Friday, June 3, 2011

Catch-22

Dr. Heller: "This is Dr. Heller, on behalf of Major Illness Insurance test authorizations. Who am I speaking to?"

Dr. Grumpy: "Hi, this is Ibee Grumpy. I'm calling to get an MRI authorized on a lady."

Dr. Heller: "Okay, let me check her file... It looks like we denied the MRI because it isn't clinically indicated."

Dr. Grumpy: "Well, I'm worried this lady has MS, and want to do an MRI to find out."

Dr. Heller: "So does she have MS? We'll cover the MRI if she already has a diagnosis of MS."

Dr. Grumpy: "I don't know. I want to do the MRI to find out if she has MS."

Dr. Heller: "Our policy is only to do MRI's on patients with known MS."

Dr. Grumpy: "So how am I supposed to find out if she has MS in the first place?"

Dr. Heller: "You're the neurologist."

40 comments:

Anonymous said...

Honestly on the surface it may seem funny but it is horrible to me.
I'm sorry to say this but healthcare in Canada rocks compared to that kind of stuff.

Anonymous said...

Chicken bones, you toss chicken bones into the corner and see what they spell.

girish said...

I've been following your blog from India for the past year.

Was taken aback to see the Hungarian? feed and wondered if you've abandoned the blog.

Grumpy, M.D. said...

Not at all.

I have no idea what the problem is, and am working on it.

Old MD Girl said...

Hungarian feed? I feel like I missed out. Oh well.

Insurance companies make me really really mad.

RehabRN said...

I love it! I hear all sorts of horror stories from the other MS nurses (including NPs) in our local journal club, but this one takes the cake! Who the heck needs any MS criteria, eh?

I'm sure the ladies will enjoy!

Hmm, just goes to show that the doc has no clue how modern MDs diagnose MS.

Packer said...

Not to be contrarian.....but did anyone ever get diagnosed with MS before the widespread use of MRI equipment.

Ok, so I am contrarian, but you do see where I am coming from.

I realize MS is not the equivalent of a twisted knee or sprained ankle, but it seems as if there is a rash of knee MRI s .


For those who do not believe that cost containment is a valid objective I need only point you to the Federal Deficit.

Let the firestorm begin. I shall withstand your slings and arrows. :) In other words--BRING IT

Anonymous said...

Isn't MS a clinical diagnosis? You can diagnose it without an MRI I thought...

Grumpy, M.D. said...

1. There are A LOT of things that mimic MS, and an MRI can exclude many of them.

2. Prior to MRI, MS was based on clinical grounds, spinal taps, and the intracranial imaging available at the time. This was a horribly painful procedure called a pneumoencephalogram.

3. The patient in question turned out NOT to have MS when this happened. She had a large tumor with spinal cord compression, and without the study would have ended up quadriplegic in a few weeks. She had surgery and did fine.

Anonymous said...

MS IS diagnosed presumptively by clinical symptoms, but an MRI is confirmatory - preferably done with contrast. This is basic medical school knowledge - I'm a rising MS3 about to take Step 1 and know that.

Dr. Grumpy was doing what any doctor would do - presumptive clinical followed by confirmatory MRI. Not sure why there is confusion here?

Packer said...

http://www.msneighborhood.com/content/in_the_news/archive_2301.aspx

It can and has been diagnosed prior to the widespread use of MRI
equipment. The real question is it the most efficient means of diagnosis. Efficient meaning most economical, least dangerous to patient health, most certain to produce an acceptable and certain result balanced with cost effectiveness.
Not merely the easiest , and that is how our medical testing choices should be made.

Grumpy , it would seem by asking for it believes it to be a choice agt the top, as do others. But is it an automatic .

JoAnna said...

Well, I guess you could officially diagnose her with MS just so the patient can get the MRI, and then change the diagnosis if the MRI results don't point in that direction.


Still, the illogic is stunning.

Haven said...

I don't suppose you can just /tell/ them you've given MS as a diagnosis even if it's in the most unofficial, off the record kind of way.

There's probably something ethically improper about my reasoning.

Kim said...

Hungarian Feed? I must have missed something.

About MS...I had an ophthalmologist once think I should have all sorts of tests because I apparently have 'Christmas Tree Cataracts' (?!) and he said that was a sign of MS. Odd. I didn't bother with tests and I am perfectly fine, so I'm guessing I don't have it.

About the insurance authorization: That reminds me of when my son was clinging to life in the hospital a few years ago. The insurance company refused to pay for the last 5 days of the hospitalization because they claimed it wasn't needed. Funny, he was hooked to all sorts of tubes, had 3 surgeries in a short period of time, and they really weren't sure if he was going to pull though, but the insurance company thought they knew best. The doctor wrote a few well worded letters, and I made a few phone calls where I wasn't exactly nice, and the insurance company reversed themselves. My son, btw, pulled through nicely and is very healthy now.

Kim said...

Wait, maybe it wasn't MS that guy thought I should be tested for, it might have been a form of muscular dystrophy. One of those 2, anyway.

Polly said...

So, when it turned out that it wasn't MS but instead was a tumor, was the insurance company all pissed off? I mean, it wasn't even MS, and now they have to pay for surgery! Damned sick people, it's always one thing or another with those folks....

ndenunz said...

Dr Heller: "Your're the neurologist."

Dr Grumpy (under his breath): "Yeah, and you're the orthopod."

Dual Citizen, M3 said...

About Canada, to the first anonymous poster:

Speaking as someone who's lived in both countries, I find it quite ironic that you chose to mention Canada's superior health care system in the context of ability to provide timely advanced imaging services, which is one area where the US healthcare system (such as it is) is vastly superior.

And in fact, based on Dr Grumpy's 8:53 AM comment, this patient did end up having an MRI relatively quickly. In Canada, depending on the province and city, they might well not have been able to get the MRI before irreparable damage was done.

Anonymous said...

To dual citizen:
We could argue all day long about this and who's best, whose father's stronger and whose mama's fatter/makes the best sauce...doesn't matter to me.
My point was solely that up here there's no need to fight with insurance cies.
Your experiences may vary depending on location within CA but I'm in a very remote community up north and if your physician says you need an MRI, you get an MRI.
I didn't mean to turn this into a political/partriotic thing at all my friend. But the "no fight with insurers" remains true.

Dual Citizen, M3 said...

It's not a patriotic thing. As I said, I'm a Canadian.

May I ask if you've actually had an MRI? The Ontario government, for example, has a public database of waiting times for diagnostic and surgical procedures. I did a search for MRI wait times in Timmins, ON, which is relatively remote. Their MRI waiting time is *131 days*, which is slower than the speedy provincial average of *108 days*, and far slower than the desired 28 days. So yes, if your physician says you need an MRI, you get an MRI... in 3 or 4 months.

Here's a link to the search I did if you'd like to see for yourself:

http://www.waittimes.net/surgerydi/en/Data.aspx?LHIN=&city=Timmins&pc=&Modality=3&ModalityType=4&dist=25&str=&view=0&period=0&expand=0&Type=0&

And here's a link to the search page. You can find the waiting time for emergency rooms, various surgical procedures, and diagnostic imaging:

http://waittimes.hco-on.ca/

Anonymous said...

I see... I'm actually in northern Quebec. Things may be a bit different in our small community(but I have no clue by how much). My wife very recently had an MRI. There was a waiting period but quite brief, not even two weeks.
Not that it matters but I'm a clinical biochemist here and quite active in the hospital, scheduling, consults and everything and things don't appear as dramatic here as the numbers you presented for ONT. Just my 0.02 of course. As I stated before, things may be quite different in various cities, let alone provinces. We may be even luckier than we realize up here. It just depends on the angle at which you chose to look at the situation...

terri c said...

Here's what I wonder: how much does employing Dr Heller and his company really SAVE?

gena said...

As tempting as it might appear to some to just diagnose the patient with MS, if she doesn't in fact have it, now it's in her medical records and can become a nightmare for her down the road. If she gets dropped by her present insurance company or changes companies, it's one of things that can pop up later and be used to deny or severely impact her ability to get coverage.

ERP said...

Jeeze. PITA.

Anonymous said...

As you do not know if she has MS without the MRI then at this time she has and does not have MS at the same time. There for she can have the MRI because there is a probability that she has MS until the act of observation [the MRI] collapses the wave-function to one of the possible eigenstates.

Anonymous said...

Insurance company once told me I couldn't have my wisdom teeth out because I already had them out. I asked, why would I want them out again, if I didn't have them. They said they didn't know, but that I had already had the surgery...I asked for the supervisor.

Jon said...

It's Grumpy versus the Death Panel.

SarahRx said...

Okay, so out of curiosity I looked up the wait times for an MRI in the community I work in, the one I live in and the next one over from that: 107-89-41. The hospital where I work has the longest wait time. Of course the wait time is "the point at which 9 out of 10 patients have completed surgery or have had their exam" - it's not the average wait time.

Lois said...

It makes me sick that any business has authority over health care, diagnostics, and everything else that should be none of their damn business. So did she get her MRI?

Eileen said...

As another recipient of non-privatised medical care, this time in the UK, I would also like to say we don't need to get approval for any procedure the doctor feels is necessary for the differential dx. I needed a CT, echocardiograph, carotid scan, MRI and EEG a couple of years ago. The first 3 were done on the same day (which meant I could be discharged), the MRI in less than 2 weeks (it was non-urgent) and the EEG (also non-urgent) within a month - the only delay was in writing the detailed report as there was little of note to be found.

Yet in the press you hear the scare stories about months of waiting for an MRI and everything else - they are the exceptions rather than the rule and probably for the patient with a sore knee that doesn't respond to their non-compliance with treatment. And a presumptive dx of MS before sending the patient for that MRI to confirm it would never compromise their medical insurance costs in the UK - we pay a fixed proportion of our income for social benefits. Trouble is - it also benefits other people from outside the country. But you'll never be asked if you have the money to pay before getting the same treatment as everyone else. Maybe that's our problem...

Kay said...

Dual Citizen, There are lies, dammed lies and Statistics...

The wait time stats are average for all MRIs. I can't speak for Timmins, but locally, any requisition has a little set of boxes where a clinician is asked to select ACCORDING TO HIS MEDICAL Judgment, the degree of urgency, if any for the requisition. My friend just had one in Ottawa Ontario with a delay of 3 weeks for a "Routine" one to clarify a question on an x-ray, that was totally without symptoms and found during an x-ray for something else, but the Doc wanted to be sure it wasn't anything important. If it had been Urgent she would have had it the same day. However if the doc coded it has "this patient is a PITA who doesn't really need one" well they go at the bottom of the pile and get called in in 3 years for a MRI on Christmas day when the tech is there in case of emergencies but has nothing better to do.

Also fumy but when I Access http://www.waittimes.net/SurgeryDI/EN/Priority.aspx?View=1&Type=0&LHIN=13&LHINIDString=&city=Timmins&pc=&dist=0&Modality=0&ModalityString=3&TrendModality=0&ModalityType=4&ModalityTypeString=23&TrendModalityType=4&hosptID=907&HospitalIDString=0&str=&Level=3&IsServiceExits=0&period=0

For Timmins, the numbers are
Timmins and District Hospital

90% completed Wait Time (days)

Priority # of Average
Level Cases Wait
Priority 2 62 1
Priority 3 49 7
Priority 4 1198 71

Has we can see Priority 1 are handled immediately (Which is why they are not tracked on the wait tables), Priority 2 Average within a day (90% within 2 days) it's the priority 4 that slews your numbers.

Hey Dr. Grumpy, how long does it take to get a MRI approved and scheduled and done for a possible MS patient? (My guess is that she is Priority 2 or 3)

So DC I defiantly call you on your use of Stats.
Kay

Kay said...

Just want to add, that her Routine one probably would have never been done , because the Insurance company would have said no way, unless they had a couple of grand to toss at the MRI center while here every patient who the doc thinks needs a MRI gets one.

Kay
PS oh the person who the doctor doesn't think needs one and refuses to order one (or browbeats the doc into ordering one that is coded for the bottom of the pile) always has the option of going the private clinic route.

Meg Thornton said...

Another socialised health recipient speaking here - this time from Australia. Over here, there are a lot of diagnostic tests which are covered by Medicare (which means you can get the cost of the test largely refunded) and if you have a health care card or pension card or senior's card, you can generally get them bulk-billed (which means you pay nothing out of pocket for the test). Either way, the decision about whether or not the test is justified is the call of the requesting physician, not of the health care bureaucracy. If a doctor is requesting a lot of expensive tests for just about anything, they may get Medicare asking why, but most of the time, our health care system is willing to accept that the doctors know what they're doing.

Oh, and a little wrinkle of publicly funded health care systems like ours: there are private suppliers of health care services functioning right alongside the public suppliers. In fact, there's actually more private health care providers than there are public health care providers (particularly if you take the majority of general medical practices into account - most of these are privately run and administered, but they claim costs back from the public system). Private health insurance is readily available (and compared to the US version, dirt cheap - top level full hospital and ancillary cover costs under $100 per fortnight for most funds) and having full private health cover gets you a reduction on your Medicare levy as well. Private health insurance is useful for things like covering the costs of elective surgery (room costs, surgeon's fees etc) and for covering things like dental care and spectacle frames that Medicare doesn't cover.

But the real difference between the US system and the Australian system is one I can point to as an unemployed Australian: I can afford to get sick. I can afford to see my GP for little things like a sore throat. I can afford to keep taking my medication on a regular basis (and I don't have to choose between meds and food). I can afford to have an accident and bust my ankle (provided I don't need an ambulance). If I wind up with my thyroid condition triggering a malignant growth, I can afford the surgery and chemotherapy for thyroid cancer, and it won't wipe me out for the next twenty years financially. What I can't afford, strangely enough, is a funeral. Even a pauper's funeral and cremation would be more than I could cover the costs of right now. What a pleasure to know I'm able to afford to live, instead.

Lorelei Armstrong said...

I went to my bank a couple of years ago to get a home equity loan to replace my roof. My mortgage is paid off and the home is entirely in my name. I have no other debt, and have other assets that would pay off the loan easily many times over. I know, I'm a bad American.

The bank turned me down. Why? Because they would only loan money on houses that were 100% intact. For the two weeks it took to replace the roof, the house would not be intact. They were willing to loan me the money after the roof was replaced. But they would charge me a base 7% with a 1/2% penalty because the loan was under $50,000.

I paid cash for my new roof.

Jake said...

Dr. Heller must think MRI's may possibly cause MS...

catrowan said...

I lived in Timmins, Ontario and worked in the hospital that houses the MRI (it really is a small world, isn't it). Priority was given to most serious cases. I never heard of someone who didn't get an MRI and was paralyzed, etc. If patient had progressive neurologic symptoms they would be given priority.

Haddayr said...

No Packer. 'The real question here' was whether or not the woman had something else that might cause MS--like the tumor she had, which would have left her paralyzed had they not discovered it quickly with an MRI. The correct way to defend the abysmal US health care system is not to say: who needs newfangled stuff, anyway? Back in the Middle Ages, we had leeches, and WE WERE HAPPY.

Haddayr said...

My last post should have said "MS-like _symptoms_," not "MS."

Unlike Packer, I actually have some education on MS.

23 Skidoo said...

Dr. Heller... hehe... giggle...snort....I get it..

Anonymous said...

Sounds like what happened to a relative of mine - he collapsed one night, came around, collapsed again. Three incidents of losing consciousness all together, in about 30 minutes, along with trembling that looked frighteningly like seizures. He was taken to the ER, admitted, and they ran tests to make sure he hadn't had a stroke or something else serious, and finally released him with a clean bill of health.

So of course, the insurance refused to pay for anything because 'fainting' isn't something that requires hospital admission.

 
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