Chat Highlights
Glaucoma and Insurance
September 6, 2000

Norma Devine, Editor

On Wednesday, September 6, 2000, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Glaucoma and Insurance." 

Moderator:   Welcome, Dr. Wilson!

Dr. Wilson:   Hello everyone.  Sorry to be late.

Moderator:   The topic tonight is "Glaucoma Insurance."   Dr. Wilson, I have two questions for you, when you're ready.

Dr. Wilson:   Fire when ready.

Moderator:   What kind of programs are there for glaucoma patients who do not have medical insurance? 

Dr. Wilson:   There's Medicaid for the indigent, and the  Lions Club and other benevolent organizations will help.  Sometimes the state or local Society for the Blind and Partially Sighted has helped patients get care. Indigent patients can usually get medications directly from the pharmaceutical company by going through a lot of paperwork with their doctors.

Moderator:  How does a patient with no insurance find a doctor for general care or a second opinion?

Dr. Wilson:  The American Academy of Ophthalmology's Project Glaucoma 2000 will put patients without doctors in contact with doctors who will see them.

P:  I called them and they referred me to local help -- like United Way, Lions Club, Salvation Army.

P:  Maybe you should refer to the Project 2000. Perhaps the person you were speaking with didn't know about it.

Moderator:  Yes, that might work. I know someone here got help from them.

P:   The New York Times had a long article about drug development that mentioned the free drug program.  I recall that after all the paperwork and acceptance, there was a time limit, at least in cited cases, of about six months.

Dr. Wilson:  That is probably true.

Moderator:   Do you think that managed health care has affected the way you follow a patient and treat patients?

Dr. Wilson:   Absolutely.  I was just talking to other doctors today about that.

Moderator:   So, Dr. Wilson, you might want to proceed one way but you cannot?

Dr. Wilson:   Probably ten times a day I do not get the tests I would like to because I needed prior approval from the general doctor, who understands next to nothing about glaucoma.

Moderator:   This one is for the group.  Has anyone ever been denied a visual field, follow-up visit, etc., by their insurance company or primary doctor?

P:   I had a primary care doctor deny me a visit to my eye doctor during an attack.

P:   My insurance only pays for one intraocular  pressure check a year.  I pay for the rest myself.  

Dr. Wilson:  Can you complain to the state insurance commissioner?  That is certainly poor care.

P:  Do insurance payers limit the number of diagnostic procedures you can perform?

Dr. Wilson:   If I have one of my technicians try to get the approval while the patient waits, it will probably take more than an hour. 

P:  Prior to my diagnosis of normal-tension glaucoma (NTG), I was told that insurance refused to pay for regular visual field tests as a means for screening, since so few people have NTG.

P:  That is not true about few people having NTG. 

P:  I didn't know "gate keepers," or general physicians, had to approve a specialist's tests!

Dr. Wilson:  Depending upon the plan, they do.   I've also added one person per doctor just to take care of all the pre-approvals for surgery and scheduling.

P:  My experience with disability insurance was very disheartening. Several insurance companies denied me disability insurance for glaucoma.

Dr. Wilson:  Was that due to a pre-existing condition?

P:  Yes, Dr. Wilson. Exactly.

P:  What about Social Security?

P:  Many of these "gatekeepers" are moonlighting, doing this assessment on the side and/or are not qualified to make such important health care decisions.  The name of the game is to deny and wear you out. But I've persisted and won.

Dr. Wilson:  Right.  You have to be tenacious in demanding your rights.  The other problem is with advanced surgery when I have to go to the medical director of these programs to get permission to do the surgery. The director is usually a retired pathologist who has no idea of what I'm speaking about.

Moderator:  What is advanced surgery, and why would you need a medical director's approval?  

Dr. Wilson:  Aqueous shunts are an example of advanced surgery.  I need the director's approval so I would get paid for doing the surgery.  My group, which has over 15 doctors, provided $800,000 worth of care two years ago, for which we did not get paid because we had not had pre-approval.  Often the care was urgent or the patients said they had talked to their general practitioners and the approval would be mailed.  If they found out the care had already been given, we would not get paid.   That is why doctors now want to see the pre-approval before seeing a patient.

P:  I have found that most of my other doctors know little or nothing about my eye problems.

Dr. Wilson:  That's what we thought.  That amount of money really got our attention with the reduction in most reimbursement.

P:  As serious, chronic ailments go, glaucoma is one of the least expensive, I'm guessing.

Dr. Wilson:  The cost of  visual fields, HRTs, and medications add up over time.  

P:  It's very important to follow up with insurance carriers and find out why they deny a claim.  My carrier (I'm not in managed care and don't need any referrals) denied coverage for an office visit, thinking it was a routine eye exam. When I explained I was a glaucoma patient and the visit was not for eye glasses, they said they would pay it.  Apparently that was a case of  a wrong code being entered somewhere.  And this is as simple a situation as you can get!

P:  As Dr. Wilson said, so much depends on the coverage plan.  Also, insurers know that most people don't put up a fight.

P:  Do you think a patient bill of rights will help?

Dr. Wilson:  Yes.  You all should be pushing your representatives in Washington for a patient bill of rights.

P:  Insurance companies are licensed by the state.  Everyone should file complaints to insurance commissioners, with copies to officials, every time an unreasonable decision is made by insurers.  Imagine, if  everybody did this!

P:   After hearing these stories, I know I won't give up my Blue Cross - Blue Shield.  I see my doctor for pressure checks every other week right now.

P:   Make sure you have good major medical coverage.  The peace of mind we get from almost complete coverage is worth every penny.  It's  expensive but I'd rather cut down on something else.  

Dr. Wilson:  Managed care in America has taken significant money from hospitals and doctors to give less care to patients. The extra money that used to be put into patient care is now given to shareholders and administrative salaries.

P:  A Canadian's opinion:  you need to stop having profit as the prime motivating factor in providing health care, and institute state-run medical coverage.  Most of the industrialized world has it.

Dr. Wilson:  Right.  For the richest country in the world, our health system is about 13th in the world in total citizen health and we're about eighth in education.

P:  My concern is that I will be denied coverage because of a pre-existing condition like glaucoma.  I dare not quit my job for fear of not being able to get coverage elsewhere or certainly unable to buy coverage on my own.

P:  The problem is that we are living much longer, the medical advances cost a ton of money to develop and perfect, and many in this country have no care or insurance whatsoever. So someone (us) has to pay, and those running the system have to find ways to reduce the costs. It's a deplorable system, but someone needs to articulate a better way for all of us.  

P:  After quitting my  job, I was able to find my own health care coverage that accepted my condition, bad as it is.  I pay almost $200 a month for it, but I have coverage.

P:  Is that for your whole family?

P:  Just for me.  I have a co-pay of  $10 primary, $20 for the specialist,  and I need referrals.  I pay no deductible, but lots of co-pays at $10 and $20.

P:  In Canada,  co-pay is called extra billing and it's not allowed here, or the federal government reduces the amount of money it sends to the province that allows it.

P:   In the U.S., it's used to offset premium costs.

P:  Only Blue Cross will accept my family, due to my glaucoma and my daughter's blood condition.  I pay $500 a month and still have a $1,000 deductible and $1,500 co-pay.

P:  In my case, after I pay $1,500 + $1,000, the insurance covers everything. I'm considering surgery, and know I better get it before December since I've already met my deductible for this year.  It's terrible that an insurance company can  dictate when I should have surgery.

P:  I was lucky and had surgery on December 30 one year,  just before my outpatient deductible went up from zip to $100.

P:  I pay $500 a month for a family of five.   Family deductible of $1,000. Co-pay of $1,500 a year. Not great.  In fact, I accepted a job I didn't really want just to be included in their group insurance plan.

P:  My insurance covers the doctor (as in "network") at 90%, but doesn't cover the surgical facility. I think that is ridiculous!

P:  Folks, I am flabbergasted by the high costs of your health care premiums.

P:  I feel many of us are stuck in awful jobs just to keep insured.

P:  I've had several strange calls with my insurance company.  Insurance paid for one laser procedure I had in the doctor's office.  Another laser procedure I had in a different room of his office, which they called a surgical facility, insurance would not pay for.  

P:  Our BC/BS has a deductible of $50.  They pay 80% of prescription costs and and doctor visits, and 100% of surgeries and tests.  It costs $200 a month.

P:  Do physicians as a profession have a medical system they would like to see implemented nationally?

Dr. Wilson:  There are lots of ideas. I feel we need a national plan, perhaps something on the order of Oregon's. There the doctors all got together and created a rank list of what in health care was most important and what was the least important in the health of the population. High on the list were children's immunizations and glasses.  Low on the list were heart-lung transplants and spending $700,000 to save a premature child weighing less than one pound who would never be right. The politicians then would have to make the hard decisions as to what society was willing to pay for health care and fund down the list as far as they could.

P:  Doctor, that sounds good to me; but the public gets all drippy about a story on the front page of the newspaper about a dying kid that says the insurance company won't pay for her experimental transplant that costs a million dollars and has less than a 10% chance for success.

P:  I was heartbroken when the Clintons were not given a chance to work through a variety of possible solutions to national health insurance. I don't mind paying a lot for coverage. Health costs can make up a third of the GNP (gross national product).  This is a productive industry that employs an enormous number of people, but coverage must be high quality across the board for everyone.  That 40 million people are not covered in this country is obscene.

Dr. Wilson:  A national plan, versus Darwinian survival of the financial fittest (as we have now), would have to provide for keeping alive inner city hospitals and rural hospitals. They won't survive if we keep going the way we are. The best guess is that 50% of the hospitals in Philadelphia will close till we get rid of the "excess" beds in the system.

P:  There is a bill on Capitol Hill that would provide glaucoma coverage or screening with Medicare.  Does anyone else know about this bill?

Dr. Wilson:  It would provide for coverage for screening exams for glaucoma.

P:  In Switzerland, where nothing is socialized, about four years ago, health care reform was introduced. No one is denied coverage and the premiums are shared by all the population. Insurers have to take their fair quota of sick and elderly, and the young, healthy people pay higher monthly premiums.  That has not worked out as well as promised, because many people cannot afford the premiums.

Dr. Wilson:  There are no easy answers. Unfortunately.

P:  Doctor, I think your suggestion to bring these issues to our elected representatives' attention is a first step.

Dr. Wilson:  Please do. You help all of us if you do.

End of chat highlights for September 6, 2000.

On September 13th, Dr. Rick Wilson discussed "Conquering the Fear of Glaucoma" in the Chat room. Click here for highlights of that meeting.

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