Monday, May 4, 2015

The Service Requested is Not Medically Necessary...

Written by Justin Lane
(guest author)

The Affordable Care Act was admittedly, a step forward. Millions of Americans who could not access health care before because of costs and pre-existing conditions are finally able to access the medical services they need. That said, it is far from a perfect system – and is a poor substitute for publicly-funded, guaranteed, no fuss, no-nonsense health care services enjoyed by those living in Canada, the United Kingdom, Germany (which instituted universal health care in 1872), France and virtually every other industrialized nation. Periodically, there are reminders that health care services in the United States are still operated by a corrupt, for-profit system – and too many Americans are still falling through the cracks.

Case in point – Rod H.
An aspiring actor residing in Los Angeles, Rod's income disqualified him from obtaining insurance through California's marketplace. Fortunately, California is one of the states that has adopted the Medicare Expansion, so he was able to obtain coverage through Medi-Cal. Unfortunately, when the rubber hit the road and Rod was in serious need of medical attention, the company he wound up with – a “managed care” network known as “Preferred IPA” – demonstrated that in many ways, the bad old days of bureaucracy, denials and “profits over people,” bottom line corporate mentality are still with us.

Given Drugs and Sent Home
Rod had been with Preferred IPA only a short time when he began experiencing pain and started noticing blood in his urine. While there are multiple reasons as to why this occurs, it's generally a symptom of a serious medical condition – and not one to simply be ignored. Rod went to a nearby emergency room at the beginning of August, 2014. Diagnosis: infection. Treatment: send patient home with antibiotics.

The bleeding and pain continued. Rod's next step was to schedule an appointment with his “Preferred Care Provider” (PCP). Getting into see the doctor took over three weeks. The PCP scheduled an entire battery of tests, including blood, stools and urine. All results came back negative for cancer, the primary concern. Again, Rod was sent home with pills.

Since getting those test results, the bloody urine has become a near daily occurrence – and the pain has not eased. Over the next several months, Rod visited the emergency room numerous times. Each time resulted in the same diagnosis and treatment. In Rod's words: “Hey! You have blood in  your urine! Really? And a very, very minor infection. So, here's  some pills and go the f*** home!” In November, Rod returned to his PCP. The physician wondered if he might have kidney stones – a painful, potentially serious, but easily treated condition caused by excess minerals in the urine. Rod underwent two sonograms in order to discover if this was indeed the case – but the procedures revealed nothing.
It was time to consult a specialist.

The Final Diagnosis
Rod was finally able to see a specialist in January, 2015 – over five months since he had begun experiencing symptoms. The urologist discovered that Rod had a bladder tumor. It was not known if the tumor was malignant or not – but it was urgent to have it removed immediately, if not sooner.
Preferred IPA, with its corporate mentality, has its own idea as to what constitutes “urgent.” Rod would spend the next several weeks in attempts to get his surgery scheduled. This proved to be like the proverbial mating of elephants (done with a great deal of heaving and grunting at a high level, taking two years to obtain results).  By mid-February, Rod's PCP, also frustrated by the delays, advised him to “take the bull by the horns” and apply pressure by calling his urologist daily to find out if his needed surgery had been scheduled.

That was on February 24th. In the meantime, Rod was forced to cut back on auditions and turn down paying work for fear that it would aggravate his condition. Finally, however, Rod received notice on March 12th that his surgery had been approved.  Over the next two weeks, he was sent information on the procedure as well as prescriptions for various medications in preparation for the operation.
On March 24th – nearly eight months since the onset of his symptoms – Rod was scheduled for surgery.

Only in the USA
Only hours before undergoing surgery, Rod was informed that the surgery had been canceled – not by the doctor, not by the hospital, but by Preferred IPA, which had approved the surgery in the first place. The initial reason given was that the insurance company wanted the operation performed by a surgeon that was “in their network.” However, in a letter, Rod was also told that, according to the California Code of Regulations, Title 22 CCR, § 51303, the “service requested is not medically necessary.”

To re-iterate: the man has a painful bladder tumor that may indicate a serious, even life-threatening condition – but according to “regulations,” having it removed is “not medically necessary.”
Rod was referred to another “in-network” for “evaluation and treatment to be done at a LA Care MediCal contracted facility.” On a social media site, Rod posted his feelings about the latest delay, which could have been said by any number of Americans over the past generation and more:
“...a significant delay will be had before any actual surgery takes place. Meanwhile, of course, the tumor continues to grow and I continue to bleed and insurance  companies continue to profit.”

Still Waiting...
As of this writing, Preferred IPA has graciously deigned to allow Rod have (yet another!) consultation with an “approved” urologist on April 30th in order to confirm what the previous specialist has already diagnosed (there's some “free market efficiency” for you!) By then, it will be nine months since the onset of his symptoms – and he will still be waiting for surgery to be approved and scheduled. In the meantime, he has called upon his friends and acquaintances to contact Preferred IPA as well as the surgeon and demand that the date of surgery be moved up. Rod also contacted a lawyer from the Independent Medical Review Board. The conversation was brief – primarily, the lawyer wanted to know if he was “satisfied” with Preferred IPA's decision.

Rod gave the answer one would expect. It's a conversation that would not even be necessary if the U.S. was not controlled by amoral, profiteering corporate vampires determined to literally suck the lifeblood out of the American people – the same corporate tyrants that blocked every attempt to institute true, guaranteed, publicly-funded health care of all.

As Rod continues to suffer pain and bleeding every day, and as this potentially dangerous tumor in his bladder continues to grow while he waits for a procedure deemed “medically unnecessary” in the USA that would have been done for him almost immediately in any other democracy on the planet, his story serves as a reminder that under America's hyper-capitalist, bottom-line society, profits continue to trump concern for human life and well-being. The Affordable Care Act may, as talk show host and author Thom Hartmann says, be the proverbial “camel's nose under the tent” – but there are millions of Americans who may not be able to wait for the rest of the camel.

Rod has had a biopsy from his new urologist (results pending) and his tumor, of course, has grown larger since the previous procedure. Surgery is scheduled for later in May.

Rod has had surgery (results pending) has been officially diagnosed with cancer.



Joel Applegate said...

Expertly laid out, Mr Lane. All the best, Rod.

Tirseh said...

Well written. How disempowering.