The main topic of discussion in American healthcare reform discussions is how to give everyone “access” to medical care. The main focus appears to be on under- or non-insurance, as it is mistakenly believed that coverage entitles one to access. Regretfully, things are significantly more intricate.
There is no assurance that a person with health insurance will get the necessary medical care. Not because their plan is not strong enough, but rather because the obstacles to service approval (included in the plans) are so severe that providers of the service frequently give up before receiving insurance authorization. In my experience, a patient’s ability to receive the necessary treatment, examination, or operation frequently rests on their doctor’s personal preferences and resolve. And we ought to have a conversation about that.
Consider being admitted to an inpatient rehabilitation center. Patients with brain injuries and those with broken bones are similar in many ways. As everyone knows, in order for bones to mend properly, they must be set (or surgically repaired) as soon as possible. Similar to other organs, the brain requires immediate intense multidisciplinary rehabilitation after injury in order to promote optimal repair. However, insurance companies frequently refuse to pay for brain damage rehabilitation during the crucial healing period. They will authorize their care in a nursing homes singapore, but not the extensive cognitive therapy they require unless their physician engages in a protracted and intense authorization battle to reverse the denial of care, which may take up to ten days! If your hip was broken and your insurance company only allowed you to go to a nursing home, can you imagine that your orthopedist would have to plead, lobby, and testify for ten days in order to mend it? Would they be open to doing this? In the interim, what would happen to your hip?
In order to save money for the insurers, the “prior authorization” procedure for imaging studies and non-formulary drugs is also intended to gradually weaken the clinicians and passively refuse patients’ access to care. Patients are unaware that obtaining an MRI could result in an hour of automated phone system “hell” for their doctor, while they wait to talk to an insurance customer service representative whose algorithm decides whether or not the patient is qualified for the service, independent of the doctor’s opinion or the specifics of the patient’s case. An estimated 20 hours a week are spent by doctors and personnel in the typical American primary care office trying to get insurance clearance for required tests and prescriptions. Will your doctor be able to persevere and win? That could mean the difference between an early or late cancer diagnosis.
“Oh,” but the insurance firms respond, “to prevent over-testing and exploitation of the system, we had to place these bumps in the path.” I concur that it is important to identify and put an end to certain bad actors. Consider the fraudulent suppliers of durable medical equipment, who defraud Medicare and private insurance companies by recommending costly and superfluous wheelchairs, scooters, and other equipment. Even while there are not many rotten apples, their presence means that all the “good guys” are getting screwed over and never given a chance to help a patient with multiple sclerosis receive a walker.
Regretfully, private insurers have no motivation to relieve “good guy” physicians of their pre-authorization duties. As a result, legislation will most likely be required to do this. Finding extreme provider outliers and reviewing their practices should be quite simple with big data. For the remainder of us, our track record of prudently recommending tests, services, and procedures ought to earn us a reprieve from the daily rigors of pleading with, threatening, and bribing payers so that we may consistently provide our particular patients with the care they require. True access to healthcare will depend on your doctor’s willingness to advocate for your needs rather than just having health insurance until this freedom to practice medicine is realized. These days, a “good doctor” needs to be more than just a skilled diagnostician; she also needs to be a tenacious patient champion and a shrewd navigator of health insurance regulations. Remember that when selecting your next doctor!
