This is a story of a timeline, a modicum of savvy, access to resources, and perseverance, more than anything else. It is also a story about how our health care access and insurance systems can fail, and how someone who is fully eligible for coverage could completely fall through the cracks.
I am a big believer in immunizations and I am also well aware of how devastatingly debilitating shingles can be, and how anyone, whether healthy or compromised, can suddenly be affected. Shingles is the resurgence of the dormant varicella herpes virus in individuals who have previously been infected with chickenpox. Most of us had chickenpox when we were little. In fact, doctors used to encourage parents to allow their children to be exposed to this contagious infection with the idea that the disease is much more serious, with a much higher complication rate, the older we get, so kids ought to just get it over with when young and resilient. It used to be viewed as pretty harmless, though now many children are vaccinated for chickenpox. It’s not a requirement in most venues but I strongly feel it should be, because by preventing chickenpox the incidence of shingles in older populations can be vastly reduced. No infectious disease is fully benign, including shingles.
Shingles, which arises from the nervous system where the virus resides, in its simplest and most common manifestation causes a burning, extremely painful skin rash along nerve roots that usually, but not always, resolves within a month or so. In some people, such as my mother, the pain takes far longer to resolve–sometimes more than a year–and the rash leaves tender scars. And it can be much worse, invading the eyes for example. So why would anyone leave themselves open for that if there is effective prevention? It is recommended, given that there was no avoiding chickenpox in my cohort, that folks over 60 be given a “shingles shot” to obviate or mitigate the occurrence of shingles. Please read the official word from the Centers for Disease Control and Prevention.
So at my annual checkup early this year, I asked my doctor about it. Note that he practices at the University of Chicago, which styles itself “at the forefront of medicine” and is indeed a major tertiary medical center. Mind you, I am 61, so why he didn’t bring it up himself I can’t say. In any case, he told me that because the vaccine is not carried in the University’s formulary he would give me a prescription, and told me to get it filled at a pharmacy and to bring it back to clinic to be administered. I checked at my local Osco Pharmacy; yes, they could get the vaccine, but they would have to order it. The cost was $225. Okay, I thought, I’ll check my local Walgreens to see if they have it in stock. In fact, Walgreens had a big lighted sign to that effect at the corner of two main drags and two more lesser signs near the store entryway. From the signs I learned that the pharmacist could not only sell me the stuff, but administer it as well. Bingo!
Assuming no appointment was required, I presented myself at Walgreens pharmacy one early March evening. The pharmacist on duty happened to be the grandson of my neighbor. I’ve known the guy since he was a pre-teen. He’s a perfectly lovely and very intelligent young man who now works for Walgreens as a rotating fill-in pharmacist. Although this neighborhood has long been his stomping ground, he doesn’t work regularly at this particular store. He said, “Sure! I can administer it, give me a few minutes and I’ll take care of you.” He then disappeared into the back for a good 20 minutes before emerging to confess he could not find the vaccine. I said, “OK, I’ll just come back another day.” (drat!) By the time I got home, he had left a message on my answering machine that he had finally located it and I could come back any time.
The next free moment I had was several evenings later, by then someone else was on duty. “Sure!” she says, “I can administer it, if you can wait about 20 minutes.” I said fine, and sat down to people-watch at this busy drug store. After a half hour, I inquired as to whether I was still in the queue. The pharmacist said, “Oh yes, I was just trying to figure out how to charge it to your insurance (Blue Cross-Blue Shield).” I said, “Oh, don’t bother, I know they won’t pay for it, because Walgreens is out of network, but I can pay for it out of pocket and [based on how they had handled my claim for a $29.99 flu shot, administered at another pharmacy the previous fall] although they won’t reimburse me, they will at least apply it to my deductible.” So with this information, she finally came out to the waiting room and gave me the injection, somewhat embarrassingly, it the blobby fat at the very back of my arm almost in my armpit. Apparently this is where “subcutaneous” injections are now routinely given. Whatever. I’m usually pretty oblivious to injections, but this thing might as well have been a wasp sting. Yikes!
It quieted down, but with a day or started to itch and burn and turned a quite large patch of skin deep red like nothing else. I looked it up on the internet (thanks, Google!) which assured me that this is not an unusual reaction. I think (I hope) it meant my immune system was launching a robust response to the antigen challenge. Anyway, it took a full week for it to settle down. After all that, I’d better be good and resistant to shingles for the rest of my life!
So in order to claim the out-of-pocket $219.99 against my deductible, I mailed the claim (regular old 44¢ USPS ) to BC/BS of Illinois on March 12, four days after receiving the injection. I checked on it on April 1, but did not see it on-line in my account, so I FAX’d it. It wasn’t there in April 12 either, so I called. “No, I’m sorry, I don’t see it” said the nice service representative. I FAX’d it again April 18. Still didn’t show up a week later, so I tried again April 21. On April 26, I had KLK FAX it from his office. Finally! (Don’t ask me why it worked for him but nor for me, in spite of the confirming assurances of the FAX machine where I work.) Samantha, another pleasant service rep, confirmed on the phone that it was in the pipeline at BC/BS. I patiently awaited adjudication, assuming it would be treated the same as the flu shot: no reimbursement, but counted toward my deductible.
Lo and behold, at the end of the first week in May I got an explanation of benefits. Although the principle was precisely the same as the flu shot that was denied as being “out of network,” unaccountably they determined it would be eligible for 50% coverage. The EOB announced, “Payment of $110.00 was made to VERONICA WALD on 05-06-2011 check number 56176223.”
WOO-HOO, methinks, although I’m mystified by why it wasn’t handled the same way as the flu shot last fall. So I wait almost a month, and guess what? No check. I call, and am politely told I must wait 30 days before a new check can be issued. Thirty days later I was out of town, so I called on June 20, thirty days and then some, later. The kind representative said, “We’ll issue a new check, expect it in 10 to 30 days.”
Do you believe it? The actual check showed up on July 1. I deposited it immediately. What do you think the chances are the check will bounce?
But the real points of all this are: 1. Health care professionals, even at highly reputable institutions, can be oblivious to the potential enormous benefits of inoculation, so take charge of your own doctor visits; 2. I supposedly have very good health care coverage, but it’s amply clear I must monitor it closely and stick up for myself, because the administration of the plan is not even remotely efficient; 3. My “quality” health care insurer can’t determine what its own policies and coverage rules are and apply them consistently; 4. If I were elderly, debilitated, without have convenient access to FAX machines (since mail turns out to not work either), or otherwise had no way to work the system, I would certainly not have received any reimbursement. $220 is a lot out-of-pocket for some people, and those who could not afford it would just not pursue vaccination; 5. The insurance company is being very shortsighted by not readily paying the full cost for vaccinations, regardless of where they are administered. Those unfortunate enough to have to seek help for full-blown shingles would then cost the health insurance system far more than $220, including a diagnostic visit and semi-palliative, though not curative, treatments; 6. What if the stakes had been really high, like with cancer treatment, organ transplant, by-pass surgery, and the insurance company lost claim after claim and then didn’t apply its policies consistently?