Health care workers, it's the system that bothers me, not you

Way back when (to be more specific, the 1970s and 1980s), I was, in order of my career moves, a research associate in the Oregon Medical School Department of Family Practice, a manager with the State Health Planning and Development Agency, and the executive director of Oregon Health Decisions, a pioneering community-based bioethics effort.

As I like to say, I must have done a terrific job, because now our state's health care system is running perfectly smoothly with no problems.

Of course, that's a blatant falsehood. Oregon, along with the rest of the United States, has a disjointed health care system marked by inefficiency, inequality, and crazily high costs.

However, most people are satisfied with their health care providers. I know I am.

The dissatisfaction is mostly with the system that these providers have to work in, and under. Often this doesn't become obvious until someone has a medical problem that is causing them a lot of distress, so speedy treatment is desired, and the health care system moves with decided unspeediness.

As you probably have guessed, one of those someone's is me. After suffering from sciatica in my right leg that started off very painful in 2020, when I was a youthful 71, then got better though it never went away, the sciatica has morphed into being very painful again now that I'm 75.

So I've been seeing my primary care provider, a physical therapist, and the staff who have gotten me a lumbar X-ray and MRI. I like all of these people. It's the system that isn't working so well.

On the most basic level, there's a disconnect between a person with a medical problem, me in this case, and policies that are a buffer between what people and their providers want, and the insurance that pays for most of health care.

I don't mean to burst the bubble of those who are looking forward to becoming old enough to get Medicare, having tired of the B.S. private insurance companies engage in. I used to be in that bubble myself. I couldn't wait to rid myself of my Blue Cross/Blue Shield insurance.

However, when I became eligible for Medicare, I decided to sign up for a MedAdvantage plan, as that seemed, well, advantageous. Kind of amazingly, I chose Regence MedAdvantage -- you know, the same corporation that offered the private insurance I detested for so many years.

It seems to me that with every passing year, Regence MedAdvantage introduces more barriers to getting needed care, probably due to cost containment pressures. What particularly irritates me is how third-party contractors are used by Regence MedAdvantage to assess referrals made by my primary care provider.

This doesn't happen with every referral, but often enough. For example, today I had an appointment with my physical therapist. He'd given me exercises to do over about five visits, and offered some great advice about how to manage my sciatica. 

Since it seemed time to stop our visits, he started to suggest a plan for how to maintain an ability for me to see him again if I needed to.

Then he glanced at his computer screen and said, "Oh, but you have _______ as an intermediary. If we don't close out your case, and I see you again, they'll only approve half the visits they did this time, like from eight to four. And after that, they'll keep cutting the visits, like from four to two. But if we close your case, after 60 days they'll treat you as having a new problem and grant the original number of visits."

OK, I got what he was saying. However, it seemed strange that we weren't talking about what would be best for treating my sciatica problem; we were talking about what would be the best approach to dealing with my insurance problem.

Again, I have Medicare. I'm much better off, bureaucratic B.S. wise, than people who have private insurance.

But "much better" doesn't equate to pleasant. It bugs me when my primary care provider orders, say, a lumbar MRI to find out what is going on with my spine, then I have to wait for an approval from either Regence MedAdvantage or whoever Regence contracts with to decide if an MRI is warranted.

I realize this is a crazy idea, given how our health care system (actually a non-system) is set up, but it sure would be great if health care providers were the ones making the decisions as to what is appropriate care, with outsiders getting involved only if there's an obvious problem with what has been ordered for a patient.

Currently I'm waiting for a referral to a pain and spine clinic to be processed. I've been told that the referral has been approved. It just hasn't been processed, whatever that means. So I bug my providers, asking them what's taking so long, and they've been patient with me. I try to assure them that I'm not unhappy with what they're doing.

It's like when I hear my wife calling her MedAdvantage company when there's a problem with a prescription or care being denied. After explaining the problem, she always says, "I'm not irritated with you; you just work at ________; I'm irritated with management and your company's system."

 

Comments

[Susan Maginnis]

I am having knee replacement surgery in a week. They will be sending me home 24 hours after the surgery. I requested a hospital bed delivered to my home and a caregiver to help with food and housekeeping. Although my medicare advantage policy says it will provide both, my request was refused because they considered it medically unnecessary.