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.