Special to Valley News
Ever wondered why medical costs are so high in California, the highest in the nation, and in particular Riverside County, the 5th highest in California?
Medicare, the federal health insurance program for the elderly and disabled, establishes the fees doctors and hospitals are allowed to charge Medicare patients, but generally only pay 80 percent of those fees. Patients are left to cover the remaining 20 percent. Many people enroll in Medicare health maintenance organizations or HMOs, or they buy Medicare supplemental policies to help cover the gap.
For example, in the past year patients with Medicaid paid $2,116, people insured by the Veterans Health Administration paid $2,367, people with employer-sponsored insurance paid $5,492, patients with Medigap policies paid $5,670, patients insured by a Medicare HMO, paid $5,976, and people with traditional Medicare and no supplemental insurance paid $8,115 on average, out-of-pocket costs.
Hospitalizations, poor doctor choices and prescription drugs are a main driver of out-of-pocket costs.
On Oct. 1, I received a letter from our primary care physician that he was leaving Hemet Community Medical Group effective Nov. 1. He had been our primary care physician for over 5 years.
I called him to discuss continuity of care at University of California Irvine Medical Center, where my wife was diagnosed and was being treated for pancreatic cancer. UCI Medical Center was the second opinion that I requested after the first incompetent doctor, Dr. Raghuwanshi of Southland Gastroenterology Medical Group, in Hemet Community MG’s network said that my wife didn’t have cancer.
Our old primary care physician suggested that she stay with Hemet Community MG to insure that my wife had continuity of care at UCI Medical Center, including established referrals. After discussing this idea with him, I called Hemet Community MG, told them that since my primary care physician was leaving their management group we needed a new primary care physician for my wife and asked them to please send me a complete list of all of the doctors in their network.
On Oct. 25, my wife received a letter from her insurance company, stating that some meathead was our new primary care physician. In the new Health Net Medicare Advantage HMO Plan Provider Directory, this doctor isn’t even listed as a primary care physician. He is listed as a family practice doctor.
I called Hemet Community MG to ask them what was going on. Hemet Community MG said that since we hadn’t picked a new primary care physician, the insurance company picked one for us, and that this doctor was our new primary care physician. When I looked up this slug on the internet, I could tell that he was not someone that anyone would ever pick to be their physician, let alone their primary care physician.
After numerous calls to Hemet Community MG, I finally speak to customer service supervisor Doreen at Hemet Community MG for the second time Oct. 31, and she agrees to send me a complete list of all of the doctors in their network. Unfortunately, she only sends a partial list of doctors. It wasn’t until Nov. 9 that I finally did receive a complete list of all doctors in their network.
Why do you suppose it took Hemet Community MG almost 40 days to send me a complete list of all of the doctors in their network? The reason is quite simple, they have some number of poor doctors in their network who don’t care about good quality health care but completely rely on the insurance companies to provide clients to them.
On Oct. 21, my wife spent 11 1/2 hours in the operating room at University of Irvine Medical Center hospital for a Wipple procedure in relation to her pancreatic cancer. She was released on Saturday, Oct. 29.
When she was released from the hospital, she had a catheter, and an appointment was set up for her to have the catheter removed on Monday, Nov. 7 at the UCI Urology department.
On Friday, Nov. 4, I get a telephone call from the UCI Urology department stating that Hemet Community MG would not authorize the procedure. I was somewhat surprised that Hemet Community MG would not authorize the removal of my wife’s catheter by the UCI urology department.
Hemet Community MG told us that we had to go to our primary care physician, who has never seen us and was selected by our insurance company, to be referred to a urology doctor in their network to have the catheter removed.
Let me explain how it works. You visit the primary care physician. Cha ching! He sends you to the urology doctor. Cha ching! Cha ching! Then you go back to the primary care physician for follow up. Cha ching! Cha ching! and Cha ching! It just doesn’t make sense unless you are just in it for the money and to hell with good quality health care.
On Thursday, Nov. 10, a social service worker from the Riverside County Department of Public Services was standing at our door with a Temecula police officer wanting to know why my wife isn’t seeing her primary care physician. Hemet Community MG is trying to harass and intimate us by using the Riverside County Department of Public Services because we will not go along with their scam to help them defraud Medicare.
If most insurance bills were paid directly by the insurance companies, instead of through a third party like Hemet Community MG, medical care would cost far less, and health care would be significantly better.