HMO Horror Story

Good morning, and thank you for the opportunity to speak today. My name is Paul Martin. I've worked as a school counselor in New Hampshire public schools for the past twelve years, and before that, as an English as a Second Language teacher. In November, 1995, after suffering from back pain for more than a year, my doctor indicated that I seemed to have an unusual case of a rare condition called myofascial pain syndrome. It's typically limited to a specific muscle or muscle group, but in my case it's both chronic and "diffuse," meaning that it involves many muscles, especially in my back. The muscles develop painful "trigger points" (TrPs), and the muscle tissue near these points forms "taut bands" - very hard bands that feel like the doctor's plucking a guitar string when he identifies them manually. People with this condition are highly susceptible to hurting themselves by making the slightest "wrong move," causing TrPs to develop in new locations or recur in old ones. When episodes like these are left untreated, the TrPs tend to proliferate, and you can develop a whole new region or level of pain.

The mainstays of treatment for this condition are physical therapy (PT) and TrP injection. These treatments usually produce recovery, although it can take years. If you don't recover, they are necessary for pain management and to keep the condition from worsening.

In my own treatment, my doctors are emphasizing PT and limiting injections, since it's thought that repeated injections over time can lead to muscle scarring, and I have already had some adverse reactions to injection. Additionally, home exercise programs are critical to maintenance and possible recovery for people with chronic MPS, and it's the physical therapists, not the doctors, who oversee your changing home program needs.

Early last September I hurt my left low back from prolonged sitting on a hard bench. It hurt constantly from then on. Prior to this incident, low back pain was less bothersome than mid-back and sometimes upper back pain. When I began feeling pain in my right low back as well, my doctor and I knew the TrPs had started spreading, and the doctor prescribed PT. The prescribing doctor was a leading national authority on musculoskeletal problems. I should also mention that my local specialist here in New Hampshire - a Healthsource provider, and the first doctor Healthsource recommended to me as a doctor with expertise in this area - also wrote to Healthsource strongly recommending that I receive PT. And I should mention that Healthsource had been providing me with PT coverage for the previous two years.

On October 1st, without warning, after just two PT sessions for my low back, Healthsource terminated my PT benefit.

There's a lot I don't have time to tell you concerning how Healthsource dealt with me in its denial of benefits and appeals process. All we have time for now is the bottom line, after an appeal that took three months despite all my efforts to expedite and facilitate it, including enlisting the help of a negotiator available through my work place. The bottom line is this - and I quote from the final letter to me from Healthsource's grievance committee on December 24th: "The condition for which you are treating is long-term in nature. As the benefit is designed for short-term acute medical conditions only, benefits do not apply."

So a healthy Healthsource policyholder who occasionally twists an ankle that would probably heal anyway has a PT benefit. But a Healthsource policyholder with a more serious medical problem or an actual disease of the muscles receives, in a word, nothing.

I thought at first there had to be some mistake, and called Healthsource's appeals coordinator. There was no mistake: no more PT coverage, ever, unless it was for something unrelated to what I suffered from.

In that same letter of December 24th, Healthsource gave its rationale for denying me coverage. They cited the two sections of my policy that you have in front of you - the only language in the policy discussing PT, and the only grounds for denial that Healthsource has ever been able to offer throughout their three-month process. You'll notice these passages don't say a word about not covering long-term medical conditions, or anything about any kind of condition or diagnosis at all. Nothing in the policy excludes by condition. The policy says only that long-term therapy isn't covered - and I've never had long-term therapy. I've never had PT for more than several weeks in succession, and in an entire year of 52 weeks, I've never received PT for more than about 8-10 weeks. I get PT when I really need it and my doctors order it.

I'd like to tell you about my experiences with the insurance commissioner and lawyers - the first was no help, the second I couldn't afford - but there isn't time.

The health and life consequences to me of Healthsource's neglect of my condition over the past eight months have been enormous. Again, there's only time here for the bottom line - I'm omitting a great deal.

By January, unprecedented nighttime pain started causing serious sleep disturbance. The low point came during a three-week period when I was sleeping between a half hour and four hours a night and missing workdays because of sleep deprivation. I'd never experienced anything like it. Twice I became disoriented while driving - didn't know what road I was on or where I was going. I'd misplace things twenty times an hour. I'd forget what I was saying in the middle of sentences so often that it was hard for family members to have a coherent conversation with me on the phone. Their level of concern finally reached a point that one of them made the thousand mile round trip to come stay with me for a while.

What I've ended up doing to survive in my part-time guidance position is to rely on prescription sleeping pills, and change my hours at work. I go in every day now, but not till 11:30 a.m., allowing me to sleep in. My position, however, is likely to become full-time this fall.

There are several features of the HMO Accountability Act I'd like to comment on, but I'll only comment on Section 329.1, Page 2, in boldface. The gist of it is that HMO medical directors would be regarded as practicing medicine when they make decisions affecting patients' health care. I was astonished to learn that they could be viewed in any other way. What else are they doing when they overrule the decisions of a patient's doctors? It seems to me this is a greatly overdue piece of legislation.

Finally, this closing thought:

As a nineteen-year-old undergraduate at UNH, I read a novel by Charles Dickens called Hard Times for a literature class. The setting was the early industrial revolution in England, before the need for any sort of social legislation was recognized, before child labor laws, when ordinary middle and working class people were pretty widely and generally mistreated.

I considered myself very fortunate back then to be living in a place and time that had gotten beyond those sorts of social conditions.

Well, I know I'm just the tip of a very large iceberg. I know that for every person standing in front of a microphone, there are many more too sick, too tired, too discouraged, too overwhelmed by their own plights in relation to their HMOs, to be here. And for myself and all those people, these are hard times - right here, right now, all around you, every day and night. And I most sincerely hope that this legislature will do something about it by passing the Governor's Accountability Act. Thank you.