For almost 10 years my electric scooter has given me the physical independence, control and purposeful motion long since eroded by multiple sclerosis. Nonetheless, the scooter is heavy and awkward to transport, and a manual chair works better in certain circumstances. Deciding to get one, I plunged into the health insurance maze.

When I purchased my scooter, my gold-plated indemnity policy had covered wheelchairs, but not scooters. A scooter, they said, was a "recreational vehicle" analogous to a golf cart. Despite indignant calls from two neurologists, the insurer held firm, offering to fund a four-wheeled electric wheelchair (then about $4,500) but not a scooter (roughly $2,300). I paid for the scooter myself.

This time, after years of managed care, I was schooled in the drill for approval. "Absolutely," wrote my primary care physician (PCP) by return e-mail. "I'll support your getting a manual chair." Thus armed, I telephoned my managed care company (MCC). After 10 minutes navigating the automated answering service, I reached a human who concurred. "Absolutely. We'll cover your wheelchair."

Four weeks then elapsed, four weeks of unreturned calls and misdirection. In the first false start, MCC's designated dealer only rented chairs and only offered a single model --a no-frills version with a sling seat and no options. When I protested, MCC steered me to another authorized vendor, Devi-Deals. I was assigned their sales representative, Joe Corrigan,* who was to handle everything. As scheduled, late one afternoon, Joe arrived at my office pushing a wheelchair in basic black and carrying glossy pamphlets advertising different models.

While not an expert, I know that wheelchairs have biomechanical implications. I know they should fit well and be chosen with some consideration given to the user's physical needs and personal lifestyle. Joe readily answered my myriad questions. Nevertheless, I felt uncomfortable allowing him, alone, to direct this important purchase.

* Names of people and vendors have been changed.

"Don't you see the conflict of interest?"

"What do you mean?" Joe responded genially.

"You represent Devi-Deals. On the one hand, you have an incentive to recommend the most expensive chair to make the biggest profit. But on the other hand, under managed care, you want to keep MCC happy with Devi-Deals so they continue your contract. That gives you an incentive to suggest the cheapest chair."

Joe seemed perplexed by my discomfort. "I decide what to get people all the time."

I shook my head. "Look, I'd just like a little professional help deciding what would be best. Let me call around and get back to you."

The next day I called a physiatrist friend who proposed that I attend their "seating clinic" for an assessment by a physical therapist expert in wheelchair evaluations. Forearmed with another PCP approval and the MCC referral number, I made the appointment. Everything seemed set until their scheduler contacted me several days later.

"You can't go to that wheelchair clinic," he said. "You have MCC insurance. You need to come to the Devi-Deals clinic."

"What do you mean? Is the clinic run by the Devi-Deals salesman?"

"Yes. He has to be there."

"Isn't a physical therapist in charge?"

"Sure, there's a physical therapist. But the Devi-Deals person is there, too."

"Isn't this a conflict of interest?" I realized that my question was largely rhetorical and expected no answer.

"That's the only option for you with MCC," he reiterated, unruffled. I made the appointment.

The Wheelchair Clinic

Arriving early, I parked my scooter in the hallway outside the physical therapy unit to await my turn. The hall was busy. Around me, newly disabled people took their first walks, encouraged, exhorted or cajoled by vigilant physical therapists. A tall elderly man and a short elderly woman, obvious survivors of strokes, walked unsteadily, encircled by guiding arms of therapists. Another woman, slightly younger, arose from a wheelchair on her one remaining leg, the physical therapist silently positioning her walker in front. The woman hopped toward me, arms straining with the paired imperatives of remaining vertical and moving forward. Reaching her destination after five yards, she slumped, exhausted, into the waiting wheelchair. The women smiled at me, shyly but with implied connection.

The young man striding down the corridor struck a decidedly dissonant note. "Remember me? Joe." He grinned.

Distracted by my thoughts, I had not immediately recognized him. "Corrigan," I instantly rallied, trying to ignore his tacit victory. Yes, Devi-Deals would now participate in my theoretically objective wheelchair evaluation. Joe seemed conscious of his ascendancy as we went into the back room to meet Nancy, the physical therapist and expert in wheelchair evaluations.

Nancy and Joe had obviously worked this Devi-Deals clinic many times before. They bantered back and forth, easily and respectfully, about the latest news of shared professional acquaintances, meanwhile seating me on a wide bench covered by a gym mat. Nancy operated the control that lifted the bench until my feet dangled freely. Then they each produced a tape measure and positioned themselves on either side of me. On cue they proceeded, a bilateral team, to measure various dimensions of my body.

Tennis Game, Match Point

"Twenty-two inches," led Nancy, the professional.

"Check," concurred Joe, jotting in his notebook.

"Nineteen inches," called Nancy.

"Right," replied Joe, jotting again. In the single instance of disagreement --by one-quarter inch-- Joe conceded to Nancy's authority. Measurement accomplished, they moved to the wheelchair's specifications. Here, the professional authority remained Nancy's, but the power base for decision making clearly shifted. More than a dozen decisions were required, such as the type of seat cushion, back support, wheels, pushrims, tires, armrests and footrests. A pattern arose.

"What would you like?" Nancy would turn to me, outlining options for a given feature.

"What would you recommend?" I would reply, acknowledging my ignorance, her expertise and her presumed advocacy for me.

Nancy would state her preference. "OK," I'd say, and we'd both turn simultaneously toward Joe. He, the Devi-Deals representative, controlled the order form. If there was a conflict of interest, this was the moment of truth. In most instances, Joe scrunched his nose, paused briefly to consider, then ticked off Nancy's recommendation on the form. But other times, Joe and Nancy battled --politely and professionally-- and money was clearly the issue.

"You should get a quad axle release," Nancy would say. "It will make things easier."

"No, no, not necessary," said Joe as he buried his face in his paperwork.

Nancy signaled her dissent to me. "See, it's expensive," she told me semi-surreptitiously but archly, clearly intending Joe to hear. "They don't want to pay for it." Joe, MCC's proxy, didn't contradict her, but steadfastly refused her suggestion. In other instances, he talked her into a lower-priced option. Reluctantly, she would concede his choice was almost equivalent to her preference. Almost. Clearly beyond my expertise, I couldn't judge whether these "almost" options were mainly cosmetic or had functional significance.

With the back and forth, the Devi-Deals clinic felt like a tennis match. My head rotated from side-to-side, watching the ball --my wheelchair under construction-- bounce between Nancy and Joe. Usually the omniscient hand of managed care is like the Wizard of Oz, controlling events from behind its curtain. Here it was in full view. Nevertheless, I was comforted by Nancy-the-expert's general equanimity.

With only one instance of paperwork gone astray, MCC approved my wheelchair specifications, and six weeks later Joe rolled my new chair into my office. Compared to the standard-issue manual chairs I'd used in airports and hospitals, my new wheelchair felt like a dream. Whether I would have gotten what seemed a deluxe model without my insistence on the seating clinic remains imponderable.

What about others without my knowledge, persistence, connections and access?

Lisa I. Iezzoni, M.D., M.Sc., is Professor of Medicine at Harvard Medical School and Co-Director of Research in the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center in Boston.