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Time Not Well Spent: How Health Insurance Keeps Doctors From Patients

By Steve Simmons, M.D.

Last week, my partner wrote about a game played between doctors and insurance companies. After reading his post, I recalled the time I first learned that modern medicine was something altogether different than what I had expected. I began my career as a primary care physician in 1996.  Fresh out of residency, I was optimistic, naïve, and unaware that a very real game was being played. As time passed, I became a player in this game, but slowly realized that something of value was lost by my patients trying to translate their insurance coverage into health care.  Likewise, the struggle to interpret the healthcare system for my patients caused me the same frustration that has led many doctors to leave primary care today.

Early in my practice I was eager to begin my career, relieved that my training was over.  However, my training in the game had just begun. To my consternation, insurance company demands soon usurped the time I spent on everyday clinical problems. Often, I’d find my office stacked deep with charts waiting for my review and approval, a consequence of an insurance company changing a drug formulary involving dozens of patients. It seemed a day couldn’t pass without administrative staff requiring an explanation for a treatment I had already recommended so they could arrange pre-authorization.

Insurance coding was not taught in medical school or residency, yet it’s the primary language used to communicate with insurance companies. I needed to learn this ‘skill’ on the fly, using a code book to translate each medical diagnosis into a five digit number, with an additional number serving as a cipher to explain the type of work I had done for a patient.  This code book does not contain some diagnoses and many of its diagnostic codes inaccurately describe medical conditions, causing inevitable mistakes that led to non-payment.

In Money-Driven Medicine, Maggie Mahar describes the 1990s as the time of HMOs, when reimbursement became paradoxical. Then, an HMO gave a primary care physician $10 a month per patient, regardless of what we did or did not do for that patient. If we saw our patient in the office we kept the co-pay, but nothing else was reimbursed.  If we admitted a patient to the hospital, we received $0, resulting in lost office time, lost opportunities to see other patients, and lost revenue.

Some wonder why primary care physicians don’t go to the hospital anymore. Here’s why:  They can’t afford to leave the office.  They must stay put and move people through their office, which resembles an assembly line, if they want to stay financially afloat. When I observed that the only way to earn money caring for someone in an HMO was to never see them, my partner looked at an older colleague, smiled, and said, “He finally got it.”

Navigating nonsensical limits and rules became infuriating.  One young man, brought to me by his tearful father, was hearing voices. Soon into my exam I realized he suffered from a mental illness. His plan stipulated the patient only could initiate mental health benefits, not a family member. However, the voice was telling him not to call; yet he agreed to see a psychiatrist if someone else would call. I spent well over an hour pre-authorizing his mental health benefit.

Examples include physical illnesses too. I diagnosed a cancer in a woman whose HMO offered only one specialist; someone I would not have consulted. With no choice, I referred her. Days later, she returned in tears stating that she would never see someone who knew less about her problem than she did. I agreed and spent the rest of the afternoon wrangling with her insurer to get a different specialist approved.

When I moved to the Washington DC area, I left primary care.  For ten years I worked in urgent care, earning a steady paycheck while avoiding overhead expenses. I could go home without being followed by the constant frustration of trying to untangle impossible knots.  Yet, I missed the opportunity to build relationships with my patients and was not using the skills I had developed. When given the chance to work in primary care again without the endless hassles, I seized it.  Today, I am gratified to have returned to my calling. It is more rewarding to practice medicine outside of the current insurance model and I remain thankful to my partner at doctokr Family Medicine for the opportunity to do so.

Today, much is lost between patients and doctors.  If physicians and patients could connect without so many distractions, primary care would, again, resemble a calling more than a job and the primary care shortage would not be reaching a crisis point. Too much time and effort is spent on a game controlled by endless rules and regulations; time that could be focused on the patient — who should be the true focus, after all.

Until next week, I remain yours in primary care,

Steve Simmons, MD


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4 Responses to “Time Not Well Spent: How Health Insurance Keeps Doctors From Patients”

  1. Thanks for this post, Dr. Simmons. Maybe practices that move outside of the insurance paradigm will be the source of innovation we need for broader change to ripple out into the mainstream.

  2. depressedmd says:

    Dr. Simmons,

    I am glad that you have found a way and a place to practice medicine as we were told to do througout medical college and residency. I wish you could share with me under what model you practice.

    I have been an internist for 17 years. I bought a practice from a retiring physician two years ago and now I regret it.

    I treat patients with respect and patience, listening to all their concerns. Patients constantly comment to staff that they love coming to the practice, that they like me, they like the staff, they like that they don’t typically have to wait more than 15 minutes.

    By word of mouth, the practice is growing and I am now getting 4-5 new patients a day.

    You would think this was all very wonderful but I am would quit today if I could.

    The number of rules and regulations of medicine and insurance, the constant reject of payments because of insurance companies dumping all the responsibility on me to make sure that the patient is insured, that the insurance hasn’t changed, that if the the insurance is the same that the plan hasn’t changed, if the plan hasn’t changed that the insurance companies’ address where they want claims has not changed, that the cpt codes have changed, that the state legislature has put another unfunded demand on more paperwork, etc … These things though frustrating as hell and taking as much as 40% of my time is not the tipping point.

    The tipping point is not that I go through all the hassles mentioned above so that I can continue to treat patients. The tipping point are the relatives of the same patient who loved that I am taking care of them. If the patient passes away due to their disease (such as cancer) and I have treated them well and to the best of my ability why does the relative, who never comes nor sees the hoops and hurdles I run through to take care of the patient, within a week of the patients death come with a sleazy lawyer to find someone to blame? Where is the appreciation that one would expect for all the energy, time and expertise committed to help the people?

    I have seen it happen to my colleugeues as well. I can understand the son, daughter, spouse’s pain that they lost a loved one (probably after going through months to years of strain supporting them through treatment) but what right has the lawyer to state to these people: “You lost your loved one, lets find someone to blame and get you a lot of money to help in this time of grieving.”?

    This malpractice jackpot system has left me totally disgusted and emotionally drained. I (and most of my colleugues) now see every patient as a career ending time bomb. How can we practice medicine the way it is supposed to be practiced? How can we have empathy for the patient when we know that the moment their is a bad outcome (even though the outcome is not within my control and through no negligence of mine) the lawyers will be out in force trying to shred me apart?

    I don’t know what else I can do. I still have to see 25 patients a day to break even because the Insurance Companies and Government do not want to pay fairly for the risks and hassles and expenses. I have almost 400 thousand in debt for education and the practice.

    It doesn’t feel like there is a way out. I don’t see any path but to reduce risk as much as possible, see as many patients as possible and quit when I have paid off my debts. I pity the 2% that altruisticly still take the “primary care” route.

    depressed md

  3. SeaSpray says:

    This is so sad. Such a waste of skill and compassion. People aren't automatons. I am fortunate that I have a PPO. Still..docs do rush. next thing you know… the front reception area will have numbers to give out like in the deli. Although… I have to say..my docs are good about answering questions.

    I feel for both the docs and patients.

    If you haven't already seen it…you will appreciate the YouTube: Insurance company rules
    http://www.youtube.com/results?search_type=&sea...

    Very funny, sadly true. :)

  4. SeaSpray says:

    Depressed MD – I am so sorry that this is so dismal for you and your colleagues. You sound like a wonderful physician that any patient would be blessed to have.

    As a patient… I am disturbed by the comments of disheartened physicians as it just seems so wrong. You set out with ideals and purpose to help your patients as well as achieve/maintain a certain lifestyle and it seems so many things work against you these days.

    Shame on the people that would sue you or any other physician when their loved ones have received good care.

    And it concerns me because we patients may lose good doctors in the future because of these things.

    It is a shame that one has spent/sacrificed so much time and money becoming a physician… to only want to leave the profession because they have become so discouraged.

    Years ago…a surgeon told me if he could get out of the business he would…and that was in the 90s!

    I do hope things turn around for the better for you and all the good docs out there that feel as you do. :)

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