[OT] Managed Care Rant
Let me preface this by saying that I am sick. Not a little sick, like a cold or the flu, but really sick. Life threatening sick. Thus, my level of patience with the managed care system may well be even more limited than normal. I consider this reasonable: When you are really sick, and there are people who appear set on preventing you from trying to stay as well as you are or getting a little better, you are likely not to like them.
Further, I have had illnesses all my life that have made me averse to managed care. I have a rare disease that pre-disposes me to a number of unusual illnesses. Your average physician is not aware of the possible difficulties, there is no chance a clerk or an RN at a managed care company will understand the details of my disease. For instance, desmoids tumors are frequent complications of my disease. They are "benign," however my niece died of complications from a desmoid tumors at age 20. I pay more not to have to get any referrals. Sadly, a CT scan needs a "Pre-Certification."
On Friday, January 27th, my doctor wanted me to get a CT the following week (week of January 30th). My doctor is a very good doctor, Chief of the Gastric and Mixed Tumor Service at Memorial Sloan Kettering Cancer Center, a pretty good cancer center. He felt it was important for me to get a CT this week. Initially, I was only able to get an appointment only for the following week (9:30 PM on the 9th), however, the doctor's office said they would try to do better.
On Tuesday, January 31st (late) I got a call about a moved up CT, now scheduled for February 2nd at 2:40 p.m., arrive at 1:40 p.m. On February 1st in the AM, my doctor's office faxed the requested information to Care Core National (who manages imaging issues for Aetna NJ). This was the first of three times this information was sent.
On February 2nd, I called Care Core National first thing and was told that my doctor's office had not sent the requested information. I called my doctor's office again and they assured me that they had sent the information to the correct number, and had a confirmation that it arrived the prior morning. I called a number of times trying to get Care Core National to acknowledge that they had the fax, but was eventually forwarded to a "supervisor," a Ms. Rivera. Ms. Rivera suggested that if I had the physician fax the information once more (a third time) marked as Urgent, perhaps it would be read within an hour or two. Otherwise, it might take 4-6 hours or longer for the other faxes to get read. Note that the person who forwarded me to Ms. Rivera when I requested a supervisor implicitly lied, as Ms. Rivera supervises no one.
At this point, I assured them this was not a vanity CT. I am trying to stay out of the hospital, trying to stay off of IV nutrition at home, and for all these reasons, it was critical to do the CT when my doctor felt it was important. I called back as I drove the 2 hours into Memorial Sloan Kettering, and was told that, in spite of the fact that my doctor considered my need for a CT scan Urgent, someone who was not a physician, likely an RN, at Care Core National had determined that I did not meet their criteria for Urgent, and they could not tell me what those criteria were.
I eventually got to the first level supervisor's supervisor (a Mr. Robinson) via voice mail and left a message explaining the circumstances, the degree of my illness and how his organization has made this difficult time so much more difficult. I never heard back from Mr. Robinson (he says he called twice, but never left a message). I called him, and he offered no real insight into how someone who is very sick should go about getting a CT when only a day or so in advance was possible due to hospital scheduling and patient need. I asked for information regarding lodging a formal complaint, but never got any answer. I assured him that his organization had ticked off their worst nightmare: A sick guy who can write and speak with time on his hands.
Aetna, by the way, washes their hands of all of this, saying that they contract to Care Core National, and even when they disagree with details of a case, they can do nothing.
As a postscript, I eventually did get pre-certs for both scans (less than 24 hours after I actually had them). I am now told by Mr. Robinson that these pre-certs will be applied to the scans from yesterday.
Is this the way we want desperately sick people to spend their time? As a society, is this compassionate care? A patient with a life threatening illness, doing the best he possibly can for himself to stay out of the hospital and off of other expensive therapies must waste a precious day of his life fighting for what he pays a great deal of money for. I hear you saying, "Well, you are sick, you must use your insurance a lot." Of course I do. I have no choice in the matter, I do not smoke, I do not drink. Prior to some recent surgery, I ate a normal American diet, which is to say likely too much, but otherwise lead a normal life. At the same time, I buy car insurance, and have not used it in many years. I have homeowners insurance that I am pretty certain I have not used in this century, and probably not the last decade of the last century. That is the point of insurance, you share risks. I am a terrible risk with respect to health insurance, a much better risk with respect to car and homeowners insurance. That is what Insurance should be doing.