In ‘95 I was in a day treatment program at Fairview Riverside. My depression had become so severe that I had stopped functioning. But I was making progress in the group I was in, connecting to the other consumers and with my group leader, Susan. Things were starting to look up and I was feeling some hope. Then I learned that my HMO was kicking me out of the program. Susan, the hospital staff and my psychiatrist appealed on my behalf to try and convince the insurance people to let me continue in the program. In desperation, I called and talked to the woman who was handling my case at the HMO.
Q: I just joined a new HMO. How difficult will it be to choose the doctor I want?
A: Just slightly more difficult than choosing your parents.
As we talked, I learned that she wasn’t a mental health or medical expert in any way—she was one of the proverbial “bean counters.” But by controlling the insurance/financial end of my treatment, she was, in actuality, making the medical decisions for me—overriding the opinions of mental health professionals that, together, had accumulated over 80 years of experience. While we were chatting, I learned that I had used only 40 percent of my allotted treatment days for that year and asked why I was being kicked out of the program when I still had paid time left for professional help. She told me that since it was already May, with seven months left in the year, she would be doing me a terrible disservice by allowing me to use up all of my treatment days—that I needed to save some of them “for a rainy day.”
I explained to her that I was battling despair—that before I got into the program, I was considering buying a gun to end my life. That I was almost too ill with my depression to get out of bed. I told her: “Guess what? IT’S RAINING!!!” She allowed me to stay an additional half-day. And I never did get to use the other 60 percent of my treatment days.
Q: What should I do if I get sick while traveling away from home?
A: You really shouldn’t do that. You’ll have a hard time seeing your primary care physician. It’s best to wait until you return, and then get sick.
Insurance issues and pressures are one of the extra burdens with MI. I’ve spent many a precious hour talking with my doctors and therapists, not about my recovery or treatment of my MI, but about insurance problems and billing problems. Spending time in hospitals racked up enormous bills, which were usually sent to collection agencies that hounded me for years—agencies that used my hospital records and mental health information against me to shame me into paying. (They are so kind to you in the hospital and so unkind when you get out that it makes you crazy again so you have to go back to the hospital where they are so kind to you!)
Q: I think I need to see a specialist, but my doctor insists he can handle my problem. Can a general practitioner really perform a heart transplant right in his office?
A: Hard to say, but considering that all you’re out is the $10 co-payment, there’s no harm giving him a shot at it.
Here’s one part of the solution to this insurance problem. Join your local NAMI (National Alliance for the Mentally Ill) affiliate, Mental Health Association or any of the other wonderful mental health organizations close to you. With 1 out of 4 American families dealing with a mental illness at any given time, joining our voices, dollars and votes will start to give us the clout we need. Bringing these illegal, prejudicial actions to the attention of a lawyer or the district attorney can hit the HMOs where their cold hearts are: in the pocketbook. It is also powerful when we write editorials to our newspapers or tell our personal stories—and these methods open peoples’ hearts, which is the best way to open their minds.
These are also good ways to affect national, state and county budgets—to help assure that mental health resources aren’t cut more than they have been. It’s discouraging that we often measure political success for our cause not by what we’ve been given, but by what we haven’t had taken away. There isn’t a money problem with our insurance companies, politicians and state budgets, but there is a value problem. Paperwork has somehow become more important than People Work. Our politicians and insurance companies need our help to be reminded where true help is crucial—that penny-wise and pound-foolish cuts will make the problem worse, and that alleviation of human suffering is something that often can’t be put on a pie chart or measured on a budget sheet. We need to let them know that It’s Raining!
Q: Do all diagnostic procedures require preauthorization from my HMO?
A: No. Only those you need.