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Human Suffering, Health Insurance, and a "Miracle"

Posted by Dr. Lachlan Forrow  March 17, 2014 06:10 AM

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It is easy these days to be cynical about health insurers. We all know they only care about "the bottom line", which we of course are smart enough to know means "the money".

This issue is complicated (very, very complicated), especially because most private health insurance companies are "for-profit".  What any for-profit company is designed to do is (of course) to make a profit.  Ideally as large as possible.  This is arguably the most fundamental ethical responsibility the company has, since any company is ultimately responsible to its owners and investors (literally, its "stockholders"), and their bottom line is usually the size of the financial return on their investments. (So we should stop blaming leaders of for-profit companies when they do what they are hired to do.)

I have become increasingly convinced, however, that our cynicism is deeply unfair to insurers, and especially to the individual people who work for them.  I may be spoiled, however, by living in Massachusetts, where the leading insurers are all "not-for-profit" (or, more simply, "non-profit") companies, whose purposes are (by definition) different from those of "for-profit" companies.

To explain, I will tell one story about one patient.  The story, like the issues about health insurers generally, is complicated, but I'll stick to the essentials, and then offer three conclusions.

Since the story is about a patient with "Federal Blue Cross" insurance, which I have been told is the best insurance money can buy, before I tell the story let's see what the BC/BS website says they offer to patients.

If you go to the BC/BS of Massachusetts website, you will learn that "At Blue Cross Blue Shield of Massachusetts, we're committed to ensuring that our members get the best care."  It then goes on to define "best care" in just six words -- "best care" is care that is:

Effective
Efficient
Equitable
Patient-Centered
Safe
Timely

And then there is one more phrase, just 7 words:

And delivered in the most appropriate setting.

These words, which most people choosing health insurance probably don't even notice, sometimes turn out to be important.


The story began at ~8:15pm one evening, when I stopped in the room of a patient with advanced cancer, worried about how she and her family were doing.  The most fundamental goal of "palliative care" is to prevent or alleviate suffering of any kind -- physical, emotional, and/or spiritual. Everyone in the room that evening was suffering.  But their suffering was not caused by the cancer (or the massive stroke that had been caused by the cancer).  The cause was a health insurance issue.  

I asked the patient's wife what time she first learned of the issue, and she said it was around 4pm.  I found myself saying something like "I think 24 hours is the longest acceptable time to fix this.  I'm not yet sure how, but that should be our goal."

I honestly didn't know at that point what I was going to try to do, but one of the basic tenets of "palliative care" is that when anyone is in unacceptable pain, reducing the pain to a tolerable level is a "medical emergency".  And 24 hours (or nearly 20 additional hours from the time I learned of the problem) is a very, very long time to suffer when you are in serious pain.

Below I have copied a series of email exchanges that started the next morning.  "Andrew" is Andrew Drefyus, CEO of BC/BS of Massachusetts.  "Eric" is Eric Shultz, CEO of Harvard Pilgrim Health Care. Nancy Turnbull is Senior Lecturer on Health Policy and
Associate Dean for Educational Programs at the Harvard School of Public Health (employer of the patient's wife).  I have their permission to share these emails.  They asked,however, that I make sure that there will be no possible violation of patient privacy, and so I also have the permission of the patient, and the patient's wife. 

The thread begins at 7:16 a.m., leaving only 8 hours, 44 minutes to relieve the suffering within 24h of its onset.


From: Lachlan Forrow, MD
Sent: Thursday, February 27, 2014 7:16 AM
To: Dreyfus, Andrew;Schultz, Eric

Cc: Nancy Turnbull

Subject: Quick/simple but truly urgent need for you to show how great (and fast) your organization's caring can be

 Andrew/Eric:

I (actually a patient I am caring for at BIDMC) need one or both of you to show how quickly you can fix a small problem.

 1. The Problem

 My patient is a 40 year old woman (BC/BS subscriber; listed in our computer as "Federal Employee PPO w policy #xxxxxxxxx).  She is hospitalized with a major stroke (leaving her almost totally paralyzed on one side of her body) that we have found is the result of a hypercoagulable state caused by widely-metastatic pancreatic cancer. 

Every day of her likely-limited remaining life really, really matters.

She needs to start rehab immediately, but her BC/BS policy reportedly does not cover Hebrew Rehab, her preferred place.

Her wife is an HSPH employee and HPHC subscriber who is now trying to add the pt to her HSPH/HPHC plan.

 2. The Solution

Actually, I see two.

a. BC/BS could immediately approve Hebrew Rehab for her.

b. HPHC could immediately add her to her wife's HSPH plan. 

3. Request to You Two -- Compete for the Fastest Solution

I would like you to compete to see which of your two organizations can solve the problem the fastest

I suspect that a "solution" will count as winning this competition if I just have something in writing by email certifying that the problem will be solved and that the pt can be transferred to Hebrew Rehab, even if there are some bureaucratic details that will take slightly longer.

If there is anything anyone in your organization needs from me, please have someone email me immediately, or call my cell phone.

If there is anything anyone needs from HSPH, please have them contact Nancy Turnbull there, whom I have copied on this message.

4. Gratitude

Even before you respond, I am sitting here in my kitchen on my laptop marvelling at how wonderful it is that here in Massachusetts we have two health plans like yours.  You'll both understand, I hope, when I use the term "Schweitzer-spirited" as the highest form of praise. 

Thanks in advance for any help you or one of your staff people can give. 

gratefully,

Lachlan 

"The greatest thing is to give thanks for everything. He who has learned this knows what it means to live." 

 -- Dr. Albert Schweitzer (1875-1975)

 

From: Dreyfus, Andrew
Sent: Thursday, February 27, 2014 7:26 AM
To: Forrow,Lachlan (HMFP - Medicine);Eric Schultz
Cc: Nancy Turnbull
Subject: RE: Quick/simple but truly urgent need for you to show how great (and fast) your organization's caring can be

Since she is our member, let’ see if we can solve the problem this morning.


From: Lachlan Forrow

Sent: Thursday, February 27, 2014 7:32 AM
To: Dreyfus, Andrew; Schultz, Eric
Cc: Nancy Turnbull
Subject: RE: Quick/simple but truly urgent need for you to show how great (and fast) your organization's caring can be

Great.  I had told her and her wife that we would solve this by 4pm (24h after the problem was identified).  I'll now hope for noon.

thanks, thanks, thanks,

Lachlan 

From: Eric Schultz

Sent: Thursday, February 27, 2014 7:44 AM

To: Forrow,Lachlan;Andrew Dreyfus

Cc: Nancy Turnbull

Subject: RE: Quick/simple but truly urgent need for you to show how great (and fast) your organization's caring can be

Hope all goes well with your patient Lachlan. 

Andrew. If you need any coordination with Harvard Pilgrim, please contact my office directly. Thanks.

Eric

EXCERPTED From: “AZ” [staff person at BC/BS]
Sent: Thursday, February 27, 2014 10:59 AM
To: Forrow,Lachlan (HMFP - Medicine);Nancy Turnbull
Subject: RE: Quick/simple but truly urgent need for you to show how great (and fast) your organization's caring can be

 [Excerpt from original email]

 Dr. Forrow and Nancy,

 Andrew asked me to get back to you both with what we’ve learned.  Blue Cross has not received any requests for discharge… Hebrew Rehab is indeed in our FEP network, and our initial review is that at this point she would be approved for discharge to there if that request had come in and that is the place she and her doctors want her to go.

 Our apologies for the miscommunication. While it’s true that historically there was an FEP exclusion for long term acute care, that is no longer the case.  Maybe there was confusion about this…

 “AZ”


From: Forrow,Lachlan (HMFP - Medicine) 

Sent: Thursday, February 27, 2014 11:36 AM
To: Eric Schultz; Dreyfus, Andrew
Cc: Nancy Turnbull; “AZ”@bcbsma.com'
Subject: CONGRATULATIONS!!!

To EVERYONE!  (Andrew, “AZ”, BC/BS; Eric and HPHC; “XX” and HSPH; and most of all this patient and her family)

Problem solved at 10:59, 61 minutes ahead of the noon goal, and 5 hours and 1 minute ahead of what people thought was the unrealistic goal of 4pm.

Mornings like this make being in health care in Massachusetts a true joy.  Please let me know if in the future there is ever a way in which I can help any of you with something.

Gratefully,

Lachlan

I titled this blog entry "Human Suffering, Health Insurance, and a 'Miracle'" because when I first announced we would solve the problem within 24 hours more than one person said "that would take a miracle".  And afterward I heard several people refer to me as "a miracle-worker". I looked up "miracle" and found here this definition: "an extraordinary event manifesting divine intervention in human affairs."  But I don't think anything in this story had anything to do with "divine intervention"; it was just real people taking the suffering of a patient (and the patient's family) seriously.

I said I would draw three conclusions, so here are three "lessons" I think this story tells us.

1. Human suffering in hospitals is not just caused by "disease", but sometimes by our health system.

2. Sometimes human suffering can be alleviated much faster than anyone might have thought possible, especially if we just decide that allowing the suffering to continue is unacceptable.

3. Leaders of health insurance companies (or at least of two insurance companies in Massachusetts) care as much about preventing and alleviating suffering as you and I do.

This blog is not written or edited by Boston.com or the Boston Globe.
The author is solely responsible for the content.

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About the author

Lachlan Forrow, MD is Director of Ethics Programs and Director of Palliative Care Programs at Boston's Beth Israel Deaconess Medical Center and Associate Professor of Medicine at Harvard Medical School. More »

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