One of my patients recently had her request for a relatively
common medication for attention-deficit hyperactivity disorder, Vyvanse, denied
by her insurance provider. I tried to appeal the decision, but her father — the
chief executive of a health care company who purchased insurance for hundreds
of employees — had better luck. He called up the head of the insurance company
and got the drug approved.
Last year, my 5-year-old fractured her ankle. The bill for
the 12-minute orthopedist’s appointment was $1,125, and about half of it was
covered by insurance. I wrote the doctor a letter — please revise this bill, as
it is clearly erroneous — and included my “M.D.” Instead, the doctor left me a
message saying he was waiving the bill entirely as a professional courtesy.
Stories like these reveal an uncomfortable truth. Our health
insurance system is so broken that pulling strings — or rank — is sometimes the
only way to get the coverage you think you’ve paid for…
Wendell Potter, a former Cigna executive turned
whistle-blower and a co-author of the recent book “Nation on the Take,” says
that “insurance companies profit by introducing hurdles in the coverage and
claims process.” These hurdles lead some patients to simply give up and pay or
forego treatment altogether. He calls this the companies’ business model.
This strategy has given rise to a new business. After his
son was born with cerebral palsy, Scott Leshin, then an associate at Goldman
Sachs, made it his business to read the fine print of his health insurance
policy so that he could fight for the services his son needed.
His son started walking only this year, at age 10. And yet,
“I still have to prove to UnitedHealthcare that he has C.P. every six months,”
Mr. Leshin told me. His success in getting services covered led him to found
his business, SJ Health Insurance Advocates, which now has a staff of 19. He
works on a contingency basis — his customers pay only when his team succeeds…
But the best way to advocate for yourself is simply to be a
doctor…
These workarounds are necessary because the health care
system doesn’t follow any rational rules of economics, where the customer
should be king.
Economies of scale are supposed to bring costs down. But in
health care, large hospitals are often more expensive than smaller ones because
they can demand higher payments from insurance companies, which are then passed
down to patients.
In most realms, those with the least ability to pay should
receive the biggest discounts. In health care, it is often the uninsured and
indigent who receive bills with the full “chargemaster” fee — the wildly
inflated prices that nobody really pays — while large insurance companies get
the biggest breaks…
Finally, our insurance system drives up costs for everyone.
Between 1998 and 2015, the cost of cosmetic surgery for top procedures, which
is paid by the consumer and not covered by insurance, rose at about half the
rate of inflation, while overall health care rose at around double the rate of
inflation — more than a threefold difference…
But when everyone is feeling the pain of decreased access
and increased costs, physicians currying favors will only foster resentment.
Shouldn’t we be advocating for reform, rather than finding our own shortcuts?
Talk is cheap. Last year, another instance of M.D.
favoritism was presented to me in a time of need, and I grabbed it without
flinching.
I had a herniated lumbar disk, and was in pain for weeks on
end. Finally, my orthopedist suggested an M.R.I. The day before the study, the
radiology office said that my insurer, Aetna, had denied the test and I would
have to pay $1,000. In pain, I told them that I would keep my appointment. The
next morning, I called Aetna.
I was patched through to a third party, Evicore, which
evaluates requests for imaging. (This company is basically one of the hurdles
described by Mr. Potter, intended to reduce costs for the insurer.) I was told
the test had been denied because I had not yet had six weeks of unrelenting
symptoms. This was not true — I had been counting the days, and it had been six
and a half long weeks.
“I’m sorry, sir, but the only way to reverse the denial is
for your doctor to call our doctor.” Indignant, I declared myself a physician
and said that my pain was interfering with my ability to see patients.
The representative asked what type of physician I was.
“A psychiatrist,” I replied.
Was I licensed?
“In two states.”
“Would you like to do the doctor-to-doctor review?”
The call was scheduled with a radiologist, whose number came
up with a Nashville area code. The icebreaker was easy: I trained at
Vanderbilt, I told him. “How’s Nashville these days? Isn’t real estate
booming?”
Then he got down to business: “O.K., tell me about this
patient. I mean, about you …” I went through my clinical history. Less than
three minutes later, he approved my M.R.I.
Was this wrong? I told myself I was using my status to fight
a small injustice, not to get special treatment — though in our faulty system
the two are often inseparable.
Aetna, however, got the last laugh. The $1,000 M.R.I. was
discounted to $525, which was within my “imaging” deductible, making my Gold
plan feel more like a Bronze.
Welcome to American health care, I thought. I’d succeeded in
persuading my insurance company to cover the procedure — but I still had to pay
for it.
Courtesy of Doximity
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