HMO Systems Can Be Tantamount to Blackmail

By: Loolwa Khazzoom, Founder, Dancing with Pain

August 25th, 2008 • Patient AdvocacyPrint Print

HMOs systems can be tantamount to blackmail — human dignity demanded in exchange for healthcare (often substandard at that). As a patient trying to get medical treatment through an HMO, I can end up feeling like a starving person being told to drop my panties and stand exposed before being given a scrap of bread. That’s how I felt today — disempowered and violated.

Here’s what happened:

A few months ago, my health insurance informed me that they were no longer covering treatment by my primary care physician. So my doctor referred me to another doctor, whom I ended up liking a lot.

Among other things, this new doctor is gentle and caring; she listens; she treats me like an intelligent human being who knows my own body; and she works with me in partnership. Last week, I called to make an appointment with her, to get a referral to an eye doctor.

My mom had just found someone who was able to diagnose a condition that nobody else was able to catch — namely, that my mom was at the beginning stages of going blind. (Quite a thing for the other doctors to overlook, no?)

Because this new eye doctor caught it in time, my mom was able to start a treatment regimen that, G-d willing, will keep the condition at bay. My mom of course called me in excitement, telling me that I should see this doctor as well. Because after two visits with different ophthalmologists and multiple visits with one optometrist, I still have problems with my right eye.

Unfortunately, my new primary care physician was not available to see me (for a referral to the eye doctor) until the very end of August. That would make it too late to see the eye doctor before I would move. So I made an appointment with the physician’s assistant, thinking it would be no big deal — a straight-up referral, right?

I got there today and handed the receptionist my HMO card, only to find out that my co-pay is now two and a half times as much as it cost the last time I went to the doctor. So I decided that as long as I was there, I might as well get a referral for two other non-urgent issues that have needed attention. If I couldn’t get in to see those doctors before moving, I reasoned, I could see them when I would be back in town in the next month or so.

In the examining room, the physician’s assistant (PA) asked why I was there, and I said that I needed three referrals — to an eye doctor, a dermatologist, and a gynecologist. I rattled off the names of the exact doctors I wanted to see (though I couldn’t remember the last name of the gyno).

PA told me that I didn’t need a referral to a gynecologist. I tried to clarify whether that was true for any visit, or only for the yearly pap smear. She asked why I want to see the gynecologist. I said I had vaginal pain. She started asking me questions about the pain. I didn’t feel comfortable getting into it with her, and I didn’t see any reason why I should have to — being that she’s not a gynecologist.

So I answered nominally, just to avoid tension with her, then came back to my question about whether the gyno visit would be covered by health insurance or if I needed a referral. We did this dance a couple of times — her trying to get me to talk about the issue, and me trying to get her to answer my question about referrals.

“Are you a doctor?” she suddenly asked me. “No,” I answered, thinking that was a strange question. “Because usually patients come in and say what their symptoms are, and we determine where to refer them,” she said.

“Well I figured it’s pretty obvious,” I said. “Vaginal pain: Gynecologist.” She laughed but continued with her line of questioning — telling me that in order for her to be able to refer me, she had to know what she was referring me for.

Vaginal pain. That’s what you’re referring me for. And do I even need a fucking referral? Answer the damn question.

Knowing that this woman’s demands stood between me and my gynie’s speculum, I decided to play along and answer her questions as briefly as possible. But she was having none of that. The questions got increasingly involved, leaving me feeling increasingly violated.

Not only did I feel that PA’s line of questioning was both unnecessary and intrusive, but I also felt it was presumptuous. Who deemed her worthy of my seeking out her opinion? I very clearly had no interest in it.

And that’s where we get to the blackmail: I won’t be given access to what I need, certainly not when I need it, unless I play by the rules of someone else’s game – no matter how distorted those rules are. Access to health care is swung before me like a carrot on a stick, and I have to jump through certain hoops in order to get it, no matter how irrelevant or demeaning those hoops may be.

I stopped PA’s personal inquisition a couple of times, saying that I didn’t feel comfortable and that I only wanted to discuss the issue with my gynecologist. Then PA started asking questions about my gynecologist — how many times I had been to see my gynecologist, had I mentioned this issue to my gynecologist before, and had my gynecologist done anything to treat it.

Only after, like, my 10th exasperated question about whether I even needed the damn referral did PA finally answer, “I don’t know. It depends on the insurance coverage. Sometimes yes, sometimes no.”

With that, she started in on my eye pain: What caused it, how long has it been going on… I kept coming back to the relevant point: My eye is in pain. I need an eye doctor to look at it.

But she needed details. So many details that after finding out my mother had recommended the doctor I’d requested, she started asking me about my mother’s condition and how is it that we have the same eye pain, if mime was caused by a splash of liquid nitrogen.

“We don’t have the same eye pain,” I responded with irritation. “But you said your mother kept going to see a number of different doctors, like you did,” she said. “Yes,” I answered, “for a different condition.” “What condition is that?” she asked.

Tell me something: How the fuck is my mother’s eye condition in any way relevant to my getting a referral to an eye doctor for my own fucking issue? “She’s going blind,” I spat out with venom, hoping PA would see what a prying shit she was and regret having asked me. “Why is she going blind?” PA asked.

Are you fucking kidding me? “It’s irrelevant,” I said, noticing how over the course of questioning, my body had collapsed into a child-like, vulnerable, disempowered form. “Her condition has nothing to do with mine.”

How can this happen? I wondered. With all of my self-education and self-empowerment, with total consciousness — while it’s going on — that what’s going on is completely fucked, how is it possible that the system can still leave me crumpled like this?

Because with HMOs, someone else holds the keys — to our healthcare, to our choices, to our power, to our dignity. And as with any dictatorial regime, our lives are ultimately in the hands of someone else’s mercy.


laurie edwards August 26th, 2008

Ugh, what a nightmare. So frustrating that there is so much inefficiency and ill logic standing between the patient and the access to care the patient needs! I just read the follow-up, too, and I can’t even believe the ineptitude involved here. I hope you do make that call!

ddsharper July 8th, 2009

In my opinion, you are one of the victims of the HMO act of 1973, created by the US government, codified and snuck into the health care system without permission from citizens. Most HMOs, due to the fighting for their rights by OB-GYN docs, consider gynecologists primary care physicians and thus you don’t need a referral. The key to navigating the system is to lie. The safest is to say you have been bleeding or that you went to an outside physician, keeping the name private, and they recommended a referral. The referring physician, or PA in your case, has to have a legitimate reason to refer or the insurance company will reject the referral. This is a terrible system that actually kills people and when the government gets its proverbial feet completely through the door, with universal health care.

brainwave September 18th, 2009

Thanks for this! I’ve been reading over at the Brainwave Entrainment Forums, and viewing this post was the ideal confirmation for much of the info I found out. :)

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