Suddenly last summer, bubbly, nine-year-old Ronee Larivee changed into a scared
little girl who didn’t want to go out of her house. Before, she’d always been
an outdoorsy, gregarious kid who made friends easily. Then, all at once, Ronee
couldn’t bear to be away from home, couldn’t stand to be separated from her
parents, Tommy and Sheri Larivee, even for a few moments. She returned early
from a visit to her grandparents’ last June — not even the fantastic allure of
the horses they owned could keep her there any longer, but she gave no clues
about why. As the first day of fourth grade at Kocurek Elementary approached,
Ronee expressed more anxiety about leaving the house to go to school. It was
puzzling — Ronee had attended Kocurek since the first grade, so it wasn’t as
though she didn’t know what the school was like. Sheri thought meeting Ronee’s
new teacher before the first day might alleviate some of the girl’s jitters,
but it didn’t. Ronee didn’t triumph over her inexplicable fright, and her first
day of fourth grade was not a success. “That night she cried, `Don’t make me
ride the bus, don’t send me to school’,” her mother recalls. The next several days blurred into each other. Ronee retreated to antics
expected from a much younger child — weeping uncontrollably, screaming, and
throwing tantrums. The elementary school counselor could calm her down enough
to return her to class temporarily, but the child was soon phoning her mother
at work, sobbing. Ronee began hiding under her bed at night, sleeping fitfully,
and employing all manner of tactics to avoid being sent to school, including
stashing her shoes away where they couldn’t be found. She couldn’t dress
herself, she trembled so, and was sick to her stomach. Ronee was crumbling into
a tear-soaked heap, right before her freaked-out parents’ eyes, and she was
incapable of offering them an explanation. And they didn’t know how to help
her. It was time, the Larivees decided, to take her to a doctor.
Thus began one Austin family’s odyssey through the bureaucratic nightmare of
managed care. One year, five therapists, and a record 42-day hospital stay
later, Ronee is making progress. However, her parents, who bring in a combined
income of $45,000 to support three kids, two cars and a house payment, are in
the hole for $13,000 — money that Sheri and Tommy say they can’t spare and
shouldn’t have to pay. Of course their insurance provider, Prudential, sees the
situation differently. According to a company spokesman, Sheri and Tommy erred
when they chose doctors not on Prudential’s list. The Larivees contend that at
one point they were forced to find a doctor, any doctor, because the only
appointment a Prudential network provider would grant their child — who was
becoming suicidal — was three weeks away. Later on, they said, they were led
to believe they were using an approved doctor, only to discover afterwards that
he was not. The couple has lost three appeals to Prudential and, without money
for lawyers’ fees, it appears the Larivees will have to pay up for services
that could have been covered. They say they feel like many Austin families who
have had to go up against the behemoth which is their insurance provider:
helpless and alone.
The Drama Begins
After the third day of the psychodrama unfolding in her home, Sheri sought theadvice of her pediatrician, who had been treating the Larivee children for the
last 13 years, long before Sheri was ever employed by the Austin Independent
School District (AISD) as a teacher’s aide, and was thus eligible for benefits
such as major medical insurance. She had thought it a lucky coincidence that
her beloved children’s doctor was on one of the plans available to her through
AISD — Prudential Plus, a so-called “preferred provider organization,” or
PPO.
From a consumer’s point of view, such a set-up straddles the advantages of
both a health maintenance organization (HMO) and fee-for-service medical
insurance — it offers the services of in-network doctors for a $10 co-payment,
but also extends the much-vaunted “choice” of seeing any doctor not in
the insurance company’s network. In the latter scenario, the policyholder pays
a $500 deductible annually, and 30% of the tab thereafter, while the company
picks up the other 70%.
As an AISD employee, Sheri had $177 a month deducted out of her gross pay of
$1370 for the children to have Prudential Plus (the school district pays for
her coverage); Tommy’s employment at a pawn shop has never included any such
benefits, and they elected not to cover him on Sheri’s plan because it would
cost an additional $150 every month. After eight years of skating by with no
health insurance, she figured having some coverage at last had to be better
than nothing. She now thinks she was mistaken about that.
According to the PPO’s rules, Sheri didn’t need to obtain a referral to see
any of the specialists on the Prudential Plus list of in-network providers, but
she rather hoped her pediatrician would point the way. But the doctor wasn’t
familiar with any of the seven psychiatrists on the in-network roster, nor any
of the seven clinical psychologists, and suggested that Sheri simply start
calling their offices.
None of the providers she contacted saw children as young as Ronee, but as
practitioners at the Austin Regional Clinic (ARC), they referred her to their
ARC colleagues who were able to treat children under 12. Five days after she
called the clinic and filled out the requisite paperwork, Sheri learned that
the earliest appointment Ronee could get with an ARC therapist was three weeks
away. Sheri reeled in despair. She was afraid that the way things were going,
Ronee might not make it that long before she harmed herself. She asked if there
were an earlier appointment and was told she would be placed on a list and get
a call if there were a cancellation.
Sheri wasn’t experienced with the world of mental health services, wasn’t
familiar with its vocabulary, protocol, and practices. But she’s unwavering in
the belief that she made it clear to the ARC that she couldn’t wait three
weeks. However, John Watterson, Ph.D., assistant director of the Austin
Regional Clinic’s mental health department, maintains that Ronee’s mother did
not indicate that Ronee was in need of emergency help. Watterson adds that
clinic workers make it a point to tell people to get back in touch with them if
things deteriorate.
“We tell everyone if something falls apart to call us back and we’ll get you
in with a crisis intake therapist — and we do that every day,” says Watterson.
He says he can’t explain why the Larivees were first offered an appointment
three weeks away. ARC’s policy in even the most routine cases is to secure an
appointment for patients within one week. Still, the attitude at the clinic is
that “families need to be flexible,” says Watterson.
The Girl Wants a Girl Doctor
Meanwhile, Ronee’s behavior at school grew more alarming, as she would becomehysterical before even reaching campus. Ronee declared to her teacher she was
going to stab herself with a pencil; failing that, she’d get a knife from the
cafeteria to do the job. “She was ready to die to keep from going to school,”
Sheri says firmly. And there were days when Sheri and Tommy couldn’t muster
what it took to get a screaming Ronee out the door; the child began missing
school, and school officials were calling about her absences.
But along with extraordinary anxiety about school, Ronee was also increasingly
gripped by the dark fear that her parents would somehow get hurt or even
killed. “She started saying she was afraid something was going to happen to me
or Sheri,” Tommy says in a low, halting voice. “All kinds of weird stuff, just
coming out of nowhere.”
Well, maybe not exactly out of nowhere. During a conference at school, the
Larivees say, they were asked to confront the possibility that little Ronee had
been sexually molested. The horrifying prospect of sexual abuse seemed to jibe
with Ronee’s claims during the second weekend after the onset of her school
phobia that she didn’t want to talk to a man about what she was feeling. It
might be easier for her to talk to a woman, she told her mother. Unfortunately,
Ronee’s news put a wrinkle in the headway Sheri had made earlier that week.
After pleading again with staffers at the Austin Regional Clinic, she says, she
secured an appointment earlier than the first one she’d been allotted — but it
was with a male therapist.
Watterson points out that the ARC did offer, during a third telephone
conversation, to work Ronee in that same day — with a female “crisis intake”
therapist. But Sheri, the amateur, was operating with the understanding — and
perhaps it was a misunderstanding — that the school counselor wanted Ronee
assessed by a physician before she returned to campus. Sheri also says
her pediatrician’s office told her, too, that they believed that services from
a physician were warranted. The ARC female intake counselor was not an M.D. The
panicked Larivees, who both freely admit they were in quite an emotional state
themselves the day of this exchange (clinic records read, “patient’s mother was
extremely angry and absolutely hysterical”), told the ARC that they would talk
to them later. Instead, the desperate couple took matters into their own
hands.
Through a family member, they connected with a female therapist, M.L. Winter,
who was not in the Prudential network — although she was on board with several
other managed care organizations, fee-for-service plans, employee assistance
programs, and even Medicaid. Ronee opened up to Winter immediately. No, Winter
wasn’t an M.D., either, but Sheri says she didn’t know that at the time, and
later learned it didn’t matter very much — information that would have been
helpful to know when she was dealing with the ARC.
After a few sessions, Winter agreed that Ronee may have been molested. She
also determined that Ronee’s talk of stabbing herself amounted to much more
than a play for attention — “suicidal ideation,” it’s called in professional
jargon — it was a cry for help that needed to be immediately addressed with
hospitalization.
Winter says she diligently searched for a psychiatrist with hospital
privileges at St. David’s Pavilion (a Prudential network facility) who was also
an approved Prudential provider; when she did locate an M.D. who would take
Ronee’s case, she maintains, the company assured her that the admitting doctor
was approved as a Prudential in-network provider. Some relief for the Larivee
family was on the way at last, although Ronee literally went to St. David’s
kicking and screaming.
Stuck with the Bill — Again
Ronee received treatment at St. David’s for 42 days (though the majority of itwas day or “partial” hospitalization, her mother was told this was still
somewhat of a record for a child that young) where she was diagnosed with panic
disorder, anxiety, and depression. Halfway through Ronee’s treatment, however,
the Larivees learned from the insurance company’s case worker that the
admitting physician was in fact not on the Prudential network. What the
Larivees were originally led to believe is a moot point as far as Prudential
Plus is concerned.
This meant that their expected financial contribution was increased
substantially, as they were now liable for 30-50% of the charges, instead of
the 10-30% they’d anticipated. At this point, the Larivees estimate that they
owe at least $13,000 in medical bills — a daunting prospect for a couple who,
raising three children on their modest salaries, thought they had medical
insurance. It was difficult to decide which problem was more discouraging —
their child’s illness, or the fact that they would owe thousands they couldn’t
afford. But they felt there was no abandoning Ronee, because the therapy was
working.
Since Ronee’s aversion to school seemed to precipitate the whole crisis, she
was screened for learning disabilities (she has some). She was also determined
eligible for designation as “emotionally disturbed,” according to criteria set
by the Texas Education Agency; St. David’s doctors recommended that AISD also
evaluate her for special education. She eventually returned to school, but
transferred to a small class of so-called “emotionally disturbed” children at
Barton Hills Elementary, a much smaller campus than Kocurek. The source of
sexual abuse, if it occurred, is still undetermined. She continued therapy with
Winter after the hospital treatment — per St. David’s recommendations upon
discharge — making good progress, until Winter moved out of state a few months
later.
The untimely exit of Ronee’s trusted therapist didn’t have to threaten the
child’s recovery, as long as Winter was replaced with another woman, the
Larivees believed. Knowing that their financial burden with Prudential was
already beyond their means, the Larivees attempted once again to find a female,
in-network provider. One person told them she could not take on any new
clients; the other, after cheerily announcing that she was a good friend of the
insurance company’s case worker, proffered the opinion that Ronee didn’t need a
female therapist.
This was after a single session, the Larivees claim, during which the
therapist never spent any time alone with the child, and instead, directed most
of her inquiry to the two of them. It wasn’t that the Larivees didn’t believe
they needed to participate in Ronee’s recovery; they readily entered family
therapy with Ronee in the hospital. But out of all the indignities they
endured, Sheri and Tommy say, answering personal questions from a person they
were not sure they trusted (given the therapist’s admitted chumminess with the
very person assigned to keep a lid on costs and services) — and in front of
Ronee — was the worst.
“It’s like they sent her to work on me and Sheri,” Tommy says. “And we wanted
somebody to work with Ronee, and find out what happened to Ronee.” The Larivees
didn’t wait for Prudential’s next move; Ronee’s well-being was too fragile.
Although again, it was not their “choice” to do so, the Larivees found another,
female therapist for Ronee — out-of-network.
Determining “Medical Necessity” Prudential does provide for a three-level process of appeals when “members”
have grievances (although on January 1, 1996, the company amended this policy
to only two appeals). Sheri, rocketing between despondency and outrage, has
already exhausted all three of her appeals — during which, she says,
Prudential mangled many of the facts of her case. The company ultimately ruled
not to pay in-network benefits for any of Ronee’s treatment. Sheri and Tommy
are now contemplating what their legal recourse might be. The Larivees could
sue for bad faith practices, but with no money for lawyers and scant
documentation to back up their claims, there is little hope they could force a
sophisticated multi-million dollar corporation like Prudential to pick up the
medical tab.
Dr. Allan Chernov, M.D., vice president of medical services for Prudential
Health Care’s Southwest region, chaired the review committee for Sheri’s third
appeal. He says there is simply a “gap in perspectives” between Prudential and
Mrs. Larivee; the committee, upon reviewing the details of the case, determined
that “appropriate care” in the network was available to her. “That’s from our
perspective,” Chernov says. “Clearly, Mrs. Larivee’s perspective is that
appropriate care was not available.”
Yes, but what of the child’s clear articulation that a woman, not a
man, could help her? “I understand where the mother is coming from and why she
had a preference,” Chernov answers. “I’m not saying Mrs. Larivee’s preference
isn’t important. But the dividing line is medical necessity. In the final
analysis, gender was not a significant issue in giving her the care she
needed.”
Timeliness of services continues to be an issue in this case, too — Sheri and
Tommy have long suspected that had someone evaluated Ronee right away, during
the initial onset of her school phobia and rejection, the hospital treatment
might have been averted. Chernov does not subscribe to that theory, either.
“It’s not necessarily established that early intervention is critical” to
preventing psychiatric treatment later on, he says.
“Managed” Care or “Limited” Care?
A couple of Austin-area doctors strenuously disagree with Prudential’s
assessments of the Larivees’ situation. “School phobia is defined as one of the
few emergencies in child psychiatry, besides suicide — and they know that,”
says Dr. Deborah Peel, M.D., a psychiatrist active in political lobbying for
patients’ rights. “It needs direct and immediate attention.” She pronounced as
“absolutely wrong” Chernov’s opinion that early intervention in a mental health
crisis isn’t necessarily required. Too many medical studies have proven that
lack of psychiatric care contributes to increased medical services —
and costs, the very thing “managed care” is in business to keep down, Peel
argues.
Dr. Maureen Adair, a child psychiatrist, concurs with Peel’s opinion that
school phobia and/or school refusal is a serious problem because such behavior
is a sign of a child’s anxiety and depression. “Generally, the longer it goes
on, the worse and more entrenched it gets,” says Adair. She also believes that
a woman’s or child’s request to see a female therapist should make one wonder
whether abuse by a male might be a factor in the person’s illness. And what’s
more, Adair adds, for a therapist to zero in on family dysfunction or marital
problems when a suicidal child has just been released from the hospital — as
was the case with the Larivees when they first met with an in-network therapist
— is not appropriate; the child is the patient, not the parents.
“That’s sort of like taking her to a pediatrician and having the doctor ask
you about your health,” Adair says. But this sort of procedure is
endemic to the entire industry; managed care treats populations, not people,
Adair says.
Peel is even more blunt: “The idea is not to manage care; it’s to limit
access to care — at least, that’s the effect.” Peel is convinced that stinting
on psychiatry has become the tool for managed care organizations to balance
their budgets. She believes managed care is such a barrier to proper treatment,
she’s not even a provider on any plan in the Austin area. “They’re not trying
to provide the best quality at the lowest cost, they’re trying to manage the
flow of dollars,” Peel declares.
And haven’t the Larivees learned that? Oh, and along the way, they’ve been
taught a few other lessons, too: They are people without distinction, their
problems don’t move anyone who might be in a position to solve them, and their
tale is just another managed care horror story, that’s all. Whose fault is it
that they were so ignorant of psychiatry and counseling, doctors and hospitals?
What did they expect when they signed up for a deal with a plan like
Prudential’s, anyway?
“I thought I could look at this cute, nice list they have with all these
doctors on it and call one of them up and get my daughter treatment,” Sheri
says evenly, ruffling the pages of names of Prudential Plus’ preferred
providers. We’re spread out at their kitchen table, poring over all the
literature that came with Sheri’s policy.
“They were just like this rock,” says Tommy, tapping his index finger on the
slick, four-color, printed folder bearing Prudential’s familiar icon. “Every
time we tried to do the right thing, that rock would be right in front of us.
We’d have to try something else, go this way, go that way.”
And the Larivees say getting around that rock, never mind getting a piece of
it, has been impossible. “Their doctors wouldn’t see us when we asked them to,”
Tommy adds, after a moment. “We begged them for help.” n
This article appears in June 21 • 1996 and June 21 • 1996 (Cover).