It happened again today. It happens to frequently. I saw a patient in clinic, she needed an imaging study that costs more than a haircut, and based on her insurance we could foresee the prior authorization from a mile away. So we marched her off to the emergency department so that we could declare the situation critical, force the hand of insurance, and get the chest CTA to look for a pulmonary embolism. Fortunately, my patient does have a right lower calf thrombus, but no embolism in her lungs. (US is dirt cheap enough they never fight that.) Why do we have to do this dance though? I do have a vested interest in our radiology department, and full financial disclosure, when I order tests in my hospital, we charge insurance for them. There is monetary gain. However if I was truly going to violate all ethics for monetary gain I would have done an x-ray first, (her leg hurts!), then full panel of labs (could be a prothrombotic condition, we need a D-dimer to screen for thrombus, did she burn through all her platelets and clotting factors is this DIC!?). No, I just want to screen the warm area of her calf for a clot, she has left chest wall pain, can I look for a clot there? Would I could I, I certainly would use US for the chest, but alas it is not the gold standard. So I see a patient who acceptably comes to clinic, I know what tests to order, and someone in a building across the country says I cannot do that until some other individual, probably in some other building deems it necessary. Cost saving measure. Until I put her in the emergency department and bill for a visit there, rather than in clinic.
I initially wanted to write an article on how this terrible system came to be. Honestly I could not find any concrete facts to share with you. There is no smoking gun, no one bill passed in the senate that gave the insurers all the power. Which is too bad, we could possibly reverse that one statute, take the power back. Rather it appears to have been an insidious slowly advancing, cancerous process where the insurers slowly gained the control over our healthcare system. It is not slanderous to say they did so to turn larger profits, to make more money. This is not only apparent, but well documented. Problem being, they purchased lobbyists to fight for changes in our healthcare system that will allow for more and more profit, which purchases more lobbyists. We (under-reimbursed) healthcare provider entities will never reverse this system. They will always outspend us.
A recent discussion on this site asked us healthcare providers to weigh in on legislation that would force hospitals to disclose payer negotiated rates to the public. A vast majority of responses were in support of this. Likely because we all understand that if the behind the curtains shenanigans were exposed, people could find the health insurance that covers patients best, but also it would be exposed how little these entities actually pay the healthcare providers, providing the services rendered. Most appalled would be those who realize their co-pay is more than their insurance company paid, or even worse those who paid full price requested, who see how little the healthcare insurance companies are allowed to pay for the same service.
With any luck, full disclosure may very well be the first step toward righting the ship. I fear it will not change anything. Public opinion matters not, when every insurer is culpable. If everyone is doing it, and getting away with it, there is no onus to change.
I opened with a patient who certainly needed further work up to rule out/in a concerning diagnosis. I will close with one quite the opposite. It turns out we can be too skilled of clinicians in these situations. In clinic I had a 16 year old female with right lower quadrant pain all day. She presented to clinic. I examined her and it was textbook appendicitis. The pain had started in her umbilicus, moved to the LLQ, then the RLQ where she was still tender. Psoas sign+, Rovsings sign+, she had a fever, we ordered a CBC, she had an elevated WBC with left shift. So I ordered a CT scan of her abdomen and pelvis with contrast. The insurance company said they would get back to us in 72 hours, but added: the case appears to be classic appendicitis with diagnosis made CT is not recommended. Heaven forbid we A: confirm the diagnosis, but more importantly B: assess the status of the appendix, how enlarged is it, has it ruptured already, how much time do we have before she goes septic? I was in outreach so we sent her to the emergency room in the neighboring community, when I could have sent her straight to the surgeon. I thought it best to burden our community hospital ED with this nuisance rather than the trauma center with the surgeon. Right or wrong in that regard, the fact we had to jump through that hoop was ridiculous.
Sadly it is not just imaging studies as we all know, it is medications, medical equipment, sometimes even the right for the patient to see a specialist. My only hope is that in the near future, somehow, we can find a way to make practicing medicine make sense again. It is giving me a headache, and I know if I blow a vessel in my brain it will be days until insurance says I can have a head CT.
Sean Conroy PA-c 