The Cruelty of Managed Medicare


Jeanette Brown had lost twenty pounds, and she was worried.

“I’m not trying,” she told me at her regular diabetes visit as I pored over her lab results. What I saw sent a chill down my spine:

A normal weight, diet controlled diabetic for many years, her glycosylated hemoglobin had jumped from 6.9 to 9.3 in three months while losing that much weight.

That is exactly what happened to my mother some years ago, before she was diagnosed with the pancreatic cancer that took her life in less than two years.

Jeanette had a normal physical exam and all her bloodwork except for the sugar numbers was fine. Her review of systems was quite unremarkable as well, maybe a little fatigue.

“When people lose this much weight without trying, we usually do tests to rule out cancer, even if there’s no specific symptom to suggest that,” I explained. “In your case, being a former smoker, we need to check your lungs with a CT scan, and because of your Hepatitis C, even though your liver ultrasounds have been normal, we need a CT of your abdomen.”

I scrolled around in her chart. She was up to date on her mammogram and colonoscopy.

She was clearly worried.

“We’ll put in requests for the Prior Authorizations for these scans and let you know when they’re approved,” I said.

She looked puzzled.

“I have Martin’s Point Generations Advantage, that’s good insurance,” she said.

I sighed. “Well, it’s managed Medicare by a for-profit company, like an HMO, and on the one hand, they pay for physicals, unnecessary screening tests like carotid ultrasounds on people without bruits or symptoms, gym memberships and whatever, but on the other hand they don’t automatically pay for things like CT scans for weight loss.”

She looked incredulous.

“We’ll keep you posted,” I promised her.

Sure enough, a day or two later my referral coordinator came and told me:

I’ve just spent 45 minutes on the phone with these people and they’ve denied the CT scans.”

“Here we go again,” I answered her and thanked her.

I called Jeanette up and told her. “You’re due for your liver ultrasound pretty soon anyway, so we’ll do that, and we can get an x-ray of your lungs right here if we stress that you have a smoker’s cough. And, even though your thyroid test was normal six months ago, we can repeat that, plus I can run a test to make sure you’re still making your own insulin and not turning into a Type 1 diabetic.”

The chest film and extra bloodwork came back normal. But the liver ultrasound suggested a problem in the pancreas. A “pancreatic protocol CT” was suggested by the radiologist.

Martin’s Point approved the CT this time.

It showed calcifications in the pancreatic duct and an irregular appearance of the texture of the distal pancreas. Now the radiologist recommended an MRI evaluation of the pancreas and its ductwork.

Martin’s Point denied the MRI. After 45 minutes on the phone with my referral coordinator.

Medicare for all? That’s coming up a lot in the American health care debate these days.

Which kind, would be my question. The Lyndon Johnson kind or the Martin’s Point, Aetna, WellCare, Cigna, United Health kind?

I know the difference. I have a brand new red white and blue card in my own wallet.

And I’m probably breaking some obscure insurance gag rule right now. But this story happens every week in clinics like mine and it’s got to stop.

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

1 reply »

  1. “Medicare for all? That’s coming up a lot in the American health care debate these days.”

    “Which kind, would be my question. The Lyndon Johnson kind or the Martin’s Point, Aetna, WellCare, Cigna, United Health kind?”

    How about the Canadian, German, or French kind. Medicare has never refused a doctor ordered treatment for me.