Having gone through proton therapy and been on an expensive medication myself during the last year, I know first hand the problems most Americans face when seeking medical treatment. One of the biggest is the effort by insurance companies to deny coverage and/or restrict permitted medications for the simple purpose of reducing payouts. The companies that happily take your premium payments simply do not want to have to pay out claims when their insureds need medical care or expensive medications. In my own case, everything was eventually covered after protracted confrontations with my prescription insurance carrier. Many are not so lucky and the reality is that most of us find non-medical personnel trying to dictate our medical care. An op-ed in the Washington Post looks at this problem which, to me, is the reason a private for profit health insurance system without a significant challenge of a public option will never best serve individuals' and families' needs. Here are column excerpts:
We know how important it is to have insurance so that we can get health care. As a physician, parent and patient, I cannot overemphasize that having insurance is not enough.As a gastroenterologist, I often prescribe expensive medications or tests for my patients. But for insurance companies to cover those treatments, I must submit a “prior authorization” to the companies, and it can take days or weeks to hear back.
Because it ends up with the desired outcome, you might think this is reasonable. It’s not. On most occasions the “peer” reviewer is unqualified to make an assessment about the specific services. They usually have minimal or incorrect information about the patient. Not one has examined or spoken with the patient, as I have. None of them have a long-term relationship with the patient and family, as I have.
The insurance company will say this system makes sure patients get the right medications. It doesn’t. It exists so that many patients will fail to get the medications they need.
I’ve dealt with this system from the patient side, as well. My daughter has a rare genetic disorder . . . She receives applied behavior analysis therapy, an approach often used for autism, and which has been wildly successful in improving her skills and communication. But recently, our health insurer reduced the amount of therapy they thought she needed.
I probably have better access than almost anyone else can get, yet the ability of my daughter’s providers to mitigate denials for services they deem appropriate is slow and often ineffective.
My daughter can languish for months or years not receiving care that every highly qualified person who treats her agrees she needs. While we wait, the window to give her a little bit more function, a little bit less suffering and a little better life gets smaller.
Consumers have a right to appeal denials for health-care services, but regulations still largely focus on the process, not the content. For instance, insurers are required to notify you in writing of a denial, and patients have the right to an internal appeal; if that fails, some states also allow for an external review.
Insurance companies know that many patients don’t bother to appeal at all. A smaller fraction ask for an internal review, and still fewer seek or even know about external review options available in most states. Of the cases that do end up under external review, almost a third of all insurer denials are overturned. This is clear proof that whatever process insurers have to determine medical necessity is often not in line with medical opinion. A study of emergency room visits found that when one insurance company denied visits as being “not emergencies,” more than 85 percent of them met a “prudent layperson” standard for coverage.
This is a system that saves insurance companies money by reflexively denying medical care that has been determined necessary by a physician. And it should come as no surprise that denials have a disproportionate effect on vulnerable patient populations, such as sexual-minority youths and cancer patients.
When an insurance company reflexively denies care and then makes it difficult to appeal that denial, it is making health-care decisions for patients. In other words, insurance officials are practicing medicine without accepting the professional, personal or legal liability that comes with the territory.
We don’t have to put up with this. Health care in the United States is shockingly opaque; it’s time to take insurance companies out of our decision-making process.