Wow, first post! Thanks to the other front-pagers for inviting me – I’m truly honored. I plan to do a three-part series on healthcare, with the first two parts detailing what is so wrong with the system, and the third part offering what I think are the solutions. I’ll be showing you what this looks like from the provider side, rather than the patient side.
The place I’d like to start is identifying why I think the system is broken. Let me say at the outset that I am not a big-government person, nor am I a small-government person. I’m a constrained-and-watchdogged, effective and fiscally responsible government person. I’m a liberal centrist, and mostly a pragmatist, and I could care less if a demonstrably good idea came from Dennis Kucinich or Newt freaking Gingrich. If it’s logical and it works, I do not care. My approach to the whole question of healthcare reform is not rooted in ideology. At all.
Instead, it’s rooted in the years I have spent in the healthcare field. As a retired nurse, married to a Family Practice physician, I have spent many years observing how our system works from the inside. I was both nurse and office manager, billing/referral/pre-authorization clerk, phone person, lab tech, and chief cook and bottle washer for my husband’s solo private practice. I helped him set up that practice from scratch, with all the insurance contracts, credentialing, inspections, and everything else it entails.
So, now that I’ve established that I know (at least a little) what the hell I am talking about, let’s talk about insurance companies. Let’s talk about what goes on, on a daily basis, in a real live medical practice. We’ve all heard the horror stories from the patient end, the big denials. Those exist in abundance, but I’m not going to address that here, because we all know those stories, and we are familiar with them. Instead I’m going to try to show you, and hopefully help you understand and get a feel for, the sheer, crushing volume of all the other, “small” stuff. The dailyness of it all, that has become overwhelming.
It’s a chess game, played mostly blind, in which the rules and players on the board change constantly, at the will and whim of something much bigger than you are. It’s exhausting. It’s frustrating. It’s a real morale-killer. Oh, you thought I was talking about diagnosing and treating disease? No, I was talking about getting anything a)covered and b)paid for. You will see later that those two are not the same thing.
So – let’s check in at the office. What’s it really like, behind the scenes?
The first hurdle is getting things covered: Patient A has come into the office during the height of flu season. She has classic flu symptoms that began yesterday. Suspecting flu, the doctor orders a rapid flu screen test – a simple nasal swab, largely accurate (70 to 90%), and most importantly, the results are almost immediate. It’s positive for infuenza A. Great, so let’s write an RX for Tamiflu! That was easy. But before she leaves happily with her Tamiflu prescription, I tell hubby, “Can’t do it. You know she’s Cigna, right?” Uh Oh. Groan. You see, we’ve been having this argument with Cigna for weeks. Cigna refuses to pay for Tamiflu without a positive influenza culture, not a rapid swab. Yes, a culture is almost 100% accurate, with no false positives or negatives. It is also completely useless unless one is doing research, because it takes a minimum of 3 days to do it and get the results back. Tamiflu is only effective if started within 24-48 hours after onset of symptoms, so by the time you get the test back they’ve been sick for 4 to 5 days, and there’s NO POINT in prescribing the medication.
We have called. We have argued. We have railed at them to no avail that it’s a pointless policy. But you see, its only pointless if your intention is to treat the patient. It makes perfect sense if your intent is to create a “plausible excuse” for not paying for an expensive medication like Tamiflu. Cigna would like you to know that they absolutely do not refuse needed medications, not at all. They’re just insisting on the most accurate test to make sure it’s needed, dontcha know. Wink wink.
The phone is ringing again. Patient B, who had horrible, horrible gastric and chest pain in the past, has been happy and stable for months on his acid reflux medication, but is having a problem. The pharmacy won’t fill his Aciphex – they say it needs pre-authorization. I pull his chart, and take a look. “What?” I say, “I got that authorized for 6 months, just 4 weeks ago!” Oh, wait, his employer has changed insurance plans again. This is a new company. We’ll have to do it all over again. So I call. I go through a phone tree, then get put on hold (3 times), and after about 30 minutes, finally get a person. They say he has to try the (cheap, totally different drug) Zantac first, for at least 6 weeks. I tell them that he already had a 6-week trial on Zantac, with no relief. The Aciphex is working. I’ll gladly fax them over the records, proof that he just HAD a trial on the cheaper drug a few months ago. No dice. He has to do the process all over again, with this new insurance.
I am hoping that he is not one, as many of our patients are, who has his insurance changed by his employer 2 or 3 or even 4 times in a year. Jeebus, we’ll never keep the man’s gut and esophagus stable if we have to keep going through the same process over and over. Maybe he’ll just give up and decide “Screw it, I’ll just pay for that pill out of pocket rather than keep going through this.” Ahhhh, now wouldn’t that be very conveeeenient for the insurance company if a lot of patients did that. But that’s not the reason they put nonsensical rules and illogical preconditions in place – of course not.
You can’t keep it straight, is the worst part. All the insurances are different, all have different coverage parameters, what is preferred, what is not. This one will pay for a lab test drawn in the office, but that one makes them go to an approved lab across town. This one will pay for a wart removal by freezing, that one only if you code it as an excision. They change the criteria, all the time, unilaterally, and you have no recourse. You can’t just treat the patient, not even in normal, everyday matters, because you are constantly having to check what their plan covers, what it doesn’t. A medical practice may be contracted with 150 or more different insurers, all of whom have different coverage, with different requirements, that shift again as fast as you can figure out what they will/won’t allow. One day you realize that as much time is spent getting (or trying and failing to get) treatment approved than you spend actually treating the patients. It’s out of control. This isn’t working.
Take the above examples, multiply them by dozens and dozens of patients a day (phone-in plus office visits), five or six days a week, 52 weeks a year. A lot slips through the cracks, because you just can’t keep up. You end up doing a procedure or test, and not finding out until after the fact that it needed a pre-certification, or isn’t covered. I’m sure the requirement was of course buried there in section 213, subsection 15, paragraph (h) of the latest amendment to the plan that was mailed to you along with the 2-foot stack of mail last Tuesday. Or maybe it wasn’t – who the hell knows? And is it worth hiring yet more staff to make sure?
Good luck figuring out which of your patients it applied to, and getting that noted on their file somewhere, and actually having time to check it before you treat them if you did. You’ve got people stacked up in the waiting room, and you simply cannot dig through the fine print of a 300 page coverage explanation on every patient, every single time they walk in the door. But you were (likely) “duly notified”, so you’re shit out of luck. Add in the frustration of not being able to provide any real continuity of care, because you can’t tailor your practice of medicine to what works for the patients, you have to tailor it to dozens or even hundreds of different and constantly changing versions of what is allowed.
The insurance companies are not stupid. A lot of the sheer bureaucracy and nit-picky requirements and hoop-jumping is now designed for exactly the effect it has. To exhaust the providers. To make them give up. To make them decide that it is just easier and cheaper to treat the patient, and eat the loss themselves if it’s not covered, than to spend the time, effort and man-hours necessary to figure it all out. They know damn well that most of what they are requiring a pre-approval for is, in fact, quite routine and WILL be approved if you spend that hour on the phone. They are banking on your inability to do that a lot of the time – it is a planned strategy.
This is important for you to understand, because it is NO ACCIDENT. It is deliberate. It is calculated. It did not used to be that way, but it is now. This is not your father’s Blue Cross Blue Shield. This is not “competition”, and this is not “free-market forces”. They are engaging in a predatory war of attrition, daily. It’s relentless. It’s exhausting. It’s confusing. It’s maddening.
And it is crippling and killing the practice of medicine in this country.
We’re not done yet, though. Now that I’ve said all that, realize that I have only touched on the first half of the problem: getting things covered. The second half of the perpetual adversarial chess game is getting things paid for. I want to introduce you all to some particular Big Insurance activities that are little known or discussed outside of the medical field. We’re going to talk about practices known as bundling, and downcoding, and black box downcoding. It’s nasty, nasty business.
What? You thought Goldman Sachs were the ONLY ones to have bright ideas about proprietary computer algorithms, that multiply fairly small price-shaves from billions of transactions into a tidy profit? Au contraire, my friends. Insurance companies have been doing it to doctors for years. Stay tuned.
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