My nephew has Kaiser, developed Diabetes as a young adult, presenting with ketoacidosis. He got diagnoses as a type II insulin resistant, even though he had DKA, and had to drop his BMI down from 28 to 19, eat no carbs, and be chronically ketotic (and feeling ill all the time) to keep his glucose under 500. He was OBVIOUSLY insulin deficient. But endocrine refused to see him because his internist considered him insulin resistant, and his Nurse Practitioner told him to follow a low carb diet, exercise more.
It took me and an old friend of his, each with backdoor connections to Kaiser to get an endocrinologist to review his case. Once that happened, he finally got appropriate treatment. Now he’s fighting to get insurance to cover the money he spent on insulin (on my advice) because it ‘wasn’t necessary for him’.
I loathe what so much of the US health care system has become.
That made me laugh out loud. Member Services didn’t respond to my repeated complaints about their erroneous billing until I had a lawyer send a ‘cease & desist’ letter along with objective evidence that the supposed treatments were not applicable (several actually occurring before I was even on a KP plan), and even after acknowledging their completely irrefutable error still referred the bill to a collections agency which took a lot of detangling to avoid a credit rating hit. Basically, their way of dealing with ‘member’ complaints is to ignore them until they go away or get ramped up to an actual threat of legal action.
Possibly, but it could also be the rheumatologist refusing to take people in, not the PCP refusing to try. And it’s not impossible that the reason for such a refusal is something like “the insurance won’t pay for the tests we need.”
It just seems rather bizarre for a PCP to not try to talk to the specialist and get you in. In my experience, the issue was always that they had to find a specialist who would take my insurance.
But, granted, I’ve only ever had regular insurance or Medicaid.
The problem here is that Kaiser (and other integrated medical services like HMOs) the medical provider and the insurance company are financially intertwined even if they are technically separate organizations. A medical provider should be looking out for the patient’s interest first, e.g. referring the patient to a specialist even if there is additional cost, but it is in the insurer’s interest to minimize costs by rejecting more expensive treatment, especially if it requires going to an outside provider whose costs are not controlled by the plan. In the case of Kaiser, they have controls on what the physician can and cannot recommend to a specialist, e.g. non-specific general inflammation may be considered non-referrable, as stupid as it sounds to not look for a solution because you don’t know what the problem is. The PCP may actually have his hands tied, or not know how (or want to go to the effort) of justifying a referral whereas for an independent GP a referral to a specialist would be the obvious next step.
I’m going to check with some family members who have wrestled with Kaiser for years. A few thoughts off the top of my head:
Change PCP if she can
Call the advice nurse with specific, time sensitive complaints
Go to the ER with etc, etc
Options 2 and 3 can work to get you to a specialist, but I’m not sure how well it works for this situation. This is why I’m suggesting focusing on the symptoms and making them an acute problem (rather than framing them as a chronic problem).
Another thing that has worked is to go out of network to get an assessment, get a report sent back to the PCP and then get in-network help. This one takes money, which isn’t always feasible.
But you have not said why my assertion is wrong. Are you saying it is impossible for the NHS to have a complaint like that of the OP? Are you saying that doctors in the NHS don’t make mistakes and there aren’t complaints?
Look, I dont give a crap about yet another lecture of why UHC aka single payer is better than the USA method. I said twice that it is. But Doctors there make mistakes or make the patient angry just like anywhere else.
Given the low level of health care and the scam that is health insurance in the US, that’s not saying much. It’s like saying most Americans prefer being hit in the arm with a bat than in the face with an axe.
Kaiser Permanente was a good idea when the company was founded early in the last century, but I’ve heard all kinds of horror stories about them.
When my sister first moved to California in the mid 1990s, I told her to go without insurance before signing with Kaiser, and she’d already heard that, more than once.
So the PCP won’t give a referral until a source for the inflammation is found. Does the PCP agree that whatever problem Mrs. Cad is having is due to inflammation? If so, has the PCP tried to find the source of the inflammation?
As I understand it, rheumatologists treat mainly arthritis, immune-related disorders such lupus, and chronic diseases of the connective tissue such as sarcoidosis. They also treat fibromyalgia, although the source of that disease is unclear. Does Mrs. Cad have a condition like this?
Once again completely missing the point. What you describe as a “lecture” about single payer was an attempt to explain how the cost-control model is completely different from private insurance, which consistently engages in meddling at the clinical level through tactics like questioning the “need” for treatments or referrals or attempting to deny claims. What I’m suggesting is the likelihood that the behaviour of the PCP and/or the policies of the specialists are being heavily influenced by insurance company policies and the possibility that those providers wouldn’t get paid by the notoriously claims-denying health insurer. These problems simply don’t exist in single-payer. Is it possible that under single-payer a patient may be refused a referral and may get upset over it? If such a thing happened, it would almost certainly be a medical decision, made for good reason, and not a bureaucratic dictat by an insurance company. It’s not that doctors are inherently better under single-payer, it’s that they’re not constrained by an idiotic and self-serving insurance bureaucracy and are free to practice medicine as they were trained.
Of course they do, but not for money reasons. Since Kaiser does have to worry about a outside insurance company saying no, that is not the problem in the OP’s case, which you would know if you read the OP. The Op’s issue has nothing whatsoever to do with insurance issues.
So again, the lecture on how wonderful single payer can be is useless, and not in any way shape or form germane or useful. Not to mention you are preaching to the choir and I already knew everything you are posting- which is not germane in this debate. You continue to miss the point in your desire to preach how wonderful single payer is. Which it is, OK, so please stop.
Not because the Insurance company denied to save $$. The issue at hand here has nothing to do a financial decision by a outside insurance company.
And under single payer it could also certainly be because the Doctor is lazy, doesn’t really care, or is mildly incompetent. It does not really have to be a “medical” decision. Sure it is not a financial decision, but it can be just a plain bad decision.
I will not reply to your posts anymore, you are not getting it.
Right, they don’t have to worry about an outside insurance company saying “no”, because as an integrated health management organization with their own insurance division, they can say “no” themselves.
What do you think the OP is complaining about? Mrs. Cad is caught in a Catch-22 where she is not getting the treatment she needs. And the reason for it is the massive bureaucracy and clinical meddling of the private insurance system. Why do you suppose I’ve never heard of this happening in single-payer? And if it ever did, I’d have a valid complaint about medical incompetence and would simply get an appropriate diagnosis and referral from a better doctor, which I could easily do, but which you cannot do when constrained by the rules and limitations of an HMO’s own networks and service providers.
That is true! I’ve heard a lot of horror stories about BC/BS over the decades, but I have it now, self-purchased, and it paid my medical bills in 2017 and 2018 with nary a hiccup.
Back when I worked at the grocery store, my older customers often referred to their health insurance as “Blue Cross” regardless of what it really was. It had become a generic name along the lines of Kleenex, or for that matter aspirin.
Kaiser has a grievance procedure. It’s a form you can pick up at any of their facilities. By filling out the form, you can at least get the matter reviewed by someone other than your PCP. (The most likely result is they will point to the exact page and line in your contract that absolves them, but that’s not guaranteed to happen.)
I think you have the right, at the very least, to demand a diagnosis. You don’t need to give a damn if it’s your PCP or a specialist who does it. I think your PCP is just lazy or doesn’t care much. Mrs. Cad should find a different PCP.
I think OP’s wife should simply choose a different PCP at Kaiser. (The difficulty there is that Kaiser so overbooks all their resources that it’s hard to find a new PCP who is accepting new patients.)
Any doctor at Kaiser CAN override the guidelines if he can make a medical case for it. It’s been done for me a few times – F’rinstance, I am currently using an expensive medicine that they really really don’t want me to use, because the better known and cheaper medicine simply does absolutely nothing for me (and my PCP just took my word for it without investigating).
An update to show how the Kaiser system can do more harm than good. Mrs Cad has been trying to get a diagnosis for her widespread bioinflammation for a couple years and has been continually gatekeeped by Kaiser from the rheumatologists (the experts in inflammation) to get a diagnosis because she doesn’t have a diagnosis other than “You have bad inflammation. Hell if I know why.” Finally the orthopedic doctor took pity on her and wrote her a referral to the rheumatology department for “suspected arthritis” (I suspect a BS diagnosis but thank you Dr. for playing the game).
Took the rheumatologist (remember, the expert on inflammation) about 15 minutes to diagnose her. Went over her history of Hashimoto’s, how long her lab results have come back with inflammation indicators, the last six months, etc. The doctor (who is an expert in inflammation) gave a tentative diagnosis of polymyositis. He has prescribed a treatment to see if his diagnosis is correct and to relieve her symptoms and she starts tomorrow.
Why did it take years for her to be allowed to talk to the people that could actually help her?
My in-laws had Kaiser before my father-in-law retired. It was by far the worst insurance that I have ever heard of. While it’s true that everyone has a horror story, Kaiser (at least in the Baltimore area) has a well-deserved reputation for being the worst of the worst. Or it did back then, anyway. I can’t speak to how good or bad they are outside of that area, and I have no experience with them in the last decade or so.
They are fine if all you need is something simple like an antibiotic to clear up an infection. For anything serious, the main problem is that they just don’t want to pay for anything, so they constantly try to do the absolute minimum, even when it risks the patient’s life. The OP’s PCP isn’t the problem here. It’s Kaiser. The PCP is most likely doing the best that they can while operating under what Kaiser will and will not pay for. My in-laws didn’t have just one horror story. They had several. I don’t think they ever got anything close to proper medical care the entire time they were with Kaiser.
Yep. They are consistent about that.
If Mrs Cad has any other choice in insurance, she should switch. Well, maybe not to United Health Care, but just about anyone else.
I was on UHC for years before I went on Medicare, and had no problems. My company was self-insured, and UHC mostly did the paperwork, but still no issues.
The difference is that most doctors’ offices will work with you on getting insurance to pay, and are not going to turn you away to save the insurance company money. Kaiser is both the insurance company and the healthcare company. They have incentive not to treat you. As Mrs. Cad found out.
