Fighting for My Daughter’s Health in a Broken System

When Ear Infections Become a Battleground

When our older daughter was about six months old, she began experiencing a wave of ear infections. It seemed that we scarcely recovered from one before another had set in, leaving her constantly crying and pulling at her ears. We found ourselves with appointment after appointment with our pediatrician, and prescription after prescription for antibiotics, none of which seemed to resolve the problem.

Like any parent, I was worried: worried about how her hearing might be affected long-term, and equally worried about how a string of no fewer than six antibiotics was affecting her immune system. Her pediatrician – one of the best in our community – was candid: Our managed care network would not cover surgery to insert drainage tubes for her ears until we had run a full course of antibiotics and a sufficient time period had passed.

That was not a good answer for me.

At the time, I was an attorney – practicing employee benefits law. Working with healthcare questions was one of my primary areas of expertise. And addressing questions about managed care networks’ decisions regarding how and under what circumstances insured care would be authorized was a major focus for my law practice.

From Lawyer to Advocate

With the list of antibiotics and the coverage protocol in hand, I got to work, pleading our case before the managed care network. After a couple of weeks of rather unrelenting and persistent railing from me, the managed care network approved the surgery for the tubes without further delay. Post-surgery, our fussy baby was almost instantly happy and healthy, with no more ear infections and no more antibiotics required. I’m grateful for our pediatrician’s transparency, for the surgeon who performed the surgery – and for having been able to successfully plead my case before an insurer to get the care we needed. I’m too keenly aware that so many others aren’t so lucky, with far more critical care needs at stake.

Welcome to the world of managed healthcare.

How do managed care networks work? Essentially, managed care networks employ captive physicians in utilization review teams who determine the circumstances under which healthcare procedures will be most effective – and only under those circumstances will the procedures be approved for coverage under an insured healthcare plan. The determinations are based on a study of medical procedures and positive outcomes, basically allocating medical resources to those conditions and procedures and where positive outcomes seem most likely.

If a patient isn’t yet sick enough, the procedure will likely be denied – at least, until the patient is sicker. If the patient is now too sick for the benefits of the procedure to be deemed helpful, the procedure will likely be denied. A utilization review panel that has never seen the patient makes the managed care network’s decision about whether and to what degree insured medical care can be provided. And, because someone has to absorb the cost of the managed care network, these gatekeepers add another layer of fees in the insured medical marketplace. Executives of some of the more prominent managed care networks each earn millions of dollars annually in salary and incentive compensation.

Some might argue that managed care networks keep more patients alive and healthy because our nation’s limited healthcare resources require some gatekeeping to ensure that people who most urgently need certain procedures and specialist physicians are able to access the care they need. Without the gatekeepers, some would argue that the sickest patients might find themselves waiting an unacceptably long period of time for medical resources to be freed up for them.

Some might call managed care a rationing of healthcare that profits no one except the managed care networks.

The Truth About Managed Care Gatekeeping

Whatever one might call it, managed care’s focus isn’t what specific patients and their physicians might deem best for those patients’ health. Patients who fall outside of managed care’s protocols – and who aren’t skilled at (or can’t afford attorneys who are skilled at) making persuasive arguments for care – experience denial of coverage when community-driven statistical data suggests that outcomes from certain procedures won’t be favorable.

And, even if patients were willing or able to pay out of pocket, appointments with many specialists require referrals, which the managed care networks also largely control. The gatekeepers are watching.

In 2002, a film called John Q. was released. The film, starring Denzel Washington, explored a desperate father’s actions when his son was unable to receive a needed heart transplant. The family’s complicated story – a change in insurance coverage, delayed testing and high out-of-pocket costs for the surgery that were beyond the family’s means – left a desperate father taking matters into his own hands to save his son’s life. Believing himself to have no other options, the film’s title character is reduced to criminal activity in taking a hospital’s emergency room hostage. Although his plan isn’t executed without a hitch, he does succeed in saving his son when the hospital’s administrator agrees to provide the child’s surgery pro bono. The film laid bare some of the flaws in our nation’s healthcare system – flaws that many would argue haven’t significantly changed over the past twenty years.

The High Stakes of Denied Coverage

But what are the alternatives? There are certainly arguments that if care isn’t “managed,” demand for medical services and specialists would even farther outpace supply, and costs on an otherwise open market would increase so dramatically that even more persons could find themselves without access to care and physicians. Already, shortages of physicians and nurses have meant long waits for appointments and procedures. Certain areas of our country, especially rural areas, are without access not only to specialists but also to primary care. Does the answer lie in a greater number of physicians – more supply to meet patient demand? With the cost of medical school also high, the likelihood that we will train significantly larger numbers of doctors seems slim.

What’s the Christian response? When Americans celebrate the killing of a managed care executive and laud his killer, we know that frustration with the healthcare system is high. The question is how best to relieve that frustration – in a system in which some coverage that an individual and that person’s physician request will inevitably be denied –.

One might offer that our Gospel accounts don’t show Jesus “denying” healing to those who came to him for help, even after physicians of the day had done all they could to bring about healing and were not successful (We have to acknowledge that Canaanite/Syrophoenician woman who pushed back when it seemed initially that Jesus was not going to offer healing to her daughter, but on “appeal,” her request was granted!). With Jesus as a healer, there were no protocols, no co-pays, and no required preauthorization; Jesus simply healed.

The healing accounts would beg the question about whether coverage for all patient-requested or physician-requested procedures should be granted, in an age in which patients may be overly-influenced by advertising, and providers may feel driven to keep their outcomes favorable.

Then we recall that, in the healing accounts that we find in the Gospels, Jesus was certain about outcomes; he wasn’t weighing alternatives and their cost – financial or resources – within a medical system. Ours is not a perfect world.

Wherever we go from here, it seems that the American public will be frustrated over access to medical care and physicians – awaiting some brilliant solutions that will limit, or at least reshape, the role of gatekeeping managed care networks, while also keeping costs affordable and access to physicians reasonable. Until we find those solutions, all of us would do well to become better informed about our own healthcare coverage – and offer support to neighbors who need our help navigating the system.