The insurance companies don’t care if my patients go blind
One of the proudest accomplishments of my profession, ophthalmology, is the reduction in blindness from glaucoma. Decades ago, it was common to hear “Uncle John went blind from glaucoma.” Now such tragedies are rare. But now the insurance companies are refusing to pay for the most effective glaucoma medicines while increasing the patients’ deductibles. The result will be that more patients go blind.
Unlike many diseases, glaucoma has few symptoms in its initial stages. In most cases, the pressure in the eye is elevated causing damage to the optic nerve, the nerve that transfers visual images from the eye to the brain. Usually, glaucoma affects the peripheral vision first. But many patients don’t notice this as it occurs gradually. This is why ophthalmologists advise all patients to have their eyes checked, even if they have no visual complaints. A simple eye pressure check along with examination of the optic nerve can identify patients at risk for glaucoma.
Over the past generation, the pharmaceutical companies developed some fantastic eye drops that greatly reduced eye pressure. This combined with the willingness of the insurance companies to pay for the visits and tests required to monitor the glaucoma resulted in plummeting blindness rates. The other beauty of these drops is they reduced the need for surgical procedures.
But then cheaper generics for these drops were developed. The problem is that these cheap generics are not as effective, but the insurance companies are insisting that we ophthalmologists use them. They refuse to pay for the better drops, so that patient has a choice: fork over $250 a month for the better drops or increase the risk of going blind.
It should be mentioned in all fairness that the insurance companies will pay for the better drops, but this requires that we ophthalmologists try the inferior drops first and document that they are not working. We must waste the patients’ time with multiple office visits and costly glaucoma tests. Since the patients now have huge deductibles or large co-pays, they are understandably irritated. And since many of these patients have no visual complaints, they drop off the radar.
If this wasn’t bad enough, glaucoma does not affect each race equally. Blacks not only have a higher incidence of glaucoma, but more aggressive cases. In fact, glaucoma is the leading cause of blindness in blacks (for whites it is macular degeneration). As blacks disproportionately have no insurance or poor insurance, many more will go blind.
The reader may wonder why insurance companies are not liable for such obvious malpractice. The reason revolves around an arcane 1998 legal case, Bast v. Prudential Insurance. Prudential refused to pay for a bone marrow transplant on a patient, Mrs. Bast, even though her policy said it was covered. Thus, she died. Her family sued Prudential. The court ruled that the insurer only had to reimburse Mrs. Bast’s family the cost of the bone marrow transplant, not for the loss of her life. I am not making this up. Perhaps someday, there will be a legislation that requires all judges to disclose whether they have hidden foreign bank accounts to transfer pay offs, but that’s a topic of another article.
Thus, insurance companies can tell doctors what tests to order, what drugs to use and whether surgery is necessary and not worry if the patient suffers a catastrophe. In fact, if an insurance company refuses to pay for a CAT scan and a brain tumor is missed, the insurance company is off the hook but the doctor who ordered the test can be sued! And if a few glaucoma patients go blind, it will not impact the million-dollar salaries and stock option values the insurance company executives are pocketing.
Politicians from both parties allowed this mess. The refusal of Republicans to protect citizens from pre-existing conditions opened the door for Obamacare, a hideous plan that forced everyone to buy lousy insurance. This stifled competition. The solution would be to cover all Americans with Medicare for annual health bills that exceed $75,000 a year. Buying insurance to cover this amount would be inexpensive and allow patients to shop for plans that cover them properly.
Joe Bentivegna MD is an ophthalmologist in Rocky Hill.
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