How our health care system failed Jane

As a family doctor, I am reminded daily that American health care is broken. A local administrative assistant, “Jane,” was working on her roof on a Wednesday afternoon when she fell. X-rays showed two elbow fractures. She was put in splints that immobilized her arms from the armpits to the fingers. She went home at midnight in the care of a friend with instructions to call her doctor in the morning for home services.

Nobody considered that home services are structured to provide only a few hours of support a day. She recalled: “I couldn’t scratch my nose, or feed myself, or get a glass of water, or pull my pants down.” She needed around the clock care. Jane called her insurance company, which told her that her plan included 100 days of skilled care.

Arrangements were made to go to a rehabilitation facility on Friday, which was good because Jane’s friend had to go back to work. When Jane arrived, around noon, administrators told her that the insurance company had denied her claim and that she could not be admitted because she had no need for skilled medical care. After a couple of hours on the telephone, no one had a better idea, so she was sent back to the emergency room. By this time, she needed to go to the toilet, but staff refused to take her because of fear of liability. Her ex-husband helped her.

The emergency room was packed. She was seen by a doctor who asked her if she had cash to pay for a hospital room. He talked to her about going to a local shelter. Jane was hungry, dirty and in pain. “I just need someone to take care of me,” she said. A stranger who had been following the story brought Jane supper at 10 p.m. and fed it to her. She was admitted at midnight.

On Monday morning, the insurance company confirmed that it still denied the claim and that Jane was responsible for the bill. Jane appealed the decision and waited, not having any choice.

Eight days after the accident, the insurance company notified her that it would cover the claim and that she must be transferred to a rehabilitation facility immediately. She was sent to the same facility that had treated her so badly before and spent three weeks there, enjoying inappropriate food, an accidental injury, an often unclean toilet, miscommunications between staff and her orthopedist, and a banging door that prevented sleep. The splints were removed. Jane went home with a new case of athlete’s foot. She learned to use her arms again and is now back at work. She feels her family and friends were very supportive.

A Harvard study published in 2005 in Health Affairs stated that illness and medical bills caused half of all the personal bankruptcies in the United States. According to that study, three-quarters of the people who went bankrupt were insured. Jane is not unique. Many people do worse.

There has been no consequence to insurance companies for the poor service they provide. Jane’s insurer did not get sued. There was no investigation. It did not even lose Jane (or me) as customers. On the contrary, when the company denies care, it saves money.

When a reputable insurance company argues that two broken arms are not a medical problem, all of us are vulnerable. Jane did not fall through the cracks. She fell into the Grand Canyon. We can do better. We can create a health care system that is efficient, transparent, complete and accountable. There is no reason that we cannot learn from all of the other industrialized countries in the world that have systems, building on their successes and avoiding some of their failures.

When the politicians come calling this fall, let them know that this is a priority. Let them know that you read and that you vote.

Karen Hover, M.D., of Orono is a family physician.