HMO Reality Check

If a symptom manifests itself in the specialist’s office but is not specified on the primary care provider’s referral, is the pain real? Whether this is a problem of metaphysics, rhetoric, or distributive justice, I learned that it is at least one of these when I broke my foot and experienced a variety of annoying complications, only some of which were physiological (also rediscovering the astonishing truths contained in the old song that goes "The leg bone’s connected to the knee bone…"). As it happened, I had recently switched over to an HMO for the first time, and my accident presented the first opportunity to try it out. I quickly learned that in this new world, just like on the television show Voyager, you have to understand the system if you want to see the doctor (well, unless you are some kind of alien life form whose mere presence may constitute a threat to the entire population of the ship and maybe the galaxy but they have to examine you to be sure, in which case standard rules may not apply).

When 7 of 9 gets banged up a bit helping the Voyager crew ward off Q or some other menacing creatures whose names I can’t remember, she knows she’s not going to get any help from the doctor if she shows up when he’s off on the Holodeck, or more to the point, when his program is not activated. Similarly, I had learned the important lesson: if a tree falls in the forest and breaks something, it won’t get in to see the nearest tree surgeon (on its plan, it goes without saying) without a referral from its primary care provider.

On what was probably my third or fourth visit to the orthopedist after my accident, I brandished my fresh referral cheerfully and confidently (to the extent one can make such a gesture teetering precariously on crutches), proud that at last I understood the System. (One might think an alert philosopher would instantly recognize this as a sign of delusion, expecting order and coherence where one knows it is not to be had. It’s true they did warn me those painkillers might have "cognitive effects.") I reported my new symptom of knee pain to the nurse, and asked whether she thought the doctor would want an x-ray. "Is it on the referral?" she asked. "What do you mean?" I replied uneasily, in my last moments of innocence. "Each injury has to be specified," she said sternly. "But this is all from the same injury!" "No, each body part has to be specified on the form in order to be treated. Which knee is it?" she asked briskly. "The right one." "Well, if the referral doesn’t list your right knee, then you can’t talk to him about it and he can’t look at it or treat it," she said before shutting me in the examining room. I felt a little uneasy sitting there alone with the Body Part That Dares Not Speak Its Name, but by the time the doctor entered, I had mustered the courage to speak out, defying the Health Maintenance Regime and yes, taking perverse pleasure in it. Yes, I was part of the Resistance, waiting to see how this act of defiance would be met. Thrillingly, the doctor was more than ready, discussing knee pain and even glancing at my right knee once or twice. Of course, it was behind closed doors, so he may well have denied the whole thing later.

The significance of the referral form as primary ontological determinant surely has startling philosophical implications (not unlike the lyrics of the artist formerly and currently identified as Prince—and it’s still not too late to send in those contest entries to alw@gwu.edu! But I digress). I will leave these to others, only noting that the HMO, not unlike Voyager’s doctor when he experiences a Holodeck malfunction, is in dire need of (medi-)metaphysical therapy. But what does the referral form look like? (It’s a new contest! Maybe even a new philosophical specialization! Please send your answer to alw@gwu.edu.)