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A day in the life of a primary care physician: prior authorizations, denials, & delays in treatment

For Profit HealthcareThe national debate on health reform has uncovered innumerable “health care horror stories” in which cancer 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

About Aaron Fox

Dr. Fox is a primary care physician in a community health center in New York City. He is also a member of the National Physicians Alliance New York City Local Action Network.



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