Insurance plan

What happens when your doctor and your insurance plan disagree?

Look beyond the surface.

The people behind the scenes – whose names we may never know or whose faces we may never meet – often control our destiny.

Some call it luck, and some call it fate. Apart from their own perseverance, even elite athletes and star actors refer to the undercredited staff that enabled their success. But we’ve all experienced inflection points in our lives decided by people without our knowledge – whether it’s an admissions committee decision, a job offer that never materialized. materialized or a radiologist’s report that changed our lives. On the one hand, our life experiences can seem random, fortuitous, chaotic and predetermined at the same time. On the other hand, these depersonalized moments create the illusion of objectivity which can exaggerate how arbitrary major life events can be.

The proud city of Brockton, Massachusetts is home to over 100,000 residents in Plymouth County. Known for its surprisingly high wind speeds, historic role as our soldiers’ primary boot maker during World War I, and boxing legends Rocky Marciano and Marvin Hagler, it also happens to be the hometown of Caron Campbell – one of a small group of trained and certified medical technologists left in healthcare.

“It’s a dying field, but it’s my calling. You really can’t do this job if you don’t love the job,” Campbell said of her profession, which oversees, implements, trains and assures the quality of the millions of lab tests that hospitals order daily for analysis, from blood tests to fertility samples. Campbell’s background in laboratory research, technical work, management and business has positioned her well to ensure the critical decisions doctors and nurses make daily are based on accurate data.

Campbell lives beyond the surface in medicine. She lives at a distance from the doctors who rely on her work and the patients whose fate depends on the integrity of her lab tests. For someone with Campbell’s expertise and passion to call her profession a “calling,” she attributes her impact on patients and doctors on the surface of health care to fate.

Campbell has spent more than 45 years as an adult eating well, staying active and seeking annual health checkups and screenings. She walks 5 miles a day on concrete lab floors to supervise, verify and analyze. In her free time, she leaves Boston Harbor. Her husband, Bill, is also cut from the same fabric as an officially trained and certified medical technologist. They have been married for 28 years. Unfortunately, Campbell developed severe knee arthritis with subsequent deformity over the years. Now it’s gotten to the stage where it’s started interfering with his basic activities of daily living.

After doing her homework by talking to joint replacement experts and reading peer-reviewed literature, Campbell was drawn to the precision and accuracy of robotic arm-assisted surgery with haptic feedback. While she understands that there is currently no definitive literature to suggest that this emerging technology would definitely result in a better outcome than a traditional knee replacement, it has been encouraged by several recent reports – and could certainly be linked to the importance of precision and accuracy in medicine.

“I knew what I wanted, and I felt it certainly couldn’t hurt to be as precise as possible during an operation. But when I inquired about the surgery with Dr. Antonia Chen, my insurer denied it. They told me – and I’ll never forget – that “well, nine out of ten doctors don’t think robot-assisted knee replacement is medically necessary.” Where did they get that from? I don’t even think nine out of ten surgeons have a robot. They then told me that if I wanted the robotic surgery, I would have to pay $2,100 out of pocket, plus a $500 co-pay. I was just amazed. Who calls the shots here? It’s definitely not me, and it’s definitely not Dr. Chen. I am healthy and have never given my insurance a reason to deny me after years of contributing to my plan,” Campbell said. “I just think I have the right to get the operation I want, and I think my surgeon has the right to perform the operation he wants.”

When Campbell asked about other precision technologies for his knee replacement, “they told me they would pay for a custom knee, and I said ‘you know that requires a CT scan as well, n ‘is this not? They said it would be covered. What’s worse is that they actually told me ‘you know, if you just wait a year for your medicare to kick in, they’ll pay for all the robotic surgery.’ I was surprised they actually suggested this.

When it came time for insurance companies — who also live inextricably beyond the surface in health care — to reciprocate, Campbell was left out. And in doing so, his worldview rooted in precision, fidelity, and destiny for the betterment of society faced arbitrary practices, bad luck, and chaotic profits.

What would you do if you had a flat tire? Broken exhaust pipe? Leaking engine? Like most Americans, you’ll likely visit a reputable mechanic, pay them for parts and labor, and then walk away. But what if you have an arthritic joint – a joint that gives you throbbing pain with every step? As most people like Campbell know, it’s not that simple. In fact, neither the patient nor his doctor are completely free to make important decisions regarding treatment. But in a country that has arguably the most advanced healthcare resources in the world, should taking care of our bodies really be more difficult than taking care of our cars? Who really calls the shots? The decision to use technology in surgery should be based on a shared decision-making paradigm that is evidence-based and non-biased. The consensus between insurers and surgeons that enables the adoption of innovation and progress should be a two-way conversation, not determined unilaterally by the health insurance company.

Today, Campbell is yet to undergo knee replacement surgery. She waits in pain while battling her insurer who decides what type of surgery she should receive. Although she was offered a traditional knee replacement by Dr. Antonia Chen at Harvard’s Brigham & Women’s Hospital, Campbell is adamant that “insurance companies shouldn’t be the ones dictating patient care.”

As someone who respects the impact of his work on the surface of health care, Campbell has made silent contributions to the health of countless others. But when she needed her insurance plan to reimburse her when she became the patient, she was pushed around by one-sided insurance-based guidelines that failed to respect patient preferences, scientific evidence, logical fiscal responsibility and the doctor-patient relationship.