Only in America can local and national health insurance companies have such a disruptive hold on patients and providers. I have previously described the practice of one local health insurer coming into private medical offices only to copy patients' protected medical information and to remove it to places unknown to be "reviewed" by persons unknown. Other insures, instead, send the reviewers to the doctors' office to conduct these reviews in private. "For profit" health insurance companies are privileged and can invade patient privacy at will. They also commonly interfere with effective management of a patient's disease state by requiring medication and/or procedure "pre-approval". The following are a few of the insurance issues I have had in my office in the last week alone.
1. A 58 year old female patient of mine came to the emergency room on a Friday with crushing chest pain and shortness of breath that was relieved by nitroglycerin and who has family and personal risk factors for heart disease. She was admitted for a workup. While hospitalized she had intermittent recurrence of her chest pain and shortness of breathe several times. We reviewed her previous cardiac workup, obtained a gastroenterology consultation resulting in stomach endoscope, evaluated her for possible blood clots in her lungs then obtained an evaluation of her swallowing mechanism which revealed a swallowing problem which was allowing liquids to trickle into her lungs giving her spasm of her airways and giving her pain in her esophagus. This was leading to her symptoms. She was discharged the day the diagnosis was made, and on appropriate therapy. Now her insurance company states this should have been completed in 24 hours and are currently declining to pay past the 24 hour "approval". This work up progressed over the weekend, which is a time the insurance reviewers do not work and are not available to us. Consequently, we have "Monday morning quarterbacks" critiquing what we have done while they were off enjoying their weekend. I doubt they would have the same objections to her care if this had been their mother, sister or daughter. Currently her admission is "under review".
2. I have a 78 year old woman with a failure of her pituitary gland and she makes no cortisol at all. Cortisol is required by the body to function. Symptomatically she had failed other medications before we finally got her nicely controlled on her current drug. Her insurance company sent me a letter stating they would no longer pay for her medication unless she failed a trial of each of the generic drugs in turn. Since the medication is required for her to live, I am not sure how I would measure the "failure". I cannot get the medical director to call me. Hopefully, they will drop this demand.
3. On one day last week I received from a single local health care insurer separate requests for me to review patient medication records on 30 patients to see if I would change some of the medications to better suit the insurer. None of these requests were for quality of care issues, but simply to better suit their drug formulary. Considering the time it would take to process these requests by pulling the patient charts, reviewing the reasons that those patients are on those medications, deciding if it is or is not reasonable, contacting the patients to explain these changes and then contacting the patients' pharmacy with the changes, I wonder if the insurance companies think I have as much time to fiddle with paperwork as they apparently have. Thirty requests times 10 minutes each comes to 5 hours of time required to adequately respond to their letters. I fully agree with any review related to quality of care, no matter what the time requirement. However, I fully resent any extra time I have to spend to enhance their profit margin.
Other instances could be described from this week alone though space is limited. The private "for profit" health insurance companies are holding back any hope of health care reform in America. We need the average private citizen to educate themselves and to become involved. We can then force our legislatures to directly address these issues or to be voted out of office.
Mark Green MD