Putting the “Care” Back in Healthcare by Showing That We Care-Advocating For Your Patients

Putting the “Care” Back in Healthcare by Showing That We Care-Advocating For Your Patients

Dr. Neil Baum

Professor of Clinical Urology at Tulane Medical School

There are so many occasions where an insurance company places the doctor in the middle of a coverage issue between the patient and the insurance company.  We all know that the insurance company and their medical directors are motivated to keep down costs and often deny coverage for medications, services, treatments, or durable medical equipment (DME) that are in the “gray zone”.

I would like to share one of my successful experiences as serving as an advocate for my patient. Shelly, that’s her real name and her name is used with her permission, was a quadriplegic patient from birth secondary to cerebral palsy.  She did not have use of her voice and could only make unintelligible sounds that were understood only by her parents and close friends.  She wanted to attend public high school but was not able to communicate with the teacher or her classmates.  With public funds she received a voice synthesizer (VS).  This is a computer program that is controlled by the patient’s mouth and allows him\her to select words that become audible and even digitalized so they can be used for homework and other assignments. Shelly received the voice synthesizer and learned to use it very well and was able to graduate with honors with her class.  Shelly’s parents requested that she be allowed to keep the VS program upon graduation so she might attend college.  The school board met and denied the request by using the comparison that the VS was kind of like a football helmet used by a player while he was on the team and that it was on loan and couldn’t be given to players upon graduation. The VS was not going to be useful to any other student and would remain in the school’s closet, gather dust, and eventually be thrown out.  The school would not make an exception and grant her the use of the VS upon graduation.

I suggested that her family request a VS device, which cost about $10,000, from the insurance company. The medical director quickly denied the request.  I contacted the medical director in order to obtain an explanation.  The medical director told me that this was a “creature comfort” and that the insurance company would not pay for the VS.  I wrote a letter on behalf of the Shelly to the medical director with a copy to Shelly’s father’s employer, UPS, requesting an appeal.  I was not able to attend the hearing in person but was there on a conference call along with Shelly’s parents.  The explanation that was given was that Shelly was born without a voice and, therefore, it wasn’t the insurance company’s responsibility to provide her with a voice that she didn’t have at birth.  They concluded that replacing her voice was not in the contract.  They offered up the comparison that if Shelly was born without a leg, they wouldn’t be required to provide her with a prosthesis. However, if she lost the leg after birth, then a prosthesis would be provided.

This response infuriated both the parents and myself.  Her father was fearful about causing a problem with the employer and was hesitant to pursue the matter any further and was considering taking out a bank loan to buy Shelly a VS so she might attend college.  With the permission of the family, I told them I would be their advocate and make an effort to help Shelly get her voice back.

I first wrote a letter explaining the situation to the insurance commissioner of the state where Shelly lived.  I sent a copy to the employer and to the medical director.  I received a meek response but without any offer to help the young girl get her voice.  I then wrote a letter to the family’s U.S. Congressman and their state’s U.S. Senators asking for their intervention.  I then wrote a letter to 60-Minutes telling them the story and offering to have Shelly and her family tell the story and give the name of the insurance company and the employer on national T.V.  Again, a copy of this letter to 60-Minutes was sent to the medical director and the employer.  One of the U.S. Senator’s sent a letter to the insurance commissioner of the state and to the medical director indicating that the U.S. Senator wanted a better explanation of the denial of the request for the VS.  Within one week of the U.S. Senator receiving a letter, I received a copy of a letter from the medical director that was sent to the family indicating authorization for the VS!

Shelly soon received a brand new VS.  Shelly went to college and is an author and working on a book about living with cerebral palsy and which includes a whole chapter on how she got her voice back.

That success of advocating for my patient was one of the highlights of my medical career.  There are so many instances when we receive a rejection from an insurance carrier who is motivated to keep down costs and denies an appropriate treatment or a device that restores people to good health, keeps them out of the hospital and doctors’ offices, and even gives them their voice back.

Certainly, I am unable to do this for every patient but I can find the most egregious rejections and serve as an advocate for my patients.  I can share with you that there is nothing in medicine that will give you more pleasure and satisfaction than standing up for your patient when you know you are right and your patient is made to suffer because the insurance company is focused on their bottom line and not on the patient’s healthcare and well-being.

I would like to hear from you if you have a patient advocate story.  (doctorwhiz@gmail.com) Perhaps we can write a book, Chicken Soup For The Patient’s Soul….and Voice!

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2 Responses to “Putting the “Care” Back in Healthcare by Showing That We Care-Advocating For Your Patients”

  1. Rochelle Vaughan Says:

    Dr. Baum is an old friend as we both worked at/for Touro Infirmary. My husband is also a ver satisfied patient of Dr. Neil Baum

    Rochelle Vaughan

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