Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Insurance companies cutting corners puts patients at risk

Vipan Nikore, MD
Physician
June 14, 2011
Share
Tweet
Share

My patient, whom I’ll call Jane, had a neurologic disorder that prevented her from emptying her bladder properly.

She required a permanent urinary foley catheter to help her urinate. Jane landed back at the hospital with yet another urinary tract infection – her third in one month. She had pus draining from her catheter and was infected with a multi-drug resistant strain of the bacteria Proteus. Our lab ran tests (sensitivities) to determine which antibiotics would be required to eradicate the infection, and it turned out the only oral drug that could destroy the infection was fosfomycin. Giving her fosfomycin would allow her to avoid intravenous antibiotics and be treated at home. This would prevent a lengthy expensive hospital stay. Thank goodness for fosfomycin, I thought.

One problem though: The insurance company wouldn’t pay for her 3 day fosfomycin prescription. It took several calls by our case manager and senior resident physician before, finally, the insurance company agreed to pay. And even then the insurance company decided to place a restriction on her purchasing of fosfomycin — they only allowed her to purchase only one dosage at a time. Did I mention that her neurological disorder prevented her from walking? Yes, a lady from a low-income area of Cleveland who cannot walk was required to find her way to the pharmacy three times in order to eradicate a dangerous infection. Was this just cruel, or was I missing something here?

We had to delay discharge two days, which was troublesome for Jane. Plus, the cost for two more nights in the hospital negated any savings that the insurance company gained by refusing to pay for her medicine. The time lost by our team members on the phone arguing with insurance companies easily could have been spent providing care to other patients. I’m struggling to find the winner in this equation!

Sadly, not a month has gone by in my residency where I haven’t witnessed a similar situation. This month insurance issues prevented my patient with leukemia from receiving a necessary antifungal medication to eradicate her fungal infection because there wasn’t enough ”evidence” of the infection. Was this really happening? A person who has never seen a patient and who sits in an office miles away rebutting the clinical decision of one of the world’s top infectious disease doctors? Our choices were now to either bring the patient back into the hospital, let her remain at home at risk for a life-threatening infection, or just order an expensive and unnecessary CAT scan to tell us what we already know.

Last month insurance tried to deny another patient of mine an in-hospital kidney biopsy after three years of multiple hospital admissions for uncontrolled hypertension. Finally after approval, the biopsy revealed a condition called IgA nephropathy that was responsible for her kidney dysfunction and high blood pressure.  The insurance company clearly didn’t think prevention of future hospital visits was important. I could go on and on with similar examples from this year.

Why do we as a society accept this? Cutting corners that put clients and customers at risk is generally not accepted by society. Some companies get away with it, but often they crash and burn when their faults are exposed. Just ask British Petroleum after last year’s Gulf of Mexico oil spill released 4.9 million barrels of oil into the ocean and killed 11 crew members, or Enron in 2001 after they went bankrupt and lost over $50 billion of shareholders money. If we add up the number of people who die or suffer needlessly because of a denied health insurance claim, would the impact be as large as the effects of BP or Enron? If our healthcare system continues to eat up a larger share of our GDP and bankrupts our economy then perhaps more people may start to notice what is occurring on a daily basis in this country.

Granted, insurance companies cannot pay for everything for everyone. There is an entire field dedicated to cost effectiveness in healthcare, and it is wise for organizations to use this knowledge and data. We need to ration in our healthcare system and when an intervention adds little value we need to ask whether or not it is necessary. Unfortunately the attempts to deny insurance claims I’ve witnessed in the hospital are usually not for medical interventions that add unnecessary costs to our healthcare system, but rather for common sense clinical interventions where benefits clearly outweigh the costs. This is what frustrates and frightens me.

How should the system be designed in order to ensure rationing of resources while not disrupting necessary services and interventions? I’m not exactly sure, but a quick and easy bandage solution would be to model the system after the way Cleveland Clinic provides checks for its medications. Any time there is an uncertain medication order, I immediately receive a call from my pharmacy. For example “Dr. Nikore, are you sure you wanted medication X every Y hours, given variable R perhaps we dose this every Z hours?” Many times I explain my reasoning, but sometimes I kindly take the pharmacist’s advice and make the appropriate change. Usually this conversation lasts just a few seconds. Imagine a quick call from an insurance agent providing some alternative treatment ideas, instead of a long and drawn out battle on the phone lasting days. If the doctor makes a reasonable argument, the insurance agent confirms the approval immediately and moves on. A quick conversation instead of a three day battle saves the insurance company agent a tremendous amount of time, translating into cost savings for the insurance company. Of course for this to happen insurance companies must change their mindset and truly put patients first above their own short-term financial gain and earn the trust of healthcare professionals. They must start seeking win-win situations and learn that any short-term financial loss would be more than restored by long-term gains in company credibility and public trust.

Society expects responsible value creation from its businesses, and it expects companies to meet bare minimum standards of quality. But quality and safety mean different things to different organizations and industries. At the bare minimum, Google must keep its data private and keep its servers running, United Airlines must assure its planes are flying in top condition, and FedEx better not lose mail. Benefits these companies provide beyond this minimum, such as speed of service, become competitive advantages and differentiate them from others. What does ”quality” and ”safety” mean for an organization that doesn’t provide tangible goods or services such as a health insurance company? What is a health insurance company’s “bare minimum”? We as a society need to answer these questions soon, unless we are prepared to watch our healthcare system sink toward bankruptcy.

Vipan Nikore is an internal medicine resident physician and the President and Founder of the youth leadership non-profit Urban Future Leaders of the World (uFLOW).

 

Submit a guest post and be heard on social media’s leading physician voice.

Prev

Hospital inefficiencies observed during a surgery rotation

June 14, 2011 Kevin 0
…
Next

A history of smallpox in America

June 14, 2011 Kevin 0
…

ADVERTISEMENT

Tagged as: Hospital-Based Medicine, Patients, Public Health & Policy, Residency

Post navigation

< Previous Post
Hospital inefficiencies observed during a surgery rotation
Next Post >
A history of smallpox in America

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

More by Vipan Nikore, MD

  • a desk with keyboard and ipad with the kevinmd logo

    Pizza or insulin: What does our society value more?

    Vipan Nikore, MD
  • a desk with keyboard and ipad with the kevinmd logo

    Primary care is the missing link in global health

    Vipan Nikore, MD
  • a desk with keyboard and ipad with the kevinmd logo

    The first step to changing the culture in healthcare

    Vipan Nikore, MD

More in Physician

  • When the white coats become gatekeepers: How a quiet cartel strangles America’s health

    Anonymous
  • The man in seat 11A survived, but why don’t our patients?

    Dr. Vivek Podder
  • When did we start treating our lives like trauma?

    Maureen Gibbons, MD
  • Medicalizing burnout misses the real problem

    Jessie Mahoney, MD
  • Why some doctors age gracefully—and others grow bitter

    Patrick Hudson, MD
  • The hidden incentives driving frivolous malpractice lawsuits

    Howard Smith, MD
  • Most Popular

  • Past Week

    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • In a fractured world, Brian Wilson’s message still heals

      Arthur Lazarus, MD, MBA | Physician
    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • How doctors took back control from hospital executives

      Gene Uzawa Dorio, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Why shared decision-making in medicine often fails

      M. Bennet Broner, PhD | Conditions
    • My journey from misdiagnosis to living fully with APBD

      Jeff Cooper | Conditions
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
  • Recent Posts

    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • Finding healing in narrative medicine: When words replace silence

      Michele Luckenbaugh | Conditions
    • Why coaching is not a substitute for psychotherapy

      Maire Daugharty, MD | Conditions
    • When the white coats become gatekeepers: How a quiet cartel strangles America’s health

      Anonymous | Physician
    • Why doctors stay silent about preventable harm

      Jenny Shields, PhD | Conditions
    • Why interoperability is key to achieving the quintuple aim in health care

      Steven Lane, MD | Tech

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 14 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • In a fractured world, Brian Wilson’s message still heals

      Arthur Lazarus, MD, MBA | Physician
    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • How doctors took back control from hospital executives

      Gene Uzawa Dorio, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Why shared decision-making in medicine often fails

      M. Bennet Broner, PhD | Conditions
    • My journey from misdiagnosis to living fully with APBD

      Jeff Cooper | Conditions
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
  • Recent Posts

    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • Finding healing in narrative medicine: When words replace silence

      Michele Luckenbaugh | Conditions
    • Why coaching is not a substitute for psychotherapy

      Maire Daugharty, MD | Conditions
    • When the white coats become gatekeepers: How a quiet cartel strangles America’s health

      Anonymous | Physician
    • Why doctors stay silent about preventable harm

      Jenny Shields, PhD | Conditions
    • Why interoperability is key to achieving the quintuple aim in health care

      Steven Lane, MD | Tech

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Insurance companies cutting corners puts patients at risk
14 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...