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Sicko: Personalized Medicine, Impersonal Healthcare

There were a series of amusing anecdotes presented at the
very beginning of Sicko.  Various people
were denied coverage by health plans for things that didn’t have the right
coding or were submitted incorrectly.
One woman received a message that her ambulance transportation to the
hospital from the scene of a car accident (where she was knocked unconscious)
was not covered by her health insurance because she did not obtain pre-approval
for the ambulance ride.  She asks, “When
could I have called for pre-approval?
It’s hard to get permission when you’re unconscious.”

Another person was declined coverage because he was too thin
(he was six feet tall and only 130 pounds), and one young woman was
denied because she was overweight (5’1” and 175 pounds).

While these denials are laughable, they are ridiculous
specifically because they are decisions that appear to be made by a computer –
or perhaps by applying inflexible rules to real life scenarios without the
benefit of human interpretation.  [See my cartoon on the subject.]

And as we consider Mr. Moore’s proposed solution to the apparent
capriciousness of health insurance company coverage policies – we see that his
single-payer solution is really no different.
He is trading one impersonal decision maker for another.  Big government is no more capable of
delivering personally relevant care than is the health insurance industry.  The problem with both is that they take
decision-making away from the patient and those closest to their situation – the providers who have a
much better sense of what is needed and appropriate.

As a physician it really upsets me when a third party payer denies coverage of an important treatment to my patient.  I understand that we have to have some broad, population-based rules for medical coverage as a means for cost containment – but a one-size-fits-all system will always fail some people.  We physicians are regularly on the phone on their behalf, explaining to appeals associates why our patient needs X, Y, or Z… and then have to re-explain the medical necessity up the chain of command until a Medical Director is finally reached, who then has no incentive (other than basic human decency) to give in to the pleading physician’s request on behalf of her patient.  We (and our staff) spend uncompensated hours upon hours doing this every week.

And Medicare creates rules to deny coverage to people too (and it probably doesn’t save on administrative costs over health insurance plans anyway, notes Charlie Baker at Harvard Pilgrim Healthcare, Inc.).   So from a physician’s perspective it feels as if we’ve had our clinical judgment usurped by bureaucracy and for-profit health insurance companies.  We have been reduced to claims advocates rather than clinicians.  It is exhausting and infuriating – and I don’t see this improving any time soon (and neither does Paul Levy at Harvard).

Healthcare is not free, as Dr. Leap points out, and unfortunately it’s also not personal.  And that’s what I am lamenting – the depersonalization of medical care.  My patients will not be able to make a full range of informed choices with my help – they will be given a very limited menu of options from their third party payer – who will argue that they are not limiting care because the patient can always pay out-of-pocket for anything their physician believes is necessary, but is not covered under their plan.  And so where does that leave the patient on a modest income?  Effectively, they are indeed limited to the options covered by their third-party payer.  And this is so ironic, given the new push for personalized medicine (optimizing individual treatment via genetic testing, etc.)  In the end it seems that we’re aiming for personalized medicine and an impersonal healthcare system. And maybe that’s part of what’s “sicko” about all of this.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.


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6 Responses to “Sicko: Personalized Medicine, Impersonal Healthcare”

  1. droliver says:

    Very astute observations in your last two posts.

    I’ve written a number of related posts here & here in recent months over at Plastic Surgery 101

  2. Joe G says:

    The plight of the overweight applicant rings true.

    I was denied health insurance less than a year ago, because my BMI was too high (I’m a 30 year old non-smoker with no other physical problems). I know this, because Virginia law requires that a health insurance company must provide a specific explanation to anyone they turn down. They even were so helpful as to tell me how low I’d need to get that figure before they’d cover me.

    Thankfully, RHG has normal health insurance now, instead of that good-in-theory/horrific-in-practice “here’s a voucher, try and find an individual policy” approach.

    And if I — a young, relatively healthy person — got nixed, how is an older person ever supposed to get coverage?

  3. KimRN says:

    Are you ready for this one?  I tried to get Kaiser insurance for the family, paying for it instead of getting through an employer (I wanted to go per diem).  Everyone in my family was accepted….except my then eleven-year-old daughter.  The reason she was denied? She stutters.  Yep, stuttering was the reason she was denied MEDICAL benefits.  We were already paying out of pocket for speech therapy, I never even expected Kaiser offered it.  That was over fifteen years ago.  Go figure.

  4. ValJonesMD says:

    Kim I am truly sorry to hear that… that’s so wrong!

  5. avivagabriel says:

    Another excellent post. You're really articulated beautifully the irony of spending research and treatment dollars on “personalized medicine” vis a vis genetic and genomic technologies, while simultaneously nurturing a comprehensive system of depersonalized (or impersonal) medicine by inserting corporations between doctors and patients.

    I don't know enough to truly argue the relative merits and demerits of having government versus private corporations administer medical insurance. However, my current understanding and instincts lead me to prefer a single-payer plan at best, or a public option at worst.

    Still, I fully “get” that neither “third-party-payer” solution will “fix” the depersonalization of medicine (or any other substantive dysfunction in our country's health and medical system).

    Your post on Participatory Medicine, and this post on Impersonal Healthcare, are encouraging to read. Why?

    1. Because you're raising issues that have been left by the wayside in the imbroglio over “who's gonna fund and run healthcare” in the U.S.

    2. You've also written in comfortable language, which makes your posts accessible to many (unlike the gnarly, rigid, sneaky, or inflammatory language of so many other bloggers).

    Thanks!

  6. avivagabriel says:

    Another excellent post. You're really articulated beautifully the irony of spending research and treatment dollars on “personalized medicine” vis a vis genetic and genomic technologies, while simultaneously nurturing a comprehensive system of depersonalized (or impersonal) medicine by inserting corporations between doctors and patients.

    I don't know enough to truly argue the relative merits and demerits of having government versus private corporations administer medical insurance. However, my current understanding and instincts lead me to prefer a single-payer plan at best, or a public option at worst.

    Still, I fully “get” that neither “third-party-payer” solution will “fix” the depersonalization of medicine (or any other substantive dysfunction in our country's health and medical system).

    Your post on Participatory Medicine, and this post on Impersonal Healthcare, are encouraging to read. Why?

    1. Because you're raising issues that have been left by the wayside in the imbroglio over “who's gonna fund and run healthcare” in the U.S.

    2. You've also written in comfortable language, which makes your posts accessible to many (unlike the gnarly, rigid, sneaky, or inflammatory language of so many other bloggers).

    Thanks!

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