Our Story

By Sheri Larivee, Board Member of The National Coalition of Mental Health Professionals and Consumers, Inc.

      Before I begin my family's story I want to point out the definitions to a few terms that I feel are used loosely when managed care is being discussed. 

We were once patients.  Now managed care companies refers to us as consumers.  Patient seemed to get lost somewhere along the way.  Perhaps we can find it in the same place as quality care.

In August of 1995 our PPO plan jeopardized the life of my 9-year-old daughter.  The only mental health provider in the network that was qualified to see a child under 12 wanted my suicidal daughter to wait three weeks for an appointment.  We were forced to go out-of-network so that someone could see my daughter immediately.  Although my managed care company was informed of the trouble I was having getting her in to see an in-network provider we received no offer of help.  But then again, why should they help?  After all, they would save money by our having to go out of the network.  Later, they said that our choosing to go out-of-the network was the reason why they could act they way they did, in a way that jeopardized the life of a child; a way where they can make profits and get away with their inappropriate actions.

While I was trying to get a doctor for my daughter, the counselor at her elementary gave me a number to call to get some help.  The emotional emergency clinic told me that my daughter needed to be brought in immediately.  During the course of the conversation I mentioned to him that our managed care plan was causing problems for us.  He stopped the conversation immediately and told me that they could not see her.  He told me that they only saw children who didn't have insurance.  So if we did not work hard and pay premiums for insurance my daughter could have had more immediate medical attention.

The out-of-network provider to whom we took my daughter immediately hospitalized her because she had suicidal ideation with a plan.  As her stay in the in-network hospital got longer, my managed care company's representative who called herself my daughter's case manager, said they would not pay in-network benefits for the hospital because the provider that placed her there was out-of-network.  She also told us that if she was reaching her maximum number of payable days, under our contract.  When we protested the case manager laughed at us like it was some sort of joke.

I got tired of being told there was nothing I could do because my daughter didn't kill herself.   Because I couldn't believe that jeopardizing the life of a child wasn't illegal in this country I went to the law library to research managed care laws.  I, by the way, have absolutely no legal background.  I found a gatekeeper law that said PPO plans couldn’t use "gatekeepers".  For our managed care plan to say they wouldn't pay for the hospital because an out-of-network provider placed her in there was like saying you have to go to one our in-network doctors also known as the "gatekeeper."  The Texas Department of Insurance failed to believe I knew what I was talking about and closed my complaint file.

I went to testify to the Texas Senate Interim Committee on Managed Care and Consumer Protection in Dallas, Texas.  The chairperson, Senator Sibley of Waco, assured me that he would find out why the Texas Department of Insurance closed my complaint file saying that there was nothing they could do.  Although I was never notified by the Texas Department of Insurance, my complaint file was immediately reopened.

It took the Texas Department of Insurance a year and a half to make the PPO plan pay in-network benefits.  It was a year and a half too late to keep us from having to file bankruptcy because of our out-of-pocket expenses.  The Texas Department of Insurance said there was nothing they could do about us being forced out of the network which had created more out of pocket expenses because of the deductibles.  When I asked the Texas Department of Insurance representative how much trouble the managed care plan was in because they broke the law their answer was, "I don't think you understand Mrs. Larivee, we can't fine them anything because we approved the plan."  This meant that the state agency that was founded to protect people like me from insurance fraud failed at their job.  They approved a plan that had an illegal clause in it.  So the managed care plan doesn't even get a slap on the wrist.

Again because I was told that because my daughter didn't die there was nothing anyone could do.   I went to the Texas Senate and House Committees and testified for the liability law so that managed care companies could be held responsible for denying coverage for necessary medical care for patients who suffered or died.  It looked like to me the only thing managed care companies cared about were profits.  They don't care whether you’re a child or not.

In June of 1997 we were on an HMO plan when my husband had a back injury.  For five months he waited for the necessary surgery to relieve his severe pain.  The HMO plan denied to pay for any of his medical care by saying that it was work related and therefore workmen’s comp needed to pay for it.  After we attained a sweet attorney who charged us nothing he threatened to file a liability lawsuit if the denials weren't reversed and proved the injury was not work related.  He gave them ten days to decide.  The managed care plan's representatives asked the attorney why were we in such a hurry.  Our attorney replied, "this man has a wife and three children, he has been in severe pain and out of work for five months, he has been humiliated by filing for food stamps so that his family could eat and you want to know what the hurry is?"  The managed care plan reversed the denial unable to remember why it was denied in the first place.

We didn't wait on the HMO plan to approve my husband's benefits to get him some treatment.  My husband couldn't work, we were running out of money and the constant severe pain exhausted him.   We went to the Texas Rehabilitation Commission to see if they would pay for the necessary surgery my husband needed.  They would.  Now I have learned that we, as taxpayers, are paying our taxes to pay for medical care that people who have insurance need but are being denied so that managed care plans can again make profits!

I never would have thought that the law I testified for, so that others would not be harmed, would actually help us only one year later.  I could only hope that it was working.  Only as the years go by that I do research about managed care plans I have learned that this law was not that great.  For example, if a person dies because the managed care plan denied paying benefits for a shot that would have kept them from dying, then the only money they would have to pay would be for the price of the shot.  Nothing is being done about the life that was lost at the hands of managed care.  The law wasn't what I thought it was.  You know the law that the PPO plan used by saying you had to go to one of their "gatekeepers."  Now the PPO plan says that the patient doesn't have to go to an in-network provider to get placed in a hospital but the out-of-network provider has to call an in-network provider to get permission.  They just found a way to get around the law.   In fact they already have ways around the bills that might be made into laws.

At this point I used to laugh and joke about the only thing managed care can do to us now is to make us homeless.  Only in October of 1999 my husband hurt his back again and again he is suffering in severe pain as I write this.  The plan has denied for my husband to see the only specialist in the network that we were told could help him.  We were told by our health plan that if we switched PCP's then the specialist would be in the network.  We did this, which has taken two months to do so.  Now the PCP's network is telling us that we can't because according to their contract the specialist is only contracted through them to see patients with scoliosis.

Our health plan is blaming the network and the network is blaming our health plan.  I choose my plan by what the health plan says and in the booklets it sends me through my employer.  How am I supposed to know about the contract between the providers and the networks?  My own health plan doesn't even know what their rules are.  I have found out that there are networks within networks that patients don't know about.  All I am being told about the situation is that everyone is terribly sorry that I was given the wrong information.  As for my husband he is the one suffering.

I am so sick and tired of everyone blaming the patients.  How can we get an even vague idea of what our managed care companies will pay for?  They aren't going to tell you what they don't want you to know and the representatives that answer their member lines have no idea what is going on.

Through my five years of doing research about managed care plans what I learned is that when you belong to an HMO you need a primary care physician and you need to stay in the network when the physician gives you a referral.  I stayed in the network and still we are being denied benefits for necessary medical care.  I also learned that managed care plans only care about profits as I have said before.  They are killing our children and our family members.  Let's not forget that as we get older it will be cheaper for you to die then for them to pay for medical care for you.  Why do you think the HMO's are dropping Medicare patients?  Their medical care cost too much.  They can't make a profit if they can't keep all of the premiums.

The other day my 96-year-old grandmother was told she had to leave the nursing home because as they say, she can be taken care of at home.  They call it custodial care and they won't pay for trained nursing care in the home.  They say that the family can do it and therefore again they don't have to spend their money.  My parents begged them that she was not well enough and they said it doesn't matter.  Her HMO plan says she can go home so she is going home.  They would at least wait for the home evaluation my parents requested to be done.  Later that night my grandmother had a heart attack.  They are still talking about kicking her out in a few days.

I also learned in my research that managed care plans repeatedly talk about their surveys where most of their members are happy with their health plan.  Let me assure you that these members are the healthy ones.  If you are elderly, disabled, or chronically ill you are not happy if you are on a managed care plan.

I beg everyone who reads this to do something about it.  It only takes a phone call to legislators to let them know you are tired of American citizens getting murdered at the hands of managed care plans.  It is not that hard and they want you to call and let them know how you feel.

My husband can't work.  I returned to work to support a family of five.  We had to voluntarily have our second vehicle repossessed; we were again on food stamps, which helped until we were recently denied for them because I make $10.00 too much per month to qualify.  My husband suffers everyday in pain and is depressed because he can't support his family.  We have sold furniture and anything of value to help make our house payments so far but we have ran out of resources and we are getting later and later at making those payments.  We have had to beg for help to the school district for school supplies because we can't afford them.  As for food our pantry is grim but the children haven't gone hungry yet from little help that our families can afford to give.

I learned when I asked for help or assistance from the government agencies that we are in what they call a "gray area."  I don't make enough to support a family of five but I make to much to get assistance.  We are on the edge of being one of the many homeless statistics that are just glanced over by others as they read the paper.  And why are we a statistic?  Because we did what used to be the right thing and paid health insurance premiums so that if anything happened we would not suffer financially, physically and mentally and could get the medical care that we needed.

We need to end the murdering era of managed care.  Managed care fosters a lesser quality of care that creates costly "after care."  Therefore managed care is no longer lowering the cost of medical care for which they promised they would do.  It is time to end it.

You know when people say that I am lucky because no one has died in my family they are wrong, there is a part of us that has died.  It is the piece of our hearts that causes us to stand tall when we say the "Pledge of Allegiance.  It is the piece of our hearts that causes our eyes to tear when we hear the song "America the Beautiful."  It is the piece of our hearts that causes us to be proud when we hear our "National Anthem."  It is the piece of our hearts that has lost faith in what we once believed was a great country.

Please help us by exposing what managed care is doing to a hard working, law abiding, tax paying citizens of this country.  I know with my experiences that we are not the only people that is happening to.   Something has to be done and done immediately before others die.

Thanks

Sheri Larivee

Consumer Advocate on the board of directors of the National Coalition of Mental Health Professionals and Consumers

Organizer of the Austin Texas Capitol Rescue Health Care Day Protest

Member of the Patients Assistance League

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