“Don’t call me ‘ma’am.’ It’s ‘Doctor,’” I snap at Barbara, a nurse. I am trying to get insurance to authorize treatment for Sam, my patient, who is severely depressed and needs a course of electro-convulsive therapy (ECT), often called shock therapy.

Sam and I often joke about ECT. “Time to get zapped?” I ask him when he seems low.

“Can’t I just stick my finger in the light socket?” he’ll respond. “It’d be a lot cheaper.”

When Sam goes to the hospital for treatment, he often wears his AC/DC shirt, the one with the lightning bolt. “You know, doc, I don’t think they get it,” he told me once. “But I like to wear it anyway. It brings me luck.” He has another shirt that says, “You’re just jealous the voices don’t talk to you.”

Before we tried ECT, Sam nearly died, several times, from overdoses and an attempt to hang himself. The bills from his multiple hospitalizations nearly bankrupted Sam and his wife, Liz, and they nearly lost their house. ECT is their personal miracle, but it is not a cure. Sam has not been hospitalized in years. Even so, his depression recurs despite weekly therapy, support groups, and a rotating cast of up to six psychiatric medications at a time.

ECT wasn’t an easy sell. Historically, psychiatry was not always a kind profession, and One Flew Over the Cuckoo’s Nest didn’t help rehabilitate ECT. ECT (and psychiatry) are gentler these days, and the treatment can help dramatically where antidepressants and other therapies have failed. When I first suggested ECT, Sam and Liz got the predictable deer-in-the-headlights look on their faces. Sam, Liz, and I spoke at length. I offered a YouTube video that shows what the procedure looks like. Ultimately, they agreed, and I referred them to a local ECT provider. At present, Sam gets a maintenance course of treatment around twice a year.

When Sam becomes depressed again, he calls his usual ECT provider, who would normally book him at a local hospital for a same-day outpatient procedure. This time a routine referral turns into an obstacle course.

The local hospital is having staffing problems and can’t take Sam. We need to find a new doctor who admits to a different hospital. While we scramble to find a doctor and arrange an appointment, Liz takes family leave from work and I see Sam three times in one week. Sam has good self-care skills and keeps his head above water with the help of friends and family, attending AA meetings and hanging out with his cats.

We find a new doctor, Dr. G, who will see Sam, but Sam needs screening lab tests and a routine head and neck CT scan. The CT is booked, but a day later Sam’s wife phones me. “Sam’s CT scan was canceled,” she tells me. “Our insurance won’t approve it.”

“Why not?”

“They say it’s not required for ECT.”

“It always has been before,” I say.

“I know,” she says. She sounds depressed herself. “I hoped we could start treatment on Monday.”

Need I tell you that Sam has crappy insurance? His insurance is among the worst I’ve dealt with in my twenty-plus years as a physician. Unlike hospitals and doctors, insurance companies are protected from lawsuits and accountability. Sam’s wife is employed by a large Midwestern city. Due to a legal loophole, its mental health insurance provider is not accountable to the state Department of Insurance which handles most insurance complaints. In fact, I have been unable to find any government agency to which this insurer is answerable. There isn’t even a useful Yelp page, or Facebook, or Twitter account on which to publicly shame the company.

“I’ll call your insurance myself,” I promise.

I pick up the phone and the usual runaround ensues. Menu 1, hold. Menu 2, I get a human who refers me to another department. Hold for twenty minutes. Nurse 1, first name only, Barbara.

“This is Dr. Kronmal. I am calling regarding a patient who needs authorization for a CT scan,” I begin.

“Yes, ma’am,” she says.

“Don’t call me ‘ma’am. It’s ‘Doctor.’” Normally, I’d let the lack of my proper title go, but I am primed for a power struggle and tired of being on hold. I explain the reason for my call and Barbara looks up the record.

“We couldn’t approve the head CT because we need clinical information which Dr. G couldn’t give us. He will need to appeal the decision,” Barbara informs me.

“I can give you the clinical information,” I say.

“Sorry, I am not able to handle the appeal,” she says. “There needs to be a ‘peer-to-peer’ review.”

This review consists of a conversation between a treating physician and a physician “peer” who works for the insurance company. Barbara tells me that I cannot speak to their doctor unless Dr. G, who requested the test, assigns the appeal to me. Dr. G will have to call them so that I can proceed with the review.

“Is there a direct line to reach you?” I ask Barbara.

“No.”

Of course not. I’m glad she can’t see me roll my eyes.

I call Dr. G’s office and speak to his nurse. I tell her that this is regarding Sam and that his CT scan was denied by his insurance. I feel guilty wasting his time, but what choice do I have?

“I’m sorry to bother you, but could Dr. G call Sam’s insurance and tell them I can handle the appeal?”

“I’ll talk to him and get back to you as soon as possible,” she says.

Dr. G calls the insurance and the appeal is assigned to me. The ball is in my court.

I call the same number as earlier, move through the menus. I reach a new nurse, Kathy.

“I need three times you are available so our doctor can reach you,” Kathy says.

“This is urgent, can we do it today? The patient is suicidal, after all.”

“The doctor is in practice too,” she tells me. “He may not be available.”

“I can be available any time this afternoon.”

“Until when?”

“10 p.m.”

“We close at 4:30 p.m.”

“Of course, you do,” I mutter. Insurance companies take long lunch breaks and close early. Clearly, I picked the wrong profession. “I’m also available tomorrow until 1 p.m.”

“So, 10 or 11 a.m. tomorrow. I’ll call you back with a time.”

But she doesn’t call back. The next morning, I wait for a call. 9:30 a.m. Nothing. 10:05 a.m., I see I have a voicemail on my work line. It’s Kathy. “The doctor did not get back to me until this morning. I will call you at 10 a.m.” I’m home in my pajamas. I throw on a jacket and run to the office. The nurse has called three times. “If you are not there the next time I call, we will need to reschedule,” says the last message. I try to call her back but navigating the menus seems to take an eternity. I’m still at menu 2 when my phone rings.

“We’ve been trying to reach you,” Kathy says.

“I gave the other nurse my cell number,” I tell her.

“I didn’t have it,” she says.

Yeah, right, I think.

Kathy tells me she will connect me to the doctor, who she assures me is a psychiatrist. (Managed care appeals have been known to be handled by specialists in entirely different areas—imagine an obstetric call being reviewed by a podiatrist.)

“We don’t use names,” she says. “You will be called the ‘Attending Physician’ and our reviewer will be called the ‘Reviewing Physician.’”

What is this, a drug deal? I wonder. A hand-off of stolen top-secret documents? The reasons for anonymity are similar, to ensure the lack of accountability of the players.

The doctor wants to know why the patient needs a CT. Does he have a neurologic disease, seizures, a tumor? No, but it is routine to perform a scan before ECT because of rare complications due to increased fluid pressure in the brain or severe neck arthritis. I know Dr. G will not proceed without the test.

The doctor says that the information I give him is not enough to warrant the test. “I can’t approve it for that indication.”

Grasping at straws, I offer, “He has migraines.” After all, migraines are a neurologic condition, although they are unrelated to Sam’s depression. Good enough, even though the migraines are irrelevant. The procedure is approved.

I call Sam and tell him he can go ahead and schedule his scan and treatment. A few hours later he calls back. He reports the CT is scheduled for the following day at 7 a.m., and his ECT will be in two days. I congratulate him. “My wife says she never wants to piss you off,” he tells me. I don’t tell him I feel like crying.

If honesty were part of the process, both the insurance doctor and I would have acknowledged that the appeal is a sham, a process that exists only to deny care to the insured and demoralize doctors. I have won a battle, but it feels like a low moment in the history of medicine.

Shara Kronmal is a psychiatrist in private practice. When she is not fighting with managed care organizations, she enjoys photography, travel, and writing. She wrote this bio in Lisbon, having escaped the polar vortex in her hometown of Chicago. “Unmanageable Care” is her first publication, unless you count a PhD thesis and miscellaneous professional pieces. Shara can be found on Twitter as @SKronmal.

 

Header image by Ian Espinosa via Unsplash