Health Insurance Is Not Your Friend

If you have a uterus, at least

Health insurance is not your friend. I mean this in the same way us millennials had to learn “Your boss is not your friend” - do you still have to have one? Yeah, probably, in one form or another. But don’t fall for the subway ads and think you’ve got an ally or someone watching your back. What you have is a contract relationship with a for-profit entity that does not actually care about your quality of life, and will leave you to rot on the side of the road if it saves them a single dollar. CAN YOU TELL I WORKED AT A STARTUP?

Being a person who has never had much money, but who experienced actually good health insurance as a kid due to my dad being in the teachers’ union, I ALWAYS stayed inside my health insurance’s network. I’ve talked a lot about the reasons I didn’t aggressively seek out a diagnosis for my period pain once I hit the inevitable brick wall of a normal ultrasound, and the price tag was definitely the biggest of those reasons. There were plenty of times I struggled to pay the $50 co-pays for my in-network appointments to get treatments for UTIs or sinus infections, so I obviously wasn’t going to seek out wildly expensive diagnostic tests with a doctor who was outside my insurance network or *gasp* DIDN’T TAKE INSURANCE.

I assumed private practice doctors who didn’t take insurance were just…only interested in wealthy clients, I guess. Honestly I never really thought much about the doctors who existed outside the various insurances I was on and off throughout my 20s and early 30s. The idea of their existence kind of passed over my head without really registering as relevant to me, the same way the idea of a “wealth advisor” did - sure I guess that exists, but it isn’t likely to ever have anything to do with me.

But after interviewing Dr. Iris Orbuch, I have a new understanding of how insurance companies are absolutely screwing those of us with uteruses over. If you’re reading this, I assume you already knew that our insurance system in the US is not…good. And you’ve all probably had your own frustrations and battles and bill-opening anxiety attacks. But hearing about how insurance works from the medical provider’s side gave me a whole new perspective.

Dr. Orbuch diagnoses and treats endometriosis with laparoscopic excision surgery (going in with robotic instruments through small incisions in the abdomen and finding and cutting out spots of endometriosis from wherever they may be). I know I’ve had a few posts here specifically about endometriosis, since thats the condition I’m personally dealing with behind my period pain. Even beyond my personal experience, Dr. Orbuch estimates that up to 70% of patients with severe dysmenorrhea who have no diagnosed cause likely have endometriosis, so I think it’s worth talking about.

This is an excerpt of a longer conversation with Dr. Orbuch.

DR. ORBUCH: The reimbursement from an insurance company is so woefully inadequate. So, I don't take insurance anymore and I can't, because I could be in surgery for seven hours, and the insurance company will reimburse me about $660 - if i'm lucky! Divide that in half for taxes. It's $300. I can't even pay my staff. Forget about turning the lights on, forget about my malpractice insurance, forget about buying gowns in my office.

The insurance companies don't recognize the value of how difficult the surgery is. It's really difficult to do. When I was in Manhattan, I would get tons of referrals from Sloan Kettering because they didn't want to do these surgeries, because it's harder than cancer surgery. The insurance companies are not recognizing the complexity of it.

So if I went and had a shoulder arthroscopy or a knee arthroscopy, which could take 15 minutes, maybe it takes a half an hour, they will probably get four times the amount for a 15 minute surgery than I would get for a five or seven hour surgery. And then you have to remember. What's included in that care if I took insurance is every visit for the next three months. I wouldn't get reimbursed for those visits for three months after the surgery. People vilify physicians, but it's the insurance companies who are creating the biggest nightmare. And if I'm taking home $300, it could take me 30 hours of staff time just to get the surgery approved on the back end, 30 hours of me paying a staff member, plus giving them health insurance, plus giving them paid time off, plus everything. I'm losing tons of money. I'm in the negative when it comes to operating. The system is such a mess.

KATE: Wow that starts to make my experience make a little more sense. I tried for years to get treatment for my severe dysmenorrhea. Every time I saw my GYN it would be a different GYN, under a different insurance, I would say, Hey, I'm having really painful periods, it's been my whole life since I was 14, like, what could it be? They'd give me an ultrasound, it would come back normal. Some of them would say “It might be endometriosis, but you'd have to get surgery for that, and that's really difficult, you're only having symptoms around your period, so it's not bad enough that I would send you off to get surgery.” And that's what was offered to me.

So the problem is that there are millions of people experiencing this who are not getting diagnosed, not getting care because it's not covered by the insurance, right?

DR. ORBUCH: It's actually 200 million worldwide just to put a correct number out there. And it's not that the insurance isn't covering it. They're not valuing it. So the amount that they're reimbursing is so little. So in your example of what you went through, you have to understand the insurance company pays more for an office visit. Let's say they reimburse the doctor $60. I'm making this up, but it's probably about that for a visit. And that doctor is seeing eight patients an hour, right? She's giving you 7 to 10 minutes. She is running 15, 20 minutes behind. So 8 times $60 and then multiply that out in one hour, two hours, you're making what you would do in the surgery, right? So, so OBGYNs are often disincentivized to operate because when you go to surgery, you're there two hours early, you're there two hours after, then you're taking care of the patient for three months afterwards.

And also, you have to understand Big Pharma's role in all of this. They're trying to band aid everything. It's easier if you've got seven minutes, which is kind of what the insurance company allows you. If you see patients for longer, you can't even bill a higher level of service 'cause you'll be audited. It's a whole nightmare. The more tests you send a patient for, the lower grade you get as a doctor in the insurance manual.

KATE: I’m sorry, what??

DR. ORBUCH: Yeah, so doctors are graded with levels. The more money you spend on a patient, you're not valued by an insurance company. I used to take a bunch of insurances when I was back in New York and I would get a grade, like I'm spending too much per patient. That's a disincentive. So it's very easy to say, here's a prescription for an ultrasound. Here's a pack of birth control pills. Move on next one, $60 down, move on.

There's so much that has come into play. Our general OB-GYNs are more like primary care. They're not well versed in surgery. They're not comfortable in surgery. These are difficult surgeries. They're not being reimbursed. So it's just easier to see more office patients, which is reimbursed more when you think about it. [So most OB-GYNs are] dividing up their time into 7-10 minutes per patient so they can bill that, then prescribing a prescription, which is helping out the pharmaceutical industry, and then sending them for an ultrasound, it's just it's just a mess I'm so many levels.

Medicine is a quick band aid fix with pharmaceutical things. I'm like, let me get to the root. Let me make you better forever. But our medicine is not geared for chronic illnesses. And unfortunately, more and more these days, autoimmune diseases are on the rise, there's more chronic illnesses, and we're trying to bandaid our way through chronic illnesses, and it's going to implode.

Insurance companies are incentivizing doctors to do fewer tests, prescribe more medication, and spend as little time as possible with each patient. They’re also failing to recognize the value of a surgery like endometrial excision - and let me go a little further down the rabbit hole here.

There are two kinds of surgeries to treat endometriosis - ablation and excision. Both are laparoscopic, with the small incisions and robotic instruments. Ablation uses heat to burn off the surface of the endometriosis lesions wherever they are outside the uterus, one by one. Excision uses cutting instruments to cut out the entire endometriosis lesion and remove it. While neither are technically a “cure”, people who get ablation are more likely to come back for another surgery because of returning symptoms. Dr. Orbuch compares ablation to “cutting off the white part of your fingernail”, and excision to “removing the whole nail” - less likely to grow back, and if it does, it will take much longer.

And how many surgeries you get matters - the more surgeries you get in one area, the more likely you are to experience “central nerve sensitization”. This happens when your body and brain change the way they process pain due to repeated painful stimulus in one area. And if you have endometriosis, you may ALREADY be experiencing some form of sensitization due to the severe pain and inflammation that usually comes with endo. So you definitely want to avoid central nerve sensitization!

But insurance companies don’t reimburse ablation and excision surgeries for endometriosis differently. They share an insurance billing code (58662, you never know when that might be helpful), meaning insurance pays your doctor the same amount for both surgeries. Even though ablation has objectively worse outcomes, and experts now widely agree that excision is what every endometriosis patient should receive. ¹ Because guess what? Ablation is a significantly quicker surgery that requires less training than excision. So if a doctor is taking insurance, what would the incentive be to do all that extra training, spend all that extra time, when the reimbursement won’t even be enough to cover paying a receptionist to answer phones while you’re performing the surgery.

Hope is not lost! According to EndoFound’s guide on how to get your insurance to cover your surgery, it’s possible to get your insurer and your surgeon to get together and negotiate a fair rate for this surgery. This is called a Single Case Rate, and by the way, anytime you find yourself in a weird gap in your insurance, you can absolutely request one of these. Obviously the insurer doesn’t want to do these because they are labor intensive for the insurer. So you have to advocate A LOT, meaning bother a LOT of people over and over again until it’s less work for them to give you what you want instead of continue to deal with you.

It’s a case of BEING a pain in the ass, to avoid HAVING a pain in the uterus. Idk, is that anything? My brain is full of insurance billing code numbers and I no longer talk human.

1. https://www.endofound.org/insurance-101-a-guide-on-how-to-get-your-surgery-covered#:~:text=A%201992%20Medicare%20Part%20B,and%20further%20damaging%20at%20worst.