IN A WORD … “NO”.
By Mickey Skidmore, ACSW
Most parents like to think that “Mommy” or “Daddy” is one of the first words their child utters. However, think for a moment … how many times do you suppose a child hears the word “no” before their 5th birthday? Come to think of it, I suppose it is a word that we continue to hear rather frequently throughout our lives in varying degrees. This month’s “Perspective” however, shines a light on how insurance plans and managed care companies seem to pursue strategies to say “no” in increasing and alarming fashion.
Consider a day in the life of a Managed Care company doctor. Below is an edited version of Dr. Linda Peeno's talk at a forum sponsored by the Ad Hoc Committee to Defend Health Care, at Faneuil Hall in Boston, December 2, 1997.
I come from a little rural town in Kentucky. I was a single mother through medical school--the idea of going to medical school was just an impossible dream. I loved medicine, I loved patients, and I believe medicine is a calling. There was a book that I carried with me that was literally my bible in the '70s called "The Effective Clinician", written by Philip Timulty. He had a quote in there--"A clinician's prime function is to manage a sick person by alleviating most effectively the total impact of the illness upon that person. The things he or she works with are intellectual capacity, unconfined clinical experience, and the perceptive use of his or her eyes, ears, hands, and heart."
In the '80s when I was trying to juggle children and medicine and several other things, I unwittingly went to work for Humana--this was a time when health care was changing and I wanted to be part of the changes. I had grand ideas about it and I had no idea what was happening behind the scenes. Just to give you a quote from one of the managed care textbooks with which I was groomed: "Perhaps the most difficult of all the tasks of a medical director is dealing with the difficult and non-compliant physicians. Failure to take action is the mark of weak and ineffectual management of this common operational problem in managed care."
I left my six figure job in 1991 in ethical protest and said, "I can't do this." I can't view the patients and physicians as "operational problems." For those of you who think people in the managed care organizations sit around tables eating granola
bars, trying to figure out how to make people healthy, I am going to tell you exactly what happens. I have structured this in terms of a day in the life of a medical director. I also want to preface this [by saying that] even though all these incidents didn't occur in a single day, they have occurred in all the jobs in which I've worked. And they cross all insurance companies, so there's nothing unique about . . . I'm not going to malign any insurance company--I think they're all evil.
I want to give you an idea of how a medical director spends
her or his day. At 8:30 a.m. I'd go to my office at the HMO. I have a meeting with the marketing department to continue a project for redoing our benefit booklet. We're trying to get better language and limitations on some of the costly benefits. This morning we work on changing the language for long-term rehabilitation. It used to be defined as "any service needed as long as there was continued improvement." But this is very costly in cases of multiple trauma, strokes, deteriorating neurological diseases, etc. So, we changed it arbitrarily to a 90-day limit no matter what. Marketing assures me that this change will go unnoticed by our members. And when those persons who need more than 90 days are denied care, they will never know what the previous booklets said. For the few that do and may try to challenge us we hope they change plans because they represent expensive conditions that we don't want.
We also work on clauses that will give us more leverage for denial in cases of new treatments, especially expensive out-of-network referrals. Before I leave the meeting one of the marketing reps asks me a question about breast cancer. He is meeting later with a new group and has found out that one of the women working there has just had a lumpectomy for breast cancer. Do we really want that employee group? he asks me. Won't she cost us a fortune? We talk about the size of the group, age and gender mix, and decide not to ask it.
At 9:30 a.m. I meet with the executive director to prepare material for a board meeting the next day. Last month we were over budget in emergency room costs. Although our members were required to get authorization from their PCPs before going to the emergency room, our methods for controlling cost were not working sufficiently--we had non-compliant physicians. We had not created enough penalties to make our PCPs enforce this with their patients. We needed some strong incentives for both the physicians and the patients.
But any kind of financial disincentives or changes in the way people access the emergency room would take months to years to see the effects. We decide to immediately begin reviewing all ER services retrospectively for medical necessity. We never notified our patients or members about that; they just started getting denials and their emergency room visit--no matter what it was for--was denied.
Our zeal for better numbers has paid off and we have a good report for the next board meeting. However, there are losses in other areas and I know they're going to tell me to continue to ratchet down the denials in the emergency room to make up for those losses. In the next board meeting they did exactly that.
The executive director expresses concerns that I'm not denying enough and maybe that's why our financials are fairly serious. He wishes I would be a tougher medical director. This is the beginning of my demise in managed care. I meet with the hospital review coordinators at 10:30 a.m. to determine what denials need to be made regarding continued stays on our hospitalized patients. With the exception of one ICU patient I instruct her to call all the physicians involved and tell them" their patients' coverage will not extend beyond this day," which is our euphemism for denials.
We're very careful about language. We have sessions with our medical services people to learn how to use language euphemistically for patients. The ICU patient presents a problem because the doctors wish to use an investigational device for her cardiac problems. We pay the hospital on a per diem basis, so they're complaining about the cost that they may have to pick up. The coordinator says one of the administrators of the hospital wants to know if we can put some pressure on the doctors and move the patient to another place. This review nurse says to me "She's going to die anyway, just not fast enough to suit all our needs." I decide we can use our current language on experimental therapies for a refusal to pay, so l call the administrator and tell him our plan.
At 11 a.m. I go through my stack of ER face sheets, referral requests and other medical requests for medical necessity, some with only a line or two of information and many more that are essentially illegible. Unless somebody was admitted or was near death, I deny them all. I'm able to go through this stack quickly--others are a little bit more difficult. It bothers me that I do not have the expertise and experience in some of the areas in question. I don't really have a clear justification for the denials, but if the doctors call me back and challenge me, then I'll base them on something in the contract. I'll figure it out when they call--if they do. The hassle factor usually works well; fewer and fewer physicians challenge the decisions we make any more because it's time consuming and mostly futile.
When I began this job I worried about my own liability as a physician when adverse things happened to patients as a result of this kind of distanced medical practice. But I was soon told that the HMOs had a great shield called ERiSA and that I would be virtually free of any liability. Even though we said in our members' coverage book that the final medical decisions rested with us, we made sure we put escape clauses in our physician's contract, making him or her independent in their medical judgment. We make the medical decisions and the doctors take the hit.
Instead of going out to lunch I prepare a presentation that my regional vice president has asked me to give about how we drastically improved our bottom line. I look for material for a talk and I see a cartoon with a doctor in a foxhole, and decide to use a military model of our war against rising costs of health care. Really, I end up making it a war against physicians and patients, something that everybody understood. After this appalling, disgusting presentation, the audience of some 500 medical reviewers, nurses, and medical directors gives me a standing ovation. It was horrible but it struck a chord--that's really how they perceived the work they did.
Finally, I attend meetings with contract people and Member Services and Provider Relations. I end the day going over my board reports and trying to justify how we ended up paying for a liver transplant that I couldn't figure out a way to deny...
I would like to end with an 1886 quote from a public figure who was responsible for significantly ending colonialism. When somebody said, "acts of rebellion are hateful," he replied:
"No, what is hateful is not rebellion but the despotism which induces the rebellion. What is hateful are not rebels but the persons who, having the enjoyment of power, do not discharge the duties of power. They are the persons, who having the power to redress wrongs, refuse to listen to the petitioners that are sent to them. They are the persons who when asked for a loaf, give a stone."
The health industry understands acts of power, greed, self interest and apathy. What the industry can't understand are acts of heart and soul and resistance. I hope this is the beginning; where we surprise the industry and take back the stones of corporate health care and return them as loving medicine, for our patients and for ourselves.
In one respect I actually welcome this practice to continue. For as this strategy escalates, in the end the industry will ultimately crash down upon itself, or lead to a groundswell of national revolution towards a different and more reasonable health care system for us all.
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