Is there a Doctor in the House? No Seriously....Is there?

It's amazing how something so simple as finding a physician can suddenly become so difficult. As I'm sure all the regular readers of A/O know, I've been having an ongoing series of problems with the insurance assigned to us by Kynect, the Kentucky healthcare exchange which was modeled after Obamacare. Supposedly, Kynect was going to make our lives so much more easier when it came to getting insurance. It was supposed to evaluate our healthcare needs, income levels, and provide a list of potential plans to select from. In some instances, it also picks up partial coverage. After a pretty rough start (I had initially applied in August 2013 but didn't get coverage until April 2014), I was pretty pleased with the coverage. Kynect picked up a portion of the premium while we paid for the rest. The quality was good and there were no problems with our doctors or prescriptions. By the end of 2014, I started receiving notices that my coverage would soon be changing. Puzzled, I contacted the insurance company. They assured me that my coverage remained the same, although the name of the plan was changing, that was all and I should ignore the notices, which I did. However, I received a second and then a third notice. I contacted the insurance carrier again and got the same response. I decided to contact Kynect this time.

Well, it turned out that Kynect was changing my coverage and my insurance provider...effective March 2015. "Why?" I asked. Because there had been a change in their income formulation. I advised the "navigator", as Kynect likes to call its customer service folks, that nothing had changed on my part. However, the change in calculation was on their end and as a result, I couldn't keep my current provider. Needless to say, I wasn't happy. At that point, I was transferred to a new department; one in which I would have to deal with from here on out.

While I found the individuals at Kynect to be polite and somewhat helpful, they maintained that their hands were tied and there was nothing they could do. I had the choice of accepting the new provider they assigned or pay full price for coverage on the open market, which, they said, would be in the neighborhood of about $2500.00 per month (an awfully expensive neighborhood I thought to myself). However, on the upside (as if this was actually an "upside), I could still pay for any office visits if my doctor didn't accept the insurance; they would still pay for any lab work or x-rays.

Well, as it turned out, I had a upcoming visit to my primary doctor of 32 years for my annual physical in a few weeks so I decided to wait and see what happens. After all, I had been told there wouldn't be any problems and I would lose my primary doctor. When I showed up, I was told they no longer accepted my insurance provider effective the first of January. Not a problem I thought. I told the receptionist that I would go ahead and pay cash for the visit. "Sorry, but you can't do that" she said. She went on to tell me that under this policy, it was either accepted or I walk. I was not allowed to pay cash, check, or even credit card for the office visit. To do so, I was further informed, would be considered "fraud". WTH? So, I left feeling slightly embarrassed and more than a little flustered. Because of a change in policy calculation that I neither had anything to do with or knew about, I lost the insurance policy I liked and in the process my primary doctor of 32 years, and, oh by the way, what about my prescriptions?

After I got home, I called Kynect to vent. I was told there was nothing they could do and it was suggested I call the new insurance provider, which I did. I explained the situation to that first poor soul who had the misfortune to get my call. Despite the continuous "I'm sorry" which I concluded was written into a script somewhere to sound sympathetic, there was nothing she could do. So, once again, I was transferred to another department which was a near carbon copy of the first. Finally, I managed to work my way up the food chain, where I was told I could submit a "Continuation of Patient Care" form if I wanted to. Seriously? Hell yeah I wanted too! After completing the process with my newly found best friend, I was warned that this review process could take up to 7 to 10 days and I should be patient (little did she know!).

The 10 days came and went without a word, so once more I was on the phone. I called everyday for almost two weeks beyond their 10 day cutoff date. Finally, I heard back. I was told that they wouldn't allow me to keep my primary doctor. I had previously stressed that not only was this my doctor of 32 years, he's also a subspecialist and as far as I knew, the only one around! While my now former bestie went on to repeatedly apologize, she managed to work in that there were no appeals, but they would be happy to help me find a new doctor. Really? Someone who is a subspecialist? Well, no I was told, but they may be just as good! It was at that point I started to wonder just how bad prison food really was.

Well, to make a much longer story more manageable, I've called some 24 doctors now and there's been no takers. The first six were GPs (which I didn't need or want). Most of the doctors weren't accepting new patients; some acknowledged up front they couldn't treat me; and the rest were a hodgepodge of winding down their practice, not being able to understand them or their staff, and one who had been repeatedly cited by the Kentucky Medical Board. Where are the doctors? What good does it do me to have insurance but no doctors? Is the game now to find competent care? Am I going to have this same problem with hospitals or outpatient care? Sigh. So, I called the insurance company again and as usual, had to bring ever-changing customer service rep up-to-date (she also put me on hold for about 10 minutes while she read the notes on my case. I chuckled to myself as I envisioned her cursing her bad luck).

When she returned and after the obligatory "I'm sorry for the problems you've encountered", we got down to business. I told her that I needed more doctors. She suggested that I give her the names of those I called; it might make things go a little faster. I was again given six more names (and with each their names got more difficult to pronounce). She then asked me how I was doing on my prescriptions. I acknowledged that I was getting low. She asked what I was taking, which I happily provided. She then put me on hold while she spoke with their in-house pharmacy. While I was on hold, I blissfully thought to myself that maybe, just maybe, they could help me with this problem resolved (such are the straws of desperation made of).

When she came back (and apologized again), our conversation began anew. First, she read back to me each of prescriptions, milligrams, and frequency I was taking them (oh boy I thought, maybe the gray clouds were finally clearing). I dutifully confirmed each one and what they were for and for how long I've taken each. After we completed the inventory process, she started reading back each one from the top then informed me that I would need to get a new prescription from your doctor. Huh? "I have to get new prescriptions?" I asked. "Yes" she said. "I don't have a primary doctor" I said. "How did you get the medication?" she asked. "From my primary doctor". "You just said you didn't have a primary doctor" she said. "I don't know. You all won't let me see him any longer". "Why?" she asked. "Because he doesn't accept your insurance " I explained. "Then you can't see him". "I know" I said, "and I can't pay cash for the office visit right?". "Under our policy, you can't pay cash for the office visit. It would be considered fraud". "I know" I said. "So, how do I get my prescriptions refilled?" I asked. "From your doctor". "But he doesn't accept your insurance" I said. "Then you

can't see him" came her deadpan response.

As for one prescription in particular, she said the doctor would need to call and get permission to write the prescription first. "Why?" I asked. "Because of the nature of the medication". "But I've been taking it for close to 10 years and it's the only thing we found that works" I said. "Would you like to speak with our in-house nurses?" she asked. "Why?" "So they can explain your medications to you" she answered. "You mean the medication I've been taking for 10 years or the other medications I've been taking for the last 15 or so years?". "Yes sir, those". I politely explained that I most likely know more about my medications than their in-house nurses. "If I did, can they refill them?" I asked. "No sir, you have to see your doctor for that" in perfect monotone. Then it dawned on me. Those weren't gray clouds over my head. They were pigeons.

The Great Obamacare Circle Jerk: The Final Round

I'm one who really hates leaving loose ends. Call it a quirk of mine. I just like finishing whatever I start, particularly if there is the potential to learn something new. So on that note, let me take you back to a previous article of mine,"The Great Obamacare Circle Jerk", which I posted on April 12. As you recall, I had been stripped of my primary healthcare provider of nearly 33 years by my state's healthcare exchange and forced in to a new healthcare program which I didn't want. My wife and I were completely happy with what we had.

I filed a "Continuity of Care" request, which was submitted to the insurance company's medical review board. I pointed out that my primary doctor and I had a strong and unique relation which stretched back close to 33 years. I stressed that he became the kind of subspecialist I needed as a result of my rather unique set of medical circumstances, and that he was perhaps the only doctor in the area with this subspecialty. He treated me as an equal partner in my care; none of this "godlike" attitude which some doctors are notorious for having. He always listen to my suggestions and read any material I came across, which we'd discuss during my next office visit (I've always taken a proactive stance to my medical care). I also pointed out that if they didn't want to cover this doctor, that I would be willing to pay for the office visit out of pocket.

Although the insurance company assured me it would be only five to ten days before received a response, it was a full two weeks after their ten day limit came and went. Meanwhile, I called every day after the tenth day passed, always getting someone new, to ask if they had made a decision; explaining each time the same events over and over to whomever was unlucky enough to get my phone call. I repeatedly stressed the importance of keeping this doctor, and pointed out that I was in need of an immediate decision since I was getting low on my prescriptions.

It was always on my own initiative in calling them. Never did they ever call me. Anyway, some two weeks after their promised response deadline lapsed, I was finally advised of their decision. According to the hapless customer service representative, my request had been denied. I was told that their decision had actually been made almost a week prior but had just recently been entered into the system. How interesting I thought since each time I'd call I was told that either an email or phone message was being left with their medical review team in change of making the decision. You would think somebody would have the professionalism or common courtesy from this committee (if indeed there really is one) to either contact their own representative for a call back to me or better yet, to call me personally since I asked that my request be treated as urgent, but no.

When I asked why, I'm given a story, which in hindsight, seems a bit farfetched. Accordingly, I was told that the medical review committee designated someone to contact the doctor's office to see if they would agree to accept their insurance. As you may recall from my previous article, my doctor had carried this particular insurance for years, but effective the first of January 2015, would no longer be accepted. I was also advised that I could not pay by credit card or even by cash! Can you imagine being turned down for cash? Well, I was, and now the insurance company is telling me that I'm not allowed to pay cash or credit card for anything medical as it would constitute a "fraud". Admittedly, my first thought was disbelief. I've never been turned down for good ole American greenbacks ever. Then I was hit with the thought, could this be what people mean by the so-called Obamacare "death panels"? You are forced to accept treatment from who they approve or do without. By the same token, they can turn you down for a particular treatment and there is nothing you could do about it or any place you can go since you are "in the system" and there's no recourse beyond the appeal. As for a new doctor, I was given a choice of three---none of which have the expertise that I require. I asked if it wouldn't be cheaper to allow me to see my existing doctor than for me to see a new doctor who was not only unfamiliar with me but unfamiliar with the type of treatment I required? The end result I pointed out could be misdiagnosis, wasted office visits and fees, not to mention useless prescriptions and possible ongoing trips to an immediate care center or even emergency room...all of which they would have to pay for.

Naturally they "sympathized" with my situation, but stated that their decision was final and there was not further appeals. Since I had previously brought the matter of prescriptions, I was told that certain medicines (including one in particular that I'm taking) could be rejected no matter what it was for or how well I responded to it. To be more specific, I was told that my doctor (whomever that turns out to be) would have to call to get permission to prescribe it each time as long as there was no generic version. Otherwise, they reserved the right to decline coverage of the prescription and/or authorizing a substitute of their own choice (thus overriding the physician). Then they had the audacity to end the call by thanking me for calling and asking if I was satisfied with their responses! I admit dear reader, I've never done well with authority figures, and I tolerate even less bureaucratic simpletons setting in a cube somewhere, who has no clue who the hell I am or cares what my unique medical needs are, making decisions about me---especially my healthcare---based on their bottom line or some profit making arrangement they've made with a drug manufacturer. That just doesn't cut it with me, but there it is.

Right now, we have several local Republicans running for governor; each of whom has promised to either reform, cut back or vanquish our Obamacare based insurance system (for that matter, so are various potential and announced GOP Presidential candidates). Listen, I am absolutely the poster boy for what's wrong with my state's insurance system. It's not the hassle free system that they try to make it out to be, but at the same time, without it, we and others like us would have no coverage at all. The problem here is that it was rolled out without being fully thought through. Two years in, and there are still plenty of bugs, glitches, and administrative "Catch 22" issues, which is where I find myself.

What is needed is something more sensible like a single payer platform wherein everyone receives a basic level of coverage and then have the option of buying an additional "add on" coverage cafeteria style that fits their unique healthcare needs. This could be done either on the open market or through their employer. That way everyone gets to see at least some measure of medical care and small companies, which couldn't afford to offer insurance to their employees, could still remain competitive and those currently offering (or struggling to offer) insurance could cut back on their benefit packages without unduly affecting their employees. Another obstacle which should be removed immediately is a simple one: allow individuals to keep their existing doctors regardless of what package they have. After all, wasn't that President Obama's primary argument in selling Obamacare to the American People---that no one would lose their doctor? Or that we wouldn't lose our prescription coverage? Well, under Obamacare and at least Kentucky's version, that is proving to be a blatant boldfaced lie. Not everyone gets to keep their doctor, even if they're a specialist and no one else is available. And no, not everyone gets to keep their medication unless there's a generic substitute, otherwise, they simply don't get the medication or they're forced into taking something which may or may not work or work as well; even to the point of potentially having a negative reaction to it.

So friends, there you have it. A firsthand account of someone who has dealt with Obamacare and Kentucky's insurance exchange. For

some, perhaps even the majority of individuals, it may work. However, it remains flawed and it has been my experience thus far, that if you happen to fall into the category where you are in some way an exception to their rule, such a requiring a specific doctor, continuing with a specific doctor, or requiring a certain medication, and I would add to that requiring certain medical procedures, you're in deep trouble. The system doesn't allow for exceptions nor do the faceless bureaucrats running system seem to particularly care about your medical needs. Their sole concern seems to be about improving their bottom line, and in that quest, just maybe, is the truth about the so-called "death panels" we've all heard about. Naturally, I'm sure it's nothing personal.

The Great Obamacare Circle Jerk

I tend to keep my private life, well, private. Mainly because I think there are more important things happening in the world which warrants more attention than me. However, did you ever have one of those days or weeks where something so absurd happen that you just simply had to say something, if, for no other reason, than for simple validation that you're not going crazy? Well, as you might have already gathered, an event like that just happened to me. I guess the best place to start is at the beginning since that's the only way to grasp the full absurdity of the situation
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Let's go back to 2013. After 24 years, the company I worked for decided to lay off its senior legal department personnel, along with some of the senior clerical staff. Well, I was "the" senior legal manager for the company. I oversaw a multi-million dollar receivables portfolio; was involved in training; the company's overall top fee earner; and held an assistant vice president level position as a special projects coordinator for the company's president. Basically, I was in charge of improving efficiency, moral, and productivity. I worked with all the department heads, as well as with the head of the North America division and with senior individuals in the home office in Paris, France (we had been bought out about six years earlier by a French commercial insurance company).

As strange as it might sound, I was ok with it. Seriously. I knew it was time to leave. I was simply waiting for the most opportune moment. Well, obviously the moment chose me instead me choosing the moment. Shortly after leaving and settling into my new life, I applied through Kentucky's new insurance exchange, Kynect, which was created as part of Obamacare. This was in August. However, it wasn't until February 2014 that we were actually able to be coverage. Despite all the positive media hype, we encountered one problem after another. Even the people who took over our application encountered repeated problems which seemed to result from issues involving programming (lots of "work throughs" and "wrap arounds"), not to mention a lack of adequate personnel---especially programmers---being available. As an aside, despite claims to the contrary from the Governor's office, Kynect was fraught with problems involving a lot people than just us.

Nevertheless, come February 2014, some six months after originally applying, my wife and I finally received coverage. Because we were already in the system, we were given our choice of start dates---January, February, or March. We though the easiest avenue (to avoid further confusion) would be March. So when the documentation was submitted by Kynect to the insurance company, someone at Kynect though we really meant to say was April, not March, and so they changed the start date without alerting us. Well, that delayed things yet again, but at this point we were used to it. After that, everything seemed to settle down. We were happy with our coverage since we could keep all of our doctors and had no problems getting any prescriptions filled. Well, you know what they say about getting to comfortable right? That's usually when the rug gets pulled out from under you.

Near the end of December, I started getting notices from Kynect about our insurance being switched. I made several calls to Kynect and to the insurance provider and was told to just ignore the letters; they were likely sent out by mistake. Yeah, right. As it turned out, Kynect opted to switch our coverage without consulting us. So, after we somewhat embarrassingly found out that we no longer had the coverage we thought did (or with who we thought), I phone Kynect to ask what happened and why it happen. I was rather nonchalantly told that our coverage had been changed and, no, apparently we couldn't really do anything about it. It was suggested, however, that I might want to speak with a customer service representative in Community Based Services. Boy, did I ever!

Well, the individual I spoke with at Community Based Services was polite enough, but, alas, said I couldn't do anything. I had to take what they offered or get coverage on the open market. Some choice. However, on the upside (from their perspective), I was eligible to pick between three different but essentially same type of policies. It was suggested that I make a list of all our doctors and prescriptions and call back to go over which of the policies includes our doctors. Sounded fair enough, so I make a list of all our doctors along with any prescriptions and called back. Although I had to speak with a different individual, the notes were clear enough for them.

We determined that most of our doctors were supposedly available under one particular policy, although my primary doctor was still a

question. Not to worry I was told. Even if he wasn't covered, I could still pay cash for the office visits and they would cover any procedures or tests. Again, I was reminded that I had the option of declining coverage and purchasing a policy on the open market (which would run about $2000.00 a month). Being newly retired, I thought the better part of valor would be to accept the policy being assigned. Besides, I though, I could always pay for my visit if I had to right?

Fast forward to mid-March this year and my first visit since our policy change (for my annual physical and update on prescriptions). As it turned out, my primary doctor doesn't participate with this insurer. So, I offered to pay cash for the visit. It turns out that I'm not allowed to pay by cash or credit card or anything else under this policy type (it would be considered "fraud"). So, I left without seeing my primary doctor of 33 years. Frustrated, I called Kynect as soon as I got home. Once again, there was nothing they could do, and so I was transferred to another department where I was told unsympathetically to simply "switch doctors". I explained that my primary doctor was a specialist; the only type of his kind in the area, and besides, I had a 33 year relationship with the guy! They offered to find me a substitute, but they'll likely want to do their own testing despite any medical summary they receive. This will only further delay my medical care. That's not going to work I said.

So, I was again transferred to yet another department where I explained the whole situation once more. This time I was told that I

could file a "continuing physician care request", but it would take seven to ten days to get a response. Well, here we are 15 days into this and they can't seem to track anyone down who can make a decision. Meanwhile, I tried to have some prescriptions refilled. Turns out that this policy also doesn't include all medications! They will only approve certain medicines. What isn't approved has to be both "justified" by the issuing physician and there has to be an generic (what happens if there's no generic? Some types of medicines aren't approved for generic yet). And so here I wait. I can't see the doctor of my choice---my primary doctor of 33 years---and I may possibly have to see a non-specialist and start from scratch unless my request can be tracked down and approved. I can't get my long standing prescriptions refilled since I no longer have a primary doctor, who, if I did, would still have to contact the insurance company and "justified" his recommendations, and still there's no guarantee they'll approve the non-generic medication.

I'm remind of an old saying which says that if you can't be a good example, at least be a good object lesson. So, if you anyone tells you that Obama's Affordable Care Act---Obamacare---allows you to keep your own doctors, or go to whatever clinic or hospital you want, or that you can get your prescriptions filled without any problems, just remember my story.