As her physician, I provided some supportive counseling, prescribed medication, advised some time away from work, offered referral to a specialist, and, as the law requires, completed a report called "Doctor's First Report of Occupational Illness or Injury":

Chapter 7. Division of Labor Statistics and Research
Subchapter 1. Occupational Injury or Illness Reports and Records Article 1. Reporting of Occupational Injury or Illness
§14003. Physician.  (a) Every physician, as defined in Labor Code Section 3209.3, who attends an injured employee shall file, within five days after initial examination, a complete report of every occupational injury or occupational illness to such employee, with the employer's insurer, or with the employer, if self-insured. The injured or ill employee, if able to do so, shall complete a portion of such report describing how the injury or illness occurred. Unless the report is transmitted on computer input media, the physician shall file the original signed report with the insurer or self-insured employer.

The process is fairly straightforward and is designed to protect a worker's right to employment, to provide for income, and to pay for medical care. But as a method of providing health services the system is incredibly wasteful and counterproductive.

Ms. Crandall's experience was no exception. Returning less than three weeks after her initial visit, Ms. Crandall was in worse shape.  The process of dealing with the paperwork required by her employer's workers' compensation carrier, "a nightmare" in her words, had exacerbated her feelings of anxiety and left her even more incapable of returning to work.  

With more specificity I again referred her for therapy and added to her medication. Just a day previously her claim had been accepted by the worker's compensation carrier.  This was an important milestone, since had there been objection, a roadblock could have been erected. In California (the workers' compensation program varies state-by-state), an employers' insurer may object to taking responsibility for a claim and can in this way delay an employee's access to care.

But even absent major delays (the approval for care came on day 20), the system operates glacially.  The process of getting access to a psychotherapist required multiple calls to the nurse serving as the medical case manager at the insurance company, each back and forth consuming a few days, at least.  It is hard to interpret the case manager's role.  I was the doctor who assessed my patient's condition.  Ms. Crandall, herself, was impaired by her disability, but was functional enough to look for a therapist, to make and keep appointments with me and to make phone calls to the case manager.  Ultimately, it seems her role could only be seen as one of producing delay in the name of service.

Eventually, my patient received a listing of insurance approved psychotherapists within a ten mile range of our zip code. I knew four of the sixteen names on the list. Ms. Campbell, however, called them all.  She had to. Nine denied accepting workers' compensation patients.  Two never called back despite repeated messages.  Two were taking no new clients.  One had a disconnected phone number. One wasn't a therapist. And the final one said he might consider her as a patient after a review of her medical records if she agreed to pay up front and deal with the insurance company on her own.

It was December 2 before Ms. Crandall finally saw a therapist (I won't belabor the other trials and tribulations), six months after her initial consult.  Frankly, by this point time itself had helped her improve.  Maybe that's the idea behind the insurance company delays, but at what cost?  She's missed six months of work, time for which the insurer has had to pay. And she has suffered way more than was needed.

I could rail against the workers' compensation insurer but the problem is more fundamental.  It just doesn't make sense that health care should be paid for through a complex morass of different sources. In my practice alone, I am paid by dozens of different payers, each with different payment schedules, different referral networks, and different duplicative bureaucracies. There are HMOs, PPOs, HSAs, PPNs, and EPOs. There is Medicare, Medical (one of fifty different state Medicaid programs), SCHIP, Healthy Families, and Healthy Kids. There is health insurance, auto insurance, homeowner's insurance, liability insurance, and, as in this case, workers' compensation insurance. Sometimes the patient pays herself.

Although the same service, health care, is needed in every case, our country has developed an unbelievably complex network of bureaucracies which focus an inordinate amount of time and money "passing the buck". There are innumerable reasons why our health care system needs change (Check out Ten Excellent Reasons For a National Health Plan by Dr. John Geyman for a few.); Shirley Crandall's story is just one.

President-elect Obama has asked us to contribute our ideas for change and has said that the need for control of health care costs is a fundamental reason for undertaking health care reform.

The problem with President-elect Obama's supposed emphasis on the costs of health care, however, is that his proposals fail to deal with the biggest source of wasteful expenditures, our dependence upon private health insurance.

His plans, by continuing to embrace a role for the multiplicity of private health insurance "options" in our system, weds us to the waste, profiteering, and venality of an industry that thrives on taking our money and spending as little of it as possible on the objective, instead seeking to increase the proportion of its revenue reserved for profits by directing its expenditures first to marketing, underwriting, "product development", and executive compensation.

For my patients, and me, I'd prefer my health care dollars be spent--surprise!- on health care. Only a move towards single payer "Medicare for All" can do that.