My ongoing regular posts regarding the daily aggravations and irritations of being a PCP.
Remember the Prior Authorization that I requested for my patient who had been on multiple anti-arrhythmics and saw a cardiologist who, after trying other medications, put her back on just digoxin and said to keep her on that? — Irritation #1– Well, Cigna decided, because apparently they know more about cardiology than the cardiologists and specifically they understand treatment of the individual better than a cardiologist who evaluated her, that she does not need the digoxin and refused the prior authorization.
REALLY? REALLY? Now my staff and I have to try to get her an expedited appeal.
Answer: When the insurance company decides it is not.
A Healthcare Puzzle
The definition of screening, from a health prevention viewpoint, seems pretty straight forward: “a strategy used in a population to identify an unrecognized disease in individuals without signs or symptoms.” Typically these services are covered at 100%. However, insurance companies avoid appropriate payments for their members by changing the coding of a preventive service (which is covered 100%) into a diagnostic procedure, which is paid based on whatever the patient’s coverage allows. This change in coverage occurs because a polyp is found during the exam, which is of course, the whole point of doing the procedure: Screening and removing a polyp so that it never becomes cancer. Patients with high deductibles suddenly owe several hundred dollars in unexpected healthcare bills for a procedure they were told was covered. This is ethical and appropriate corporate policy?
And I can’t help but mention that the insurance company fancying itself a “Healthcare” company, promoting health and well-being, is the worst offender.
Subsequent colonoscopies that must be done five years later for individuals with polyps, instead of ten years, can arguably be called diagnostic. But changing the definition of a procedure solely to avoid paying for an appropriate screening exam, is another example of non-transparency, regardless of how well you explain it in the patient’s policy description.
Last week I attended the Mayo Clinic’s Annual Social Media Summit in Rochester. What most impressed me had nothing to do with the conference. On Tuesday afternoon before the Summit began I toured Mayo Clinic. It was supposed to be for an hour but lasted more than two because our group, consisting of one doctor and nineteen PR professionals, was so interested in the information being fed to us. I don’t know why the publicity folks were so intrigued, but for me Mayo’s philosophy of “patient-centered, physician-led” care hearkened back to a time when the patient-physician relationship was inviolate. It was stimulating to realize that my instincts of how medicine is best-practiced are right on target. My myopic opinion regarding the fragmentation of healthcare sees the destruction of the patient-physician relationship by multiple entities, who are primarily interested in a piece of the economic pie, as central to our healthcare mess. At Mayo, no project moves forward unless there is a physician who champions it and it is the physician’s responsibility to ensure that every project is dedicated to improving some aspect of patient care. Physicians are salaried so they spend the time necessary to care for patients and are not incentivized to increase the numbers of patients seen or do procedures to enhance the bottom line.
Every person I met who worked for Mayo reiterated the importance of putting patient care and comfort first. It was incredibly refreshing. The Mayo logo emphasizes a patient-first policy as well. I’d seen the logo multiple times but somehow never thought about what the three shields represent. Our tour guide explained: Patient care, research and education. The educational aspect was obvious as we walked multiple floors of patient care areas. I noticed no TVs in patient waiting rooms but many had computer screens where patients could learn about their conditions. It is a refreshing and calming atmosphere without the cacophony of media noise. There is art everywhere. Waiting rooms are spacious and well-lit. Meditation rooms and educational spaces abound.
Children’s waiting area
Mayo has always represented excellent healthcare in my mind. Patient reports that come to me after a visit there are extraordinary due to the extent of the integrative care the patient experiences from multiple medical disciplines coming together. I expected to be impressed. I did not realize I would also be reassured. Putting patients first is what I’ll continue to strive to do, despite insurance interference, governmental policies or EHR dysfunction.
As a quick follow up to The Healthy Uninsurable Patient, a few weeks after the blog was posted my daughter received her COBRA (Consolidated Omnibus Budget Reconciliation Act) papers. By this time she had obtained individual health insurance with a high deductible, but a reasonable cost. The COBRA quote came in at $569.04 per month. This is, by the way, more than I pay for my family plan that covered four people. This is also more than she makes in a month. How many 26 year olds can afford $569.04 monthly for health insurance? Of course I have a cadillac plan as an employed physician at a hospital but there are no other options offered. There is not even any information on how she might obtain other coverage included with the papers.
As a side note, it turns out that she was covered by my insurance when she had the CT scan done. Despite the fact that the letter received from Humana stated that her insurance would terminate when she turned 26, she actually was covered until the end of her birth month. She is a post-graduate student and I’m a doctor who deals with insurance issues every day and we still got it wrong. No one at the hospital where she had the tests, including the financial aid people, realized she was still covered. And this is where I work!!! Nor did the upper management in my office or the office staff at the surgeon’s office understand that she had continued coverage until June 30 (and the surgeon is employed by the same hospital I am).
Of course payment for the scans will be denied because pre-authorization was not obtained for them and we will have to appeal and cross our fingers. What a mess.
When she saw the premium amount on the COBRA papers my daughter asked, “How can they send this stuff out with a straight face?” Of course we don’t know that they do, since we don’t know the people at Ceridian in Florida who mailed the papers. More surprising to me is the number of patients in my office who keep a straight face when they say “But there is nothing wrong with our healthcare system. It’s the best in the world!” No. It’s not.
On the heels of the Supreme Court ruling regarding the Healthcare bill my oldest daughter turned 26. (If you aren’t aware, this is the age after which your child can no longer be listed on their parent’s health insurance plan). After this, a saga began. She applied for a high deductible personal insurance with Anthem right before her birthday. At that time the extent of her medical problems included a twisted ankle about a week before she applied, for which she took a couple of days of naprosyn. Other than that she’s been perfectly healthy. They declined her. Unbelievable! Exactly who do these people give insurance to?
She contacted an independent insurance agent, who was equally mystified, to try to help her. Anthem has yet to provide her with the promised explanation of their denial.
So here is the amazing thing–immediately after her denial, she developed epigastric and chest pain. She had recently been on an airplane and her chest pain was worrisome for a pulmonary embolis. So of course she got a CT scan which she will have to pay for out of the money she has saved for medical school. My question is–are the insurance companies now omnipotent, able to see into the future? If so, how do I, as a Family Physician, obtain the same powers. It would really come in handy in my line of work!
(Of course now she’ll NEVER be able to get personal health insurance.)
Ms. “X” came to see me a few days ago. She is a pleasant middle-aged woman with multiple medical problems, most of which could be cured or curbed by losing weight–hypertension, hyperlipidemia, “pre”diabetes, esophageal reflux and asthma. She belongs in the “super” obese category and her financial and familial problems are not helping her motivation to lose weight. She used a medication called buproprion in the past for her depression and it was helpful. It does not promote weight gain like so many other anti-depressants, so I prescribed it, hoping it would help normalize her mood. When she went to the pharmacy she was told that her doctor needed to get a “prior authorization” on the drug. For those of you who don’t understand this terminology, it means my office must call the insurance company and justify why she needs this medication rather than another. Buproprion is the only medication in its class and is generic. I was surprised that this was a problem. Despite being a generic medication, it IS still expensive–$130 for a 30 day supply. However, because it is the only medication in it’s class I’ve never had a problem with insurance coverage. Nonetheless, we called and were told that Ms. “X” plan doesn’t cover buproprion, we would have to write a letter of appeal and send it to Arizona. (I work in Kentucky). There was no fax number to send it to, just snail mail. We sent it certified but I still want to know why United Healthcare was not covering this medication since I have plenty of other patients with this insurance.
Here is where the saga begins. My medical assistant called the drug “vendor” who dispenses the medications. After speaking to three people whose native language is NOT English, she turned it over to me. I got through to someone in this country who referred me to someone else. Finally that individual told me that this was not a “United Healthcare” problem, it was due to her own company’s policy. She needed to call her HR department to find out what the problem was. I persisted and was told I needed to call United Healthcare, not the drug vendor as they just did what United Healthcare told them to do. So I tried that route. I spoke to two individuals in another country and was finally routed to someone a little closer to home who apologized and told me to call my regional provider rep. By this time it was 5:30 pm on a Friday afternoon. Temporarily defeated, I resolved to begin again on Monday. On Monday I began my dialogue with him. At no point have I had access to a medical director in the company. That would be a peer-to-peer discussion and apparently the medical directors at United Healthcare don’t consider me a peer. I can’t decide if that’s a good thing or a bad thing. Anywho…after several back and forth discussions it appears that the company that my patient works for is “self-funded” and the company has decided not to cover buproprion. So I said to the United Healthcare rep–OK, fine. But SOMEONE made a MEDICAL decision regarding not covering this medication. If United Healthcare is responsible for administering the plan, they should also be responsible for seeing that medical decisions regarding coverage are consistent with good medical care. For the umpteenth time–WHO IS RESPONSIBLE FOR THIS DECISION AND HOW DO I TALK TO THEM?????? We are now ten days out from when I wrote the prescription and still, no answer.
I have encouraged the patient to contact the Attorney General’s office and register a complaint with the state Insurance Commission because, guess what? I CAN’T DO IT! Only a patient can.
Believe me, I rarely get mad enough to devote this much time to insurance coverage issues. And there are plenty of doctors, much smarter than I am, who would never, ever get involved in these sorts of issues. But every month the problems with coverage seems to multiply–medications, lab tests, radiologic tests, other diagnostic tests, hospital admissions, durable medical equipment. My life is awash with pre-certification, medical record audits, pre-authorizations and appeals. This blog has not yet covered the number of insurance company documents I get tell me what tests I’m NOT getting on patients that I should, what medicines I’m NOT using in patients that I should…another blog for another day. And people wonder why doctors are so frustrated!
The New England Journal of Medicine published an opinion piece this week entitled “Defining ‘Patient-Centered Medicine“. Now to those of you who are fortunate enough to have avoided time in the ER, hospital or multiple doctors offices, this may seem obvious. All care should be patient-centered, right? After all, that is what it’s about, taking care of the sick person or helping a well person stay that way. For the rest of us, who have had the misfortune of being ill or helping a loved one navigate our healthcare “system“, it is obvious that we could call our system “insurance company centered” or “healthcare provider centered” or “government centered” or “pharma centered”. Rarely does anyone stuck in the middle of a disease process entailing many specialist and hospital visits feel like they are the center of the medical universe.
At its best, a patient-centered therapeutic milieu would consist of a supportive environment where communication is the highest value followed by caring, well-trained, humble providers who are not impeded by the needs of profit-driven pharma, insurance companies, hospitals or providers. As anyone who has made the journey will attest to, if you are going to spend an extensive amount of time in our health care system, you need to be a well-informed self-advocate OR have an advocate beside you every step of the way. You need to question every doctor and nurse that treats you unless and until you are sure they deserve your complete trust. And we “healthcare providers” need to be open to the questions and do our best to answer them and find specialists who are not offended or unnerved by the questions. Patients and doctors must provide the “push back” necessary to change this system for the better.
It is hard to get past the avarice of the many entities involved and see a better way of treating patients, but a dash of common sense would sure improve a lot of the system problems I see every day. To quote my favorite again: “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.” William Osler MD