Healthcare: Doctors Denying Benefits
Part II of a series on healthcare reforms
Adam J. Wolfberg wrote an excellent commentary for the Boston Globe today on “Hippocritical Doctors”. The issues he describes in his column go right to the heart of the issues at the heart of the PBM problem in my previous posts and deeper to the heart of the overall brokenness of our healthcare system.
Dr. Wolfberg’s daughter has cerebral palsy. The best treatment for her condition is physical therapy which was denied by his insurance by two separate doctors paid to review and deny claims. Describing his experience, he notes the following:
While one of these doctors has no expertise with cerebral palsy, the second one does. In his other job, he cares for children with severe physical disabilities and is a proponent of therapy for disabled children. As he wrote to me in an e-mail, “my personal view is that children with [cerebral palsy] benefit from therapy services.” However, in his review of my appeal, he wrote a careful explanation justifying why the health plan should not pay for the therapy.
So two doctors, one with NO expertise in the area of treating children with cerebral palsy, and one with extensive experience in the field and who holds the personal opinion that children benefit from physical therapy, are charged with saving the insurance company the cost of covering the therapy. Dr. Wolfberg definitely has an opinion about this:
This doctor and others like him are making money denying care – and they might as well hang up their white coats. They may believe that their administrative decisions are medically justifiable. However, it often appears that they are hired because their MD degrees lend a patina of legitimacy to administrative decisions that are based on interpretation of a health plan’s policies, not a chart, lab test, or CT scan.
This is the dark side of our healthcare system: There is only incentive to deny claims, not to evaluate them fairly and approve or deny based upon facts, expertise and the best interest of the patient. The ones who are harmed are the patients, with real conditions, some life-threatening, others not. Dr. Wolfberg concludes with this:
Individuals are harmed when medical care is withheld. Many of these health plan doctors, whose job it is to reject claims, end up being paid to violate the Hippocratic oath they took when they graduated from medical school – to “first, do no harm.”
That is the heart of the matter: There is an irreconcilable conflict when insurance companies place physicians, bound by oath to do no harm, in a position where their decisions are driven by the bottom line instead of the patient’s needs. The most qualified individual to determine a patient’s needs is their own PHYSICIAN. What we have here is a system where the decisions of treating physicians are disrespected in favor of an arms-length review and denial by colleagues who sold their white coat for a paycheck.
Anyone seeking a career as a doctor (particularly one in general practice) today would have to be certifiably insane. Assuming they make it through medical school, their internship and residency, they come away with tremendous debt. Then they are injected into a system where their decisions are second-guessed by insurance company physicians, their malpractice insurance costs equal more than they pay for their homes, their rates are dictated by arbitrary price-fixing and they have to navigate a maze of red tape and paperwork to see patients at all.
Contrast this with one person’s recent experience in an emergency room in France:
…there’s no paper needed anywhere, no forms, no signatures. The French have developed what I would call the USERNAME system of medicine. Just like many web sites who just want you as a user and don’t really care about your real identity, the French Emergency Health care system is the same. They would like to know who you are but they do not need to know who you are when you are in a medical emergency.
…there’s absolutely no paperwork. I had never seen anything like that. You tell them your name, they believe you, you tell them your address, they believe you. They don´t ask you for medical insurance nor for any kind of payment and the whole admission takes at most 45 seconds.
… the legal system is mainly absent from French medicine. When it was all done it was shocking for me to leave the hospital without having to sign any release forms. The surgeon herself notified the administrative staff that I was done and she released me simply saying that I could go home without seeing anybody.
This author concludes:
But what’s wrong with the American health experience is that it is invaded by a lot of elements that are foreign to medicine. The result is a cost so onerous that the percentage of GDP Americans spend on medicine is much higher than in France but the results are very disappointing.
Indeed.
(Hat tip to Kevin, MD for the link to Dr. Wolfberg’s article)
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