The Cases That Haunt Me
My Thoughts & Prayers Require Preauthorization
What does a for-profit healthcare system governed by corrupt insurance companies look like on the provider side? Here are some stories from my experience as a licensed physical therapist assistant (PTA) to explain why even, perhaps especially, medical staff who care for vulnerable populations aren’t sympathetic to the recent demise of a certain CEO.
Rule of Law
When I was in school for physical therapy, a lot of time was spent going over convoluted, tedious Medicare & private insurance rules for billing treatments. Compliance is hammered into students in these programs. But during my last clinical rotation & when I started working in skilled nursing facilities (SNFs) as I waited on my full license, it was obvious many of the laws we had to memorize weren’t actually enforced. And the reporting process in the rehab world is transparent in the sense that the reporter isn’t granted anonymity. The lesson in school was to report violations committed by other therapists or facilities, but the implication was that you might be blacklisted. Very cool to learn 3/4s through a super expensive program!
In my second clinical rotation, I was placed in a long term acute care facility (LTAC) specializing in respiratory care. The patients came in fully ventilated with the goal of weaning them off, but these patients were unable to speak without the help of a valve placed by a respiratory therapist. The facility had some great care providers, but unfortunately the not-so-great ones could get away with a lot because the patients were in such vulnerable states. Those 8 weeks felt like 8 years.
Eventually, the LTAC was reported by a former employee to the state & an investigator came in to question the staff. As a PT student, I wasn’t interviewed, but I observed the process which consisted of the investigator interviewing nursing staff…in front of the Director of Nursing. Of course, none of the nurses reported any violations despite the appalling conditions & treatment of patients. John Oliver’s Last Week Tonight episode on state medical boards explains the physician malpractice version of this, but it’s not dissimilar from the rehab field.
After applying for licensure, I initially worked in SNFs & the rehab agency I signed up with was one recommended by the school. I’d later find out they were notorious for preying on new grads & placing them in ethically questionable scenarios. The focus was often on generating profit over patient care despite the carefully worded HR language in your contract.
I switched to home health where I would have more autonomy & not be subject to something known as productivity standards, which deserves its own longform explanation. There’s not enough time to get into all the details, but every setting has its problems with fraud, malfeasance, & reduced quality of patient care because they’re incentivized to do so by insurance companies.
To say I hate insurance companies is an understatement. Every day I find more love in my heart for my patients & more hatred in my heart for insurance companies. And I wasn’t a fan of them going into this field. The things I’ve seen in my time as a licensed PTA are jarring, heart wrenching, & absolutely infuriating.
Rehab services like physical therapy, occupational therapy, and speech language are the arts department of the medical field: crucial to human thriving but often the first to get cut or not considered “medically necessary”. This year has seen reimbursement cuts for services conducted by PTAs leading to gaps in care & regression in patients’ progress. It’s maddening & embarrassing to explain to patients who are achieving milestones in their progress that you can only see them one more time before they’re on their own again, if you even get the chance.
Sympathy for the Devil
So no, I don’t give a fuck about a CEO experiencing an occupational hazard that is inherent to the work he chose. The more I learn about this CEO Brian Forgettable First And Last Name Thompson, the more it appears he was an even bigger piece of shit than originally believed. But I wouldn’t care if he didn’t also rip off firefighters along with the “legitimate” work he did as CEO for UHC. This asshole had a direct hand in killing thousands of people through denial of crucial medical services. A few people, protected by their privilege of never having been thrown into the woodchipper of the U.S. healthcare system are saying it’s the end of civility & yada yada yada. But someone explain to me how the fuck it’s more civil to use algorithms to determine who lives & who dies?
You know who I’m haunted by, still furious for even if it’s been months or years since I’ve had them on my caseload? My patients who were denied care when they were on the precipice of goals they had worked weeks, months, or years to achieve.
The Real Victims
One of my first patients in home health was a writer who had been wheelchair dependent for several years due to a congenital condition. They had recently been discharged from a SNF after a traumatizing stay. This patient’s trust in healthcare professionals was at an all time low & they were skeptical if I could help them at all. Their cynicism about the medical field was completely understandable given their lifelong interactions with it. They had a faraway hope that they would be able to walk again, but no expectation they would — they merely hoped to get stronger to be in less pain. They couldn’t even stand for more than a few seconds with support inside a walker when we first started.
After several sessions, they became strong enough to stand for longer periods & even do mat pilates exercises. The monumental day came when they were strong enough to take their first supported step in a walker. They were able to take two steps before needing to sit back down but that was two more steps than they had taken in 10 years. It was beautiful to help facilitate & we both teared up over this milestone. We had planned on going even further in the next appointment.
The following week, their insurance denied more visits & they were discharged from my care. When I tried to help them navigate the appeals process, we found out that the appeal should have been sent prior to services being cut off, which could not have been foreseen by either of us or their doctors. To say this was devastating is an understatement. I think about it all the time & it reinforced the pessimism this patient had about the healthcare system while demoralizing them even further.
Another patient was a young person recovering from a traumatic brain injury where they lost a significant portion of motor function on one side of their body. They relied on a leg brace & adaptive equipment to walk. They lived in an apartment with stairs but no elevator & had been stuck inside the apartment for years with only brief trips out when family members could give them significant support. We got them navigating stairs & even doing single leg step ups on the stairs with the previously partially paralyzed leg. We were planning on climbing the full set of stairs at our next appointment when their PT services were abruptly cut off without prior warning or explanation. You don’t get a reason why services were cut off when you ask & often it’s because insurance only approves a very limited number of appointments to begin with with no indication if you’ll get more visits.
One of my most recent patients was receiving PT following a cervical spine surgery that had been delayed by 3 years despite all of their doctors documenting the need for emergency surgery. In those 3 years of waiting for approval, their condition became so severe that they were at risk of quadriplegia. Since their spinal structures were so deteriorated, the surgery had to be modified while it was happening as the surgeon discovered the extent of damage. The pain this person was in when I got to them was debilitating as the side effects from delaying the surgery & the surgery itself left them in constant, shooting pain which required heavy painkillers to manage. But their pain medication was on the verge of being cut off due to “lack of medical necessity” & “drug seeking behavior” despite the fact that every time I saw this patient they were in such severe pain while on their prescribed medications they could barely participate in sessions. The patient wasn’t able to get high from the pain killers as the pain was barely managed by them. The damage done to this person by insurance delaying their spinal surgery is permanent, possibly progressive. This patient was part of a demographic that I see being denied care far more frequently than other demographics & bias in medical care is a known problem that could also have its own essay. Yet again, John Oliver comes through on this topic.
The horrendous treatment I’ve seen of my patients who don’t fit the majority demographic by doctors & insurance companies is the stuff of nightmares. It’s in such sharp contrast to the incredible feats I’ve seen accomplished by my patients. I love what I do, but to do this type of work is to live in a constant state of whiplash.
I’ve helped patients with progressive degenerative neurological conditions like Parkinson’s go from nearly bed bound to climbing 3 flights of stairs. I’ve seen patients with spinal fusions who were told they would never walk again doing goblet squats with 30 lb kettlebells & single leg step ups on two foot tall tables. I know that the term “never” coming from doctors is given to patients not necessarily to discourage them, but to temper expectations. But I’ve seen exceptional shatterings of this label by patients who defied the odds or were able to vastly improve their wellbeing with consistent PT. I know the impossible is possible, I see it every day.
“Essential” Workers
The patients ultimately suffer the most, but insurance reimbursement cuts demoralize care providers. Rehab services, along with other medical services have been gig-ified like much of the rest of the economy. We don’t have unions in the PT world outside of hospital settings where you can join with nurses unions, but these settings are difficult to break into because they’re highly coveted. You can choose from employee work with some benefits where there’s pressure to sacrifice patient care for profits & work off the clock for low ball pay or contract with multiple agencies to piece together full time work without benefits.
I don’t love being a contractor working for multiple agencies chasing down payments, but I’m unwilling to play the “productivity” game or double/triple book sessions. That means I get to pay high premiums for even shittier insurance, too.
Next year I’m switching from Kaiser Permanente who made the decision in March of this year to not cover COVID-19 vaccines for people in the bronze-level & below categories if god forbid they were outside of network, but get this — they stopped offering the vaccines in network during the surge in infections this summer. When I got mine out of network (paying $185) after begging them to help me before needing to travel out of state to visit elderly relatives, I filed a reimbursement claim. They gave me back $7. But I could afford to get the shot even if it was not a cost I had planned for. How many working class & poor people were forced to choose between food, rent, or not dying from a debilitating virus that’s still disabling people? Kaiser Permanente, one of the supposedly better insurance companies for not denying claims literally said, “How about you poor people just die?”
You’re not protected by the medical field just because you work in it. We all saw how “essential” workers were discarded & sacrificed over the past several years while corporations were making record profits. The fact that people haven’t revolted harder is a surprise to me after these same corporations committed to price gouging & colluding to build monopolies to punish consumers.
All of the factors leading up to this assassination have stressed people beyond a breaking point. It’s not just the problems with profit-driven healthcare, it’s the culmination of corporate avarice at every level. These CEOs hiring private armies for protection should have been scared of these outcomes a long time ago. The reaping is happening.
Playing The World’s Tiniest Violin
So I won’t apologize when I say my thoughts & prayers over the death of a scumbag CEO require preauthorization. Being a greedy dumpster fire of a person is a pre-existing condition not covered by empathy services. Compassion in this case is not medically or morally appropriate. At least he died doing what he loved: increasing shareholder value. Generic corporate CEO Brian Johnson/Thompson/Whatever The Fuck has reached his limit of authorized visits to shareholder meetings & can appeal this decision through the bureaucracy of Hell where he’s deservedly burning, even if I don’t believe in the concept.
Because we’re already in Hell. We’re in Hell because of CEOs like him who use AI algorithms to automatically deny medically necessary treatments for patients. While my scope is limited to the rehab setting, thousands of people are denied life saving medications, surgeries, & procedures in favor of increasing profits for people who have more money than they could ever spend in a lifetime. What about them? How many people have to die for things to change (isn’t this The Question of the last 4+ years)?
Everyone knows someone whose life has been cut short or who’s quality of life has been significantly reduced because some C-suite glad-handing fascist lacks the mirror neurons to be a decent human being. If they want empathy, they can go first. Or they can continue reaping what they’ve sowed to the pity of no one.