What happens when your doctor and your insurance plan don’t agree?


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 fate.

Some call it luck, and some call it fate. Aside from their own perseverance, even elite athletes and star actors refer to under-credited personalities that made them successful. But we have all experienced inflection points in our lives decided by people without our knowledge, whether it was an admissions committee decision, a job offer that never came through. materialized or a life-changing radiologist report. On the one hand, our life experiences can seem random, fortuitous, chaotic, and predetermined all 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 town of Brockton, Massachusetts has over 100,000 residents in Plymouth County. Known for its surprisingly high wind speeds, its historic role as the primary manufacturer of boots for our soldiers in WWI, and boxing legends Rocky Marciano and Marvin Hagler, it also happens to be the hometown. by Caron Campbell – one of a small group of formed and approved medical technologists left in health care.

“It’s a dying area, but it’s my calling. You really can’t do this job if you don’t like the job, ”Campbell said of his profession, which involves supervising, implementing, training and quality assurance 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 enterprise has positioned her well to ensure that the critical decisions physicians and nurses make on a daily basis 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 laboratory tests. For someone who has Campbell’s expertise and passion to refer to her profession as a “calling,” she attributes her impact on patients and physicians on the surface of healthcare to fate.

Campbell has spent over 45 years as an adult eating well, staying active, and having annual checkups and screenings. She walks 5 miles a day on concrete lab floors, supervising, checking and analyzing. During his downtime, he left Boston Harbor. Her husband, Bill, is also cut from the same cloth as a formally trained and certified medical technologist. They have been married for 28 years. Unfortunately, Campbell developed severe arthritis of the knee with subsequent deformity over the years. Now it has come to the stage where it has started to interfere with his basic activities of daily living.

After doing her homework chatting with joint replacement experts and reading peer-reviewed publications, Campbell was drawn to the precision and accuracy of the robotic arm-assisted surgery with haptic feedback. While she understood that there is currently no definitive literature to suggest that this emerging technology would certainly lead to better results than a traditional knee replacement, she was encouraged by many recent reports – and could certainly relate to the importance of precision and accuracy in medicine.

“I knew what I wanted and felt it certainly couldn’t hurt to be as precise as possible in an operation. But when I learned about the surgery with Dr Antonia Chen, my insurer denied it. They told me – and I’ll never forget it – 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 robotic surgery, I had to pay $ 2,100 out of my own pocket, in addition to a $ 500 co-payment. I was just stunned. Who is calling the shots here? It certainly isn’t me, and it sure isn’t Dr. Chen. I am in good health and have never given my insurance a reason to deny me after years of contributing to my plan, ”said Campbell. “I just think I have the right to have the operation that I want, and I think my surgeon has the right to have the operation that she wants.”

When Campbell asked about other precision-based technologies for his knee replacement, “they told me they would pay for a custom knee, and I said ‘you know that requires a scanner, right? They said it would be covered. The worst part is that they actually said to me “you know, if you wait just a year for your Medicare to take effect, they’ll pay for all the robotic surgery.” I was surprised they suggested this.

When the time came 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, loyalty and destiny for the betterment of society was confronted with arbitrary practices, bad luck and chaotic profits.

What would you do if you had a flat tire? Broken exhaust outlet? Leaky engine? Like most Americans, you would likely visit a reputable mechanic, pay them for parts and labor, and then leave. But what if you have an arthritic joint – one that gives you shooting pain with every step? As most people like Campbell know, it’s not that simple. In fact, neither the patient nor his doctor is completely free to make important decisions about treatment. But in a country with arguably the most advanced healthcare resources in the world, should it really be harder to take care of our bodies than to take care of our cars? Who is really calling the shots? The decision to use technology in surgery must be based on a shared, evidence-based, unbiased decision-making paradigm. The consensus between insurers and surgeons that enables the adoption of innovation and progress should be a two-way conversation, and not unilaterally determined 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 operation she should undergo. Although she was offered a traditional knee replacement by Dr Antonia Chen at Harvard Brigham & Women’s HospitalCampbell firmly argues that “insurance companies shouldn’t be the ones dictating patient care.”

As someone who respects the impact of his work on the surface of healthcare, Campbell has made silent contributions to the health of countless other people. But when she needed her insurance plan to pay it off when she became the patient, she was trapped by unilateral insurance-based guidelines that did not respect patient preferences, scientific evidence, logical fiscal responsibility and the doctor-patient relationship.


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