Health care problems hit home

We definitely have health care problems in Nevada and the nation.

On Aug. 31, I sent a letter to the officials I believe to be most interested in solving these problems: Senators Richard Bryan and Harry Reid, Rep. Jim Gibbons, Gov. Kenny Guinn (his health care task force had not yet been appointed), Sen. Bill Raggio, Assembly Speaker Joe Dini, members of the Legislature's Statutory Committee on Health Care, Executive Director of the Retired Public Employees of Nevada and the President of the Washoe Chapter, RPEN.

Speaker Dini responded to the issues I raised stating he hoped that "by the first of the year, Medicare carve-out is eliminated from the [state] plan."

I retired from the Legislative Counsel Bureau in September 1993 after some 20 years of service. I also worked 30 years in private employment contributing to Social Security. I'm a member of RPEN and have primary health coverage under Medicare and secondary coverage through Nevada's self-funded plan administered by UICI as the third-party payer.

In 1997, I was diagnosed with hyperparathyroidism, which causes abnormally high levels of calcium in the blood. I use a cane and no longer drive because of the muscle weakness in my leg but have been spared more serious complications such as kidney stones and pancreatitis. I've had two operations since 1998. A third surgery is scheduled Oct. 27 in San Francisco.

Parathyroid surgery is delicate neck surgery that must be done in a hospital. Medicare paid the bulk of the Reno hospital and surgeon's fees for my March 1999 operation but noted: "Medicare pays less for this service when it is done in a hospital setting than when done in a doctor's office." Was this another bottom line decision by someone lacking medical knowledge?

Like many others, my husband and I are concerned that while Americans probably have the best health care available in the world, we can no longer afford it. Even insured people struggle to pay their share. Twenty percent of $100 is affordable; 20 percent of $25,000 or more may not be, especially if the annual premiums and deductibles amount to $3,500 or more.

These last two items cost us $3,486-plus in 1998 but will be $3,984-plus for 1999. The so-called Medicare carve-out of $3,000 per year was imposed on retirees as an additional deductible before UICI contributes toward reimbursement.

The 1999 Legislature was told it was necessary to raise premiums (an additional $90.80 per month for us) and cut benefits in order to bail out the self-funded plan. Actually, these changes took effect in January 1999 prior to the session. We had no choice! We were required unfairly to compensate the plan because of embezzlement of thousands of dollars by an employee(s) of the previous third-party payer.

We question the administrative abilities of UICI, the current payer, when it processed the same claim totaling $330 on four different occasions with four different outcomes as to our copayment:

(A) July 28: UICI paid zero - our share, $330;

(B) July 30: UICI paid $79.29 - our share, $30.93;

(C) Aug. 10: UICI paid zero - our share, $110.22;

(D) Sept. 1: UICI paid zero - our share, zero.

Neither Medicare nor UICI pays our prescriptions. We have paid some $800 for these nonreimbursable necessities so far this year.

Another eye-opener for us - when Medicare is the primary insurer, it usually approves a charge less than the billed one and bases its 80 percent payment on that lesser amount. The plan administered by UICI is billed for the remaining 20 percent of that lesser Medicare-approved amount, but usually the insured is responsible for copayment also. Thus, 100 percent of a provider's charge is seldom paid.

Would providers of goods and services in any other field accept such forced reductions in their fees/charges? I think not. Try the same tactic on your grocer, plumber, utility, your daily newspaper and see how far you get.

From a review of my billed expenses through Aug. 31, 1999, it's apparent providers also have taken quite a hit. Against total billed charges (rounded off) of $22,700, they received $7,956, leaving a balance outstanding of $14,744 with no reimbursement in sight. Medicare paid $6,114, we paid $1,563 and UICI paid $279.

An article headlined "State health insurance program stops losing money" in the Aug. 27 Nevada Appeal indicated, "It may not be necessary to raise premiums for defendants and pensioners by 12.7 percent next January ... it may be only 7.4 percent." Another increase? Based on our experience, we already are paying the plan/UICI not to provide adequate coverage. How much more can we stand? Insurance companies aren't the only ones with bottom lines.

We're aware that the Congress, governor, appointed task force and committees are considering these problems. Our concern is that unless all the facts are gathered from all the players - insured persons, both ill and healthy; providers (doctors, dentists, hospitals, nursing homes, pharmacists); insurers (HMOs, PPOs, group/private, Medicare); and third party payers such as UICI - a true picture of the challenges we face cannot possibly emerge.

No one wants to be sick. Certainly, we don't, but the reality is, many of us are. Our state and national health care systems need revamping. All of us are paying more for administration than we are for health care. It will take everyone working together to make it more fair, affordable and more beneficial to all concerned.

Ellen R. Nelson is a longtime Carson City resident, former chairwoman of Common Cause and retired Legislative Counsel Bureau employee.