A Doctor's Story

Delving deeper into the idea of illness as a commodity, I want to introduce Richard. Richard was three when he came to our office for the first time. He had been born three months premature. He was oxygen dependent due to chronic lung disease. He had large sections of intestine removed due to something called narcotizing enterocolitis, which is not unusual in very premature infants. He also had severe reflux disease. Because of these digestive problems, he had a permanent feeding tube inserted through his abdomen into his stomach, and he required an unusual and expensive formula. He could not tolerate any other alimentation. He was on multiple medications, and required follow up with a number of pediatric sub specialists. He had extensive durable medical equipment needs, such as feedings bags and pumps, oxygen tanks and tubing, nasal canulas for oxygen delivery, etc.. The child had historically been covered by Medicaid. The child had many long established relationships with health care providers, pharmacies and suppliers of medical equipment. Mother also had a disabling medical condition. They had been using ‘the system’ successfully and appropriately for several years.

The family came to our office because the child lost his Medicaid coverage. Mother was unclear as to why or exactly when this happened. She denied receiving written notice of the termination. This is common. Families living in poverty tend to move more frequently and to stay with extended family or friends. Their mailing address may not correspond to their physical location, and it may not be stable over time. In any event, mother was not sure why she lost coverage. She became aware of it when, two months prior to her first visit to our office,  Richard was denied care by the gastroenterology and nutrition clinic that he was normally followed in. Mother was told that the child’s Medicaid coverage had lapsed. Mother had begun the reenrollment process, but had been stymied by problems with transportation and income verification. She came to our office in a state of true desperation because her child had no portable oxygen, no feeding bags and no formula.

We, of course, saw the child although there was no source of immediate payment. I must point out here that this was not a significant economic risk. This child was disabled. He would, at some time in the not too distant future with a bit of assistance, regain Medicaid coverage. The Medicaid system allows providers reimbursement for services rendered to a given recipient for up to three months prior to the date of the recipient’s application. As long as the applicant states that retroactive coverage is needed, providers of care during that three month window will be paid. Anyone with basic knowledge of Medicaid reimbursement guidelines would have known this. Certainly billing staff in a specialty clinic in a major medical center would be familiar with these guidelines.

After assessing the clinical situation, we got to work. First we called a foster parent who cared for a large number of medically fragile children to see if we could borrow some of the necessary supplies on a short term basis. I knew she would have them because I cared for all of her kids. We sent a staff member to retrieve the supplies. Note that we did not send the parent or the nurse caring for the child. They were too stressed to be reliable and efficient. Maria then began the battle with Medicaid. As usual, mom had the child re-certified within twenty-four hours. However, the home care agency that they had used historically had some unpaid claims secondary to the child’s interruption in coverage. They would not resume service. We called a local home care agency. They had great difficulty obtaining authorization for the supplies needed. Days passed. You see, just having Medicaid coverage does not guarantee payment. The supplier must submit lists of supplies requested and corresponding diagnostic information provided by a physician. The physician must be the primary care provider for the patient in question. All of this paper pushing is time consuming. It was a full week before the supplies were delivered, and they failed to obtain authorization for the specialty formula. They would not supply it without payment. Maria wrote a check to the home care agency in desperation, then stopped payment on it. This bought her a couple of days in which to light a fire under the appropriate bureaucrat’s ass and get the purchase authorized.

Children such as Richard are like cash cows for the health care system. Medicaid reimbursement is relatively low, but it is very reliable if one is familiar with its idiosyncrasies. I say this based upon much personal experience. And it pays well if you are a volume supplier, as I have already discussed. Richard was using tons of medical equipment, lots of medication, daily home based nursing care, as well as physician and hospital based services. All of these services were ’medically necessary’. Do not misunderstand; I believe that, in this case, the services were medically necessary, although I would have advocated  providing them differently. But all of the folk that signed documents asserting these services were medically necessary dropped the ball as soon as they weren’t getting paid! Did the services become less necessary because Richard had no reliable source of payment? Of course not. Such an assertion is patently ridiculous. But that is exactly what the actions of players inside our for-profit system tell people in need of essential health care services every day. These players will milk that cow till its dry. Once it dries up, they just kick it to the curb; cannon fodder.

These cash cows, otherwise known as cannon fodder, are people who bleed red like you and me. Certainly the wealthiest country in the history of the world can afford to do better. Certainly anyone who deserves to be called human must work to right this shocking wrong.