A day in the life of a primary care physician: delay, denial, bills -- everything but practicing medicine
- From: "Kickin' Ass and Takin' Names" <old_redneck@xxxxxxxxxxx>
- Date: Sun, 28 Jun 2009 13:01:29 -0700 (PDT)
http://tinyurl.com/mv7erh
The national debate on health reform has uncovered innumerable "health
care horror stories" in whichcancer patients worry more about their
bills than their malignancy or where pregnant women are laid off and
dropped from their insurance soon before their due date. These
stories are tragic, and unconscionable for the richest country in the
world, however, as a physician, this is not my typical experience.
Instead, what I see every day is patients with private health
insurance who cannot afford the copays for their medications, delays
in treatment as I grovel for prior authorization with a non-physician
utilization reviewer, and patients stuck with huge bills for routine
services that they thought they were covered for.
In my practice, patients have a mix of private and public coverage.
While I work with some extremely impoverished patients who qualify for
public insurance through Medicaid, it is the people with employee
sponsored private insurance who are most at risk for roadblocks to
care. As a primary care physician, it is hard enough to fit all of
the recommended screening, health education, and chronic disease
management that complex patients need into a fifteen minute visit.
When the burden of battling with insurance companies is added to the
equation, there is no way that I can succeed. My patients, especially
the ones with private insurance, are forced to deal with the high
copays, denials of claims, and delays in care.
Reflecting on the past week, a bunch of cases come to mind. While
these stories may lack drama, it is nonetheless troubling to me how
frequently my treatment recommendations are impeded by difficulties
with health insurance. And I am sure my patients are not alone in
suffering the consequences:
Ms. P, came in Wednesday. She has high blood pressure and very high
cholesterol. I had not seen her in over six months, but she works a
demanding job, so I figured that she had just been busy. In the
office, we did not talk about her blood pressure. We did not talk
about diet and exercise. She had not followed up for so long because
at the prior visit I had sent her for an echocardiogram of the heart
and she was billed $800 for the test. Her insurance would only cover
$200. We spent the entire visit talking about how she could not
afford to pay this bill. I just don’t get it. She has private health
insurance. She was having symptoms that had been worsening over
several visits and needed further evaluation – exercise intolerance
and palpitations. Now, she is receiving daily letters from a
collections agency, and she is frightened to come to the doctor
because of the bills that may show up in the mail.
Mr. J, a security guard with diabetes, hurt his knee while fishing and
had severe pain and swelling. When I initially saw him a few weeks
ago, there did not seem to be any major structural damage to the
ligaments, so I recommended a conservative approach with rest, ice,
and anti-inflammatory medications. Now, several weeks later, the pain
and swelling had not subsided, so I ordered an MRI to evaluate for
more subtle damage to the knee. After several attempts at prior
authorization, the private insurance company refused to pay for the
test. Baseball players get MRIs the same day for any bump or bruise,
but even going through the appropriate prior authorization process, I
could not order an MRI for my patient with private health insurance.
I am not looking forward to all the phone calls that it will require
to protest this denial of necessary diagnostic test.
On Thursday, Mr. A came in to have his blood checked. He requires
blood thinners to prevent recurrence of blood clots which could be
fatal. He has twice previously had clots in the blood vessels of his
calves, and he once had a blood clot travel to his lungs. He has a
clotting disorder that makes any break in treatment with the blood
thinners extremely dangerous. Warfarin is an effective and
inexpensive blood thinner, but it requires frequent monitoring because
its activity is affected by numerous interactions with other
medications and foods. His blood test showed that the warfarin was
not doing its job, so I recommended an increased dose. It takes about
three days for the dosage change to have a full effect, so I also
recommended injectable blood thinners, which act more rapidly, until
we could demonstrate that his warfarin had reached a therapeutic
level. However, he could not afford the copay for the injectable
blood thinner, so he must hope that he does not develop another blood
clot as we wait for the higher dosage of warfarin to take effect.
Yesterday, I saw Ms. R for a follow up appointment. She is only in
her 30s but has already had major back surgery for a disk problem.
She stands for six hours a day at work and has recently had worsening
of her back pain. Her spine specialist had recommended physical
therapy, instead of a repeat operation, but she cannot go because her
private insurance company requires a copay for every session. She has
been unable to work because of the worsening pain, so she cannot
afford these copays and has not been able to follow the treatment
plan. I do not want her to become dependent on pain killers, but
since the treatment recommended by her orthopedist is not a realistic
possibility, we are running out of options.
I could fill many pages with stories like these of my patients whom
are hard working, have private health insurance through an employer,
but just cannot get the care that they need, because of unreliable
coverage. It frustrates me that executives of health insurance
companies spend millions on advertising to disparage public health
insurance, and Republican politicians are stone walling meaningful
health care reform because they are afraid that a public health
insurance option would put private health insurance companies out of
business. I do not care who provides health insurance for my
patients. Whether they have public or private insurance, I just want
them to get the best care possible. If private health insurance
companies provide a high quality product, they will not be "forced"
out of business by a public plan. It makes sense that competition
between a public plan and private plans would lower costs, improve
quality, and guarantee an option to those who do not have employer
sponsored coverage. As a physician, I need to advocate for my
patients. Private health insurance companies have thousand of
lobbyists and millions of dollars to spend. So why do these companies
need so many politicians, including Democrats, advocating for them as
well? This is not about ideology. It’s about patients who cannot
afford their medications or who face bankruptcy due to medical bills.
We need change, and this will only come with a guaranteed public
health insurance option.
- Aaron Fox, MD
National Physicians Alliance
.
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