Here’s an email I just sent to our corporate benefits department. I’ve changed names to protect the innocent, and the not-so-innocent. 🙂
My name is Heather Mina, and I’m a Software Engineer assigned to the southeastern Virginia, office. I’m writing to give feedback on the health insurance available to us here in southeastern Virginia, and how it affects me personally.
I have an inherited connective tissue disorder called Ehlers-Danlos Syndrome: Classic Type (http://en.wikipedia.org/wiki/Ehlers-danlos_syndrome). The primary symptom for me is hypermobile joints, which can partially or completely dislocate very easily, resulting in sprain, strain, fracture, or simply pain. My lab tests show elevated levels of inflammatory markers – which are a prime indicator for heart attack – due to the chronic, system-wide soft tissue injury, pain, and inflammation. I have been under the care of a physical therapist since January 2007, and of a pain management specialist since December 2007. I’ve worked with orthopedists, orthopedic surgeons, rheumatologists, physiatrists, neurologists, neurosurgeons, and geneticists to find the cause of the chronic, widespread pain, and to address and manage it.
EDS does not have a cure. Treatment is by managing symptoms, managing pain, and avoiding high-impact activities. One of the key components is ongoing physical therapy to strengthen the muscles so that they can take over the work that the connective tissue can’t do. My physical therapist is a specialist in treating hard-to-treat patients, and uses a variety of hands-on techniques to find and control pain, as well as unique exercises to strengthen muscles that most people don’t even know they have.
The Insurance Company PPO plan available to us for 2008 includes 20 physical therapy visits during a calendar year, with no recourse for extending the visits for medical necessity. The copayment this year has been $20 per visit. My doctor has prescribed twice-weekly physical therapy to manage this chronic, lifelong condition, which would mean 104 visits per year. My physical therapist charges $55 per visit, and my Explanation Of Benefits forms show that Insurance Company considers the allowable charge to be $27. Of that $27, I pay $20, and Insurance Company pays $7. As a result, for my 20 visits this year, I’ve paid $400, and Blue Cross has paid $140. And now I’m paying $55 a visit until the end of the year.
For 2009, our copayment has increased to $25 and the number of visits has increased to 30. This means that when my 30 visits run out, in early to mid April, I will have paid $750, and Insurance Company will have paid $2 per visit, or $60 total. After that, I will be paying $55 per visit for the rest of the year, for a total cost to me of $4,070 + $750 = $4,820. What’s more, and I confirmed this with Insurance Company this morning, that $4,070 does not apply to my out-of-pocket maximum.
Without regular physical therapy, I am at a significantly increased risk of injury due to hyper-flexible, unstable joints. Of course, any injury will result in much higher expenses to Insurance Company than the $4 per week cost that Insurance Company takes on for ongoing physical therapy; moreover, any injury will result in increased time away from work for me and decreased productivity during treatment, which are both costs to Employer.
This physical therapy benefit is completely insufficient for employees with chronic musculoskeletal conditions – and it is the best of the choices offered to us in southeastern Virginia! In addition to the copayments for physician visits, diagnostic tests and procedures, prescribed braces and supports, and prescription medications, I’m going to be completely snowed under this year. While I certainly don’t expect Employer to help me manage my finances, I’m very disappointed in the healthcare coverage available to us.
I do not like to send a message of complaint without offering an alternative solution, but in this case, I don’t know what solution I could offer. I am sorry for that, and I hope that our 2010 options will help me to better manage this chronic condition.