Recently, I had what I’d call a true banner day in my office. One late afternoon, after I had finished seeing patients, I had started in on that iniquitous pile of paperwork that awaits all of us doctors after office hours. As usual, I was finding the task alternately arduous (can my patient comfortably carry five-to-ten pounds for five-to-ten minutes?), rewarding (the patient does not have lupus), and monotonous (there is a reason why doctors’ signatures are so illegible). But then, something unexpected caught my eye: Right there, in a stack of neatly arrayed faxes and envelopes, were four insurance company approval letters in a row.
For anybody who has spent hours writing letters of appeal to insurance companies, and even more time on the phone waiting for that infamous peer to peer review, you know what I am talking about. But just in case, let me translate: A medication, infusion, MRI, or cat scan I ordered for my patient was approved without objection, qualification, or condition. In my experience, outcomes like this have become rarer and rarer, leaving me to wonder what’s crazier, the fact that this happened, or that it is so noteworthy.
Let me go on record by saying that I truly, sincerely, and unabashedly love being a doctor. Even at its toughest, there are crystal clear moments of joy and triumph and gratitude for the simple act of healing. Yet there are decidedly days where I find myself sounding off at the water cooler about the frustrations of dealing with so much insurance paperwork. According to the Department of Labor, one out of every seven claims is initially denied. For us, that means going back over codes, placing phone calls, and ultimately resubmitting these claims, often on a wing and a prayer.
So where did it all go wrong? A few months ago, I read an editorial by another MD who, in referring to the moments when patients would get upset with him when tests and medications were not approved, wrote, “This is not what I went to medical school for.” Sardonic tone aside, he had a good point.
In medical school, we versed ourselves in path and biochemistry and gross anatomy, but there were no courses on how to “get your medications approved,” or “how to talk to insurance companies,” or maybe even “how to beat the system.” Instead, we were drilled the algorithms for treating community-acquired pneumonia, acute coronary syndrome, and neutropenic fever and hyponatremia. For years, we painstakingly practiced and rehearsed and perfected our bread-and-butter medicine. But as we went through our training, one elective, rotation, and course after another, we were not schooled in the business of medicine. Indeed, while were developing the skills to save lives, this felt like the anathema of our purpose.
I first remember really learning about the important role insurance claims would play in my life as a doctor during my residency at NYU in the late 1990s. At the time, the HMO model was fast sweeping across the country. My program had taken the initiative to educate us about these new plans because, we were told, they would directly impact our professional experience as freshly minted MDs. The days of fee-for-service medicine were rapidly shrinking and we would need to become familiar with a whole new vocabulary: formulary and non-formulary, preferred, tier 1, and prior authorization, to name just a few.
Nevertheless, for a number of years, it really felt like the system was working. With some patience and resilience, my colleagues and I would write and custom-code prescriptions for generics, formulary drugs, or alternative infusions to fit each patient’s specific insurance parameters. As the landscape continued to change, we diligently adjusted our expectations and strove to ensure we were doing what was needed to give our patients the best, safest outcomes. But increasingly, it seems, the volume of claims and the challenges of approval have outpaced us, a trend we see evidenced in the renewed interest in fee-for-service models and a growing enthusiasm over concierge medicine.
For most of us, the headache isn’t going anywhere, and fortunately, some insurance companies and startups alike are taking on this worthy challenge. For our part, let us engage our voices and experiences with the discourse. While there is likely no silver bullet solution, if we all work together, we can do better.
Natalie Azar is a rheumatologist who blogs at The Doctor Blog.