you’ll find outside of the National Comprehensive Cancer Network. But if you get tangled up in some kind of bureaucratic error, need services that are outside of their in-house expertise, or just need to go ‘out-of-network’, you basically have no options other than to aggressively challenge their restrictive outside referral process, and despite being “non-profit” and the supposed financial benefits of being an integrated medical services organization, it is demonstrably not cheaper than other options. If you do run into a challenge with them they refer you to their Member Services Department and then the corporate arbitration process that is controlled by Kaiser before you can bring a lawsuit.
It is actually great. I have a PCP, he answers my emails, he can even prescribe drugs based upon my health profile without the need for me to come in and see him.
The pharmacy is online also (if you want, they have nice, well stocked in person pharmacies) , and I simply click on the prescriptions I need and they mail then- fast, easy and free shipping, the drugs have a low co-pay.
If I have a immediate issue the Urgent care facility will handle most things short of a life threatening emergency right then and there, with a short wait time and a low co-pay.
When I had my prostate cancer, they handled it really well, giving me several choices and a class which explained the choices. They are well known for their oncology work.
Compared to any other insurance policy I even had, Kaiser is marvelous.
I had one of the best known PPO, and I went to the hospital for a eye problem- a scratched cornea. They refereed me to a specialist who worked right there in the building. But how was I to know he wasn’t part of the PPO? They send me a bill for thousands. I had to fight it.
Kaiser? You go, they handle it. Period. If it is a ER visit, they also handle it, even if not their ER.
No matter what health org you belong to- there will be the occasional complaint. Even free national health plans come under attack and complaints.
Remember: We have the best healthcare in the USA. Private insurance helps get us that great healthcare.
Really, it’s a fucking joke. My wife and I are dealing with insurance billing hell along with months long waits to be seen and a complete lack of specialty providers with seemingly no option. Providence and Kaiser can both go to hell.
Teachers in my town have no choice but to use Kaiser, and I endorse this pitting. My son-in-laws father was in Kaiser for something else. They didn’t notice that his leg was infected and swollen. A clot from it went to his heart and killed him.
When I had mine I got all those options also, and got to go to a world leading specialist for the treatment I chose. Getting mail order meds is standard now - my local CVS mails me mine free so I don’t have to go in, not that this is a big problem.
I’m sure Kaiser is better than some places, but not where I go.
So weird how different peoples experiences can be with the same company. We’ve had Kaiser for years and no problems. My wife has had many procedures and surgeries with no issue getting testing or followup. Blue Cross on the other hand caused us no end of misery and $$$$.
