Imagine that you have been suffering for weeks to months with headaches, abdominal pain, or some other such symptom which is making your life unenjoyable. Now, you are starting to get worried about it because you don’t know what it causing it. Perhaps, it is not just a migraine again but maybe something more dire, like cancer. You make the appointment and go see your doctor who explains what needs to be done next and your options. You and your doctor decide on a course of action that you both agree upon. Your doctor is also concerned and advises you to have a certain test done to diagnose your problem. But what happens next?
It would be simple if the test got scheduled in a relatively quick manner so you can stop losing sleep over not knowing what is wrong with you. First, however, you medical insurance company needs to approve that test. And many times, it gets flat-out denied without any review of the chart or the notes as medically unnecessary. And, by someone who is not even a doctor and never saw you, the patient. The decision that you and your doctor agreed upon is completely cast aside. Many times it takes the insurance 2-3 days to give you that denial.
There are times when a doctor can get on the phone with the medical director of that insurance company. It happened to me today as it has many days in the recent past. A woman was suffering from pain and I felt it was urgent that she get a STAT CT scan done. After a lengthy battle with the medical director, it was denied. I pointed out all the reasons she needed it done and it may be harmful to her health to delay the diagnosis. However, the patient did not fit in with the insurance company’s treatment pathway to allow for such a test, a pathway designed to keep costs done, not improve the health of its insured members.
What can be done next? The patient can have a less expensive test, which probably will not reveal if there is really a problem. Or she can go to the ER where her costs will probably be 10 times what the requested test would have cost. Unless, the patient rather choose to just continue to suffer.
Denials of tests and procedures are happening at an increasingly alarming rate. Sure it is important to try to keep healthcare costs contained and avoid unnecessary test, but not at the expense of quality care for the patients. If anyone wanted to look up the salaries of the executives at these insurance companies, it will give a good impression of what is driving these denials in these big for profit companies.
In the US, we have some of the best advances in medicine across the globe. But what good is it if patients are continually denied access to them? As a doctor, I try to do the best for my patients. It is getting increasingly more difficult when my hands are so often tied by the companies that are supposed to be saving lives. While these battles wear me down, I will continue to wage them because my patients deserve quality medical care. Perhaps the time has come for patients to demand more from this broken system. Because all patients deserve much better than what they are getting. Do we really want to let those whose main goals are to cut costs making our healthcare decisions for us?
Copyright secured by Digiprove © 2014 Linda Girgis, MD, FAAFP
