Insurance companies cutting corners puts patients at risk

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.

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

  • Martin Young

    At one stage insurance company medical advisors earned bonuses NOT to approve medical care. Well, according to Michael Moore of Sicko fame.

    Is that still going on?

  • CS

    I see this every few weeks in my peds residency. How can we change this? I have had a few patients denied oral linezolid (antibiotic) for extended resistant MRSA infection, that had to continue to be hospitalized instead, putting them at further risk and cost. How does this make sense?

  • Anna

    I think that patients as consumers are terrified of battling insurance companies on their own behalf. They don’t feel well-versed enough in medicine to stand up for themselves, and they are belittled and bullied when they call their insurers.

    I have a daughter with a chronic condition, and I kind of enjoy battling with them. In one instance, I set my computer to fax them every fifteen minutes with my request. I don’t know if that is the reason I got my way or not.

    Effective or not, I also copy my husband’s employer on every issue that I have. I do very little on the phone, as it is not documented, and I copy his HR department. If I do call, I ask for the supervisor first and depending on the issue, some times the medical staff.

    What I often wonder is why someone would go to medical school and end up working for insurance company that forces them to ignore their oath.

  • Solomd

    “….I’m struggling to find the winner in this equation!…..”

    It’s obvious. The winner is the insurance company. You will eventually learn that. There is no way around this. The employee at the insurance company saved his/her pharmacy department $150 on the oral antibiotic, thus getting a happy face sticker at the end of the day. The fact that this lead to far more expense to the insurance company for continued hospitalization is irrelevant. If I were in your situation, I would not put much effort into fighting it. Save your energy for something that will lead to a positive outcome, like studying for boards.

  • Angela Caffaratti, MD

    Good work Anna. Doctors will continue to work hard for patients, but it helps if patients do the dirty work. I think you are on to something with HR. I was filling out FMLA and mentioned the patient will likely miss more work because treatment was denied by insurance, and treatment was then okayed magically.

  • doc99

    Patients in these scenarios won’t fare any better w Government Healthcare either, especially when Cost is the driver. At issue is the entire Third Party Payor system. When the patient is no longer the client, the conflicts of interest loom large in the exam room. If you think the PPACA will resolve these issues, think IPAB aka The Politburo. There is a better way.

    • “Client”

      The “client” without any “skin in the game” will spend an extraordinary amount of money. Why is there no comment for the “client” to pay $150 for the medication. Why is there no discussion on the price of keeping her an extra two days? Would she have stayed if she had to pay for treatment?

      We have the insurance company or the government trying to control costs. We have the “client” that spends someone elses money. And then there is perhaps the doctor that wants to maximize profits. Which one are we going to complain about today?

  • Kristin

    “Of course for this to happen insurance companies must change their mindset and truly put patients first above their own short-term financial gain…”

    If the companies are publicly-traded, this is actually illegal. Companies have a legally defined responsibility to their shareholders to maximize profits. They may have the legal status of individuals in some respects, but to talk about them like they ARE individuals–capable of empathy or social responsibility–is not productive or meaningful. Corporate behavior changes only in response to market or legislative changes. Corporate priority–maximizing shareholder profits–never changes. The system is designed, specifically designed, for this.

    Which is why insurance companies shouldn’t be publicly-traded, and why pretty much any other model imaginable would work better.

  • Eric,RPh

    The problem lies in the fact that medical benefits and pharmacy benefits are often handled by two different companies. Why would CVS/Caremark care if a patient requires two additional days of inpatient care (at Blue Cross’s expense) if they simply refuse to pay for a medication?

    If we want to get serious about health care reform, we need to start at the insurers. No more fragmented benefits. If you want to be an insurer, you must cover medical, pharmacy, dental, vision, everything. If the insurer has to cover all aspects of health care, they will be more receptive to what is best for the patient, not what is best for the bottom line of their segment of the patient’s insurance.

  • Eric,RPh

    The problem lies in the fact that medical benefits and pharmacy benefits are often administered by two different companies. Why would CVS/Caremark care if Blue Cross/Blue Shield has to pay for two additional days of inpatient care if they can simply say no to a drug?

    This will continue to happen until insurers are required to cover all facets of a patient’s medical care instead of a single portion (medical, pharmacy, dental, or vision).

  • Allison

    As long as companies offering health insurance are “for profit” this will continue. It’s unfortunate that single payer insurance was defeated. The whole system is just stupid.

  • Jeff Taylor

    Those of you who think this situation is just as common in Europe, where I’m based at present, I can assure you that it simply is not.

  • http://none Radiation Joe

    Maybe if there werent so many extra MRIs, CTs etc and duplicative services and unneeded prescriptions being billed(FFS) every day the insurance companies would not have to worry. And I dont believe the said anything about the patient not being able to have the script, they just werent paying for it. You could have still gave it to them. But I guess that wouldnt be profitable either spending others money is in this day and age.

  • Kathleen Blanchard

    I’ve found it’s about communication. If the insurance company gets the right information they don’t deny. I’ve had to go behind many physician offices and hospitals to find out clinical information is missing, forms are not filled out properly etc.PLUS – just like patients – health care employees have no idea how to navigate the system.  Educating would go a long way. It’s all about collaboration and communication, but no one has the time. Physician offices hire MOA’s instead of nurses to cut their own costs, and they just don’t have the clinical expertise needed. Many physicians think it’s enough to provide the insurance company with a diagnosis code to get approval – and they don’t have the time to do what’s needed.  Learning how to communicate effectively and thoroughly would go a long long way. Everyone needs to participate thoroughly to make things work. 

Most Popular