Precertify this!

To: my so-called health plan

From: Alice

It has come to my attention that the word "insurance" does not appear anywhere near the word "health" anywhere in the opening pages of your 200-page book, the one you would prefer I not request as hard copy. "Curing the sick" is not even on your priority list.

Well, I read the damn thing, and the sum total is, if I am told I need a test more serious than blood, piss, a pap smear or a chest X-ray, my "health care provider" can neatly ignore what the radiologists, who specialize in reading films, have to say.

The buck did not stop at the doc-in-a-box office: she sent it flying off to the hands of the money-grubbers, those anonymous people whom I cannot telephone to argue for myself. My health is in their hands, whomever they may be, the "precertifiers."

If any of them has an M.D., I'm betting s/he works for the "insurance" company because no one would have him/her as a clinician or researcher. The guy who graduated last in his med school class, the one who is called M.D. nonetheless? That would be, should Cambridge (my nom de blog for the "health plan") actually employ someone with any medical training, the one who turns down my test.

This would be the idiot at the other end of the 800 line, paid to refuse to agree with the medical opinions offered by my first-line "health care providers." This leaves me either with large uncovered medical bills from the better doctors in this town, or it leave me being screwed, and possibly ill.

Notice the term "health care provider." Sounds like anyone from the clerk at the big-box drugstore chain to a kind stranger offering a Kleenex. Does not have that authoritative ring that an M.D. once implied. Apparently the health care (insurance?) provider has the last call.

Primary care means, I have discovered, if you can't diagnose based on years of experience, you will cover your ass by calling for expensive scary tests, then refuse to follow the advice of the radiologist, and blame it on my insurance. If you are a doctor employed by one of the mismanaged nightmare plans, you are not going to be my advocate.

An M.D. with experience and balls, however metaphorical, might fight for me to have what is deemed the next logical step in the flow chart per her outsourcing. But that's not how my health care plan works, and I'm betting yours is no better than mine.

Cambridge has decided it's not in the patient's (that would be me) best interest to follow through, on the grounds the next test is too expensive to bless. I wonder how the company will feel if, ultimately, I do get the damn test and it shows me lighting up like a Christmas tree. Will Cambridge then decide I don't need an oncologist?

That would be me, the patient, self-payer of $10,000 a year and rising for my health care. New discovery in the road to middle age: a "health care provider" is fine for, say, the chicken pox or the flu. If, however, you go in with a smoker's cough, you will find the PCP has never met a smoker in her practice.

Never heard of Nicotrol, the nicotine inhaler used to get smokers to stop and too scared to write the script on her own. Ever hear of a doctor NOT jump all over the smoker to help her stop? That's my "primary care provider." I should see a pulmonologist to confirm the need for medicinal nicotine.

Never mind that I control my own nicotine intake, and it's certainly got a lot more nasty chemicals in it than the prescription kind. Or that my lungs came out clear on the CAT scan. Where did the PCP get her M.D.? I'm afraid to ask. Her decision-making abilities, not to put too kind a description on them, suck.

When I asked her to act as my advocate, the go-between between Cambridge, which doesn't want to cover me when I may be sick, and her own medical opinion, she responded with a vote of no-confidence on pushing for what I need. I'm not sure she has her own opinions; her voice is never long on confidence.

Apparently it is my job to remind the doc that if she wants me to have a test, she may need to push for it with the precertification department. Not going to happen. Yea, that guy who was last in his class certainly knows more than someone who has seen the actual patient. Ha.

I doubt this doc-in-a-box would even prescribe an antibiotic for what could just as easily be bronchitis. And I don't need any degrees to know what bronchitis feels like.

But we are way beyond the chest X-ray. Went for the (preapproved) CAT scan, and independent radiologists offered up the PET scan as the next step in the testing process. Then Cambridge steps in, and says, not enough evidence.

Hmmm: I've seen the radiologist's report, and it is pretty damn clear what is supposed to follow.

Not from Cambridge, it's not. Who the hell makes the medical call of "sorry, too expensive. Wait until you feel like you're dying, and then we'll, say, send you to hospice"?

Who need a hospital when you can go straight from your own bed to the one that says, here's the last place you'll be on this earth? No, let's keep the costs down, and hope that one day, one of your Cambridge employees, needs this test. Then she will know how it feels, to be on the other end of test? You want a $5,200 test? Oh, no -- no precertification forthcoming. Not in the cards.

When the "health care" provider starts the bidding at four no-trump, the game is over before it begins. Cambridge has all the cards, and it specializes, it seems, in dealing its customers/consumers/suckers the hand without even one heart in it.

Our system is broken, clearly, but I don't have much faith in so-called reform, despite being a yellow-dog Democrat. Even with "insurance," we already have rationed health care, and I can't imagine the next round will cover my health needs any better than the crappy system in which I am enmeshed.

One of my closest friend's mother was diagnosed with lymphoma last week. This week, she's already gone for round one of chemo. She is 80, and recently she said, "old age is not for the faint-hearted." Her daughter, a veteran of the cancer wars, is a great advocate for her.

For the rest of us, however, her mom would say, 'It's a great life if you don't weaken."

The ex-wives club

Since the papers have been signed, I count four ex-sisters-in-law, only one of whom I care about. Ex #4, A., is the mother of my niece. Despite the not-so-surprising end of the marriage, I want to stay on good terms with her. I need the connection.

A. has physical custody of my one and only niece, Kay, who is my link to the next generation. How to make nice with A. without disturbing my brother? Friends say, send Kay postcards (not that a 2 1/2 year old can read), presents, and so forth -- just to keep my name in the air in her mother's household.

When Kay gets a little bit older, I'll start sending family photos, with lengthy captions explaining who's who. I'll write her stories about my dad, the grandfather she will never have met. I'll write stories about my brother, about my mom. I will be the witness, Kay's link to a family she otherwise may know only when we die and she inherits.

In the meanwhile, I have befriended A. on facebook. We have the occasional chat -- about her school, work, and my niece. FB is good for keeping in touch from a comfortable distance. When I'm typing instead of talking, I am more deliberate in what I say.

In some ways, that cuts down on the misinterpretation factor, but at the same time, so much is left out: the body language, the facial expressions, any visual clues. This is always the problem with e-communications; here, it's exacerbated by the speed with which a typed chat occurs.

I keep clear of any mention of my brother. Today, however, I'm wondering how to interpret A.'s status. A. "is happy that things are looking up. for a change:)." Dare I ask why? I think not. I'm curious, but at some point I have to be an observer.

Occasionally I wonder: what would happen if all the ex-wives got together? Each one took my brother's last name. It might be confusing: "Mrs. Uptown, this is Mrs. Uptown, this is Mrs. Uptown, this is Mrs. Uptown."

Did they revert to their previous surnames? From Social Security to the DMV, Department of State (ex # 1 was the sole passport holder), the IRS, and whatever other government institutions in the need-to-know loop, that's a lot of bureaucracy to contend with. Each one said, "I do," then after fewer than three years (each) said, "I don't."

Hard to know why any of my brother's marriages ended: we are not a family to ask for details best left unspoken. All I know is, each time he says, "I should never have married her." That's four "hers" now, and we hope he won't take the plunge again.

Honestly? I want to take all of his divorce papers and hide them in New York, so the next time he has the urge to merge, he has to get on a plane to fetch the papers. At least it would buy some time. He may be over the marriage thing, finally, though his track record suggests otherwise.

After wife #2 didn't pan out, I stopped getting invested in my brother's partners. I assumed he would always have one, but that she was subject to change. No point in my even knowing the maiden names of the women in the ex-wives club. I do have some recollections, however, not just of their names:

Ex #1 was Smith (sic) ; ex #2, not a clue; ex #3 was Cluck or Gluck or something to that effect, courtesy of her first husband; ex # 4, Kent. Looks like surnames of one syllable have been popular. And what would Emily Post say? Not sure she covers that territory.

A quarter of a century ago, Miss Manners did: "the truly correct style is to combine Mrs. with your maiden and [married] last name...but few people use it nowadays." By that rule, ex # 1 would be Mrs. Smith Uptown. However ex # 1, like her successors, was not the type to have heard of Emily Post or Miss Manners.

Ex #1 was, to put it mildly, a bitch on wheels. (Another epithet comes to mind, one rhyming with "bunt.") Of the group, she was the most educated -- and the one who lied on her financial aid application for law school, saying she was single to get a scholarship.

If she hadn't known so many family secrets, I would have made sure she got had gotten hit by payback. But I couldn't. What I know is, payback's a bitch unto itself. Perhaps karma will take, or have taken, care of her. My brother left her on Christmas day, the best present he ever gave me.

She made out like the proverbial bandit: after she and brother were through, my brother, who should have had a prenup, had no nup left to pre. Her list of parting gifts was extraordinary: a house, a car, law school tuition, a set of sterling silver my brother had inherited, and a lot more that I can't remember, seeing that the marriage ended in 1991.

Her father was an Episcopal priest. At the wedding, someone dug up a rabbi to hold up our family's end of the heritage. I was pressed into service as a bridesmaid. (I wanted to set fire to the acetate dress, but refrained.)

My father, who was the best man, forgot his cuff links and had to sew buttons onto his shirt. We were late to the ceremony, and you don't need Freud to figure out why.

That was brother's only church (did I ever say we were religious Jews?) wedding; the rest were City Hall specials that sounded about as exciting as renewing a driver's license.

Wife #2? That was more of a drive-by than an actual marriage. They pledged their troth (tell me, what is troth?) after eight weeks together, and divorced two years later. She was the daughter of Jehovah's Witnesses and had even been christened or baptized or what have you herself.

When I heard about her religious background, I hoped no offspring were forthcoming -- because I didn't want to have nieces or nephews raised as little door-knockers offering up copies of the Watchtower.

#2 took Oprah as gospel, which I didn't realize when started pondering aloud about the power of the media and how warped it could get. Whoops. Put my brother between a rock and a hard place. I remember telling him I would get on the next plane out of town if it would keep the peace.

Prior to marriage #3, my brother's mother-in-law to be took me aside and asked about my brother's "intentions." Excuse me? Intentions? Of a 35-year-old man with two ex-es already to the good?

Wife #3 came with two children, though motherhood was not her forte. The elder daughter turned into a teenage terrorist who proved incorrigible, not that her mother helped. Elder daughter got locked up in juvie jail, and upon her release, had to have "piss tests" whenever the authorities wanted. This put a crimp in wife #3's style, or so she bitched to me.

If we had national health insurance, I suspect wife #3 would not have gained her position. Sure, my brother liked to get married, but this time, it seems, his employee benefits were a major attraction.

The third segued into the fourth, who was half my brother's age. Now he says he married her to give his child a father. Okay. Wife #4 hadn't had a legal father of her own, that I knew of. And that marriage did produce my one-and-only niece, whom I adore. Still, was the paperwork necessary? Couldn't he just have put his name on the birth certificate?

For various reasons, including the fact that gay marriage isn't legally recognized by the IRS, I have never been formally married. What amazes me is, my brother and I grew up in the same household, saw the movie of our parents' lives unfold together.

Perhaps one of us saw the director's cut and the other saw the dailies. In any case, marriage never struck me as a good deal, though it struck my brother as the best thing since, yea, sliced bread. Our adult lives have unfolded in such different directions that I don't even feel I can ask, why marry? Or maybe I don't want to know the answer.

What I do know is, I have a niece, and I want her to know me as more than Aunt Alice swooping in from out of town for a few days a year. I don't know how I'll achieve that, but I'm hoping my current strategy will be the right one.