Now began the war of attrition, in which our goal was to accelerate the review process through all necessary levels. The fight would frustrate us so many times that we would eventually give up due to exhaustion. We were instructed to begin by re-faxing all records pertaining to Mr. W to the insurer, which was done. Evasive maneuvers followed: claims that our faxes had not been received, that our phone calls had never been made, and that our rheumatology clinic personnel were lying about the entire matter. Meanwhile, Mr. W, whose Still’s disease was again under control and who was ready for discharge, languished in the hospital awaiting resolution of this dispute. After the efforts of our resourceful clinic staff proved to be unsuccessful, one of our fellows took on the role of master telephone diplomat and, miraculously, authorization came through by the end of the week. Mr. W was discharged and has done well since.
This happy ending only partly mitigates an absurd yet all-too-typical example of what the rheumatologist encounters when he or she tries to translate the stunning scientific and clinical advances in our field into optimal care. And most ACR members don’t have a cadre of support staff and fellows, along with institutional clout, to assist them in battling the often arbitrary and illogical decisions of those who pay for and profit from the care of our patients. Without these advantages I might never have been able to obtain appropriate treatment for Mr. W.
In future columns, I will go into detail about how the ACR is taking action to respond to access-to-care challenges. As always, I welcome comments and suggestions from ACR/ARHP members about this important issue.
Epilogue
- I never received an answer to my letter.
- Mr. W’s HMO has been sold (for about a quarter of a billion dollars) to a commercial insurance carrier and no longer exists. My role as an advisor to this HMO regarding treatment for rheumatic diseases has been eliminated.
- The consult team resident who helped care for Mr. W has decided to apply for a rheumatology fellowship in our unit.
Dr. Fox is president of the ACR. Contact him via e-mail at [email protected].
