Mom: So here's the deal - her doctor (who works for HMO Kaiser Permenente, NOT Mom) says..

[Triana]

...that she is NOT eligible for a colonoscopy and REFUSES to order one - even though Mom IS high-risk because she's had polyps (which can be pre-cancerous). Mom has Senior Advantage with them - basically Medicare gives K-P boatloads of TAXPAYER money to take Mom's care off their hands. And they are REFUSING to provide that care in this case.

NOW:

Medicare ITSELF does cover colonoscopies - one every 10 years for normal patients, one every 2 years for high-risk patients - which my Mom is because of the polyps. Last she had one was 2003 or so, she said. (thank you folks from my http://www.democraticunderground.com/discuss/duboard.php?az=show_mesg&forum=389&topic_id=6467446&mesg_id=6467446">other thread for providing this info).

HOWEVER - HER DOCTOR (who, mind you, works for Kaiser which is an HMO being paid by the government to provide her with care) REFUSES to schedule the test, claiming she's "too old" for it.

MEDICARE covers it.

MEDICARE is paying K-P to provide it to my Mom.

HOWEVER, K-P REFUSES to order/schedule/pay for a test that Mom NEEDS even though they ARE getting handsomely paid by Medicare to provide her with care.

SO - WHO is "rationing" health care? WHO is DECIDING THAT IF MY MOTHER GETS COLO-RECTAL CANCER SHE CAN JUST DROP DEAD because she's "old"? (can you say "death panels?") Oh Noooo. It's NOT Medicare doing this! It's NOT the "government" doing it. IT'S KAISER-PERMENENTE - who refuses to provide the care / preventive tests because they obviously want to POCKET the money they're getting from Medicare to do so -- instead of providing my Mom with the tests that Medicare would otherwise cover.

:mad:

THANK YOU TO ALL WHO ANSWERED MY http://www.democraticunderground.com/discuss/duboard.php?az=show_mesg&forum=389&topic_id=6467446&mesg_id=6467446">OTHER THREAD, HELPING ME TO SORT THIS MESS OUT. Needless to say I am LIVID about this shit. THIS is a prime example of WHAT IS WRONG with health care in this country. It's FOR-PROFIT and not FOR CARE - and the goddamned HMOs/insurance companies (in this case) are TAKING PUBLIC money into their private coffers to provide care my Mom IS ENTITLED TO AND NEEDS - but then are REFUSING to do it - so they can KEEP the profit.

Let me make this clear: MOM'S DOCTOR does NOT work for my Mom. She works for the HMO - Kaiser-Permenente. I WONDER how much of a bonus she gets each year BY DENYING TESTS AND CARE MY MOM AND OTHER MEDICARE PATIENTS ARE ENTITLED TO AND NEED - thereby allowing Kaiser to POCKET more of that money they're getting from Medicare as profit?

Eh?

:mad:

[robinlynne]

1. switch doctors!

[Dappleganger]

3. Agreed!

Obviously that doctor isn't competent enough to make decisions regarding your mother's medical care.

[Triana]

11. that was another thing I suggested - either change doctors or...

...get the hell out of K-P and just get on regular Medicare with a supplemental.

This is just rediculous.

[robinlynne]

25. just help her switch doctors. it is not hard.

[noiretextatique]

5. i agree...get another doctor

a sane one who will order the test.

[dkf]

2. Maybe "too old" means its dangerous for her?

Otherwise I don't get it.

[Triana]

12. I don't get it either...my aunt had one recently

and she's older than Mom (but my aunt has different insurance).

[orleans]

29. no--my mom is 85, her dr. wants her to have that test & she refuses. n/t

on edit: she has medicare & a bc supplemental

[Grinchie]

35. I agree. It's a myth that Regular Colonoscopies are necessary.

On the rare chance that they may find a malignancy, you put yourself at risk for a perforated Colon or secondary infection. Just ask the several thousand Veterans that got Colonoscopy with unsanitzed colonoscopes...

If people want to live in fear, thats their business.

The Doctors are trained to offer the standard marketing spiel, and regular, unnecessary Colonoscopies were welcomed and the norm. Now perhaps they realize that there is no reason to distrb the golden years of the elderly just so they can prolong their life as natural events start to work on end of life.

[msongs]

4. Kaiser pretty much sucks - 13 weeks to see a doctor n yer stuck with only one choice nt

[robinlynne]

24. no. i've learned you can keep switching doctors till you get one you like.

[Warpy]

6. First, establish the paper trail

Get a copy of your mom's medical records, especially the result of that last colonoscopy.

Second, print out the definition of "high risk" from an accepted medical site, preferably a specialized cancer hospital site.

Third, get a copy of the doctor's refusal in writing. Get it on tape if the doctor is too cagey to write it down.

Then go to the state AG department of consumer affairs. You can also send copies to Medicare. They need to know Kaiser is pocketing money illegally.

This is absolutely crazy. This is one case where prevention now will save them a bundle in the future if she has cancer and decides to have it treated aggressively.

Kaiser is being penny wise and pound foolish. They also don't expect old folks to have advocates who fight back.

[Triana]

13. Thanks....I thought about calling the doctors office and mentioning the word

"fraud"....to see if that doesn't get the lead out of their panties.

I'm not living near her so it's hard for me to do much, but I can certainly give this info to my sister. I appreciate the outline of steps. Thanks.

MEDICARE DOES cover this and K-P is being paid by them to care for her by Medicare and they're refusing. It's pretty simple, actually.

[SmileyRose]

45. What Warpy said

even if you change doctors and/or enrollment in January - if you have the energy to bust them it might save other old ladies the same problem.

[PA Democrat]

7. Those Medicare Advantage Plans are coming under more and more scrutiny.

I posted an article about them just last week.

http://www.democraticunderground.com/discuss/duboard.php?az=show_mesg&forum=389&topic_id=6424089&mesg_id=6424089

Sorry to hear about your mom. It is inexcusable to deny a procedure that can prevent a very deadly, painful and costly illness.

You have to ask the question that if they are refusing preventative care, would they also refuse treatment for the disease itself?

I would go through the insurance company's appeal process and file a complaint against them with the state insurance department.

[grasswire]

8. get her off the ADVANTAGE plans

Advantage plans are worthless, and they are aggressively marketed.

She could and should have chosen a MediGap plan. Medigap plans are structured by government law. Advantage plans are structured by HMO-type insurers.

A medigap plan provides the same benefits no matter who the insurer is. And they are clearly spelled out.

You should look into the enrollment opening for a medigap plan and get out of the HMO. Seriously.

BTW, how old is mom?

[Triana]

10. I told her to see if she can get regular Medicare with a supplemental

She'll be checking into that.

She's 81.

[grasswire]

17. she has Medicare

And she has a supplemental.

But she chose an Advantage supplemental rather than a Medigap supplemental. Medigap is regulated. Advantage plans are a scam. Guess which ones the insurance companies market aggressively?

[Triana]

18. Yep. They had been trying to get her on that crap before she moved to Cali...

They'd come to her house and try to sell her some HMO/Advantage crap...and she refused. She finally caved - my sister helped talk her into the K-P Advantage thing. Bad move, IMO.

[Horse with no Name]

9. This is deplorable

I've had dealings with KP through some of my patients. I've witnessed the same treatment. One that stands out over the years was a man that had come in through the ER with a massive heart attack and NEEDED to go to the cath lab STAT.
However, KP made it clear they wanted him stabilized and sent to their facility (closest one would have been 3 hours by the time we got him there--then he would have to be prepped) for the procedure and that it wouldn't be paid for unless we did that.
The cardiologist was an idealistic man--he told the patient the scenario. He would LOSE heart muscle or could possibly die if we shipped him OR he could have the cath done at our facility and worry about the payment at a later time--even to the point of being harassed for money from our facility but he would do his best to help him fight KP.
The man opted to have the cath at our facility.
People shouldn't have to make these decisions.
I am so sorry for what they put your mother through. First they deny her COPD medicine and now they deny her procedures.
We DO have death panels in this country.
I would suggest you send your story to Michael Moore, Howard Dean, Dennis Kucinich, KO and Rachel Maddow to try and shine the light on these cockroaches.
Good luck to you and your mom.:hug:

[Triana]

14. "First they deny her COPD medicine and now they deny her procedures."

Exactly. It's been a damn circus with these cretins.

Tell ya what, ALL OF US are in mucho trouble if the health care system in this country is not fixed.

MY FEAR IS that the "public option" will just be more of this - ie: government paying private insurers to provide care on behalf of the gov't - and them refusing and pocketing the money as profit.

I have to get this written up and will send it to Rachel (even Mom suggested Rachel - gotta love her!), MM, Kucinich, KO and the damn White House (they still haven't answered my last inquiry though I requested a response).

[Raven]

15. The Doc said she was too old??? How old is your Mom? Is

it possible for one to be too old for that test? Is there more danger of a puncture of the bowel in an older person?

[Triana]

16. She's 81 and my aunt, her sister, who is older

had one last year, I think. I never heard of such a thing. And Medicare covers it so K-P ought to as well.

[AieinAristuein]

33. I kind of know a way around your mom's dr.'s idiocy

with kp your pcp doesn't technically order a cscope. They refer the pt. to a specialist who can perform the procedure. (either a gastroenterologist or general surgeon) The pcp will often write one of the reasons for the referal as "requesting cscope" or something along the lines, but the approval/insurance authorization for the cscope must be done by the performing provider not the pcp.

I digress..get your mom to find another reason to obtain the referal to a general surgeon and that dr. can handle the cscope from there. Examples for the referal to surgery are breast lumps, cysts, lipomas, question of hernias, hemorrohoids etc, are reasons to request referals to general surgeons. Get the referral for one of those reasons and then ask them for the cscope from the surgeon. TADA!

[GoldenOldie]

19. Medicare Advantage is nothing more than privatization of Medicare

Seniors bought into it believing that there would be less paperwork or reporting.....Medicare contracts and pays private insurers to perform the Medicare functions, supposedly saving duplication efforts and cutting costs within Medicare. As with far to many Government contracting out, the Medicare Advantage-Private Insurers, have denied care, reduced payments to health-care providers and have denied Medicare clients from refuting their denial of claims. You are no longer dealing with Medicare a We the People/Government agent but a Private Contractor.....no different than Halliburton, KBR, etc., apparently answerable to no one.

Far to many Seniors who worked for private industries/corporations and/or public functions such as teachers, local government employees, etc., were/are offered to continue their insurance benefits as a part of their retirement package. They then receive a letter offering them the wonderful opportunity of opting into Medicare Advantage rather than keeping both their private health care insurance as secondary and Medicare as their first. Those choosing Medicare Advantage along with We the People/Government are the losers while the Private HMO's/Insurance contractors win. The Private Insurers make the decisions of who, what and when will be paid, if they are paid at all.

[Triana]

20. It's damn well a "put public money into private for-profit coffers" rip-off

:mad:

[imdjh]

21. It isn't the "less paperwork or reporting", it's less risk.

Straight Medicare pays 80-20 with no annual cap- so you could lose your house. Medicare Advantage does low co-pays, HMO referral bullshit, and has a maximum out of pocket that is a fraction of what could happen if you have to pay 20% of a $300,000 hospital bill.

That's my understanding of it. If someone is going to respond with "That's not how it works." I'd appreciate some back up info, because I read all the paperwork for my mom and I am pretty sure this was the deal.

[SmileyRose]

47. Many people with straight medicare buy a supplemental.

it pays the other 20% medicare does not cover. The advantage plans are more affordable. My uncle is in Kaiser senior advantage in Georgia and has gotten wonderful care. My mom was in Humana Senior Advantage in Michigan and was always fighting with them to get what she needed so she switched back to Medicare plus a supplemental.

[Nikki Stone1]

22. Send this story to Olbermann or Rachel Maddow

This is exactly the problem with private insurance.

[GoldenOldie]

23. "....it's less risk."

Your right if, all your mother has is Medicare. For those that have insurance as part of their retirement benefits, the HMO/PPO insurance becomes the secondary payor after Original Medicare pays their portion. Thus, the insured/patient may only have a very minimum payout. When the secondary payor, the HMO/PPO, becomes the only player, there is little if any accountability, they can bill the US government and then deny the medical caretakers payment.....this is why many physicians and medical facilities have been refusing Medicare patients.

[newspeak]

26. yeh know, I lived in California some years back

and at that time, Kaiser Permanente was in big trouble for patients deaths because they wouldn't do certain tests or surgeries. Patients died. My friend is a RN and she has nothing good to say about Kaiser Pemanente, and she is one for single payer.

[Triana]

27. Mom lives in CA....

...and ever since she moved there, K-P has been a pain in the a$$.

[burrowowl]

28. K&R

Talk about rationing!

[Triana]

31. Yep. That's exactly what this. Rationing "health care" for fun and profit?

Pffft! :grr:

[REP]

30. She needs to change doctors and file a complaint with KP and the state board about this one

I've had to file a complaint; sometimes, it does work - at least one fuckhead who tried to inject me with Toradol despite my nephrotic syndrome being noted on my chart no longer works there - but at least it will be documented. At least changing doctors is easy with KP; she can do it on line if she wants, and she can change doctors until she finds one who's competent (BTDT, and there are good doctors in the system).

[Triana]

32. She can't do anything online - she can hardly see...

....and isn't computer saavy. But my sister might can help her find another doctor - and / or see if they can get her off K-P and onto straight Medicare w/ a supplement.

[McCamy Taylor]

34. Age limits are not absolute. It depends on the person's health and whether they are likely to die

of some other disease. So, for instance, you might stop annual mammograms on a 75 year old who had a bad heart and is on dialysis. But you might continue annual mammogram on a woman who is healthy and whose parents lived into their 90s, since breast cancer could well be the thing that kills her.

So, your mom is only "too old" if she has other medical conditions that are likely to kill her before a colon cancer, left untreated, would kill her.

[Triana]

40. She has nothing like that which I know of

...so I'm not sure why this doctor is refusing to schedule one - EXCEPT - MONEY.

[Sander]

36. Kaiser has approved the procedure multiple times for me and my wife

Not sure which Kaiser is being referred to here. My Kaiser, in Georgia, approved and performed colonoscopies on me three times so far. My wife, twice. As soon as we reached the age where they are recommended, we were offered the procedure.

I have Medicare part A and a Kaiser policy as part of my Federal Retirement package. Don't need part B as Kaiser takes care of all of my medical needs.

I suggest you appeal this decision.

[Triana]

41. This is in California - sounds like there have been "issues" with K-P in Cali

but a damned HMO is a damned HMO, regardless. I think they all suck, in general.

[fasttense]

37. Millionaire doctor who are in medicine just for the money

This health care system seems to breed a lot of them. Millionaire doctors and CEOs, they seem to enjoy making millions off the suffering and dying of others.

[Triana]

42. mercenaries, IMO. n/t

[Orangepeel]

38. her doctor is terrible. But I don't think you are phrasing this right

KP hasn't gotten paid by Medicare yet, has it? The doctor who performs the colonoscopy (which is probably some other KP doctor) would get paid if it was done, but KP would not be reimbursed enough to make enough profit from it. So, you are right that KP is using the doctor to ration health care, because they don't think they will make enough if the procedure gets done.

But if somebody got paid for a procedure that wasn't done, it's medicare fraud, isn't it?

[Triana]

39. "KP is using the doctor to ration health care, because they don't think they will make enough"...

..."if the procedure gets done."

RIGHT THERE is the PROBLEM.

OUR "HEALTH CARE" system - particularly when it involves for-profit corporations is based on PROFIT - NOT good CARE.

MEDICARE, as I understand it - PAYS these HMOS to take patients off its hands - whether they are paid per patient lump-sum, per year, or per test/procedure - I don't give a rat damn.

MEDICARE COVERS COLONOSCOPIES - NO age limit, every 2 years if patient is high-risk - and K-P ought to be providing and covering them for her as well.

PERIOD.

[Orangepeel]

54. It does make a difference how they get paid. If they are engaging in fraud they can be stopped

of course they should provide and cover the colonoscopy. And of course, the current system is fucked up. But it does make a difference if the lousy doctor the OP is talking about is a lousy doctor working within the current fucked up system or if she is a lousy criminal taking money for procedures she doesn't perform.

Either way, your mother will have to find a new doctor. But if it the second, at least she can try to stop this one from fraudulently denying care by reporting her.

[mother earth]

43. Many doctors gain bonuses at year's end if they ration care.

And dollar signs are all they see. They are well versed in providing cheap and limited options, while there are better options, it's hard to get past greed.

[SmileyRose]

44. THANK YOU FOR THE UPDATE !!

Change Mom's primary care doctor immediately if she wants to stay with Kaiser Advantage because of finances. Keep shopping until you find someone who will treat your mom. There are MANY good and decent doctors in Kaiser. I would also re-suggest a patient advocate for your mom. Whether it's a sibling who lives in the same city, or other trusted relative, or one of your Mom's younger good friends who can be trusted. Someone needs to be in the exam room with Mom. It's much harder for a doctor to deny care when there is a patient advocate in the room.

If your family can afford to do so, enrollment comes up in January I think - switch her back to regular Medicare and buy the best supplement you can afford. When my Dad got on medicare in 2000 he just picked regular medicare. No supplement, and they paid the difference. In 2002 he found out he had cancer and bought the highest level AARP supplement. My mother went with medicare HMO. I can't tell you how much my mom raves about how grateful she was for the regular medicare plus that particular supplement. This was before Medicare D so Dad got his meds from the VA. Now that Dad is gone, Mom has decided to change to Medicare plus the same supplemental. It's costing her about $250 a month for medicare premiums plus the supplement, but her prescriptions are now covered too. She jokes it's like "hitting the easy button".

[Hamlette]

46. We all have to face the harsh reality that we should ration care.

The best way to do it is to do a cost benefit analysis and apply it evenly. In France, for instance, the gov't pays 70% of the health care costs (rations care) and you can buy insurance to cover the rest.

Since 95% of the health care costs you incur in your life come in the last 2 years of your life, it is not unreasonable to look at those two years for cost savings. (I am not saying your mom is in her last 2 years but there may be something to the docs advice. I was diagnosed with the polyps and my doc said come back in 5 years. FIVE YEARS I exclaimed, and he said yes, they are very slow growing and may disappear in their own. No need to do it more often than that.).

When I think think back to some of the medical care my father received in his last 2 years, if I had it to do over, I would not have okayed it. It may have prolonged his life but his last 2 years were not the kind of years any of us want. And it cost you, the taxpayers, in excess of $1M. Leaving me with the choice was horrid. I wish the doctors had made it and I have no objection to them having made it with cost in mind (he had triple coverage so I'm sure if cost figured into the equation with the doctors it was to do more so they got paid more.)

[SmileyRose]

48. I know exactly where you are coming from.

My Dad's last 4 years was fighting cancer. I hope to heck that's not my lot in life, but if it is, I hope I make a different choice. Every additional day I had with Dad is incredibly precious to me, but the $1Million plus that bought him that last 12 months was of such low quality and so full of pain that by the time he died I was relieved.

Is my Dad worth a million bucks? Well sure, and then some. But I'm not so sure THAT million bucks was well spent.

[DrZeeLit]

49. My doctor is at Dartmouth, NH. And if I even hint that my husband or I am having even a twinge,

she signs us up for the test, the blood work, the scopes, the specialist -- she always errs on the side of caution. I know that smacks of "making money" for Dartmouth, but I couldn't be more pleased with care.

I'm not yet on Medicare, but my husband is. He was treated magnificently when he had a heart attack and when he had a nasty fall probably due to problems with the 5 meds he now has to take daily (he passed out and did a face plant on the terra cotta tile in our bathroom at 4 am about 6 months after the heart attack). In these cases, Dartmouth doesn't just have one doctor, they have a team. And the lead is a PA who won our hearts with so many personal touches, including telling me to call her any time 24/7 while my husband was in the hospital and when he got home for recovery.

I can't tell you how amazing it is, after living in CA my whole life with Kaiser and other hospital/plans, to go to a doctor and a hospital where everyone is ON TIME (truly, I've never had to wait) and cheerful and professional.

Oh, and my husband has had polyps, too. He's on that "more often" schedule with his colonoscopy. When I turned 50, my doctor and I had a conversation and I signed up for all those baseline tests -- colonscopy and bone density especially because of my family history.

Soooo....what I'm saying is... finding the right care is equally as important as insurance coverage.

That is why this whole debate needs to be about CARE as well as insurance. I don't see so much of that going on, and I do believe President Obama has brought it up on numerous occasions.

We need to talk about CARE and COVERAGE.

[Texasbacksass]

50. Triana, I just got this notice from Medicare.....pass it along as you see fit.

Hope this can help....K P has no basis to refuse this "Mom" service......anyone that wishes to have an original copy of the email....email me and I will forward it to them...TP
_____________________________________________________________________________________________________


From: Centers for Medicare & Medicaid Services ([e-mail])
Sent: Fri 9/04/09 3:02 AM
To: [e-mail]


Important Message from Medicare

Dear TOM PEARSON

Happy Birthday from Medicare! We wish you well in the upcoming year and want to remind you to take advantage of the preventive services Medicare offers to help you stay healthy. Our records show that you have not taken advantage of some of the preventive services which are available to you.

For your convenience, the table below lists the preventive services you may receive now or in the future.

Name Eligible Since Date

PROSTATE 1/1/2007
PSA 6/1/2008
COLORECTAL 1/1/2007
PPV 1/1/2007
CARDIOVASCULAR 1/1/2007
DIABETES 1/1/2007
ABDOMINAL AORTIC ANEURYSM 7/1/2007


To see a schedule of the services you are eligible for, visit www.MyMedicare.gov and select the "My Preventive Services" tab. Or, talk to your doctor for more information.

Remember, Medicare is your partner in health.

Sincerely,
Centers for Medicare & Medicaid Services.

[aggiesal]

51. Call your congressman ...

NOW!
Let's hope he/she is not a republican.
They will be returning to DC within the week.
Maybe he/she can scare them into doing the right thing.

[alfredo]

52. Go public, send a letter to the editor detailing their disrespect for your mom.

[Techn0Girl]

53. I an NOT a doctor...

I'm a former military paramedic and surgical tech.

A colonoscopy is preformed under anesthesia. Propofol, one of the drugs that killed Michael Jackson is often times used in the anesthesia.
Because anesthesia is used, it presents a significant risk to an 81 year old person - like your mother. Depending on her other physical issues there can be a very significant risk of death just from the anesthesia to an 81 year old person.

The doctor should have explained this to you.

Although I am no doctor I believe it is entirely possible that the procedure would present more risk to your mother then the potential of having a of cancer.

We all would like our family to live forever but that is not possible. You can easily do more harm with uncalled for medical tests and procedures than the potential disease itself.

I'm no fan of HMOs - but it is possible that your Doctor may be making the right decision here.

Here is some support from the AMA on this:

Colonoscopy of Little Benefit In Very Elderly Patients
"NEW YORK MAY 23, 2006 (Reuters Health) - For people in their 80s and 90s, the risks of colonoscopy appear to outweigh the benefits, investigators report in the May 24/31 issue of the Journal of the American Medical Association. "

http://www.cancerpage.com/news/article.asp?id=9742

[Triana]

55. It's odd that my aunt, who has similar physical ailments (asthma, etc) and is 83 or 84

just had a colonoscopy though. That being so, I doubt that is the case.

Furthermore, Propofol is safe IF - IF it is used ONLY in a hospital/surgical setting with constant monitoring and an anesthesiologist present ( which was NOT how it was used with Jackson - with Jackson a quack doctor was administering it in his HOME with NO monitoring and NO anesthesiologist and after he had pumped him full of other drugs to boot - idiot )

So, it's not the same situation and can't be compared like that.

Also, I have Mom on the phone RIGHT NOW and she said last time they did a colonoscopy they did NOT knock her out - they gave her a sedative - a "pre-op" shot - she was AWAKE during the procedure because they have to get the patient to move around. So they didn't even use propofol. Profofol is only used in real surgery apparently - to knock someone completely out.

Furthermore, IF this is the case, the doctor should have explained this to MY MOTHER. I am way across the country from her. There was nothing stopping the doctor from explaining this to HER.

WHY do doctors have problems JUST TALKING TO THEIR PATIENTS?! What IS their problem?