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Fool Me Once…
“Can you assure me that you will go to the nearest emergency room within the hour?”
It was the middle of a workday—a Friday. I had sequestered myself in a small room dedicated to personal phone calls. I don’t recall how long it took me to reply to the nurse on the other end of the line, but when I did, my answer started with an “uhh” and ended with a “no.”
To be fair, I was the one who initiated the phone call to my insurance company’s 24/7 nurse line. For the past week, I had experienced discomfort in my rib cage with deep inhalation. After a few days, it was accompanied by a dry cough. No fever or chills. No achiness or fatigue, like one experiences with a typical flu. A nurse at the government clinic near where I work had listened to my lungs that same morning and said she couldn’t detect any fluid; however, she thought there was less airflow in my left lung as compared to the right. I had also told her about my heart “arrhythmia,” but she didn’t appear too concerned about my symptoms overall. She merely suggested that if they worsened over the weekend to get to an urgent care facility or come back to the government clinic on Monday when a provider would be available.
My only question for the 24/7 nurse was whether she thought the decreased airflow in my left lung might account for the heart symptoms. “Maybe with less oxygen through my lung my heart is having to periodically work harder?” She never quite addressed that. Instead, she put me through a battery of other questions. Did I think I was having a heart attack? She told me she could brief me on the symptoms if I wasn’t sure. I told her I did not think I was having a heart attack. I mean, I was having what seemed like a benign, relaxed conversation with her. How under-the-radar do heart attacks typically fly? Then she asked if I thought I might be experiencing shock and again told me she could brief me on the symptoms if I wasn’t sure. Here, my honesty got the better of me. I really didn’t know the signs or symptoms of shock. So I asked her to list them. After about the second or third symptom, I knew I wasn’t in shock. I was, however, suffering from acute ridiculousness.
That’s when the nurse strongly advised that I go to the nearest emergency room within the hour. (An emergency room? Within the hour? What the hell had I said?) That’s when I had a vague sense that it was no longer the nurse I was speaking to—it was the insurance company’s legal department.
Little did she know I had recently found myself in a similar situation. A routine screening mammogram had revealed “an area of concern,” and I was strongly advised to get a diagnostic mammogram to determine if this area of concern was … well, an actual concern. It’s a procedure that is not covered by my high-deductible health plan. I imagine most women in my position would not have given it a second thought; especially if, like me, they have a history of breast cancer in their family. But I’m one of those people (perhaps you are, as well) who has a greater fear of crushing medical debt than of death. My instincts told me I was fine, but I got the diagnostic mammogram anyway. Within a few minutes of the procedure, the technician told me the “area of concern” was no more. “I made it go away,” were her precise words. Well, ain’t that peachy. Does that mean I don’t have to pay?
When the 24/7 nurse realized I wasn’t going to budge regarding the ER, she offered (as if to haggle with me) that I proceed to an urgent care clinic within the hour. Again, I said no. Well, what were my plans, she wanted to know. I told her I would follow the directives of the nurse at the government clinic and go to an urgent care facility if my symptoms worsened. Or wait until Monday to visit the clinic if my symptoms didn’t improve. The 24/7 nurse did not like this plan. I should not—under any circumstances—wait until Monday to be seen by a doctor.
My phone call to the 24/7 nurse was over a week ago. My symptoms abated over time, if not as quickly as I would have liked. To top it off, I don’t have what would likely have been an unnecessary ER bill looming on the horizon. Do I feel vindicated in my decision not to follow the nurse’s advice? For the most part. But at the time, it felt like I was taking a chance, albeit a small chance. For me (and many like me), making a health care decision often feels like a roll of the dice. “Do I feel lucky today?” And this is only heightened by the recognition that our health care “experts” too often appear driven by forces outside the telos of the medical arts; namely, maximization of profits and protection from malpractice suits. COVID and vaccine policies have done little to ameliorate my skepticism toward the medical establishment.
I’m not sure I can get more cynical than this.
Published in Healthcare
There’s a great deal more witchdoctoring in our doctoring than we like to admit. When are you detecting the first signs of something wrong, and when are you being paranoid? Is this the sort of problem that will go away on its own, or is it the sort of problem that will only get worse from here? And the question that gets me into the most trouble: “If I go to the doctors to fix this problem, what are the odds that they’ll fix it, versus the odds that I’ll have to take another set of pills for the rest of my life?”
All of that comes before dealing with the bureaucracy and the legal department and everything else that makes modern medicine so much fun.
I’m happy you are doing better. I started off my school semester exceedingly ill and did a pump in the hospital 5 nights and and then two more shorter trips. My experience suggests to me that they are generally risk averse and lean heavily on the precautionary principle. Put aside the insurance aspect, they would have given you the same advice. Put another way, they are doctors, you always go to the emergency room or see “someone” right away. That cough could be anything. Oh and they will want to do bloodwork!
But I guess, and this is me also putting on my claims adjuster hat, they have legal guidelines they must follow. It isn’t really unusual and it isn’t clear who this benefits or hurts. But still, as you note, it isn’t really up to the insurance company. The nurse almost certainly has to comply with a variety of federal and state regulations. The call has to be documented for legal purposes (this is huge). If it comes up that you were sick and they said anything that looked like they were trying to get you to forgo a potentially covered treatment then they would be in a for a world of legal liability, even if you were fully informed and were declining the treatment. No arm of an insurance company can attempt to get people to forgo any type of activity that may be covered. Also, if you are sick you are now an underwriting expense and they will want to know that.
My own feelings of having to spend about month between doctors and a stint in the hospital leaves me mixed. We pay a lot for healthcare because people use a lot of it (its basically a normal good). In a lot of situations you’ll get a tylenol and maybe an IV. But it is also true that some otherwise very normal pains really do turn out to be something that you couldn’t beat at home and the nurse has probably heard “I think it is just a cold” a thousand times and suddenly it is far worse. We all have our stories.
Did the nurse ask if you had been playing tackle football? Did the nurse ask if you had been inhaling a lot of gas from Reddi-whip? Did the nurse ask if you had recently used pepper spray in an elevator? These are the type of important questions an unbiased screener would ask.
I’m with you on the ER – basically if I don’t think it’s absolutely critical, I’m not going to an ER.
I went to one a few years back (albeit, in California) for some stitches to my forehead and the bill was pretty extreme, despite being covered by insurance.
I’d be more inclined towards an urgent care though if it really was urgent.
Thanks for sharing your story. I am glad you received the medical help you needed and appreciate the insight you bring as a claims adjuster. I don’t doubt there are a multiplicity of considerations that go into providing medical advice to a patient. I just wish uppermost was an honest assessment of need. I didn’t include it in my post, but I went to the ER (via ambulance) back in 2016 in response to what I thought might be a serious illness. After the usual blood work and a CT scan, the doctor could find nothing medically wrong with me. “What?” I said and broke down sobbing. “But that’s good news,” he said, rather confused by my reaction. In my calculation, though, only a diagnosis of something commensurate with an ambulance ride and ER visit could have “compensated” for the medical expense.
Well said. It often seems like a damned if you do, damned if you don’t proposition.
If you youngsters think it’s fun dealing the the medical/insurance industry now, just wait until you encounter Medicare and the CMS bureaucracy.
Yeah. That’s tough. Your post reminds me of my most recent visit. The doctor did blood work in the morning (aware of long hospital stay) and said some levels were high and I needed to go to the ER (I did). The ER doc did bloodwork and the levels were down from earlier that day, but also, they just had a strong disagreement on the value of looking at the levels/enzymes in question. They let me go. It was about 9 hours in the waiting room with half of that with an IV stint in my arm. I had to prep my lecture like that. It’s not comfortable and I feel sometimes, as patients, we aren’t given the right info. It can build some cynicism. We do healthcare in a very strange way in this country.
There are two ways of diagnosing: one is to minimally test for the chief complaint and the other is to test for every tangential complaint. One is cheaper and the other significantly boosts medical costs across the board. I know of situations where docs test in excess of the chief complaint. For example a guy comes in for shoulder pain and mentions a cough and gets a chest x-ray that shows a cancerous spinal tumor. I suppose that technically the x-ray was unnecessary. But for a guy who rarely sees a doctor and treats himself at home and toughs it out, you never know what you’ll find. There is a balance between appearing to over test and not.
That’s really interesting and an important point. It’s tough. And, in talking to some people, I didn’t realize how many patients come in looking for drugs. ERs are not nice places but I can’t imagine the mental stress in having to juggle so many decisions.
Apparently it depends a lot on what insurance you have. I have Humana Medicare Advantage. When I needed gall bladder surgery just over 2 years ago, in Phoenix, I went to Banner Health. It seems Banner does a lot of business with Humana. The initial ER visits and then being admitted as an “emergent” case for laparoscopic surgery the next morning, after ultrasound and even some CT to confirm it wasn’t something else, cost me $90 for the ER and like $45 extra for the surgeon who was not a direct employee of Banner.
“This is not an E and it doesn’t feel particularly U.”
In truth, they are working off of a script/decision tree (guided by the nurse as much as she dares – your call may be recorded for quality control). While it is less dramatic than WebMD, a nurse is never going to be allowed to say, “you’re just fine,” anymore than you can be dead without a doctor’s assessment.
As the saying used to go, if they don’t control the quality it might get out of hand!
Doctors give their patients advice. Patients are free to take that advice or not. People have the right to refuse medical care and treatment. It’s up to them and them only.
Doctors and other medical people sometimes forget that and act as if they can order people around, which is unfortunate. Medical providers can take things too personally at times.
The nurse should have said, “This is what we advise. Of course, what you do is up to you.”
They probably aren’t allowed to say that either, it might be seen as “your guess is as good as ours.”
Sure thing old timer. I’m sure they’ll be tripping all over themselves to give me Medicare in the Gulag.
I couldn’t have said it better myself.
You don’t have to take anything, you are the final judge. Do take into account the professional opinion you’ve paid for but, please, after getting all the information you can, make your own decisions!
And furthermore, just for good measure, let me say my daughter (a medical professional of some accomplishment btw) has told me to be aware that whenever anyone goes to see a Dr. they will leave with a prescription because giving out prescriptions increases the pay out to the facility where the Dr. works. Just something to keep in mind, take what you need leave off the rest and please, get plenty of exercise and eat well.
People yell at me for making my own decisions.
“Just do what you think is best.”
“OK, I think I’ll just – ”
“Wrong!”
In the Gruber home, we put up a money tree in place of a Christmas tree and — so far — its been very fruitful. I’m very touched this year by the Yuletide spirit because thanks to my family and all
myPfizer’s customers, they are buying me another set of countries which has me well on my way to achieving world domination.Believe me when I tell you, you can get more cynical. I’d offer you a cigar but I only smoke $100 bills this time of year.
Oh, look. I’m a minor prophet of the Old Testament!