The View From Your Sickbed

by Patrick Appel

A reader writes:

I have had severe trouble with acid reflux for decades, and so have been taking prescription acid blockers for most of that time. Our insurance has a good prescription drug plan, so this has not been a financial problem for us.

But.

Several years ago, my wife pointed out an article in our local newspaper about how an area gastro-intestinal specialist was starting to perform a procedure that used a new piece of equipment to remedy my kind of ailment. Well, I said, let's wait until he's been doing this a while before I submit to this novelty. So, I waited. A few years later, I ended up in this doctor's office and asked him about the procedure. He told me that he had done it numerous times, that the results had been good and held up over time, but that he wasn't doing it any more, because insurance companies stopped covering it.

From his perspective, it happened this way. Before the new procedure, sufferers like me had two options: major surgery of the esophagus, or permanent reliance on acid blockers. Given that choice, most chose acid blockers, even though insurance companies would cover the surgery. With the new procedure, though, there was a third, intermediate option that was much less traumatic than surgery, yet significantly more expense than maintenance medication. The insurance industry started out being willing to cover the procedure, since it was tremendously less expensive than surgery, but as more and more people who had been avoiding major surgery decided to undergo the less invasive procedure, the insurance industry saw a net increase in their expenses. So, they stopped covering the new procedure. Quite late in the game they decided, not that the high-tech was risky, or that it was ineffective, or even that it was not cost-effective, but that it was "experimental." So, they wouldn't pay for it anymore.

I think it would have been $10,000, at the time, for me to pay for the procedure out of pocket. Not anything like the cost of major surgery, but way outside of my means.

A few years later, at a later appointment, I asked if the insurance industry had relented on the "experimental" status. No, I was told, and anyway, since the lack of insurance coverage had dried up the market for the technology, the company that made the device had gone bankrupt.

True, just one side of the story. But maybe believable?