Twisted System

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

Both agree Blackman's approach is new, but both say it's viable for some patients. They have reviewed the procedure as presented by Blackman and other surgeons at conferences, and neither call it experimental or unnecessarily risky.

Without reviewing the case, neither physician wants to comment on the possible outcomes. And both caution that Blackman has not gotten the degree of correction desired in some cases. They say they are not endorsing Blackman's method for Shawndra.

But the one thing they are certain about is that delay has only made Shawndra's condition worse.

"Sooner or later, the HMO is going to end up paying for both [an anterior and a posterior approach]," Shaughnessy says. He explains that the worse the curve gets, the more it requires entering through both the front and back. "It runs about $20,000 to $30,000 to do either procedure alone," he says. "To do both, well, the HMO is going to double its own costs."

On March 23--almost seven months after Lee wrote his first appeal letter--PacifiCare sent one final letter to the Lees, telling them their appeals were now exhausted. The Lees estimate they had spent about $5,000 on airfare, long-distance phone bills and missed work to get the same answer they got at the beginning.

In closing, PacifiCare added, "We feel it important to stress that you not delay Shawndra's treatment any further."

PacifiCare stands by its decision. In a conference room at the top of the laser-blue glass tower of its Arizona headquarters, three of the company's officers recently defended their actions.

Dr. Elk, Daniel Geary, the director of health services for PacifiCare, and Geoff Jaroch, director of public affairs, sit behind a mirror-finish conference table. Jaroch apologizes that the other three medical directors who decided the Lees' case are not present. Those physicians declined to comment.

The men dispute the Lees story in only a few places. They say the Lees could have started the appeals process much sooner, which is true. And the men insist that PacifiCare made the best medical decision for Shawndra.

The insurance company contends that the Lees got an answer in plenty of time; it simply wasn't the one they wanted.

PacifiCare controls costs by maintaining a network of providers who agree to accept fees set by PacifiCare. By signing on to PacifiCare, customers agree to stay within that network when they want to see a doctor. That's easy for colds and minor injuries, which can be treated by the primary care physician. But for anything more serious or complicated, the patient has to get a referral. If the care the patient wants is outside the network of doctors, then PacifiCare will consider paying the doctor even though it doesn't contract with that physician.

Jaroch says PacifiCare gets about five requests for out-of-network care per month. He says it covers about two of those--or about 24 a year.

What Jaroch doesn't mention is that this usually costs HMOs more money, because they don't have an agreement on fees with that physician. Inside the network, an HMO can bargain in large numbers and deal in bulk to keep prices low. The HMO might offer less to fix a broken arm than another insurance company, but it can promise to send enough patients with broken arms to a specialist to make it worth his while. Outside the network, there aren't any deals like that for the HMO.

So in the Lees' case, the real question for the HMO was: Is there a doctor in the network who can fix this girl's back?

"This was never a medical necessity issue," Geary says. "There was no reason for us to even think about another treatment. This was always about in the network or not."

Elk adds that Dr. White, who told the family they should choose the procedure they wanted, never said that to him. But even if he had, it wouldn't have changed the outcome.

"If [White] believes that patients have the right to choose the treatment they're going to have, I think it's fine for him to have that opinion," Elk says. "But health insurance does not always support any choice the patient wants to have."

The concern about the safety of Blackman's procedure was basically an afterthought. Elk and Geary say Blackman's surgery is too risky and unproven, but that concern was still secondary to the fact that doctors in the network could do a procedure that would work--even if it wasn't what the Lees wanted.

Elk concedes that none of the medical directors who decided the Lees' appeal have any experience with spinal surgery. He says they didn't consult a specialist for an opinion on Blackman's approach until the final appeal began because they already had opinions from McLean and White. And that specialist at the University of Arizona's medical school did not review any of Shawndra's records.

"I firmly believe that the best thing for Shawndra is to have the procedure done the way the specialists have recommended it," Elk says, adding that now four specialists--counting the one in New York who reviewed the case--have all said the posterior approach is standard. "It probably should have been done a long time ago."

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