Tom Garbin, a 60-year-old comedian from Australia who came to the United States a quarter of a century ago, is anything but amused at the way his health care provider has treated him over the past five years. First it stalled him relentlessly as he tried to get authorization for treatment, a series of delays that in one case almost cost him his life. On top of that it has raised his premiums with a dismaying steadiness, culminating in a staggering boost between January and March 2004 of 63 percent - from $427 to $692.
"They're criminals in what they're doing." Tom says. "They're denying me left, right and center." As to the increasingly unaffordable price increases, Tom is convinced that "this conglomerate has made up its mind to dump me."
Tom's travails began in 1994 when he signed on with Foundation Health, which was later bought out by Health Net in 1998. "Back then I wasn't sick. But it (health insurance) is one of those things you buy for peace of mind." That's especially true after you turn 50, Tom says. So he signed on, self-insured.
Things moved along smoothly enough until 1999, when Tom was entertaining at a trade show. There was a health fair there and Tom had a PSA test, which measures for prostate cancer. That was on October 7. The doctor at the health fair told Tom that his test was abnormal and "suspicious for cancer." He recommended that Tom get a biopsy.
Then came a maddening series of visits to his health care plan doctors. They ordered up an Ultrasound, which came back negative, then assured him that everything was just swell, not to worry about it and come back in a year.
Tom, they soon discovered, was not so easy to brush off. "I came here to get a biopsy," he told a health plan doctor as he slipped into his native Australian, "and I'm not leaving until I get a bloody biopsy."
The doctor ordered the biopsy on the condition that Tom leave him alone. The test, performed Dec. 21, came back positive. On Dec. 30, 10 weeks after the health fair diagnosis, the doctor told Tom he had prostate cancer and needed a radical prostatectomy within the next two months. Had Tom slunk away as they first suggested, he would not be telling his story, unless he found a way to communicate from beyond the grave.
But Tom's struggles were not over. He researched, exhaustively, available therapies for treatment of prostate cancer. But the medical director of Affiliated Doctors of Orange County, which administered his health plan, would approve neither his choice of doctor nor the treatment, brachytherapy. Finally he relented and let Tom see his second choice, a doctor at UC Irvine, under two conditions: first, that Tom not tell anyone that he was being allowed to go out-of plan; and that the UC Irvine doctor accept Health Net's rates.
The radical retropubic prostatectomy was performed on March 31, 2000, at UCI Medical Center. It is a $35,000 operation and Tom paid his $1,000 co-pay. He later discovered that Health Net paid only $880 to UCI Medical. "Now UCI won't touch any insurance company," Tom says.
Tom went to see his surgeon for follow up visits for two years, with no problems. Then one day his health plan refused a visit to the doctor who performed his surgery. Since then the plan has denied other payments, including $20 office visits. Tom is paying for his own PSA tests.
"I believe that money is not the issue here," Tom says. "My premiums are a whopping $4,536 a year and they can't approve a $20 office visit?" Tom is not buying that argument, or the providers' standard line that health care costs have gone up and are simply being passed on to customers. He thinks that, like many people over 55 in health care plans, he is being squeezed out.
"Between 60 and 65 (when Medicare kicks in) is no man's land," Tom says.
Tom has fought all this hard, writing letters to everyone from his assemblyman to U.S. Attorney General John Ashcroft. That has not endeared him to Health Net.
Meanwhile, his rates continue to rise. He was paying $166 in January of 2000. On March 1 he will be paying $692. He believes he is being singled out and has the comparative figures to make his case. But he says many folks in his age group are facing the same dismissive treatment.
The plan providers' efforts to deny treatment, combined with their profiteering, is a rancid combination, Tom believes. "You have to fight them tooth and nail for everything you have done, and they keep raising their rates and taking away benefits."
Tom wants to see health care providers forced to prove that the rate boosts are financially necessary, and that they are administered equitably. He noted that one plan representative had rattled on about how "you can count on it, take it from me, it's the same for everyone."
Tom wants proof, and he wants someone to make health care providers justify their rate increases.