What Happens When Your Doctor And Insurance Plan Disagree?
Look beyond the surface.
The people behind the scenes – whose names we may never know or whose faces we may never meet – often control our destinies.
Some call it luck, and some call it fate. Outside their own perseverance, even elite athletes and star actors reference under-credited personnel who enabled their success. But we have all experienced inflection points in our lives decided by people unbeknownst to us – whether it be an admission committee decision, a job offer that never materialized, or a life-altering radiologist report. On one hand, our life experiences can seem random, serendipitous, chaotic, and predetermined all at once. On the other, these depersonalized moments create the illusion of objectivity that may overstate how arbitrary major life events actually can be.
The proud city of Brockton, Massachusetts has a population exceeding 100,000 in Plymouth County. Known for its surprisingly high wind speeds, historical role as the primary manufacturer of our soldiers’ boots during World War I, and boxing legends Rocky Marciano and Marvin Hagler, it also happens to be hometown to Caron Campbell – one of a small group of formally trained and certified medical technologists left in healthcare.
“It’s a dying field, but it’s my calling. You really can’t do this job if you don’t love the work,” Campbell said about her profession, which involves overseeing, implementing, training, and assuring quality for the millions of laboratory tests hospitals order on a daily basis for analysis, from blood tests to fertility samples. Campbell’s experience in bench research, technical work, management, and venture have aptly positioned her to ensure that the critical decisions doctors and nurses make on a daily basis are predicated on accurate data.
Campbell lives beyond the surface in medicine. She resides at arm’s length away from the doctors who rely on her work and the patients whose fate depend on the integrity of her laboratory tests. For someone with Campbell’s expertise and passion to refer to her profession as a ‘calling,’ she chalks her impact on the patients and doctors at the surface of healthcare up to destiny.
Campbell has spent over 45 years as an adult eating right, staying active, and seeking annual checkups and screening exams. She walks 5 miles a day on concrete laboratory floors supervising, checking, and analyzing. In her downtime, she sails out of Boston Harbor. Her husband, Bill, is also cut from the same cloth as a formally trained and certified medical technologist. They’ve been married for 28 years. Unfortunately, Campbell developed severe knee arthritis with subsequent deformity over the years. Now, it’s gotten to the stage that it’s begun to interfere with her basic activities of daily living.
After doing her homework by talking to joint replacement experts and reading peer-reviewed literature, Campbell was attracted to the precision and accuracy of robotic-arm assisted surgery with haptic feedback. While she understood there presently exists no definitive literature that suggests this emerging technology would certainly result in a better outcome than a traditional knee replacement, she was encouraged by several recent reports – and could certainly relate to the importance of precision and accuracy in medicine.
“I knew what I wanted, and I felt it certainly couldn’t hurt to get as precise of a surgery as possible. But when I inquired about the surgery with Dr. Antonia Chen, my insurance carrier denied it. They told me – and I’ll never forget this – that ‘well, nine out of ten doctors don’t think robot-assisted knee replacement is medically necessary.’ Where did they pull that from? I don’t even think nine out of ten surgeons have a robot. They then told me if I wanted the robotic surgery, I’d have to pay $2100 out of pocket, in addition to a $500 copay. I was just astounded. Who’s calling the shots here? It’s definitely not me, and it’s definitely not Dr. Chen. I’m healthy and have never given my insurance a reason to deny me after years of paying into my plan,” Campbell said. “I just think I have a right to get the surgery I want, and I think my surgeon has a right to perform the surgery she wants.”
When Campbell asked about other precision-based technologies for her knee replacement, “they told me they’d pay for a custom knee, and I said ‘you know that also requires a CT scan, right?’ They said it would be covered. What’s worse is that they actually told me ‘you know if you just wait a year for your Medicare to kick in, they’ll pay for the whole robotic surgery.’ I was taken aback that they actually suggested that.”
When it came time for the insurance companies – who also inextricably live beyond the surface in healthcare – to return the favor, Campbell was shut out. And in doing so, her worldview rooted in precision, fidelity, and destiny for the betterment of society was confronted with arbitrary practices, bad luck, and chaotic profiteering.
What would you do if you got a flat tire? Busted tailpipe? Leaky engine? Like most Americans, you would likely visit a reputable mechanic, pay them for parts and labor, then be on your way. But what if you have an arthritic joint – one that gives you stabbing pain with every step? As most people like Campbell know, it’s not that simple. In fact, neither the patient nor their physician is completely free to make important decisions about treatment. But in a country with arguably the world’s most advanced healthcare resources, should caring for our bodies really be harder than caring for our cars? Who really calls the shots? The decision to use technology in surgery should be based on an evidence-based, shared decision making paradigm free of bias. Consensus between insurers and surgeons that enable adoption of innovation and progress should be a bidirectional conversation, not one unilaterally determined by the health insurance company.
Today, Campbell is still yet to undergo knee replacement. She waits in pain while battling her insurer that decides what kind of operation she should receive. Though she has been offered traditional knee replacement by Dr. Antonia Chen at Harvard’s Brigham & Women’s Hospital, Campbell resolutely maintains “insurance companies shouldn’t be the ones dictating patient care.”
As someone who respects the impact of her work on the surface of healthcare, Campbell has made silent contributions to the health of countless others. But when she needed her insurance plan to pay it forward when she became the patient, she was railroaded by unilateral, insurance-based guidelines that failed to respect patient preferences, scientific evidence, logical fiscal responsibility, and the doctor-patient relationship.
You can read the original article by Dr. Prem Ramkumar on Forbes Magazine online: