#kouri talks about healthcare

[gingersnapwolves]

reading the headlines about the governor of Wisconsin wanting to audit denied claims from insurance companies and that's great! it truly is! but there's something that I think would be an unintended consequence of this that most people aren't aware of that I want to put out there

if this goes into effect? insurance companies will simply raise the premiums (the amount you pay them in order to be insured) of everyone who lives in Wisconsin.

can they do that? you bet your ass. they decide on their own what the premiums should be. and how do I know they will do this?

because I work in healthcare. specifically, I work in medical billing. and companies who work in medical billing are charged higher premiums to insure their employees, because the insurance companies know they are more likely to fight denials and understand what is and isn't covered.

this isn't an assumption. we were told specifically by our insurance broker that this was one of the reasons our premiums went up one year. because the insurance companies pay close attention to how many denials are challenged and overturned and by who and will charge premiums to that group accordingly.

so although I fully support Governor Evers in this attempt, I think it must also come with some sort of mechanism to make sure that the cost is not simply transferred to the consumer

/soapbox

[gingersnapwolves]

So today I want to talk about puberty blockers for transgender kids, because despite being cisgender, this is a subject I’m actually well-versed in. Specifically, I want to talk about how far backwards things have gone.

This story starts almost 20 years ago, and it’s kind of long, but I think it’s important to give you the full history. At the time, I was working as an administrative assistant for a pediatric endocrinologist in a red state. Not a deep deep red state like Alabama, we had a little bit of a purple trend, but still very much red. (I don’t want to say the state at the risk of doxxing myself.) And I took a phone call from a woman who said, “My son is transgender. Does your doctor do hormone therapy?”

I said, “Good question! Let me find out.”

I went into the back and found the doctor playing Solitaire on his computer and said, “Do you do hormone therapy for transgender kids?” It had literally never come up before. He had opened his practice there in the early 2000s. This was roughly 2006, and the first time someone asked. Without looking up from his game of Solitaire, the doctor said, “I’ve never done it before, but I know how it works, so sure.”

I got back on the phone and told the mom, who was overjoyed, and scheduled an appointment for her son. He was the first transgender child we treated with puberty blockers. But not, by far, the first child we treated with puberty blockers, period. Because puberty blockers are used very commonly for children with precocious puberty (early-onset puberty). I would say about twenty percent of the kids our doctor treated were for precocious puberty and were on puberty blockers. They have been well studied and are widely used, safe, and effective.

Well. It turned out, the doctor I worked for was the only doctor in the state who was willing to do this. And word spread pretty fast in the tight-knit community of ‘parents of transgender children in a red state’. We started seeing more kids. A better drug came out. We saw some kids who were at the age where they were past puberty, and prescribed them estrogen or testosterone. Our doctor became, I’m fairly sure, a small folk hero to this community. 

Insurance coverage was a struggle. I remember copying articles and pages out of the Endocrine Society Manual to submit with prior authorization requests for the medications. Insurance coverage was a struggle for a lot of what we did, though. Growth hormone for kids with severe idiopathic short stature. Insulin pumps, which weren’t as common at the time, and then continuous glucose monitoring, when that came out. Insurance struggles were just part and parcel of the job.

I remember vividly when CVS Caremark, a pharmaceutical management company, changed their criteria and included gender dysphoria as a covered diagnosis for puberty blockers. I thought they had put the option on the questionnaire to trigger an automatic denial. But no - it triggered an approval. Medicaid started to cover it. I got so good at getting approvals with my by then tidy packet of articles and documentation that I actually had people in other states calling me to see what I was submitting (the pharmaceutical rep gave them my number because they wanted more people on their drug, which, shady, but sure. He did ask me if it was okay first).

And here’s the key point of this story:

At no point, during any of this, did it ever even occur to any of us that we might have to worry about whether or not what we were doing was legal.

It just never even came up. It was the medically recommended treatment so we did it. And seeing what’s happening in the UK and certain states in America is both terrifying and genuinely shocking to me, as someone who did this for almost fifteen years, without ever even wondering about the legality of it.

The doctor retired some years ago, at which point there were two other doctors in the state who were willing to prescribe the medications for transgender kids. I truly think that he would still be working if nobody else had been willing to take those kids on as patients. He was, by the way, a white cisgender heterosexual Boomer. I remember when he was introduced to the concept of ‘genderfluid’ because one of our patients on HRT wanted to go off. He said ‘that’s so interesting!’ and immediately went to Google to learn more about it. 

I watched these kids transform. I saw them come into the office the first time, sometimes anxious and uncertain, sometimes sullen and angry. I saw them come in the subsequent times, once they were on hormone therapy, how they gradually became happy and confident in themselves. I saw the smiles on their faces when I gave them a gender marker letter for the DMV. I heard them cheer when I called to tell them I’d gotten HRT approved by insurance and we were calling in a prescription. It was honestly amazing and I will always consider the work I did in that red state with those kids to be something I am incredibly proud of. I was honored to be a part of it.

When I see all this transgender backlash, it’s horrifying, because it was well on the way to become standard and accepted treatment. Insurances started to cover it. Other doctors were learning to prescribe it. And now … it’s fucking illegal? Like what the actual fuck. We have gone so far backwards that it makes me want to cry. I don’t know how to stop this slide. But I wrote this so people would understand exactly how steep the slide is.

[gingersnapwolves]

You know what since I’ve got a ton of new followers because my post on puberty blockers took off and people apparently want to see me rant, I’m gonna get up on my soapbox for a PSA for tumblr’s aging userbase.

Do not! Get! A Medicare Advantage plan!

Tell your parents not to get one. Tell your aunts and uncles not to get one. Tell your friends not to get one.

Why is that, you might say? Kouri, what is a Medicare Advantage plan, you might say?

tl;dr Medicare is the government healthcare plan for Americans of a certain age or with certain disabilities. It is owned, administered, and operated by the government. You are entitled, if you wish, to outsource your Medicare and have your policy run by a commercial group, such as United HealthCare, Cigna, Aetna, et cetera.

Here’s how it works: For everyone who signs up for, say, a plan that rhymes with Figna Medicare Advantage, Medicare gives Figna a certain amount of money and says ‘use this to take care of this patient’.

You can see where this is going, right? Figna says ‘sure boss! *wink nudge*’ and then shoves as much of that money into their own pockets as possible, and they do that by finding excuses to NOT pay for your medical care.

Medicare Advantage plans are pushed and marketed heavily. They’ll call you. They’ll set up stands in your PCP office to try to encourage you to buy in. They will say things like ‘with Medicare, you have to pay a 20% coinsurance, but with us you only have a 10% coinsurance’ and completely neglect to tell you that having a smaller coinsurance only matters if they approve the fucking care that you need, which often they won’t (while Medicare would have) and if your doctors are willing to accept it, which often they don’t (while they do accept Medicare).

Is Medicare perfect? Absolutely not! I've got my share of bones to pick with them. But simply put:

Medicare is government administered. It is a service. It costs the government money, which is why the GOP is always trying to cut funding to it. Medicare Advantage is corporately administered. It is supposed to make money. Which gives them incentives to deny your care and fuck you over that Medicare simply does not have.

Do not. Get. A Medicare Advantage Plan.