Getting right to the point: If you are reading this publication, you are probably an informed health care professional who works toward the goal of providing the best possible treatment to your clients. Your efforts to reach this goal may lead you to feel frustration with every insurance company’s arbitrary guidelines. And, yes, I do mean “every,” and, yes, I do mean “arbitrary.”
I am an occupational therapist who evolved into a social worker. Throughout 20 years of practice, I observed that clients with whom I worked did not receive therapy as decreed by my professional ethics and practice guidelines. This was due to systemic and arbitrary insurance regulations. Why use the word “arbitrary”? The explanation is simple: I witnessed appropriate equipment to meet the medical and functional needs of certain beneficiaries receive approval, while other beneficiaries who had the same diagnosis and functional level were denied equipment for reasons not medically related.
A definition of “arbitrary” is “marked by or resulting from the unrestrained and often tyrannical exercise of power.” Does this definition evoke a familiar and uncomfortable feeling? It did for me, and continues to do so as I receive a multitude of consumer inquiries each month requesting support to navigate the murky maze of the US health care delivery process. These stories make me take pause, as they recount how our fellow humans are denied a reasonable, medically necessary request for equipment that will provide them with the opportunity to be independent. One might go as far to say it restricts the right of individuals affected by disabilities to have the freedom to participate in the community. At this point, the frustration level begins to become intolerable.
The community of individuals who use mobility devices is not asking for the moon, and I am reminded of this by the hundreds of consumer stories to which I have been privy these past 20 years. In my experience, mobility device users are usually, by necessity, very patient and tolerant. The individuals in this community are asking for equipment that allows for independence to go to a job, fix dinner, or use the bathroom alone. Do those activities sound high-rolling? (Pun intended.)
The current insurance guidelines do not embrace our professional ethics, nor our personal ethics. They certainly do not embrace mine. Every day, whether you realize it, you may be faced with ethical dilemmas such as the following: Is my focus on arbitrary insurance guidelines or my clients’ independence? Is my focus on the “system,” or on being an advocate for both the consumers I serve and my profession?
One solution to this internal struggle may be to understand the policies that affect your ability to provide the best treatment possible, and to actively participate in efforts to effect positive policy change. It can actually be invigorating, and almost effortless.
A good way to help bring about this change is to connect with a grassroots organization such as UsersFirst, an organization dedicated to keeping therapists up-to-date about pertinent issues without bogging down their inboxes. UsersFirst messages in an easy-to-read format and offers a simple way to take action. The organization will most often ask a therapist to include consumer stories. Each consumer story exponentially affects policy emanating from Washington, DC. Policy makers realize that one consumer story represents possibly hundreds of people who feel similarly, or who themselves are in similar situations yet do not have the opportunity to speak out. Take your practice to the next level and involve your clients in UsersFirst’s collaborative efforts to increase access to therapy and equipment that provides opportunities for independence—for life.
For example, UsersFirst, along with other organizations such as AOTA and APTA, are urging Congress to repeal the therapy cap. You can read about one clinician’s struggle to keep her clinic open and have the chance to make a positive difference today. As I mentioned, one of the promises of UsersFirst is to make it almost effortless for therapists to make their voices heard. Register with UsersFirst and follow the group on Facebook so you remain in the know from the consumer point of view.
Ann Eubank, LMSW, OTR/L, ATP
