Monday, October 16, 2006

Bureaucracy Now!---- A Rant

Healthcare is riddled---no, saddled---no, ruled and regulated----by bureaucracy. From visiting nurse agencies to hospitals to private practices, bureaucracy with both a capital "B" and lower-case "b" own the airwaves and pocketbooks of the healthcare system. Whether it be fiduciary or surgical, top-down bureaucracy rears its ugly head like a rabid marsupial. You know, all marsupials have deep pockets for the protection and nurturance of the young, and the only "young" spawned of the healthcare system is money, or its popular euphemisms, market-share and capital. And don't be fooled by a hospital that's a not-for-profit. Those wolves in sheep's clothing can devour weaker competitors for lunch and regurgitate a new "satellite" branch for dinner. But I digress.

Today, I was informed by a visiting nurse---in whom I place my complete trust and confidence, by the way---that a mutual patient of ours is in need of a wheeled walker. This patient, of undisclosed race, gender or age, has long-standing AIDS with various complications including dementia and mental status changes, a newly-discovered bone spur in the lumbar spine, worsening depression, newly manifested self-mutilating tendencies, hypertension, hypothyroidism, Hepatitis C which failed treatment with Interferon and Ribavarin (the standard of care for the "cure" of chronic Hep C), and chronic pain of unknown etiology. S/he has had several precipitous declines towards disability or death, and several subsequent and equally noteworthy recoveries, like a magical phoenix rising from the ashes of a recalcitrant body's failure to thrive.

Now, having gone from fully ambulatory to walking with a cane and then progressing to a manual wheelchair, this patient is beginning to regain some of his/her strength, and with assistance and perseverance---and despite massive depression, suicidal ideation, and self-inflicted cigarette burns on both hands---this courageous individual is in need of a walker to facilitate movement from the wheelchair to a standing position, the cane not being enough to support such a transfer.

I happily obtained the necessary paperwork from the medical supply company---paperwork which is, I must say, meticulously designed to comply with the bureaucratic hungers of both Medicare and Medicaid. Discussing this newly arisen need for equipment with the primary doctor, I rapidly obtained his signature, completed the paperwork with the necessary "Medicare-ese" needed in such delicate situations, and faxed said paperwork to the supply company forthwith, content to move on to other pressing matters, satisfied that my patient would then, through the miracles of modern communication technology and computerized billing, receive a home delivery of said device within 48 hours, as is the customary turnaround time with this particular company with whom we have a chummy (and somewhat bureaucratic) working relationship.

Ten minutes later, I received a call from the above-mentioned company to inform me that the doctor had not dated the form where he had signed it, so could I please add the date to the form and re-send it? (Couldn't the person on the other end fill in the date? Oh no, the uppity ones at Medicare would examine the signature and date with a magnifying glass, and a handwriting specialist would determine if they were both written by the same person!) Feeling more and more like this was a scene from Terry Gilliam's Brazil, I filled in the date---using the same color ink as the doctor, of course---and re-faxed the form, putting the original in an envelope to be mailed, since Medicare (read: "the bureaucrats") wants an original on file.

Again satisfied that I had done my nursely duty, I moved on to other (now even more pressing) tasks, and was interrupted by yet another telephone call from the medical supply company approximately an hour later. Was I aware that the patient already had a manual wheelchair? Yes, indeed. Was I also aware that the patient has Medicare as his/her primary insurance with Medicaid as secondary? Of course. Was I also aware that Medicare will not pay for a walker for a patient who already has a wheelchair?

I stared into space, noting all of the varied colors and relative positions of the push-pins on my bulletin board. Dissociation can be helpful in times of stress (as can Prozac).

"Do you mean to say that, even if my patient needs a walker to get up out of his wheelchair, he doesn't qualify?" I asked incredulously. The answer was affirmative. "Do you also mean," I continued, "that a patient who improves and becomes more ambulatory should therefore remain confined to a wheelchair because Medicare feels the paltry cost of a walker is just too much to provide for this person's improved quality of life and mobility?" I was informed that yes, in Medicare's eyes, he should stay in the wheelchair. I hung up the phone and put my face in my hands.

Big sigh.

So, yet another bureaucratic fight for this nurse to wage? So many other battles are pending, like the patient who lives in an apartment with severely sloping floors which the housing authority claims is fine, even for a patient with severe arthritis. Oh! the humanity (or lack thereof).

What bureaucratic nightmare will I encounter tomorrow? You can rest assured that one will most likely make its presence known sooner than later. And what is a lowly nurse, a mere cog in the healthcare wheel, to do? Yell? Scream? Rage against the machine? Abuse beer and benzodiazepines? Take your pick. Til then, let's hope no faceless bureaucrat in a cheap suit is sitting in some cubicle at Medicare scheming up even more insidious ways to save money and diminish the quality of life of its recipients. Then again, that's probably an apt job description for someone with no healthcare experience who is at this moment burning the midnight oil and doing just that. He probably has a boss who told him to stay until he could figure out how to screw one more Medicare recipient out of $50 this week. (And that boss probably gets a $100 raise for every $50 saved. Go figure.) So, let's just hope he has one too many tonight after work as he drowns his guilt with cheap gin at a local bar and calls in sick tomorrow. Maybe then I'll be able to get something done after all.


Janet said...

Go to and read the last post there. Follow the link to the blog he quotes. What can we do to get a single payer system in this country?

Anonymous said...

As ever, I don't know how you cope with these frustrations, Keith.

I come across people who can't go out with their loved ones because they can't afford a gel cushion for the wheelchair and their local health service can't afford to provide one.

It sometimes seems as if the systems are set up to baffle those who have to work with them and to limit the aspirations and life quality of those who are at the receiving end of them. And yet all of the systems were set up for different reasons. The systems were set up to ease and enhance the lives of those who need them. The bureaucrats appeared because it was necessary to prevent abuse and out of control finances.

The systems can only exist because those who depend on them have neither the voice nor the energy to insist on something different. And because they burn out those people like yourself who cre enough to get embroiled with them on too regular a basis.

Best - Tony

Anonymous said...


In my occassional employment in the mental health world I encounterd similar situations when dealing with insurance companies and I can truly empathize with your position. I was pulling out my own cyber hairs as I read your account of your most recent scuffle with the absurd beaurocratic blindness that seems as heartless as the "invisible hand" of the so-called free market.

May your ability to write so eloquently (and with a dose of humor) about the senseless Bureaucracy you are forced to grapple with as you try to improve the fragile circumstances of those you care for, help you stay afloat and offer you some release of pressure and give you some supportive feedback.

Kudos to you for keepin' on, keepin' on.

And thank goodness that you (and others like you)are there to try to naviagate the endless and circuitous red tape pathways which must be traversed in order to even try to get something done for your clients.

Ciao, amore,