Dealing with Managed Care:
"Your Request for Treatment Has Been Denied"
There is a story of a man who hurt his right knee and hobbled to his doctor's office. The receptionist leads the injured man inside and tells him to sit on the examination table. Two men wearing white lab coats, each with a stethoscope around his neck, enter the room. The one whom the patient recognizes as his doctor says to the other, "This is a forty-four-year-old man who fell and hit his knee on the floor while playing racquetball. The MRI shows a torn meniscus. I recommend arthroscopic surgery to repair the cartilage and drain the excess synovial fluid."
"I think not," the second man retorts. "Let us take a more conservative approach. Six weeks of physical therapy and then reevaluate, okay?
- Yes, sir!" the first man replies as the second man leaves the room.
"Who was that?" the patient asks. "The chief of orthopedics?
- No, he's the insurance agent."
Every joke has a ring of truth. In this chapter, we will examine how a "league" of health maintenance organizations (HMOs) has taken control of health-care delivery and what we can do to combat unfair denials. As a society, we have been so crushed by the high cost of private insurance that we have unwittingly given corporate executives the authority to veto our doctors' decisions. This veto power seems absolute because the appeals process is toothless. Even though some HMO corporate directors are also medical doctors, the consequences of their decisions relate primarily to money. The irony of this deplorable situation is that sometimes the victim of the profit-driven medical denial and the stockholder motivating that refusal are the same person. In other words, many of us have stock in the very organizations that are limiting our ability to pay for care.