Patients hold very powerful roles in the healthcare system currently. However, that strength is not controlled by them but by other entities who are calculating how to profit off of them and their diseases. Third party entities consider their own bottom lines when performing these computations and the clinical guidelines are a summation. The well-being of patients is a secondary concern and plays only a small variable in the equation that insurance companies devise to approve or deny care. While they are profiting, it seems they are playing mortal combat with patients’ lives.
One example that doctors and patients face on a daily basis occurs when a diagnostic test is needed to determine the cause of a patient’s malady. Most insurance companies now play the prior-authorization (PA) game: certain tests will not be covered by the patient’s insurance plan unless a PA is done. The decision as to whether or not the patient is allowed to be covered is held in the hands of a healthcare employee. This employee received no special medical training to determine whether or not a patient’s clinical presentation warrants further testing. Rather, a set of clinical guidelines or pathways are used. Basically, a patient must fulfil certain criteria to be eligible. Again, these guidelines are not devised by medical experts or doctors but by insurance company executives.
Those same executives will tell you that this is a necessary step to bring down healthcare costs by eliminating unneeded medical testing. However, statistics declare that the cost of doing PAs is in the range of $23-31 BILLION dollars annually. It would be indeed interesting to contrast that with the cost of MRIs that doctors feel need to be done.
When a patient sees a doctor with a complaint, the doctor and patient discuss the treatment options. Ideally, they should decide together what should be done. Again, statistics tell us otherwise. According to a survey by the American Medical Society (AMA), approximately 20% of all prior-authorizations for testing and medications are denied on first pass through the PA system. The decision the doctor and patient jointly made is thrown out in favor of insurance company policies. Surely, there is some danger in allowing those with no medical ability to disallow a doctor from ordering a test or medication a patient needs. And the insurance company bears no liability for their actions; it is written into their contracts. It may seem like a mortal combat going on, but the insurance companies own all the weapons in this fight. Patients are clearly defenseless in this current system.
While the healthcare economy tends to incentivize those who hold onto the dollars the longest, patients’ lives are at stake. Few people are declaring war on their behalf. There are new patient advocacy groups rolling out, but their power is limited compared to the third-party goliaths. In board rooms across the US, decisions take place every day that effect the health of Americans. But, unless we let those with the medical expertise and patient representatives inside that room, medicine will become an economy where the winners will be those who care the least about patients. Money will drive the system and patients will be lost.
Copyright secured by Digiprove © 2016 Linda Girgis, MD, FAAFP
Socias:La verdad si la disfrute mucho. Como dije la conocia de antes pero en ese entonces como que no me fijaba bien en nada. No me arienrepto de haber regresado porque como dice la cancion: Que chula es Puebla.