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Question about healthcare & possible abuse. sm

Posted: May 16, 2011

My sister-in-law is in her mid 50's and not in good health; however, much (granted not all) of the problem is her lifestyle choice. She smokes at least a pack a day, she is sedentary to the point of using a lift chair, motorized scooter & cane to get around, she is at least 100 pounds overweight and her knees are problematic for her as there is too much weight on them.

She had a nervous breakdown about 30 years ago after a bad breakup, and then about 10 years later she got disability because of a hearing deficit. She had worked up until that point with no real problems other than the stress of a job. About 10 years ago, she had a stroke with no residual loss from her baseline.

Since being declared disabled (again, poor hearing), she seemed to have more than the average amount of doctor's visits - sometimes twice a week in a town that is 60 miles away from where she lived. It was a burden to get her to those visits but at that point she was mobile and could at least walk on her own. However, it was discovered that social services was paying for her mileage to go to and from this town, so it was like part of her income. The more she went, the more money she got.

We (all those designated to take her to her appointments) told her that she needed to schedule them all in the same day or start driving herself. This coupled with the reimbursement program ending caused her visits to come down to a more reasonable level.

I am troubled lately though by her physician who has ordered 2 sleep apnea tests in the last 2 months for her. My SIL is complaining of being tired all the time (deconditioning??). She was diagnosed with sleep apnea a few years ago and actually has a CPAP machine now that she does not use, and the tests were apparently ordered so she could qualify for a new type of machine. The first test did not go well because she is used to staying up all night and sleeping all day so they gave her Ambien before the second test (totally calling into question accuracy of the results).

My SIL is on Medicaid and pays little or nothing for these tests. I was advised by the same clinic system to have a sleep apnea test (at the cost of $10,000 back in 2005) when I was on Medicaid (my husband had left & my kids and I were "on the system"). My only complaint then was stress and fatigue - totally reasonable given the circumstances. I refused the test because I knew I would never wear a CPAP, but it troubled me how "hard" the nurse practitioner sold this idea.

My SIL has had a total of 6 sleep apnea tests counting these last 2 that were just completed. I guess I am looking for some people with medical knowledge who can give me some input on this issue. I think it is over the top, but I don't know. To me that $60,000 could have been spent more efficiently in her care and the care of others.

Thoughts???

;

I totally agree - long time CMA

[ In Reply To ..]
The first one to diagnose sleep apnea and the second one to test out the actually machine in use to see what improvement there was, but I think the rest are totally unnecessary, especially if she is not using the machine and will not use the machine. I agree, this money could be used eslewhere where it is greatly needed.

Nothing personal, but I hate when people have Medicaid or military insurance and pay nothing for constant, especially unneeded testing and visits, etc. when there is testing and doctor visits that I need but can not afford to go to because I have insurance and have a 20% copay. I am not saying that people who really need it should not get it, but there are plenty of people out there sucking the system dry and doctors raise their rates and I ended up with the bill paying the difference!

That is kind of what I am struggling with. Once we figured... - ndmt

[ In Reply To ..]
out that her doctor's visits were more social for her than anything else, we were able to shut it down a bit, but now it seems like it is the doctors who are ordering repetitive visits and tests.

I just wanted to get someone else's opinion. While I certainly want her to get all necessary care, I keep hearing that hospital census is down because people cannot afford healthcare and it makes me wonder if this is how hospitals are staying afloat.

There is a HUGE difference between - Medicaid and military insurance.

[ In Reply To ..]
Those with military insurance pay for their insurance. They take lower than private pay and are given good benefits. The pay could be better, but then the benefits would be worse. I hate when people assume that the insurance issued to the military is free. It certainly is not.

Yes, there is a difference. - Army vet

[ In Reply To ..]
I have office and Rx copays. I get a quarterly bill. It's not free. I earned it.

I am not saying anything mean about the military but - long time CMA

[ In Reply To ..]
I had a 'coworker' who was married to a man in the Army. She had no copays, etc. when she went to the hospital. She was going to the ER almost daily, switching from hospital to hospital because she kept insisting that she was having gallbladder problems and did not like what they had to say, but refused to have it out for a long time. She was getting prescriptions for next to nothing. She definitely had a lot of 'mental' issues and her and her husband were seperated. I went to the ER once and had over $400 in bills after my insurance paid and have had a few times that I really should have gone to the ER or doctors, but can not afford it, so I just suffer along while she was taking advantage of the system and going to the doctors and ER almost daily, paying nothing on the militaries dime.

Then she must have lived close to a VA hospital. - Army Vet

[ In Reply To ..]
The closest one to me is 2 hours away. There's an outpatient clinic about 20 minutes away, but anything beyond a routine pap smear and I have to drive 2 hours.

And if she's going to a "civilian" hospital, then she's dealing with a ton of paperwork to get the bills written off. I had an anaphylactic reaction to a wasp sting in October, on the weekend, an hour away from the outpatient clinic, which wouldn't have been open anyway. I can't believe the hoops I had to jump through for my military "insurance" to cover it. I think it was 9 months before I stopped getting bills from the ambulance service and hospital.

The military doesn't pay for the services, our taxes do.

Before I found out, on my own, 20 years after discharge, that I could get VA services, I can't count the number of times I really needed to see a doctor and couldn't, because it was $85 to be seen for a sinus infection. Need stitches? Super Glue and tape and hope you don't get an infection.

I'm on the low end of the totem pole services wise. I'm in the tier that has office visit copays and the one that gets booted off to make room for people with service-connected health problems.

The medications aren't all that great either. The formulary stinks. I've tried a bunch of insomnia medications, but they just don't work. None of the newer drugs are available. The only thing left to try through them is antipsychotics, which there is no way in H.E. double toothpicks I'm going to take.

I'm not being pissy or reactive, just saying that's how it is, for me at least.

My husband is active duty and I do not - active duty spouse

[ In Reply To ..]
have copays, but it is a pain in the behind to get TriCare to pay for anything. It is run by private insurance companies (Humana in the South) and I have to jump through the same kinds of hoops as anyone else with insurance. I can only go to preferred providers if I want them to pay and they will not accept a referral from an emergency room, which left me one day scrambling to try to get my PCM to refer me to a urologist with a kidney stone blocking my kidney (after the ER doc told me that I could die) because I cannot afford to pay to go to a urologist on my own dime. I have problems finding doctors who will accept the low amount that TriCare pays and sometimes cannot find one that will accept my insurance at all. In my experience with military families (and I know a whole bunch of them), they are not abusing anything. It is a terrible generalization to say that they do, based on your experience with one person and again, the health insurance is not free, it is well earned. I would think that my husband's 16 years of service to our country at lower than private sector pay has earned decent health insurance. It irritates me to no end that anyone would begrudge us our health care, all the while with people whining about how everyone has the right to the same care, earned or not.

God Bless Your Husband!! I'm so thankful for the - men and women that serve

[ In Reply To ..]
our great nation. They deserve much better than they get sometimes!! Come from a military family and so proud of each and every one of them for risking their lives, giving to our country! Please tell your husband - THANK YOU!! :)

Maybe so, but perhaps not. - sm

[ In Reply To ..]
I admit that sometimes I have been a been hypercritical of others in the past, but now that I have my own problems, I have to eat my words.

Consider: You said 2 "recent" apnea tests. Conditions change and she may now have sleep apnea. Fatigue is a legitimate symptom.

As far as the hearing problems, I am developing vision problems that are inherited that I can do nothing about it. It stinks and makes everything more difficult. I would guess hearing difficulties might be more of problem than you would imagine.

The doctor's visits. Are you present in the exam room? Do you know everything they are monitoring?

Granted, there may be something else going on here and you may be right, but I really don't know of doctors that schedule social visits--they usually refer for counseling.

When I look back at my life, I sometimes wish I had been a little kinder. Just saying.

I'm not trying to be unkind or hypercritical. As I said... - ndmt

[ In Reply To ..]
she was already diagnosed with sleep apnea and has a CPAP machine at home that she doesn't use. This was diagnosed by the 4 sleep apnea tests she had in the past. I'm simply not sure medically why 2 more were required when they sedated her for the last one and could not have gotten accurate results.

I also never said the doctors schedule social visits, in fact most staffs don't really care for her and are somewhat rude to us when we bring her in. What I said was it was her way of being social because each time you drive her on the 180-mile round trip she wants to shop and go out to eat. I am sure you can understand why it was problematic to do that once or twice a week. We had to be firm about scheduling all her appointments in a day once or twice a month.

I am not making light of her hearing problem, either. I have simply known her for years, and the hearing deficit she had never precluded her from working and has not gotten any worse. I am completely sympathetic as I have medical problems, too. I have the recent onset of diabetes and am having significant eye problems.

The background I gave was simply so people could help make a judgement. Like I said, some of her problems are self-inflicted and some are not. I am just wondering if the Medicaid factor is playing a role in this particular situation based on my experience there. I feel like they may be ordering expensive tests for Medicaid patients since it is guaranteed income for them.

I certainly have not been passionately lobbied to have a sleep test since I had to give up my insurance, and that is why I am questioning the standard of care here. The NP that talked to me that day when I was on Medicaid repeatedly said "Medicaid will pay for all of it." I just feel with our healthcare system ready to topple over that maybe extraneous tests should be avoided and those funds used to help others. Like you maybe.

Hubby "flunked" his first sleep apnea test - Happy spouse

[ In Reply To ..]
The first time around, he could not sleep with all the wires hooked on him and had to repeat the test. I am so happy he did! He has a machine now and it took several fittings to get the proper mask. From my understanding, there are new machines now that do need to be calibrated properly. Anyways, he is so much better now and no longer has the day-time sleepiness and has so much more energy and looks much healthier. I am sleeping better, too, because the sound of the sleep machine is much better then listening to him snoring!

I hope your SIL is feeling better. Your SIL may be getting more positive reinforcement from her doctor visits than from her family and friends. She may feel some guilt for the extra effort her appointments cause, and she might feel she needs to make up for it with the lunches, etc. Some people are intimidated by the medical establishment and are reluctant to ask for specific appointments.

Been there, done that. (with my sister).

I guess I need to take away from this that I'm just being... - ndmt

[ In Reply To ..]
unreasonable and unsupportive. However, I do want to point out that she doesn't buy us lunch - we do pay for gas & food and do try our best to help her out.

My question was more of a medical necessity nature of all the expensive testing (and she is not shy about dictating to office staff nor does she let anyone take her to her appointments who won't take her shopping or to lunch), but I cannot seem to make my point clear.

I won't confuse it further.

I totally get your point and agree with you and am - sympathetic to your sitaution

[ In Reply To ..]
Unfortunately, there are doctors out there that will order test after test after test and just keep on 'gathering data' and do not offer much in the way of solutions.

I would definitely cooridinate her care to get testing and visits all in on one day and yes, she is taking advantage of the situation. I 100 percent hear you and agree with you!

Sleep apnea - Happy Sleeper

[ In Reply To ..]
Looking at our charges from the sleep lab so far. The sleep lab overnight visits are charged at about $3,000 per session. My insurance apparently has a contract to pay an allowed rate of about 60% of that, and the clinic has agreed to accept that. Of that, I have a co-pay for which my "out-of-pocket" was $60. He had to go through the procedure twice. Then there are follow-up visits for the mask fitting and machine purchase. I believe the machine cost was about a thousand, but again, we are paying the co-pay. So far the charges seem to be well below $10,000--more like $8,000 or so.

Hubby had a difficult time being referred for the sleep apnea tests. He does not fit the profile except for day time sleepiness. The other major risk factors are being overweight, neck size, and smoking, and he is thin and does not smoke. Hubby had to have sleeping medication in order to complete the test, so I think the test is probably accurate with or without.

When I did billing years ago, Medicaid required a diagnosis (and code) of reason for the tests. Auditors require back up information in the chart. You said your SIL is overweight and is fatigued. You said she had the tests many times, but only two recently.

Hubby did not believe that he had sleep apnea and he needed some education that it is a serious condition. I do know a lady who eventually died from congestive heart failure secondary to sleep apnea. I also believe my husband was at risk for falling asleep while driving if he had not been diagnosed and treated. Hopefully, your SIL will be treated and be able to enjoy life once again, even with her other limitations.

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