Who works for who?

How did we allow ourselves to let a system get built up around us that makes it so hard for us to take care of our patients?

Our job is to advocate for our patients, to help guide them towards their best health, to help them understand the difficult choices and to live healthy lifestyles, to give them the tools they need to change unhealthy behaviors, and then, once they are faced with a health challenge, to be there with them all along the way.

But it’s clear that the rules created by all the bureaucracy from regulators and insurance companies have turned the healthcare landscape into a minefield.

Getting around the barriers

Every day, all day long, we are faced with these obstacles, sometimes small annoyances are placed in our way, sometimes major barriers or nearly insurmountable hurdles and barricades impede progress towards care.

I understand that the insurance companies are businesses that are beholden to stockholders, and they’re concerned with profits and losses, the bottom line, and how we are spending “their” money. And it is certainly true that there is incredible waste in our healthcare system, with all of us, every provider, providing costly “healthcare” that may not be needed, excessive testing, defensive medicine, sometimes even just giving in to a patient’s requests even though that may not be the best medical course for them to take.

But how did we let them, the insurance companies, get so intimately involved in what we think is the best care for our patients?

I don’t disagree with the concept of them having systems in place to provide some checks and balances, to make sure we’re not ordering an MRI on every patient with a headache, or ordering every lab test at every appointment, and most providers are more than willing to work with them to help build smart tools and appropriate interventions to make sure patients get the right care at the right time.

But if I, as a provider, have decided that the patient needs something, how is it that we’ve relinquished our ability to get this test, and even put this in writing in the contracts we sign with the insurers?

Doctors are the experts

Just yesterday, a patient of mine had a test recommended by a specialist, but it was denied by her insurance company, despite multiple appeals requiring long waits on hold trying to speak to a live human being.

My patient ultimately decided just to pay for the test herself.

The fact that the finding was actually there is not the point of this; it doesn’t matter if the test turned out positive or negative. A really thoughtful, talented, intelligent expert in the field had decided that he needed this test for this patient at this time. That should be it. End of discussion.

Most patients don’t have the wherewithal to pay for tests, but do it anyway, and then hope to get them reimbursed only if it is positive, and they can then make an argument to their insurer that they should’ve had it covered.

I think we’re all willing to engage in reasonable discussions about the appropriateness of certain tests, and I’ve often, during the prior authorization conversations with insurers and their medical representatives, been brought around, and have come to realize that I may have not ordered the right test, and there may be a more prudent path to explore before proceeding down this line of inquiry.

But we are the doctors; we went to medical school; all we want to do is take care of our patients. Of course, if I was doing this with some ulterior motive, if I was making a profit on every one of these tests I ordered, then I could see them slapping me on the wrist and telling me that I had to limit my ordering of PET scans or MRIs or CT scans.

I know that certain people will respond to this argument and say, “What’s going to stop every doctor in every situation from ordering every test possible? We are going to be flooded with unnecessary tests, false positives, incidentalomas, and as we all know, tests beget more tests.” A long discussion about defensive medicine and tort reform is in order, but that’s for another day.

The essence of primary care

Earlier this week, we discovered that one of our insurers has been denying hundreds of claims for patients’ appointments at our practice.

First, they said that we were not changing the primary care physician (PCP) listed on the patient’s insurance card to a provider in our practice. Then they said we were changing it to a physician at our practice, but not the physician who that patient was actually seeing on that particular day. They told us that patients needed to change their PCP on their insurance card when they were seen with an acute visit for an interim appointment, by a covering provider when their physician wasn’t there.

To me, this violates the very nature, the very essence, of being a PCP. If I’m out on vacation, or teaching, or in a meeting, and one of my patients is sick, they need to change to a different PCP? We should all be covered under the same group practice, we’re only doing what’s in our patients’ best interest, and making the patient and our support staff go through an enormous amount of work to change someone’s PCP just for today’s appointment seems ridiculous.

And then, finally, after we discovered that this actually violated the policy stated by the insurer in their own documentation, they showed us another reason for denying these claims for our patients. “Patient was seen for a 99213 E&M established patient follow-up appointment, moderate level of complexity, by a provider who is not qualified to deliver this service.”

Wait, we internists are not qualified to do evaluation and management visits? We can’t evaluate and manage problems? That’s our bread-and-butter. That’s what we do. We don’t do major surgeries or lots of procedures, but we do perform routine annual physicals, preventative care, and medical evaluation and management of acute symptoms, chronic medical conditions, and the like.

When they tell us that we are not qualified to do what we do, it’s clear that someone is just moving the pieces around on the game board to find another way to deny our patients the care we should be providing them — care they should be covering. And it’s time for this to stop.

It’s time for the nickel-and-diming to stop. Someone’s got to clear away all of these rules and regulations, this endless bureaucracy, the paperwork, the interminable telephone trees and waits on hold to get our patients the care they need and deserve. We need to stand up and say, “This needs to be a system that lets us take care of our patients in the way that we think is best.”

We can accept nothing less.

Fred N. Pelzman is an internal medicine physician who blogs at MedPage Today’s Building the Patient-Centered Medical Home.

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