The dark underbelly of health care is becoming all too visible now.

Fresh faces in neatly pressed white coats are in the halls.  Eager.  Enthusiastic.  Clearly very bright.  All hoping for a moment, an experience, an encounter that makes all their hard work worth it.  Surely they’ll have one, but not before the thousands of keyboard clicks, the mandatory lectures, rounds and lots of lengthy, lonely call nights.

He was a doctor from another time, well into his 80s.  Lovely man with an infectious smile, mesmerizing foreign accent, and almost regal presence. An authority in his time and still attends lectures to stay engaged, a question passed his way from time to time out of respect for his experience and insights.

But he kept nearly falling at night and became concerned; even confused once.  This was not like him.  So he was admitted, observed and had a heart rhythm that was not normal.  Blood thinners were started cautiously.  Surely he could manage them.  His wife, ever present at his side, was equally engaging, concerned.  And so, as fate would have it, after hundreds of thousands of keyboard clicks, I came to know them and realize his heart beat was too slow at times, dangerously so.

After lengthy discussions of the good and bad, the options, the data, he agreed a pacemaker made sense.  Trustingly, he wanted it performed soon, eager to return to the lectures he loved.  So the next morning after a night of worry, we assembled.  His smile greeted me as I came to his bedside to obtain written consent, answer any last-minute questions, and silence the noise of concern.  He was ready to go.

So I left his bedside to change into my scrubs, trying to hang my newly pressed shirt and tie to the side to preserve it for later behind a changing room curtain, when I heard a voice.

“Dr. Fisher, I’m so sorry …”

“What’s up?”

“We can’t bring your patient in the room.”

“Why not?”

“We didn’t know he’s UnitedHealthcare.  He’s Medicare Part C!”

“Wha…?”

“You  placed your order after 4 p.m., and we didn’t see it until this morning.  We have to get pre-approval from UnitedHealthcare for his pacemaker.  They said it would be two or three hours …”

“Seriously?”

“Yes.  It’s his insurance.  If you don”t get pre-approval, you won’t get paid and he might have to pay for the procedure.”

I stood, pants in hand, dumfounded.  So I finished changing and exiting the changing area to clear my head.  I called our administrator.  She said, “Let me see what I can do.  I’ll call you right back.”  Within minutes a reply was sent: “You have to wait.”

I thought of my frightened patient lying there vulnerable, so I went to his bedside to explain.  He looked at me as a fellow physician, and he shook his head in disbelief, all the while naked beneath the covers.  He agreed to wait — he had no choice.  I left to get a cup of coffee and to collect my thoughts.  What else could I do?  I put a detailed note, an order, a consent order last night, and a pre-anesthetic note this morning.  All keyed in, all according to protocol.

Then a nurse appeared with a note.

“If you call this number, hit ‘3’ on the menu selection, and enter this case number, you can do a peer-to-peer.”

“A what?”

“Peer-to-peer approval.  You talk to a medical director and they might be able to expedite the approval for the pacemaker.”

I looked for a moment at the 1-800 number, sighed, and called.

The woman who eventually answered after I heard “all attendants are busy” was pleasant enough, full of “Good morning, doctor” and “What can I do for you?”  I explained the situation and wanted the ordering physician’s name.  I spelled my name to her. Keyboards were heard in the background.

“I see that his is for a CPT code 33208, correct?”  She must have known that I knew my codes.  But I knew that was wrong.  He was not getting a dual chamber pacemaker, he just needed a single chamber, VVIR pacemaker.

“No, that’s not correct.  It should be 33207,” I replied.

“Oh.”

I heard more clicking.

“I’m sorry but I’ve tried to change that code under this case number and it seems I don’t have authorization to do that.  Can I put you on hold while I speak with the medical director to see if he can make the change?”

“Sure,” I said.  What choice did I have?

So I waited, listening to some nondescript melody in the background as I was placed on hold.  A few minutes later, the same voice returned.

“Doctor?”

“Yes?”

“It seems the medical director couldn’t change the information on this case number either, but I’m going to try to make a new number based on the CPT code you gave me, then I’ll have the right information to give to the medical director, OK?”

So we proceeded to build a new case number.  Lots of clicks interspersed with silence, then more clicks in the background, a few more statements like, “Sorry, I’m new to this” and “Could you spell your name again?” then finally:

“There.  I think I’ve done it.  Let me transfer you to our medical director.”

A click, some music, then a pleasant official-sounding woman’s voice.  “I’m sorry about the delay, I hope you didn’t have to wait too long.”

A conversation ensued.  I explained the rationale for the pacemaker, then finally was granted approval.  Case number 2342343240 and approval number A321232451, or something like that.  I notified the staff and handed the numbers to our clerk, knowing full well that pre-approval does not guarantee payment.  Forty minutes rather than 120.

It’s the game we play now.  A new game.  The game of numbers.  Of money.  Clinical doctors as agents for others who call themselves a “doctor” yet are unfamiliar with the patient and unexposed while they make the call.

As I adjusted my headlamp before scrubbing, I thought about those new interns and residents on our wards upstairs, eager, willing, able.  Bustling about, yearning to make a difference, waiting for their first chance.

Yet all being groomed to play the game.

Wes Fisher is a cardiologist who blogs at Dr. Wes.