We don’t need Bernie Sanders to tell us our health care system stinks, but it’s always nice to get a real-life reminder.
I got mine this week after my daughter hurt her knee playing basketball and we went to see a specialist. Following X-rays and an examination, he was concerned it could be a torn ligament or a bad bone bruise and instructed us to get a magnetic resonance imaging test. An MRI.
Full disclosure, my family has had three MRIs for various issues over the past 18 months that turned out to be not serious.
How do we know none of it was serious? Because we had MRIs. The specialists were concerned enough in each case to order the tests, so we followed doctor’s orders, received the peace of mind that comes with good news and went on to the next phase of treatment.
So I was surprised to show up with my daughter for the MRI this week only to be told it had been canceled. The insurance company had decided the specialist was wrong. No MRI was needed.
That’s not quite true. Actually, it was a company enlisted by the insurance company to provide “utilization management” that denied us. I know this because I called the insurance company from the parking lot and they transferred my call to someone at the utilization management company who told me their “experts” had determined that rather than getting an MRI, my daughter should use alternate approaches.
“Has she done six weeks of rehab?” I was asked.
"Well, no, of course not,” I replied. “She just had the injury, there’s some thought a ligament could be torn and so she can’t really do anything like that.”
“Has she tried medication?”
“Listen, I’m not a doctor,” I said, possibly noting that if I was, I’d be calling from a much nicer car. “So what sort of medication will put a torn ligament back together?”
She didn’t like my tone. And when I started complaining about the process — wondering how her company’s experts, who had never seen my daughter, would know better than the specialist who had poked, prodded and X-rayed my daughter’s knee before using many years of training and diagnostic skills to determine an MRI was called for — the phone flak got perturbed.
“I’m not going to debate health care with you, sir.”
Of course not.
Even after a 10-minute conversation with her, I still had no idea what utilization management meant, so I went to said company’s website to find that they “are committed to providing an evidence-based approach that leverages [their] exceptional clinical and technological capabilities, powerful analytics and sensitivity to the needs of everyone involved across the health care continuum.”
Cleared that right up. That same day we received our denial letter that said we could appeal, but that it could take 60 days to get an answer.
So I spoke with the specialist and he explained our options while bemoaning a system that allows companies to get rich off the backs of 12-year-old kids. Before pledging to lodge an appeal himself, he suggested that I Google the profits of some of these health insurance giants who are so determined to keep patients from getting expensive tests.
UnitedHealth Group, with revenues north of $200 billion, has seen its stock price triple over the past five years. Athem’s stock price has also tripled in five years. So has Aetna’s. And 10 years? Now you’re talking 10x.
Sure wish my 401(k) had returns like that.
So the specialist spent part of his Friday — when he could’ve been seeing other patients — arguing with the insurance company. Or the utilization management company, I don’t even know at this point. He has to do this frequently, but he said he doesn’t mind fighting with billionaires.
He won this fight because it turns out the other company’s experts aren’t so expert after all based on the conversation he recounted for us. He listed a few of the possible injuries our daughter could have. They were multi-syllabic medical terms that I didn’t understand and, apparently, neither did the expert, who started whispering to someone else in an effort to make sense of what the specialist was saying before reluctantly agreeing to allow the test.
Whether it’s a torn ligament or a bone bruise, this example is monumentally minor in the grand scheme. But it made me wonder how many people out there are being denied important tests every single day. Tests that might help them to significantly improve their lives. Tests that might catch something early enough to save their lives.
I couldn’t sleep at night if I was one of the experts told to make these decisions while keeping a close eye on the company’s bottom line. Of course, if the job comes with stock options, it’s probably a little easier.