fbpx

What Is The Role of Health Insurance?

What Is The Role of Health Insurance?

[Mark Lopatin, MD: How much of a role should health insurance companies have in determining the care that an individual patient receives?]

Jeffrey Lurie is the owner of my beloved Philadelphia Eagles.

He pays the players.

He picks the coaches.

However, I think we can agree that his checkbook should not allow him to be the one who calls the offensive plays.  The coach should do that.

 

So why is it different in health care?

When I was in practice, I had a patient who was diagnosed with polymyositis, an autoimmune disease that causes inflammation of muscles and generalized weakness.

It is treated with high doses of steroids to reduce inflammation and also with medications, such as Imuran, methotrexate and IV immunoglobulins (IVIG) to suppress the immune system.

My patient had all of those treatments without success.

She continued to have weakness and was unable to work.

Options were limited, but there was one another appropriate medication to try.

Rituximab had been studied in polymyositis. UpToDate recommended it for treatment of refractory myositis and in fact, promoted that it be used prior to IVIG, which my patient had already received.

So I decided to start this medication for my patient, but her insurance company denied it because its use was considered off-label for polymyositis.

The next step was the usual “peer to peer” to get the medication approved.

 

My peer to peer discussion was not with a rheumatologist, but rather with a pediatrician.

He would not approve the drug, because it did not meet the insurance company’s “guidelines”.

(By the way, when did guidelines become mandates?)

 

My peer to peer discussion was not with a rheumatologist, but rather with a pediatrician. He would not approve the drug, because it did not meet the insurance company’s “guidelines”. (By the way, when did guidelines become mandates?) Click To Tweet

 

He recommended that I appeal the decision, which I did.

Three weeks later, I was informed that the appeal would take at least another month because there were so many other appeals that had to be processed.

What does it say about the insurer, that physicians feel the need to appeal so many decisions?

 

Three weeks later, I was informed that the appeal would take at least another month because there were so many other appeals that had to be processed. What does it say about the insurer, that physicians feel the need to appeal so many… Click To Tweet

 

Clearly there is a great divide between practicing physicians’ opinions and insurance guidelines.

An insurance representative assured me that she understood my frustration.

I exploded, “Don’t tell me you understand!  You have never had to speak directly to a patient to tell them that their care is being denied.”

 

An insurance representative assured me that she understood my frustration. I exploded, “Don’t tell me you understand! You have never had to speak directly to a patient to tell them that their care is being denied.” Click To Tweet

 

I asked if I could do a peer to peer with a rheumatologist, and was told, “No, you have already had a peer to peer.”

I asked for an expedited appeal and was told, “No, only if the illness is immediately life threatening. Your patient will just have to wait.”

 

Ultimately, working through the Pennsylvania Medical Society, I was able to speak with the insurer’s senior director for medical health services for the northeast region.

She was extremely helpful (the only one who was) and ultimately the medicine was approved within 24 hours.

Overall this whole process took several hours of my time over several weeks.

Much of that occurred during patient hours, and other patients were inconvenienced, while I repeatedly waited on hold trying to resolve this.

 

This case raised many questions.

Who should be making medical decisions (calling the offensive plays): the person/ company with the checkbook (the team owner) or the doctor (coach) who is taking care of the patient?

Insurers say that they are not dictating care. They are simply deciding what they will and will not pay for.

However, when they decide this on the basis of medical information presented to them, they are essentially practicing medicine on patients they have never seen.

Is that what we want for our health care system?  Is that who we want calling the offensive plays?

 

Insurers are essentially practicing medicine on patients they have never seen. Is that what we want for our health care system? Is that who we want calling the offensive plays? Click To Tweet

 

What are the solutions?

There needs to be much better education of patients and transparency as to what insurance policies cover.

Many patients have no idea how their insurance works.

Guidelines should be just that, guidelines, rather than mandates.

If a procedure or medication is denied, I the insurance company should be required to provide an explanation other than that it “does not meet our guidelines.”

A transparent rationale for denial by the insurer, even if they simply were honest about the cost factor, would go a long way toward alleviating my and many other physicians’ frustrations.

Furthermore, a pediatrician should not be reviewing the care provided by a rheumatologist.

 

A transparent rationale for denial by the insurer, even if they simply were honest about the cost factor, would go a long way toward alleviating my and many other physicians’ frustrations. Furthermore, a pediatrician should not be… Click To Tweet

 

As a society, we must decide what we want from insurance.

Our auto insurance does not cover routine things like oil changes.

Our homeowners insurance does not cover house painting, but if it did, should the insurer get to choose the color of the paint?

 

As a society, we must decide what we want from insurance. Our auto insurance does not cover routine things like oil changes. Click To Tweet

 

Should health insurance cover routine things like doctors’ visits? If so, what exactly should routine care include?

Is the goal of insurance strictly to protect us financially from catastrophic events?

These are all legitimate questions that need to be answered.

 

Also, we have to decide how much financial risk patients should be responsible for.

If an insurance company is footing the entire bill, it is understandable that they would want a say in how that care is delivered.

The question is whether they should have complete say.  This is not an easy balance to determine.

 

The ultimate question is how to practice cost cutting population medicine without sacrificing care to the individual patient, as occurred with my patient.

Do we really want the insurance companies to be the absolute dictators of care?

If so, then they need to be held accountable for the decisions (denials) they make, and the decisions they make must be transparent to physicians and patients.

Insurers need to be cognizant of how their decisions affect individual patients’ lives.

We need open dialogue between insurers and practicing physicians re these issues to try to find an equitable compromise.  Our patients, and perhaps our profession, depend on it.

Do you have a compelling personal story you’d like to see published on SoMeDocs? Find out what we’re looking for here and submit your writing, or send us a pitch.

Share

Earn CME

This learning experience is powered by CMEfy - a platform that brings relevant CMEs to busy clinicians, at the right place and right time. Using short learning nudges, clinicians can reflect and unlock AMA PRA Category 1 Credit.

Leave a Reply

Your email address will not be published. Required fields are marked *

Mark Lopatin: If physicians are not willing to fight to protect our profession, who will?

Mark Lopatin MD, FACP, FACR, FCPP

“Health care should be a human interaction between a patient and a physician, rather than a business transaction between a consumer and a provider”

Affiliate ad

Earn CME

This learning experience is powered by CMEfy - a platform that brings relevant CMEs to busy clinicians, at the right place and right time. Using short learning nudges, clinicians can reflect and unlock AMA PRA Category 1 Credit.

Tweet Me

More from SoMeDocs

Subscribe To Our Newsletter

Get updates and learn from the best

Ladders of Love

Ladders of Love

Robert Saul, MD explains why adders of love are critical for children, providing support as children and families lift themselves from trauma to a pathway toward restoration, resilience and flourishing.

The True Art of Medicine

The Crafting Doctors

Doctors do some incredible work outside of the exam room. Some even craft! Take a peek at some of our highlighted doctors, here, in this series.

David Norris, MD, MBA

Negotiate as a Physician and Win

Catch this 8-part series, hosted by physician & business consultant David Norris, MD, MBA & produced by Dana Corriel, MD. Learn to be a stronger negotiator with these important tactics.

My “Go To” Spices for Indian Food: Beginner’s Guide

The Doctor’s Food

In honor of our upcoming virtual Lifestyle Medicine conference, we thought it would be fun to share some of what doctors eat (and prepare!), released regularly. Bottoms’ up!

Want More?

Be a part of the healthcare revolution.
Don't miss a thing SoMeDocs publishes!

Disclaimer: SoMeDocs assumes no responsibility for the accuracy, claims, or content of the individual experts' profiles, contributions and courses. Details within posts cannot be verified. This site does not represent medical advice and you should always consult with your private physician before taking on anything you read online. See SoMeDocs' Terms of Use for more information.

follow us

© 2023 SoMeDocs. All Rights Reserved.

Support A Platform that Celebrates Real Doctors

For just $10 a month, you can help keep this openly accessible site available to all & help us sponsor in more doctors.

Interested in the must-read, unique content from our magazine?

I acknowledge that this site is not to be used for medical advice.

Play Video
Our Founder Answers Your BURNING Question

SoMeDocs

“Why should I become a member of SoMeDocs if I already have my own space online?”

Site SoMeDocs Logo, square

WANT TO STAY IN THE LOOP?

DON'T MISS A SINGLE CONTENT PIECE.