Imagine this scenario: you go to the doctor, who prescribes a medication for your diabetes. You go to pick it up at the pharmacy and are told the insurance won’t cover it but wants you to try another medication instead. What if you a bought a car and went to pick it up and were told you could only have an alternate (less expensive) car instead? You would probably revolt against the car dealer, but you don’t against the insurance company. Some people verbally assail the pharmacist. Again, the pharmacist is not the one making the decision, nor the one who can change it. Why is the car so much important than your health? Why don’t patients call the insurance company and demand the medications they were prescribed?
Most prescribers are aware of the escalating costs of healthcare. We try to avoid unnecessary tests. When I order a MRI, for example, I suspect the patient has something that will show up on the MRI. I do not order MRIs just upon patient request. I do not order MRIs just to cover all bases. The MRI is a very expensive diagnostic test. I do not get paid anything for a patient doing the MRI. I do it because the patient needs the MRI. And frankly, the burden of the prior authorization and headache of appeals is enough to make me not want to do any of them, ever! For me to go through all that hassle, the patient really, really needs a MRI. I promise!
Yet my medical expertise is not enough for the insurance companies. They hired whole staffs or outside companies full of insurance adjusters to determine if the patient medically needs a MRI. Basically, this person has had no medical training. They just follow a predetermined set of guidelines to decide whether a patient they never saw or even spoke to needs a MRI.
Being a patient is hard these days. Navigating the corridors of the system can be mind-boggling. And when the end of the maze is reached, often the conclusion is not what the patient wishes to find. Others decide what is best and place those medical shackles on them. Is un-hijacking your own healthcare even a possibility?
How to regain control of your healthcare decisions
- Be smart about your health. Know the names of all the medications you are taking and why you are taking them.
- Speak up! If you are not comfortable carrying out a diagnostic test or taking a medicine say so. If the doctor is the one prescribing it, tell him/her so. If it is the insurance company deciding what you must take based on their formulary, appeal it. People are all about eating healthy. Why would anyone put a chemical in their body that they do not feel comfortable taking?
- If you feel you are being charged too much, speak with whoever is in charge of the billing. Sometimes insurance companies deny payments that should have been paid and are still responsible. These claims can be resubmitted or appealed. If you do owe a large balance, speak to the person in charge about any possible discounts. Whatever you do, don’t just pay a bill you feel is too much. You will never see that money again.
- If you need copies of your records, you should be allowed to get them in a reasonable period of time. There may be a small fee for processing the copies. In my state, 30 days is the reasonable time frame. However, I try to give them within a week. I hear many stories from patients who were unable to get copies of their records for whatever reason. I find this unethical. Patients’ medical records should not be held hostage.
- Insurance companies deny many medical services in our current times. If you feel that you need these services and your doctor agrees, fight. The insurance company is incentivized to deny medical care because it allows them to elevate their profits. They will not change unless we push back.
In the US healthcare economic system, there is big money floating around. Unfortunately, much of it is not directed at improving medical care of patients. In the process, the science of healthcare gets pushed aside while economic considerations flourish. There are few groups trying to take back the power in this economy. Patients are suffering, yet few people advocate for them.
As it stands, patients are being lost in the system. Greedy entities kidnapped healthcare and we need to reclaim it. As medicine innovates, it is no longer acceptable for health insurance companies, driven by profits, to be in charge of which treatments and tests a patient is allowed to gain access to. Medical care must be designed to give patients the best care that is reasonable. This does not mean performing every test possible, but those tests and medications that are indicated should be allowed. Doctors are in a unique position to advocate on behalf of patients, and they must. However, unless patients un-hijack themselves from the clutches of greedy corporations, we will get nowhere in changing this corrupted system.
(Book excerpt from: The Healthcare Apocalypse)
Copyright secured by Digiprove © 2016 Linda Girgis, MD, FAAFP
