Thu 16 Jul 2009
In his documentary Sicko, director Michael Moore includes a “confession” by a long-time Health Maintenance Organization (HMO) physician, who was speaking before Congress.
“My name is Linda Peeno,” she began. “I am here primarily today to make a public confession: In the Spring of 1987, as a physician, I denied a man a necessary operation that would have saved his life, and thus caused his death.
“No person and no group has held me accountable for this because, in fact, what I did was I saved a company a half a million dollars… And furthermore, this particular act secured my reputation as a good medical director, and it insured my continued advancement in the healthcare field. I went from making a few hundred dollars a week as a medical reviewer to an escalating six-figure income as a physician executive.
“In all my work, I had one primary duty, and that was to use my medical expertise for the financial benefit of the organization for which I worked. And I was told repeatedly that I was not denying care; I was simply denying payment.”
Throughout the United States, as Moore’s film reveals, such stratagems pervade health insurers’ medical decisions and are evident in the way health-insurance policies are written. Here’s one patient’s experience with Kaiser Permanente, a not-for-profit health plan insuring 8.6 million members. Its website reports revenues last year topped $40 billion.
Linda Petersen, ad manager of The West Marin Citizen, suffered 11 broken ribs, two broken vertebrae, two broken ankles, a broken leg, a broken kneecap, a broken arm, and a punctured lung when she fell asleep at the wheel June 13 and hit a utility pole in Inverness. This week she had another disastrous collision, this time with her Kaiser Permanente medical-insurance policy.
“It’s kind of insane,” she told me Thursday when I visited her at The Rafael: Assistance for Living, a convalescent hospital in San Rafael. “Having health insurance doesn’t mean you’ll be covered.”
Linda, as can be seen in the photo, still wears casts on both legs and her left arm. Her head and neck are immobilized by a steel-and-carbon “halo.” Although she remains physically helpless, Kaiser told her yesterday her hospitalization costs will not be covered after next week until she’s ready for more-advanced physical therapy.
What’s the rationale for stopping coverage? “A Kaiser representative said I was fulfilling the physical-therapy goals by being able to transfer to a wheelchair,” Linda explained. “They’re looking for all these bureaucratic excuses.”
It’s not that she can get into a wheelchair on her own, mind you. It takes a physical therapist to carefully lift her to the edge of the bed, help her balance and pivot on her right foot (which isn’t as badly broken as her left), and then seat her in the chair. Once she’s in it, all she can do is sit, which she does for an hour a day.
Kaiser yesterday told Linda that next week the lower-paid staff at The Rafael will be trained so that one of them can take over from the two therapists who have been moving her.
This may be penny wise and pound foolish since moving her requires expertise; on Friday, after this posting originally went online, a skilled therapist lost his grip while moving her, and she had to catch herself by standing on her broken left leg and shattered ankle. Now she can barely move the leg, which had begun to heal.
The Rafael, Linda explained, is one of three hospitals in Marin County with which Kaiser has convalescent-care contracts. “I have no option to go anywhere else,” Linda said, and “I can’t be kicked out.” But starting a week from now, she’ll have to pay The Rafael $1,750 per week for at least the next month.
Linda with her elderly dog Sebastian who died in the crash.
“After next week,” Linda said, “Kaiser won’t cover anything until the doctor says I can put more weight on my weight-bearing extremities [e.g. the foot the physical therapist dropped her on]. It’s a matter of what the fine print says in the insurance contract.” Linda, who got her Kaiser policy through her job, noted, “You don’t sit down and read all of it.” Nor would it make any difference if you did.
“I felt shocked that they could stand there — when I’m totally helpless — and say I’m not going to be covered,” Linda remarked. “But it’s become general knowledge that’s how healthcare works in this country. It’s mind boggling to me that anyone would vote against universal healthcare.
“As a patient, you’re confronted in a very vulnerable situation. It’s horrible. I was crying this morning. They threw me into turmoil. I don’t know how long I’m going to be here. I don’t know how much it will cost.”
“But I can’t sit here and agonize over it,” she added, and — putting on a smile — began poring over today’s issue of The Citizen.