PERSONAL PERSPECTIVE : Modern Medicine: Lost in the Maze of Managed Care

I first saw the patient in 1989 and diagnosed his problem as neuroma (a benign nerve growth). I proposed several alternative treatments, but he decided to live with the neuroma until it hurt him more. I was able to evaluate, diagnose and treat him through his private insurance company.

Elapsed time: 45 minutes. Cost: $110.

I saw the same patient again this year.

He had visited his primary-care physician, who rediagnosed the same condition that I had diagnosed four years earlier. The physician was obligated to treat the patient before sending him to the specialist (me), even though the primary-care physician encounters fewer than 200 such cases a year than I do.

Still, the patient was sent to me for “consult only.” I rediagnosed the problem, again explained the treatment alternatives to him and sent the patient away, though this time in considerable pain, until I could fill out a form to treat him.

The utilization review committee, none of whose members had ever met the patient, decided to defer my treatment request and to suggest one different from what I and the patient had decided upon. The treatment plan favored by the utilization review committee had already been tried and had failed.

So I had to persuade (by letter only) the utilization review committee to review its own documentation on this patient so they could see that the treatment plan they wanted me to try is one that had failed and should not be tried again for medical reasons.

Several days later, I received authorization from the utilization review committee to go ahead and fix the problem surgically. I told the insurance company that I could perform the surgery in my office operating room. The fee would be $400, which would cover the costs of using the room, my staff and supplies.

The insurance company responded by telling me to use hospital facilities, which would create a bill at least five times more expensive than having the procedure done in my office. Why? I don’t know.

I do know that: Too much time has elapsed in the proper care of this patient; that committees composed of doctors and nurses are “helping” me to treat this patient in a most inefficient and inappropriate manner; that this system of medical care is neither saving money nor saving time; that this is not an isolated event when it comes to managed-care systems and that I am the best doctor to treat this patient--and I am getting very frustrated.

Elapsed time: 3 1/2 weeks and counting. Cost: lots more than $110.