The Health Insurance Bureaucracy Lives!

You know it never died. But in the health policy world, it is so easy to get caught up in the lingo used at conferences and in journals — Accountable Care Organizations, Pay-For-Performance, Population Health Management — that it’s easy to delude yourself into thinking that things have actually improved for the doctors and patients. So, it is valuable to get kicked back into reality by an actual practicing physician who takes the time to put pen to paper and write about her experience. Here’s Dr. Danielle Ofri:

The letter in my hand concerned one of my patients, Mr. V., who suffers from stubborn hypertension. His chart is a veritable tome, documenting the years of effort it took to find the combination of four different blood-pressure medications that controls his hypertension without upsetting his diabetes, kidney disease and valvular heart disease or making his life miserable from side effects. We’ve been on stable ground for a few years now, a state neither of us takes for granted.

But Mr. V. had changed insurance companies, and now one of his medications required a prior authorization. The last thing I wanted was for him to be turned away at his pharmacy and have his blood pressure spiral out of control, so I called right away to sort things out.

Twenty minutes of phone tree later, I discovered that the problem was that I had exceeded a pill limit for one of his medications. Mr. V. needed to take 90 of those pills each month for the high dosage that his blood pressure required. I patiently explained this to the customer-care representative.

Equally patiently, she told me that 45 pills a month was the maximum allowed for this particular medication.

Three more phone trees and three more customer-care representatives later, my patience was flagging. Apparently a request for 90 pills was flummoxing the system. Representative No. 4 asked me to list all the blood-pressure medications that Mr. V. had been on in the past, including dates of initiation and relevant lab values, a request of epic proportions in his case.

The representative went down her checklist. “Would taking 45 pills per month instead of 90 pills adversely affect Mr. V.’s health?” she asked.

At first I thought she was joking. “Well,” I replied, “it would probably make his blood pressure shoot up in the second half of the month.”

This article could have been written ten or twenty years ago (and back then, more of the medicines would have been patented, and therefore more expensive). Despite all the new care models trumpeted by the academic and political leaders, physicians’ professional lives still consists of too much time navigating insurers’ bureaucracies. Whenever the customer (patient) is a different party than the payer (insurer) there will be some friction in the system. But the U.S. has made it worse by giving employers monopoly control of most people’s healthcare dollars. This system has two negative characteristics that Dr. Ofri’s story demonstrates:

  • “Mr. V. had changed insurance companies.” Actually, it is unlikely that Mr. V. changed insurance companies. An HR executive at his employer had changed insurance companies, and Mr. V. was swept along in that change will zero input into the employer’s choice.
  • “Apparently a request for 90 pills was flummoxing the system.” Actually, the system was destined to be flummoxed because it was not specialized in dealing with Mr. V’.s complex condition. Even under Obamacare, with its exchanges, health insurers primarily target group markets. The “tip” of the organization — its sales and marketing functions — specialize in targeting groups by size and insurance status (small group versus large group, self-insured versus fully insured) not targeting individuals by health status. So, the “tail” of the organization — the medical director — has to deal with more health issues than can be efficiently addressed under one scope of management.

In a system where individuals could choose their own insurance plan, people would buy policies that protected them from acute costs of catastrophic illness or accident, as well as from changes in their health status. Mr. V. would find a policy that specialized in patients with complex cardiovascular problems, and the friction between patient, physician, and insurer would be much less than it is today.

Comments (10)

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  1. Perry says:

    It’s sad, but you can see how much valuable time a physician spends trying to help her patient. This, in addition to all the other inane activities required to meet “quality measures”.

    • Thomas says:

      I think it is hard for bureaucrats to understand that physicians really want to help people, and bogging them down with more regulation and paperwork is only hindering this.

    • Jay says:

      I think an appropriate quality measure is to eliminate the bureaucrats from healthcare. Then will see satisfaction rates for both docs and patients shoot up.

  2. Susan says:

    I can appreciate that point of view. But I can also appreciate the point of view of the insurer where many physicians (intentionally or not) game the system costing us money. It seems we can’t have the providers or insurers guarding the hen house? then who?

  3. Erik says:

    There are reasons for quantity limitations that require prior authorization. There could be additional side effects or the drug could be being used off-label. All formularies are designed by Physicians with Physicians in mind.

    This is really a non-story.

    • Mike B. says:

      You are sadly misinformed.
      The insurance company formularies are created by businessmen (with the imprimatur of their paid physician employees who may also be stockholders) with a view to their bottom line.
      For example, how do you think Molina (a nationwide Medicaid management company with whom I deal) manages to wring a profit from the miserly Medicaid payments?
      It’s deny, deny, deny and delay, delay, delay.
      Until finally the patient goes away.

  4. Bill B. says:

    “Mr. V. would find a policy that specialized in patients with complex cardiovascular problems, and the friction between patient, physician, and insurer would be much less than it is today.”

    This would have been the outcome if individuals could choose their own plan. Letting employers and the bureaucracy control individuals healthcare dollars is obviously not efficient.

  5. Dale says:

    “Despite all the new care models trumpeted by the academic and political leaders, physicians’ professional lives still consists of too much time navigating insurers’ bureaucracies.”

    And it needs to be less this and more actually caring for the patient.

  6. Wanda J. Jones says:

    Hi, All–This is really sad, and sadly wide-spread. I had to change orthopedists in the midst of a hospitals experience for gall-bladder wherein I fell and broke my wrist because the orthopedists in my host hospital did not show up on the approved dr list for my Medicare Advantage plan. It took 3 weeks to get an appointment with a new one, during which time my wrist was in a splint, not a cast, resulting, I think, in a contracture in my palm.

    Maybe one point of light: when healthcare systems accept global fees, they can take from the health plan the micro-management and introduce care managers who are part of the total care team. How about that, physicians? Would the physicians want more of the global revenue to come to them in the form of personal income?

    Wanda Jones
    San Francisco

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