A friend’s teenage daughter is on her way to do gymnastics at a Division 1 school and has been dealing with a shoulder injury for some time. On a recent visit to her orthopedist, an MRI of her shoulder was ordered. The order from the orthopedist was submitted to their insurance carrier for pre-approval. The insurance carrier declined.
This simple scenario plays out many times—every day. It’s a perfect illustration of one of the major problems with today’s American healthcare system. Somehow, somewhere along the way, we’ve gone from “insurance” to “payers” and from “patients” to, well, “payers.” In other words, we’ve put “payers” at the center of our healthcare system, as opposed to patients and their doctors.
When I hear of an insurance carrier determining that something is “not medically necessary,” I see only one of two possibilities. Either:
- The insurance carrier is wrong in its determination
- The insurance carrier is maintaining a physician in its network that prescribes medically unnecessary procedures.
Which is it? I don’t know about you, but if my doctor repeatedly orders unnecessary tests and procedures, that would be cause for major concern. For some reason, though, it doesn’t seem to concern the insurance carriers. They just keep declining pre-approval requests without kicking providers out of their networks. Could something else be going on?
We pay insurance carriers a great deal of money to negotiate contracts with providers (hospitals and physicians, among others). The insurance process is responsible for more than 25% of the overall cost of healthcare. You would think that if insurance carriers had physicians that were repeatedly ordering medically unnecessary tests and procedures, they would accept responsibility for protecting us patients from such malpractice.
The way we have put insurance carriers at the center of healthcare plays out in other ways, too. About a year ago, I was picking up an antibiotics prescription for one of my children. When I got to the pharmacy, the pharmacist said they hadn’t filled the prescription because the insurance carrier had rejected it. I blew my top, raising my voice louder then I should have to ask the pharmacist if they really thought I was going to let an insurance company dictate whether or not my child received the antibiotics she needed. Then I asked if they had a copy of the prescription order (they did) and to show me where the doctor said the need for antibiotics was contingent upon approval of our insurance company.
Cowering, the pharmacist said they’d “try again.” I told them not to bother—the prescription was less than $10.
Afterwards, I felt badly at how I’d yelled at the pharmacist when it was really our whole system that makes me so angry. And as it turns out, there was simply an administrative error with the birthdate in the pharmacy’s record that led to the denial. But none of that was the point. The point was, “how in the world did we get here—to where we allow insurance companies to sit between us and our doctors?”
A medical relationship needs to be between a patient and their doctor. Insurance companies should not have the power to allow or disallow a test or procedure. Yes, it is true that doctors order unnecessary tests and procedures. Auto mechanics have also been known to do unnecessary tests and replace parts unnecessarily, too. But we don’t task our auto insurance company to protect us from these problems (even though we have no more experience looking at a transmission or circuit board than we do at our spinal cord). As consumers, we’ve managed to figure out which auto mechanics can be trusted and which can’t. We can do the same with our doctors, but not as long as we allow insurance companies to supposedly do it for us.
Insurance companies should only have the power to either include a physician in their network or to not. If they do, then they must accept the judgement of the physician and the patient. The real medical decisions must be between us and our doctors. Nothing else makes any sense. That’s the way it works in all other walks of life and so it must be in healthcare. When we truly have a market-driven system, this will be the ultimate result.
