In this medical fiction, Max wields his stamp with zeal, evaluating prior authorizations by cost rather than quality, as Silvia’s symptoms force her to navigate the same greedy system.
This is one of a collection of stories that are like “Final Destination” meets “The Monkey’s Paw” (W. W. Jacobs, 1902). As such, they are tragedies more than either mysteries or horror, and would appeal most to readers who enjoy the inexorable pull of a story arc that leads to doom. In each story, a protagonist makes a wish that comes true with fatal results for someone, often the person making the wish. Nothing supernatural, but just how things work out. (Or is it?) The technical details surrounding the fatal (or near-fatal) event are drawn from real cases in the US OSHA incident report database or similar sources and are therefore entirely realistic, even if seemingly outlandish. The plots draw lightly from cultural beliefs around actions such as pointing at someone with a stick or knife, wishing in front of a mirror, or stepping on a crack.
Max was a gatekeeper of life or death.
Sitting in his office chair at a dark oak desk, a green-shaded brass lamp pooling light over a surface crowded with paperwork and office supplies, Max dictated the future. With a simple rubber stamp, he could assign entreaties by physicians or members to be authorized or not. In one slim pile in the far corner of his desk, there were pre-authorization forms to be processed with a conditional promise to pay. In a bulging stack squatted directly in front of him were those stamped “DENIED.”
More officious than evil, Max wielded his rubber stamp with an imperious zeal that was long on the contractual letter and short on the caring vision. While the vision and mission statements of the health insurance company weaved a tapestry about caring and quality, the ethos that Max had internalized was all about the money. To meet this shadow-mission, Max evaluated authorization requests in terms of opportunities to deflect cost, rather than to ensure that members received medically necessary, high-quality care. It was also not the case that his manager, the department head, or the executives wanted to gouge members or inflict suffering, but that the performance metrics by which managers and clerks were judged were all about cost avoidance. This was not a unique issue in the industry; it was tediously frequent among organizations whose lofty humanistic vision and mission statements didn’t align with how they measured performance. The vision might extoll care and quality all it liked, but what people were measured by was profit and speed.
Silvia was sick. Her recurring bouts of fever and cramps had been a mystery for months. Finally, she got the one thing almost as good as a cure: a diagnosis. It had been over a year since the first time she had been doubled up on the bathroom floor in the early hours following a Sunday spent with her parents. The severe cramps, nausea, and time spent miserably crouched over the toilet had finally come to an end as a cold gray dawn rolled in like the freezing fog off the lakes. She had thought it was just one of those things, maybe the spicy wings her mother had insisted she eat to “put some meat on your bones and color in your cheeks.” It could also have been the egg salad brought by her aunt, or the cherry pie made by her sister-in-law, or, she thought grimly, it could be that other thing. On her way home from work, she picked up two pregnancy tests and ruled that one out.
Already a dimming memory by Friday, she was not expecting to be curling up on the bathroom floor again, hot and prickly, alternatingly gushing at both ends. This time she had not visited her family and had not eaten anything that was a likely cause. Again, it mostly cleared up by the next day, but this time she scheduled an appointment with her primary care doctor. In the 4 weeks she had to wait for an appointment, it happened again three times, and the last took her to the ED. She had to wait 4 hours for a doctor, but the triage nurse had already mostly ruled out appendicitis, obstructed bowel, and a few other things. The doctor was nice, but very focused on getting her admitted or getting her out, and couldn’t find anything life-threatening. After 3 minutes with the doctor, she was walking out with a prescription, a referral to gastroenterology, and an invoice for $1,286. Since she was generally healthy, and had not reached her deductible for the year, the entire bill was hers to pay.
Silvia settled into a rhythm of sorts—a few days of normal life in which her fevers, chills, and tempestuous bowels receded, and she almost forgot about them. But then came the hangover period, a sort of payment in pain and debasement for wishing to have a normal existence. On those days, she would writhe and make the sounds of a wounded animal, alternating between stripping to her underwear and cocooning in a blanket and grabbing for a bucket or staggering to the toilet. The pain and cramps made thinking impossible, and the retching and gushing focused her mind on death. She saved up as much money as she could, and months later when she judged it enough, she booked an appointment with the gastroenterologist.
The three encounters sandwiched between tests soon wrung her savings into a pile of dry receipts. The probes that snaked their way up into her bowels, or down her throat, ruled out many causes, and the stool, blood, and tissue harvested from her body eventually pointed to another specialist of a different medical denomination. The knowledge came at a price, of course, and having met her annual insurance deductible of nearly half her annual earnings, she was now begging the insurance for the treatment to be pre-approved for payment. With help from the nurse, she outlined and then hand-wrote a letter explaining how the illness was draining her life away, and that she did her utmost to live healthy. She attached a letter from the specialist with a carefully laid out clinical argument for the proposed treatment, and another from the primary care doctor who gave the case history and motivations. By the time she licked the glue and sealed the flap, tears of fear, frustration, and hope were leaving little damp wrinkled pawprints on the envelope. She then settled into a new routine of on-again, off-again days layered beneath the low cloud cover of waiting in hope for an approval.
Max cursed the stinging paper cut he got while tearing open the fat pink envelope. He contemptuously scanned the member motivations, read the physician’s notes with a sneer, and reached for the well-used rubber stamp. The standard treatment of antibiotics had already been tried, and the new generation of fluoroquinolones proposed by the specialist, in the eyes of the insurer, had not yet made the transition from experimental to general use. It wasn’t that the clinical argument was flawed, or that the use of the drug was unlikely to be effective, but that if there was an interpretation under which the insurer could refuse, then Max took that path. Simply put, Max was not in the business of paying claims because of their merit, but paying those for which he found no way to reject. With a deft and highly practiced wrist, he flipped Silvia’s paperwork into a large plastic bin besides his desk for all those unhappy claims that would be digitized and trigger a computer-generated refusal letter (and tallied towards Max’s annual bonus). His DENIED stamp was like pulling a lever that printed money.
It was nearly a week before his pale and drained face looked blearily back at him in the bathroom mirror, and hours before the bacteria introduced through a paper cut had led Max from sweaty seizures to convulsions, heart failure, and death—all from a speck of the glue that had sealed the envelope, licked by the girl with chronic salmonella.
