It’s arduous enough to be ill and to have to deal with the normal stress associated with this. The last thing needed by a sick patient is to have to deal with cruel (and sometimes inhumane) treatment. Adding an adversarial burden on top of existing illness and disability is unwarranted and inhumane. Meaningful solutions for effectively dealing with this dilemma are stuck in the halls of Congress.
S.R., a 34 year old homemaker with four children had a history of non-specific low back pain for eight years associated with occasional flare-ups. Her problem became progressively worse requiring multiple physician and Urgent Care visits. S.R. was treated with medications and bedrest and told that she would “have to live with it.” S.R.’s pain became so severe that she began having difficulty with ambulation and was frightened when, while driving her car with her children in it, she experienced a near-fainting episode and almost lost control of her motor vehicle. Following this the managed care provider physician then prescribed medication and physical therapy. Soon afterwards, following an episode of coughing, S.R.’s pain became so severe that she was unable to move or sit up. She contacted her managed care provider and was told that the earliest she could be seen and evaluated was 17 days later. Additional acute physical therapy was recommended over the phone but the physical therapy facilities covered under her managed care plan had “no openings.” S.R. remained bedridden at home. By phone a physical therapist indicated that S.R. “probably had a disc herniation” and that “a MRI appeared to be indicated.” Two days later S.R.’s friends carried her to the closest hospital emergency room where she was examined and admitted to the hospital where parenteral pain management and anti-inflammatory medications were initiated and a MRI examination of the lumbar spine was scheduled to follow. Following admission S.R.’s husband was informed by his managed care organization that the “emergency admission could not be justified and therefore would not be financially covered.” At this point the patient indicated that “there was too much mental anguish” and had her husband carry her out of the hospital (prior to the MRI exam) to a more distant hospital within the managed provider’s network. Subsequent MRI showed a foraminal disc herniation.
The case illustrated above is not unique in the managed care system. It is also not unusual for physicians who are part of managed care plans to be paid bonuses for limiting or restricting care provided to patients. This is defended by managed care by the observation: “Health care systems have a budget. Doctors have to hold down costs.” (Stephanie Kenwick, Esq., CBS 60 Minutes II, June 20, 2000).
It is certainly true that doctors need to “hold down costs.” They need to do this, however, in the patients best interest and not as part of an effort to devastate the patient. It must also be pointed out that when there is a clear and present conflict-of interest it is the clear ethical and legal responsibility of the health care professional to provide full disclosure to the patient regarding this in advance. Without such there can not be informed consent on the part of the patient. Without having obtained informed consent the health care professional can then be correctly accused of having committed real fraud and abuse.
Cruel and inhumane treatment in the American health care system is not just limited to managed care. Examples abound,the worst transgressions are those directed at our most frail and vulnerable citizens, the elderly. It is not enough that they are constantly bombarded by Medicare with bills (that they do not understand) and letters, looking like bills, which contain the disclaimer “This Is Not A Bill” (which no one appears to understand). The very worst of this state of affairs involves the terminally ill hospice patients, most in their 80s and 90s, whose life spans have exceeded federal guidelines.
Addendum: On June 21, 2000 S.R.’s managed care provider, responding to public dissatisfaction, announced “several initiatives” in the hope of “restoring public trust” and generating new customers. (Howatt G: HMO posts policies, vows ‘no secrets’, Star Tribune, June 22, 2000).