The other side of the coin

Good Evening, I have to share this experience with folks who might get where I am coming from.  Throughout the years I have read the horror stories of people who have been unable to get their insurance companies to pay for their surgery. I have seen the appeals leading to attorney intervention. I have felt the pain of others who are are trapped in their bodies with no hope or relief. I was one of the lucky ones who had good insurance that paid for me and my husband and both of out TT's. My life is now full and active and I am actually happy with how I look(my pic here is old). So, now I am on the flip side. I spent my entire day withe benefits advisors and insurance reps designing my company's new self-funded plan.In case you do know what this is, it is where the comapny pays claims rather than premiums.  I flipped to the back and saw the page on weight loss surgery. I felt the dread. Now, a couple people there know I had the surgery. I was unsure how I would approach this. We spoke about the cost and the benefits. It is our decision whether or not we include this. We have about 500 people on the current plan. The truth is harsh and the reality kind of blows. I now have to look out for the best interest of my company. That is what I get paid for. I do represent the employees too and have definitely taken stands in the past to defend certain positions. The truth is that paying $30,000 for a surgery may not have an up side. Where would they see the benefit of paying this out if the employee leaves and goes to another company who would reap the benefits of the healthier employee? What if the employee works for six months, has the surgery, and then leaves? We all know that we have looked for companies that will pay just to have it done. We all know that the overall benefit would be passed down through out the years. How do you convince a company that the liabilty is worth it when there is no immediate result and the cost FAR outweighs the possible benefits.  When everything is about the bottom line and the VP who makes the decision is 100 pounds soaking wet, there is no leg to even stand on. When I look at it from a financial standpoint, it is not in the company's best interest to assume this cost. It is way too bad, but that is the reality. I am overwhelmed and incredibly sad that I cannot advocate for us. I kind of feel like a traitor.  Thanks for listening. Terri

Terri, I am very tired tonight so I hope I end up saying what I want to say! LOL  I understand that you are in a position with a team of players (management of benefits) who is trying to determine cost effective measures for self-funded insurance.  This is a huge responsibility as I'm sure that the potential questions and decisions on the "plan" also goes into many things to offset cost to the company such as: Do we charge our employees for a portion of their insurance coverage?  Is this across the board or does upper management have a better plan, etc.  What is that charge and how should it be determined?  By income?  For example, if an employee elects to have coverage for themselves and their spouse (which  now you have to consider domestic partners and who to define that) shouldn't we charge them LESS than the employee who elects to have coverage for themselves, their spouse/significant other, and their children?  Is there a limit to children?  What if we figure coast by percentage such as:  the employee and partner pays 2.5% of their annual salary divided equally amoung the companies pay period schedule; the employee, partner and 1 child pays 3% of their annual salary; and the employee who elects coverage for themselves, partner and 2 or more children pay 3.5% of their annual salary towards the coast of coverage.  To charge a flat rate seems a unfair because obviously the employee with the wife and 5 children will cost the company more in health claims than a single employee.  Or so it seems -- STATISTICALLY.  The truth is that the large family may not be ill often at all while the one single employee contracts a serious disease, has a massive heartattack, and/or finds out they are dying of cancer. Statisic management/risk is good on the upfront but there are no guarantees that these statistic will be your companies statistics.   I think what is SAD is that one can look around the office at the employees of the company.  There is John, 34, runs, eats right, does everything he is supposed to do and he looks like a very low risk for coverage.  On the other hand, Mary is 36, the mother of 2, and is SMO.  She suffers from no currrent comorbidities but "statistically" she will experience them eventually.  While, Mary looks like the emplyee that is going to cost the company the most money b/c she appears (by why you know about her lifestyle, looks, weight, etc.) there is no guarantee that she will be the most costly employee as far as health care is concerned.  Mary, may not elect to have the surgery even if covered and go about her merry way and ever needing any immediate, emergency care.  She leaves 3 years later for a better job opportunity and she's not cost you any more than any other SEEMINGLY healthy employee.  In the meantime, John has been out for his morninig run, come into the office early and is in the break room making his green tea which suddenly, his cup falls to the ground shattering and he goes tumbling after it.  John, is rushed to the nearest ER unresponsive.  They EMT team is able to revive him and after several tests at the hospital it is determined to everyone's surprise that John needs triple byass surgery to save his life.  As soon as he is stable, they do the surgery but he is inpatient or 1.5, requires physicaly theraphy, missing work for 3-4 months and costs the insurance company will in excess of $250,000 (so far).  Don't forget about Suzie how goes in for a flu shot -- he doctor feels a swollen lymph node -- runs some tests and determines that Suzie has cancer -- and it's bad.  Iit's stage four -- she needs a radical cancer treatment to attempt to save her life, hospice, etc. but she died within 3 months.  The company  not only then coveres her cancer treatment, nursing care, etc. put has to pay our her family three times her annual salary as part of her benefit package. The point I am trying to make is that -- it infortunately seems that we "judge" a person's health by their size, how they look, their exercise program, and/or any other little thing that we know about them but in truth we know nothing and do NOT have a crystal ball to tell us who is going to be sick and who is going to be well.   The stigma and discrimination of obesity is just right out there -- in plain view -- which may make certain persons pre-judge and make presumptions on the obese persons future that may never come to pass.   John, Mary, or Suzie can leave their place employment at any time given that they are likely at will hire and fire employees.   How do you predict these things?  Truthfully, you can't.  You manage risk by statistics that I don't believe are adequate and begin with a deep seeded bias. Anyone can get sick at any time.  Anyone can find out they have cancer, move to a job whereby they have better coverage for cancer treatment and won't be penalized b/c as long as there is no lapse in coverage, there is no pre-existing condition and your company has to pay. What about the newlywed who gets hired and 2 weeks later finds out she's pregnant?  The pregnancy, delivery, and possible complicaions can cause the company to pay up large sums as well. I'm having a difficult time looking at this as a non-bias sitaution.  Because someone's illness if viably seen (obesity) they are "punished'" however, the next employer who has a heart that is a ticking time bomb is not judge and punished by excluding heart bypass surgery b/c he looks healthier than your 16 year old nephew! *shrug*   I hope I make some kind of "point" in which to consider.  The unknown is the unknown -- and cost predication and statistics are just that -- nothing grounded and nothing certain.  So, why does the obese or MO, os SMO  person be the one that is discriminated agaist in healthcare simply because their "disease" or "condition" is more clearly visable? I hope this opinion helps!

Firstly, your thoughtful reply is much appreciated and all of your advice was sound and logical. Now, let's address a few of the statements: "Do we charge our employees for a portion of their insurance coverage?  Is this across the board or does upper management have a better plan, etc.  This is already determined. The percentages are in place for all levels. "For example, if an employee elects to have coverage for themselves and their spouse (which  now you have to consider domestic partners and who to define that)" You do not have to consider domestic partners. That is a definite no. The liability is way to high and they will never go for that.  The percentages are broken out so that the single ee pays less than the family.

 "The point I am trying to make is that -- it infortunately seems that we "judge" a person's health by their size, how they look, their exercise program, and/or any other little thing that we know about them but in truth we know nothing and do NOT have a crystal ball to tell us who is going to be sick and who is going to be well. " I agree. the issue though is not who is healthier. It is what risks we are willing to take. Unfortunatley the WLS is considered an optional surgery where bypass is not. As much as I loathe that, it is just reality. We have the ability to choose if we cover WLS. Being self-funded means we could refuse to cover heart surgery, but that would never happen. WLS is still considered an elective surgery. The day we consider it the same as that heart surgery would be the day we win the fight. That day is not today.  "I'm having a difficult time looking at this as a non-bias sitaution.  Because someone's illness if viably seen (obesity) they are "punished'" however, the next employer who has a heart that is a ticking time bomb is not judge and punished by excluding heart bypass surgery b/c he looks healthier than your 16 year old nephew!" I agree 100%. That is why I feel so bad. MO, although classifed as a dsease, is still not really considered such. One of the things they spoke of was requiring the 12 month supervised diets. I scoffed at that. That is rediculous as most of us get. If it took getting them to cover it, then I would agree though. Unfortunately, the final word people do not really get it. Discrimination is a fact. If I weight the 400 pounds I use to weight I probably not even have this job. Stuffing myslef into those uncomfortable suits and trying to interview while squeezed into a chair made for a 150lb person is seered in my brain forever. Men letting doors slam in my face before holding it is thought of every time one rushes to hold the door for me now. I will never forget. I will put up a fight as it is allowed for me to do. I just know they will not approve it.  It breaks my heart.

Either morbid obesity is a disease or it is not.  You can't say a disease is elective.  We do not know enough about obesity and the role of hormones, genetics, microbs, viruses, etc. (all of which have been found to contribute to obesity) to label it as a solely behavior driven disease.  Does your insurance not cover lung cancer if the patient was/is a smoker?   I understand the conflict of your job being to keep the insurance cost down, but it also sounds like you really don't understand wls as a medical treatment.  And maybe that is why you can not rationally support it even though you emotionally feel for the people. It is a tough spot to be in. Sally

Wow, that is kind of harsh. "Either morbid obesity is a disease or it is not.  You can't say a disease is elective."  The disease may not be elective but the treatment is. There are many many forms of treatment for obesity. Surgery is not the only option and it is not the correct option for everyone. Perscription coverage is selective in what drugs can be used to treat which disease. There are different treatments for cancer as well. "We do not know enough about obesity and the role of hormones, genetics, microbs, viruses, etc. (all of which have been found to contribute to obesity) to label it as a solely behavior driven disease. " If we do not know enough about it to label it as you say, how in the world can we know enough to label it a disease? " it also sounds like you really don't understand wls as a medical treatment.  And maybe that is why you can not rationally support it even though you emotionally feel for the people." I never said I did not support it. I said I can't sell it. I am one opinion and not the end decision maker. Your accusation of my inability to understand this is unfounded and unfair.

Hi Terri, don't feel like a traitor.  You are not. Your's isn't dealing with insurance companies.  Am I right?   so you must look out for the bottom line.  Insurance companies are different.  They take so much of our money and hardly ever pay out and when they do pay,  our premiums go up. I was lucky, my insurance paid for mine but I had decided to do the surgery even before I knew they would.  If the insurance hadn't paid then I planned on taking out a loan.  Why not?  We take loans out for cars and stuff so why not take one out to make ourselves healthy? A friend told me that and she was right. Right after I had the surgery my insurance did put the clause in to stop paying for them. so don't feel like that.  Have a good night. Koukla 338/179

This is the reason people die waiting to find a way to pay for their surgery. The company is more important than the people who make it work.

You had an opportunity to be an advocate and chose otherwise. The surgery isn't as expensive as many other senerios I could think of. You're as biased as the rest of the world. Wonder if your company is planning on paying for complications of WLS  that you've already had? ( God forbid you should have any)  Will it cover others' complications who were self-pay for their WLS? Where is the line drawn?  Will the insurance pay for all the co-morbids your overweight or obese employees will present with in years to come? Your bottom line may not be properly caculated going by what you're looking at. Edited to add: First you said : "I am overwhelmed and incredibly sad that I cannot advocate for us. I kind of feel like a traitor." Then you said :I will put up a fight as it is allowed for me to do. I just know they will not approve it.  It breaks my heart." So...which is it????

...and such is the nature of business.

What's best for the company is to also include exclusions for cancer and heart attacks.  And some day that will probably happen, too. Oh, but maybe not -- those things happen to skinny people, so the CEO's probably wouldn't see that as a cost benefit for the company because it could happen to them. So sad... Deb