Chapter 17 : A Claim of a Right to Health Care

Section 5. Case Study

“Managed Medicaid at it’s Worst ” by Alison Prunty (NCC, 2009)


Billy is a 26year old man with developmental disabilities. He was born with cerebral palsy and suffers from physical and intellectual handicaps. He is wheelchair bound, incontinent and can speak only a few words. He currently resides in a private group home that is supported by a nurse 20 hrs per week for medical oversight, house managers and numerous staff who provide direct care, 24 hours a day. His medical and daily living needs are met through the collaborative effort of the support team. Billy’s family is involved in his life. They frequently visit him at the group home. Billy was covered under his Dad’s medical insurance up until 1 year ago, when it became too costly for his parents to maintain. Like many other developmentally disabled adults, he now only has NY State Medicaid. Unfortunately, he was forced to change his primary care doctor of 15 years due to his new Medicaid status. A few months ago on a Friday evening, Billy came down with a fever and had some drainage in his brief.  The nurse sent Billy to the local ER with a direct care staff, for a work up to rule out a urinary tract infection. The ER was packed with people waiting to be seen. Billy waited over 8hrs to see a doctor. When they finally examined him, they did not even bother to catheterize him and obtain a urine specimen. They discharged him with a prescription for a broad spectrum antibiotic not normally used to treat urinary tract infections and instructed the staff to have Billy follow up with his primary care doctor on Monday.  Over the weekend his fever was managed with Tylenol and he continued to have a discharge in his brief. On Monday morning at 9am Billy was taken to see Dr. Lee, his primary care doctor, by a direct care staff. At 2pm, Billy was still not back from Dr. Lee’s office. The nurse began to call the staff member on her cell phone to find out why they were not back yet. “We’re waiting for a test,” said the staff member, Gina. “What test?” asked the nurse. “A test to rule out any problems with his neck,” Gina stated. “His neck! He’s there for a urinary tract infection. What are they doing? I’m calling the office now.” The nurse called Dr. Lee’s office right away. She got the receptionist who told her that Dr. Lee was seeing patients and he would call her as soon as possible. At 4pm, Billy returned to the group home. The nurse was paged came to the residence to review the paperwork from the visit. Billy had under gone a thyroid sonogram, echocardiogram, and carotid doppler while at Dr. Lee’s. Although Dr. Lee had changed Billy’s antibiotic to something more appropriate for a urinary tract infection, he failed to do a simple, inexpensive urine test to confirm that Billy did indeed have a urinary tract infection. Instead a man who cannot walk, talk or complain waited in his doctor’s office for 7 hours to have 3 unnecessary tests performed and his bill “padded”, so the doctor could make a few extra dollars. By Monday evening Billy had been in pain and with fever for 3 days. He had spent over 15 hrs waiting to receive treatment for a simple urinary tract infection.


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© Copyright Philip A. Pecorino 2002. All Rights reserved.

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