As a patient, you're only one major health complication away from going bankrupt, even with decent health insurance coverage. Unfortunately, this is something I remind my loved ones repeatedly, as it is the sad reality of the US healthcare system. 

The problem with prior authorizations

As a physician and patient, I see the pitfalls of health insurance companies daily. For example, prescribing expensive medications or tests often requires a prior authorization for insurance companies to cover these treatments. 

When coverage is denied, I must call to set up a peer-to-peer review between myself and another physician who works for the insurance company. These phone calls are generally pleasant, and after a simple explanation (which includes a few key phrases of why my patient needs a specific medication or test) I am given an approval code. The problem with this process is that it takes time and resources, and the peer reviewer does not know the patient, nor have they ever spoken to them.

To make matters worse, they often have incorrect information about the patient, yet they have the power to approve or deny tests or medications. Insurance companies say this procedure is to ensure patients get the proper medications. 

The patient perspective

I have dealt with this from the patient's perspective as well. My mother has chronic low back pain, and once a year, she receives a lumbar epidural steroid injection which requires an orthopedic surgeon and an anesthesiologist. This past year, her insurance company denied the procedure at the last minute, so her orthopedic surgeon had to schedule a peer-to-peer review, delaying the procedure while my mother was in excruciating pain. 

Open enrollment is patients' most dreaded time of year

Health insurance is often provided to patients through their job, and when open enrollment season comes around each year, millions of Americans have to sort through health insurance plans. The language is confusing, and no matter the plan, patients still won’t have much choice in their care. The physician is the one who chooses which medications and tests the patient “purchases,” and the insurance coverage denotes whether or not these will be approved for final sale. Neither patients nor physicians know how much a certain medication or test will cost, as insurance companies are the primary decision makers regarding how much of the final bill they will cover. 

This process is clunky, the explanation of benefits difficult to discern, insurance websites are cumbersome to navigate, and contacting customer service over the phone is a chore. As a result, patients often give up trying to contact their insurance company. 

Insurance companies dictate how we practice medicine

In medical school and residency, we are not taught the business side of medicine. Instead, we are taught how to save lives. When we finish residency and go into practice, we learn that we must see a high volume of patients to make money. Therefore, we must be extremely diligent in our ICD-10 codes so we can be paid for services by insurance companies. 

In other words, we must document each physical exam finding and diagnosis in our notes to justify any ICD-10 code we bill out to the insurance company, or we will not be paid. The time we spend documenting is often more than the time we spend interacting with the patient. 

The provider contract between the physician and the insurance company determines how much we, as physicians, are paid on a fee-for-service basis. I would like to believe that physicians only order necessary tests and procedures to mitigate costs for the patient and healthcare system, but often, the more tests and procedures ordered, the more physicians get paid by the insurance company. 

On the flip side of this coin, some doctors are hesitant to order necessary tests and procedures because they fear the insurance company will deny coverage and, as a result, they will not be paid. Of course, they can go through the peer-to-peer review process, but it is ultimately up to the individual physician if they want to navigate that arduous process. 

Paying upfront may deter patients from seeking care

In addition, patients must pay money to meet their deductible before their insurance kicks in. Therefore, paying upfront to see a doctor makes visiting a healthcare professional even more unpalatable.

As physicians who want the best for our patients, we often use terms like “noncompliant” when they do not follow up with appointments or take their prescription medications. However, we also forget that this “noncompliant” behavior often stems from patient mistrust and confusion due to insurance coverage. Patients don’t want to go broke going to the doctor. If highly educated doctors are frustrated with insurance companies, can we blame our patients for not wanting to seek appropriate and timely medical care regularly?