Twisted System

A Phoenix family stumbles through the tangled bureaucracy of modern medical care

Today, Diane Lee says simply, "I wish I'd picked Aetna."
A lot of PacifiCare customers might echo that. While PacifiCare has impressed Wall Street with its growth and profit margins, it's also enraged patients and taken heat for a callous attitude.

In the last five years, the California-based insurer has been taken to court by regulators and patients, hit with fines in California and Florida for its business practices and criticized for profiling physicians who write costly prescriptions.

"This is definitely a company that is more concerned with its stock price than patients," says Jamie Court, the advocacy director for the Foundation for Taxpayer and Consumer Rights, a nonprofit watchdog group. "Patients have a tendency to fall through the cracks, particularly when they don't go to war to protect their rights."


Read more New Times' coverage of BOMEX

PacifiCare and other HMOs say they've gotten a bad rap, that denials are the tool with which they control unnecessary and out-of-control care. And they've been fighting back, particularly through political means. PacifiCare gives massive amounts to politicians--about $2 million annually on lobbying and contributions. And late last year, a consortium of HMOs, including PacifiCare, pledged to spend $20 million on an image-buffing ad campaign.

PacifiCare is run locally by Richard Badger, president of PacifiCare of Arizona, and Ace Hodgin Jr., vice president of health services. PacifiCare covers 194,000 people in the state, and more than 55 hospitals and 3,000 physicians belong to its provider network. Over the last three years, the state Department of Insurance has received 214 complaints against the HMO, ranking it third in complaints among health insurers.

After the school nurse pointed out Shawndra's condition, the Lees took their daughter to Dr. Jan Willcox, their primary-care physician approved by PacifiCare.

But Shawndra needed a specialist, and the Lees took their first step into the twilight zone of an HMO-dominated world.

In order to see a specialist, the Lees needed a referral from Willcox. The primary-care physician is often called, in HMO jargon, the "gatekeeper," who, like a bouncer, decides who gets in, and who stays out. The HMO won't pay unless there is a referral. This keeps its costs down because fewer people end up seeing the more expensive specialists.

These are the hoops most people have to jump through for health care today. About 175 million Americans are covered by HMOs, and Arizona is near the front of the pack: 89 percent of those with medical insurance in the state are covered by HMOs.

In September 1997, four months after the Lees first learned of Shawndra's scoliosis, she finally got in to see Dr. Terry McLean, an orthopedic surgeon. The curve had worsened to 55 degrees, he found, and he recommended surgery. But, according to the Lees, his bedside manner left something to be desired.

McLean, who wouldn't talk to New Times, explained to the Lees how scoliosis is treated in most cases: through a method called posterior correction. The surgery requires opening an incision all the way down the patient's back, almost like filleting a fish. Several vertebrae are usually removed from the spine, and metal rods are inserted to fuse the backbone into the correct position.

The procedure, while fairly common, is long and intense. The patient has to have blood drawn and stored to make up for the substantial loss during the operation. The incision stretches down the patient's whole back, leaving a long scar. It's usually a week before the patient can get out of bed, and months before she has a full range of motion.

McLean seemed to emphasize the risks and didn't take much time to explain things, Diane and Shawndra say. "He was very curt, very rude," Diane says. "He acted like we were wasting his time."

But even though McLean talked about the risks of the surgery, the Lees say he never told them it was urgent. He also never informed them about any other options or procedures. He said they should think it over and get back to him, Diane Lee says.

Shawndra was terrified, her mother says. "She was crying in the car on the way home, she was so upset," Diane Lee recalls. "She was saying, 'I don't want that.'"

"We didn't know anything about the operation, what was involved," Shawndra Lee says. "He was the first doctor we talked to who had done the surgery. He made it seem very scary."

When David Lee heard about this, he went looking for alternatives.
He thought he found the answer when he came across Dr. Ronald Blackman's Web site. Blackman had started correcting scoliosis with a new method, which promised less blood loss, smaller incisions and a quicker recovery time.

In Blackman's method, Lee learned, the surgeon enters the body through the side of the chest, using very small cuts--one inch to one-and-a-half inches. Then the surgeon corrects the bend and places the rods with instruments guided by a small camera. The method is called endoscopic anterior correction.

Anterior correction is nothing new--surgeons have used it to correct spinal deformity since the late '60s. But Blackman has pioneered placing corrective rods and screws through the front with the use of cameras. He's done more than 50 of the surgeries so far, almost all with good results, Lee found.

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