The Mask
"Look ye, Starbuck, all visible
objects are but as pasteboard masks. Some inscrutable yet reasoning thing
puts forth the molding of their features. The white whale tasks me; he
heaps me. Yet he is but a mask. 'Tis the thing behind the mask I chiefly hate;
the malignant thing that has plagued mankind since time began; the thing that
maws and mutilates our race, not killing us outright but letting us live on,
with half a heart and half a lung.
Gregory Peck as Ahab, paraphrasing Moby Dick by Herman
Melville
So too, do eating disorders plague
humankind. They are just the most recent manifestation of that inherent
evil assuming the guise of a disease which in prior times may have been known
as the Spanish Flu, or the Black Plague or the Ebola virus. That inherent evil
has but one goal, to strip away life and leave a wide swath of pain, anguish
and destruction in its wake. That Demon, that inherent evil hides behind
a mask disguising its true nature.
Impact on the Patient and Family
After eating disorders took Morgan's
life last October, I read through her journals. These journals were written
while she was in treatment in various residential programs throughout the
United States. Not surprisingly, insurance coverage had a tremendous impact on
her psyche and outlook on treatment.
We had some of the "best"
insurance possible ... allegedly. Group plans through United Behavioral
Healthcare and Blue Cross. These companies have contracts with most of
the residential programs ... at least those who have not yet made the decision
to no longer accept them because of numerous issues with billing, approving
treatment, cutting authorized payments and lack of communication.
When a person turns 18 years old, they
are considered an "adult" for most issues and as such, the patient
must be advised of the status of insurance coverage during treatment. Imagine a
person fighting for their life, their bodies slowly deteriorating, their brain
deprived of nutrients and yet, focused and hopeful on their recovery ... and
then being told that their insurance company is denying all future residential
treatment and unless an appeal is approved, they will need to leave the
facility the next day ... unless they or their parents can come up with a lump
sum payment for future treatment measuring in the thousands of dollars. The
medical director at the facility knows the patient still requires the higher
level of care. The patient's counselors know this. Any competent medical
practitioner familiar with eating disorders and the American Psychiatric
Association guidelines and the DSM-V would know this. And yet, the insurance
company's representative physician figuratively "pulls the plug."
In Morgan's journals, she wrote of
feeling helpless, hopeless, defeated, frustrated, angry ... not at her eating
disorder in these instances, but at the insurance company which she knew would
not allow her to receive the crucial treatment she desperately needed. She
was fighting for her life. And she knew that the insurance company would be
fighting against her. After all, United Behavioral Healthcare had to make
its $68 BILLION dollar profit in 2015 some way!
Insurance providers point to a
"peer-to-peer" program to combat the perception that it does not care
about the health of its insureds. In a peer-to-peer review, the review is typically done as a scheduled telephone call
between the insurance company's physician representative and the qualified
healthcare professional who requested the review. The reviewer applies the
health plan’s medical coverage guidelines to the clinical information, use
clinical judgment, and render a decision. Although the reviewer is a delegate
of the insurance company, allegedly the
peer physician receives no financial incentive to deny or to approve a request.
And yet, even a cursory investigation reveals that numerous peer review
companies exist and market themselves with some even touting its transparent,
competitive pricing.
Now, ask your
physician, or the residential program's physician, how often the peer physician
has reviewed all of the medical records, or if they specialize in eating
disorders or if they are up to speed on the latest medical articles or journals
dissecting eating disorders. Undoubtedly, the peer physician is acutely
aware of the insurance company's policy language. And they are ipso facto, making medical treatment
decisions on behalf of the insurance company ... and for you, the insured, the
patient.
The insurance company
has a fiduciary relationship with you. It has the duty to act in good faith and
deal fairly with you. It stands to reason that the insurer must then also
employ peer physicians in good faith, physicians who are competent and who must
hold the insured's needs paramount within the context of the insurance
policy. At that point, the question must be asked, if the peer
physician has a reasonable basis to believe that his/her treatment opinion
regarding the patient/insured does not comply with, or even violates the
accepted medical standards of care in the community, don't they have an
ethical, if not legal obligation to inform the patient/insured, the treating
physician and the insurance company of this fact? And if the peer
physician is not taking into consideration the APA guidelines or the DSM-V, how
can their opinion of treatment needs be anything but suspect? The
peer physician can attempt to qualify the remarks by stating that pursuant to
the insurance company's policy language, the insurance company is refusing to
pay for future treatment. But, interpretation of insurance policy language
should be left to legal minds ... not medical minds. What experience does the
peer physician have with legal interpretation? Or, is the insurance
company feeding the peer physician its own legal interpretation and merely
asking the peer physician to color by numbers with regard to denying treatment
under the policy? This illustrates the harsh reality that compliance
with the generally accepted medical standard of care for a patient/insured is
often secondary to the substance of the insurance policy.
So, how are we to
proceed?
A Call for Accountability
As the insured, you have a right to the
records your insurance company and its peer physician reviewed regarding your
claim ... including the identification of that very peer physician.
There is a very strong likelihood your
insurance policy does not incorporate the American Psychiatric Association
guidelines or the DSM-V guidelines with regard to reviewing and treating an
eating disorder. We all know that treating eating disorders involves
a laborious, very long process and in most cases, takes years of treatment,
therapy, pharmaceutical drugs and interaction. And yet, without
these standard guidelines, upon what basis and guidelines is the peer physician
utilizing in reviewing your claim and making rational, medical treatment
decisions which impact you? Is it legal interpretation of an
insurance policy that the physician is not qualified to give?
I am not suggesting filing a medical
malpractice claim against the peer physician. You very well may not even
have “standing” as the judicial branch defines that term to file a malpractice
lawsuit. Further, malpractice laws in some states can seem almost
draconian in their application and if you file a malpractice lawsuit in bad
faith, you could be subjected to costs and attorney’s fees. However, each
state does have it own Board of Medical Examiners. These Boards are
appointed, or voted in, to oversee the medical profession in its respective
state. These Boards are designed to protect
the health, welfare and safety of its citizens against the unprofessional,
improper, and unauthorized practice of medicine by ensuring that those who
practice medicine and other allied health professions under their jurisdiction
are qualified and competent to do so. In addition, the Boards serve
in an advisory capacity to the public and the state with respect to the
practice of medicine.
These Boards also have
a complaint process in place wherein persons who are aggrieved may seek
assistance. Most Boards can publicly or privately censure a
physician, suspend them from the practice of medicine or in some cases, revoke
a physicians’ right to practice medicine. Assuming a peer physician
is rendering an opinion regarding treatment that is not based on the accepted
medical practices or what is in the best interest of the patient, but instead,
the opinion is simply based on insurance policy interpretation, then arguably the
peer physician’s opinion could and rightly should be construed as improper,
unprofessional and not in compliance with the medical standards in the
community. Upon proper complaint, the Board should open an investigation into
that peer physician and review the process utilized by the peer physician in
reviewing claims for that insurance company. The Board could dismiss
the complaint out of hand. It could choose to investigate. Ramifications
could include dismissal of the complaint, private or public censure of the peer
physician or even a revocation of that peer physician’s license to practice
medicine.
It stands to reason
that if claims start to increase, perhaps even dramatically so against peer
physicians, the peer physicians themselves would have cause to complain against
their masters, the insurance companies employing them. In order to maintain the
integrity of their profession and reduce the number of administrative claims,
the peer physicians would necessarily have to exert pressure on the insurance
companies to amend policy language to conform with the recognized and accepted
medical practices utilizing APA guidelines.
Combined with
political and societal pressure, the insurance industry would be isolated and
confronted with the reality that they must change their business practices to
conform with recognized medical guidelines … before state or federal
legislatures require them to make those changes.
Evolution and change
is not easy; nor is it expedient. But, it is necessary. As
some of the brightest and best of our children are ripped away from our loving
arms, we must be strong and resolute.
