Valley Commentary : A Bitter Pill to Swallow : Tactics that insurers employ in the name of cost control diminish the treatment of patients by doctors and other care givers. They also influence how patients seek health care.
An alert and intelligent 70-year-old man whom I’ve known for more than 30 years has recently been having increasing difficulty with heart, liver and kidney disease.
His unpredictable episodes of critical illness often precipitate a paramedic run to his home, followed by treatment in the emergency room and then the intensive care unit. Each episode brings him to the brink of death. So far, each time he has responded to treatment and been able to return home.
On a recent Saturday night he became confused, fell at home and injured his knee. He was brought to the emergency room, where he was found to be in multi-system failure. He had fluid in his lungs and abdominal cavity, kidney and heart failure and a host of other problems. He was hospitalized and treatment was started. Because it was Saturday night, the pre-admission report required by his insurance carrier could not be made.
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On Monday morning, I was at the hospital seeing a patient when the insurance carrier’s pre-admission review nurse called my office demanding to know the diagnosis, the treatment plan, the intravenous fluids by name and rate of flow, the medication by name and dose, the anticipated length of stay and the home care needs.
This type of interrogation goes beyond the need of an insurer to determine whether hospitalization should occur. It interferes with the doctor’s ability to render care and breaches the patient’s right to privacy. With the patient’s written permission, any information necessary to the review process is readily available in the patient’s chart.
Intrusion by health insurance carriers into the patient-doctor-hospital relationship has become onerous and counterproductive. I have no objection to review aimed at preventing fraud and overuse of expensive services.
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However, prior authorization requirements, length of stay limitations and other prerequisites set by an insurance company can coerce physicians into giving less than optimal care and pressure them into discharging patients from the hospital too soon.
In this case, the patient was treated in a timely and appropriate way, and after a few days in the hospital and a short stay in a skilled-nursing unit, he has returned to his wife and family.
When I arrived at my office later that morning, I attempted to return the pre-admission nurse’s call. My office staff left messages on her voice mail. But our calls were never returned. A couple of days later, the patient received a letter threatening non-payment for the hospital stay because it had not been authorized by the insurance company.
Tactics such as these should not diminish the treatment of patients by doctors and other care givers, but they do. They also influence how patients seek care.
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For example, this patient cannot afford his insurance deductible amount, which is large because of his high-risk medical status. So during the first part of the year--when his deductible has not yet been met--he waits until the last possible moment to schedule medical appointments. More timely visits could result in preventive treatment, which might avert some of his emergencies. Letters from his insurance company threatening not to pay for services unless pre-authorized add to his reluctance to call for help when it’s needed.
The above is just one example of how boldly the insurance carriers are manipulating medical care. In the name of cost control, they decide to which doctors and hospitals patients can go, which medicine they will pay for, how long a patient may stay in the hospital, how many visits to a specialist will be permitted.
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There are often delays and rejections regarding special patient needs and expensive tests or procedures. This results in a telephonic logjam and a paper blizzard that has forced many medical offices--including my own--to hire extra personnel just to deal with it.
In spite of all this, there is no proof that insurance-company-managed care has actually saved money. Small wonder! As President Clinton pointed out, the administrative overhead of our present insurance-carrier-dominated health care system has risen to upward of 40% of the premium dollar. So where is the money going? Not for patient care!
The time has come to adopt a single-payer system that will eliminate the so-called health insurance carriers whose administrative superstructure, interference with the good practice of medicine and enormous overhead expenses are destroying what President and Mrs. Clinton acknowledge is the finest health care in the world. We don’t need micromanagement; we need universal coverage.
