It’s time for doctors to tell insurance companies how they really feel

The time has come. The time has come for patients to know how dangerous the state of health care has become and to finally do something about it. I’m ticked off. So ticked off that I’m writing this in between office patients, and I really try very hard to prevent my patients from waiting. Apparently insurance companies feel practicing medicine is as easy as checking off boxes, like hanging chads on a ballot.

I’ve been a practicing cardiologist for eight years now, and my job is becoming increasingly frustrating. Every day I try to help patients by diagnosing and treating them, and sometimes that means ordering diagnostic exams such as nuclear stress tests or echocardiograms. It was one thing when they started barely paying for them about five years ago, but now they have completely handcuffed us by dictating to us when it is or isn’t appropriate to perform one.

And how do they know this? Are they coming to the office and examining and speaking to the patient and obtaining detailed histories like I am? No.  They are checking off boxes on a sheet of paper. The patient has now been downgraded to nothing more than an ID number and a questionnaire.  And if enough boxes aren’t checked for their criteria, then you don’t qualify for the test the doctor feels you should have performed.

Several problems with that: Often their criteria aren’t consistent with published and accepted guidelines. Their criteria just favor the cheaper alternative. The second major issue, which to me is the most disturbing and the one that compelled me to write this today, is that often the decision is made by someone in a different medical field entirely. So, I spend six years post-medical school training to be a cardiologist and then a family practitioner, surgeon or ED physician is the one whom ultimately has enough experience to decide what test is appropriate to perform.

Don’t get me wrong; I’m not insulted. It’s not about ego at all. It’s just a disservice to my patients and to the many patients around the U.S. who are being denied the same tests.  Would it be appropriate if I as a cardiologist was in a position to determine whether it was indicated to perform gallbladder surgery on a patient?

I spend a lot of time with my patients discussing their symptoms, their risk factors for heart disease, their family history, and I examine them in detail. And with all the specialized training I received I also know the data very well as to when I should order a specific test in order to diagnose the problem I think my patient has. So, when a family practitioner or other physician (no offense to them) checks off a few boxes and says they don’t qualify, I think the patient has been duped. Their system is no substitute for clinical judgment. We, as doctors, through our training and even more so by developing our clinical acumen through experience, use our judgment and expertise to put all the information together and discuss with the patient what the best test or procedure is to perform.

But now we are repeatedly being overruled by the insurance companies based on these silly algorithms. I’m pretty good about appealing to the insurance companies, which can be a very time-consuming and burdensome process, and I often win. But most doctors don’t appeal, feeling it’s a waste of time because they may lose and it takes valuable time away from seeing patients.

Listen, I get it. I’m not naïve. I understand that there have been and always will be those physicians that abuse the system and order too many tests in an attempt to increase revenue. But the vast majority of physicians are good and care as passionately as I do about doing right by their patients.  I feel bad because in the end it’s the patient who’s getting shafted, because they are not getting the test they need, even though the insurance company is sending the letter saying it’s “not medically necessary.”

We shouldn’t have to wait for a few bad outcomes to change the status quo. I’ve been constantly arguing with the insurance companies about changing their criteria and becoming more consistent with current guidelines. But you can do something too. Don’t become an ID number or just part of an algorithm, because you mean so much more than that to your physician. You shouldn’t have to be part of a concierge practice to get the care that you deserve. If you are in a similar situation and receive that denial letter, call your insurance company and let them have it. Tell them they should rely on your doctor’s judgment and not some administrator behind a desk or a physician in another field.  Ask them for a list of everyone involved in reviewing your file and making that determination.

If we don’t act now then things will continue to spiral out of control.  Who knows? Soon the insurance companies may replace us with robots that will order the cheapest tests, but who can’t empathize with you and sense the pain you are feeling.  More realistically, if this continues, I fear that many more physicians will stop accepting insurance, to avoid these headaches. That, unfortunately, would likely result in increased expenses being passed onto the patients, which is something that none of us want.

David Wild is a cardiologist.

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