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.
A Country Doctor Writes: 
this is yet another example of something all of us deal with. rapacious and ignorant insurance companies bent on making us endlessly beg for the right thing. many physicians simply give up. what a complete shame
I contacted Martin’s Point’s CEO, a physician, via Doximity this morning.
Physicians will give full support on belling the cat!
Is this the advantage plan which requires more steps than the medigap supplements like a plan G? With G you don’t have to have a referral to see specialist? Are these “peers” hired by the insurance co?
Yes these are plans like Well care Humana, Aetna,Martins point and all the others. Anything except traditional Medicare with a supplement and prescription plan D. They are all for-profit and they know how to hold onto their money.
so true, but where’s the line forming?
Thank you for writing this article. We all need to be informed about what’s really going on with insurance companies and healthcare. There seems to be a GAP and it’s just not the Medicare Gap.
Yes the insurance companies make huge amount of money. Physicians should take control of medicine and should be able order tests and medications without hindrances. Prior authorizations is another bull shit. Some one on the phone without medical knowledge does ask questions to authorize!
Your comments are very untrue and misleading. As a Dr you signed the contract to be a network provider for them. Do your research before making comments like this. Here is a quote I want to share with you.
“It is better to be silent and be thought a fool, than to speak and remove all doubt.” – Abraham Lincoln.
Get real. Doctors are employees with no say in which plans their organization do business with.
Your statement are absolutely true! As an NP who works on a clinical team I get tasked with making many of these calls and almost always feels like a waste of healthcare resources. It is one of the things I thinks drive many out of medicine.