As I explained to my medical student this morning that I was ordering an ultrasound on a patient first because the insurance company wouldn’t authorize a CT scan without it, it occurred to me that medicine derailed from its true purpose. Shortly later, I found myself again pointing out why I was prescribing a certain medicine rather than the one I wanted because it was not on the formulary of the patient’s insurance company. True, health care costs are out of control, and all parties in the system need to help rein in the runaway medical economics. Most of the time, a brand name can be replaced with a generic, for example, but many other times, an alternative drug is not actually equivalent and not the best one for the patient.
How has medicine jumped the shark?
(Jumping the Shark= The beginning of the end. Something is said to have “jumped the shark” when it has reached its peak and begun a downhill slide to mediocrity or oblivion as per The Urban Dictionary).
Medical decisions are often driven by insurance company determinations. While as a doctor I may think an MRI is medically necessary for my patient, most patients will not be able to afford one unless their health care coverage. When the insurance company comes back and denies coverage, I need to find alternative diagnostic tests or treatments for my patients. Sometimes they just serve as an added layer of bureaucracy that we are forced to surrender to, but there are times a patient’s life can be put into danger.
Insurance coverage has become more complex to the point of being convoluted. Patients are now footing the cost of the premiums themselves. And then when they need medical care, they are hit with obscenely high deductibles, It is not just confusing for patients but for medical staffs as well. One insurance company can have twenty different plans. If you are fortunate enough to get everything your insurance covers and doesn’t, good for you. But, for the rest of us, we can expect hold times of hours and getting three different answers for our troubles.
Medical data is more valuable than the patients it belongs to. We’ve seen all the talk of EHRs and their benefits and disadvantages. While doctors have always kept notes, it was to have a record to refer back to when a patient came for medical care. Now, it is a billing capturing tool. Insurance companies use that data for much more than just determining whether a patient is receiving good care. Being on the frontlines, it very often seems like a game they designed to more easily deny claims. While a patient is holding their belly in pain, I now have to spend more time figuring out the right ICD-10 code to the highest degree of specificity so I can have a better advantage in the prior-authorization game. It takes much more time to ferret out the “right” code than it does to develop the treatment plan and consider all the diagnostic possibilities.
Hospitals are big businesses. I’m sure they’ve always been run as a big business. But now, there are discharge planners who help decide the best time to get the patient out of the hospital before their insurance company stops paying. During my training, we sent the patient home when they were medically well enough to go home. And guess what if they are now discharged home too early these days? If they come back within 24 hours it is considered a “never event” and the hospital will not get paid, even if the insurance company determined they would not pay for any more days because it was not medically necessary for the patients to stay in the hospital.
Regulations have evolved to monstrous proportions. There are so many now that a discussion of them all would require a whole book. But one example is HIPAA; it is important to respect patients’ privacy at all costs. But, many people implement them while not understanding them. I recently was asked to have a consent to release test results that I had ordered. Clearly, HIPAA does not require the treating physician to get permission to get the results of the tests they need to decide how to treat patients. But, some receptionist somewhere understood this to be a requirement under HIPAA.
So, if you ask me if medical practice has jumped the shark, my answer is a resounding yes. With patients living longer and with more complex diseases, medical practice should be about optimizing their clinical outcomes and allowing doctors to do the things that need to be done to give patients the best cures. Industry CEOs and politicians are not the best ones to determine how the health care system should run to achieve this: patients and doctors are.
Linda Girgis is a family physician who blogs at Dr. Linda.
Image credit: Shutterstock.com
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