Why We Need Health Care Reform, Part 1

November 23, 2009

Keeping in mind that I have what is considered to be excellent health insurance, for which I pay almost $1000 per month for myself and the babies, not counting my husband’s coverage…

Because the Burrito and the Tamale were born prematurely, they are at higher risk of problems from RSV. There is a drug which prevents RSV for one month at a time, Synagis. It costs about $1000 per child per dose. The full course would be about 5 doses for the entire RSV season, totaling $10K.

The neonatologist and the pediatrician each applied for Synagis for both babies. Both doctors felt that the insurance company would approve a maximum of 1 or 2 doses, because of the high cost and because the babies are only at moderately high risk.

The insurance company has approved 0 doses.

In the rejection letter, the insurance company states that for babies born at this gestational age, approval would require two additional risk factors (the American Academy of Pediatrics sets the bar lower at one additional risk factor). Risk factors include having a sibling under 5 at home (each baby has his/her twin, which counts); attending daycare; and having a smoker in the home.

If I decide to take up smoking, the insurance company would pay for the drug.

I understand how the actuarial system works, but c’mon. Talk about penny-wise pound-foolish.

Stay tuned for Part 2. It gets more absurd.

Edited to add: We can’t afford to pay for the drug ourselves. The neonatologist says no one pays for it themselves. So, we’ll take as many precautions to shield the babies from RSV as possible, but ultimately we just have to hope for the best. RSV is the #1 cause of re-hospitalization for preemies; one day of hospitalization costs more than the drug would have cost the insurance company. They’re rolling the dice, and so must we.


17 Responses to “Why We Need Health Care Reform, Part 1”

  1. Poppy Says:

    Only in America. I swear our healthcare systems sucks.

    I’m so sorry this is happening to you and your pocketbook. You’re so right, penny wise, pound foolish.

    I’d appeal. May not make a difference but I’d do it anyway.

  2. Kristin Says:

    That is completely asinine. I totally agree that we need healthcare reform but I don’t like the options in the Senate right now…ugh.

  3. shinejil Says:

    Argh! The idiots! Like you need more hassles right now…

  4. ana Says:

    Ummm, can you say that you took up smoking? or that a family member moved in that smokes? This is ridiculous!
    Even insurance companies don’t understand the true meaning of “insurance”—i.e. the Synagis may be expensive now, but will potentially save them tons of money in hospitalization costs down the road should the twins get RSV. (I’m not mentioning the suffering of the babies & your family because clearly they don’t care about that). And yet the insurance companies continue to pay for Viagra….

  5. BB Says:

    It is all craziness! I sometimes kid with my DH that we should start an insurance company… I am sure we will become millionaires in no time – only it would against my values!

    On a similar note as to why we need a reform… there was CBS 60 minute thingy yesterday talking about the health care system… check it out: http://www.cbsnews.com/stories/2009/11/19/60minutes/main5711689.shtml?tag=contentMain;contentBody

  6. Photogrl Says:

    Our system sucks.

    I hope you can win the appeal.

  7. Quiet Dreams Says:

    This issue pushes almost all of my buttons.
    Double argh.

    “penny wise and pound foolish”–definitely

  8. a Says:

    Do you ever wonder if the insurance company would respond favorably to a logical appeal? For instance, if you wrote and outlined the costs for treating RSV for 2 babies vs the cost of the medication – because if one gets it, the second one is likely to get it too – would they reconsider? It’s ridiculous that they won’t cover something prescribed by your doctor.

  9. Cat Says:

    I’ve made the same argument about insurance coverage for fertility treatments. If they paid the $12,000-$15,000 for an IVF cycle more people would probably be comfortable transferring only one embryo per cycle and there would be fewer multiple births requiring NICU stays.

    Granted, with our embryo quality we were given only a 40% chance for twins and a 10% chance for triplets, the same odds as our first cycle when we got a BFN (minus the triplets odds since we only transferred two that time), but we hit the jackpot and had three. We spent about $30,000 out of pocket for our two fresh and one frozen cycle. Compare that to nearly $500,000 for three babies in the NICU for almost six weeks at $1,000/baby/day just for room and board. The daily doctor visits and all the other testing and treatment was additional. Even if we’d gone through the whole process a second time to conceive a sibling it would have still been cheaper.

  10. Kate Says:

    I’m with a – try to appeal.
    Otherwise, lots of hand sanitizer, keep them away from others, and no sick people around. Man, that insurance sucks!

  11. Carrie Says:

    The smoking part is ridiculous. Basically the insurance company is saying it’s ok to smoke around your babies, we’ll make sure they are taken care of for you.

  12. strongblonde Says:

    we’re getting it…why can’t you just say they’ll be in daycare???

    also–i had no idea it was that expensive!!!

    everything else going okay??


  13. staciet Says:

    Ah yes, the fun of Synagis. My doctor used the overages from covered patients (like us) to dose the uncovered patients. Shhh…don’t tell. Maybe your pediatrician does/could do something similar? It’s worth a shot at least. Hs. Shot.

    I totally agree that there are issues with health care as we know it in this country!

  14. staciet Says:

    Ah yes, the fun of Synagis. My doctor used the overages from covered patients (like us) to dose the uncovered patients. Shhh…don’t tell. Maybe your pediatrician does/could do something similar? It’s worth a shot at least. HA. Shot.

    I totally agree that there are issues with health care as we know it in this country!

  15. A friend of mine works high up in her state’s government, and what pisses me off is that she has cadillac insurance. IVF is covered, she doesn’t pay a deductible, or have a co-pay. How much did having a baby after going through almost the exact same thing you did cost her? $0

    Yet these are the people who get to decide whether the rest of America should get health insurance. I have to stop writing now, b/c this just gets my blood boiling.

  16. Though to be fair, I should mention that she fully supports universal healthcare.

  17. mekate Says:

    but with that, wishing you a fine and wonderful thanksgiving full of nourishment and rest (HA HA HA ok I make myself laugh)–
    grateful you are here, THANK YOU.


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