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Point of View

A mere mortal

By Steven Schlozman, M.D.

We have all learned, patients and doctors alike, that the Person Who Grants Insurance Approval is an exalted individual, someone who holds extraordinary power over both time and health. To be able to speak candidly with the mere mortal who controls the levers behind this curtain is unusual. I recently had such an encounter with an insurance company representative. In one way it was a sullying experience, but in another way the very nakedness of the exchange allowed a kind of apocalyptic truth to shine forth. It was, I think, a rare and truly honest moment. Here is what happened:

One of my patients had been denied coverage for treatment with a certain medication. There was nothing unusual about the situation at the start. This is what made its conclusion so unnerving.

Upon receiving the Denial of Service Notification, along with a list of recommended alternate medications that I had already tried with this patient and had detailed on my initial Official Request Form, I settled in to plead my patient's case. I assumed this would involve dialing the appropriate 800 number and then listening to the usual 30 minutes or so of bad pop music while I waited on hold to speak with the Hearer of Appeals. And indeed this call did start out in the customary manner. From time to time I was assured by a disembodied, androgynous voice that my "call was very important," and then the bad, scratchy music droned on again.

The Point of View essay provides a personal perspective on some issue in medicine or science. Schlozman, a 1994 graduate of DMS, practices psychiatry in Massachusetts.

Irritation: As all physicians do, I had seized a moment of free time to make the call—in this case, using my cell phone while I watched my three-year-old daughter tumble and twirl in her gymnastics class. I was dimly aware of my irritation at not being able to be wholly present in the moment, sort of the way one laments a paper cut or a cold sore. But my patient needed the medication, and I wanted to watch my daughter. So I sat there watching her but listening to elevator music. Somewhere in the back of my mind it occurred to me that I was not being reimbursed for my time on hold, but I also knew that this was more or less what I had signed up for. Although I would prefer not to dip into family time to fulfill work responsibilities, the increasingly byzantine tasks required of physicians require a willingness to double up mindless tasks (such as sitting on hold listening to bad music) with other, more important endeavors.

Speaking candidly

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Eventually, a very nice-sounding man picked up the other end of the line and confirmed that indeed coverage had been denied for my patient's medication. He pointed out that the recommendations made by the insurance company all had good evidence-based support, and he suggested that I try the company-approved alternate medications for my patient, despite my having done so already. Sometimes "failed treatment trials" can be idiosyncratic, he reminded me. When I protested again, as he expected I would, he told me that I would need to speak to the medical director but that he doubted that would make a difference.

At this point, while watching my daughter do somersaults, I asked the man on the other end of the line something I'd never before asked. "Isn't this really about power?" I said. "I mean, we both know that I think my patient needs this medication. I've been clear about why I feel he'll benefit, and yet it feels like you knew when you picked up the phone that you were going to say 'no.' This wasn't really an appeal call. You already knew what you were going to say."

"Sir," he replied, "I can have you talk to my supervisor, but I can assure you that we have your patient's best interests in mind."

"Really?" I asked.

Pause: There was a long pause. The leaves outside the window swirled in the wake of a cold autumn breeze. When the man on the other end of the line finally spoke, his voice had changed. It was less formal—almost but not quite unctuous. It was a bit creepy, to be honest. Truth is often a bit creepy.

"How many hours do you work, Doctor?" he asked.

Without really knowing where this was going, I replied, "A lot."

"Bet I see my kids more than you see yours," he added.

"Maybe," I said.

"You getting paid for this call, Doc?" he continued. "Because I am—paid pretty well, actually."

"Oh," I said.

One of my patients had been denied coverage for treatment with a certain medication. So I settled in to plead his case.

"You don't have to tell me what you make, Doctor, but I bet I make more than you." There was another pause. "I get home at the same time every night to see my kids," he added, "and I make a great living."

"Can you sleep at night?" I asked.

"Can you live with your choices, Doc?" he countered.

"I guess so," I said.

There was another long pause. Then he said, "Your patient can have the meds, Doc. I've approved your request for a year."

"Thanks," I said.

"Don't mention it," he replied. And that was that. We hung up.

Guise: As we all know, such calls are always "recorded for quality assurance." Given this fact, I have often wondered if his refreshingly honest response cost the poor man his job. I hope not. Honesty, even in the service of something rank, is better than false diplomacy in the guise of patient care.

After we hung up, I started to move on to the next thing on the top of my paperwork heap. But first, I decided to watch my daughter practicing her twists and turns.

The Point of View essay provides a personal perspective on some issue in medicine or science. Schlozman, a 1994 graduate of DMS, practices psychiatry in Massachusetts.

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