"Given the Constraints of Insurance"

I’m still bothered by a conversation I had last month with a hospitalist (a hospital-based doctor) at a prominent hospital in the Chicago area. I was speaking to him on behalf of a client’s family members who were already very frustrated. Repeatedly during the 10 minute conversation, he said that he had done all he could for the patient “given the constraints of insurance.” I finally asked him what he would do for the patient if there weren’t any insurance constraints. Frankly, he stammered and gave a lame response.

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 We all know that insurance and other financial incentives drive many health care decisions, but for a doctor to flat out, dispassionately admit to a private patient advocate that insurance was what was driving his medical decision-making? It was shocking.

The sad reality is that this happens all the time in our healthcare system. Insurers - private as well as Medicare and Medicaid - make decisions about what treatments they will cover, how long a patient can be covered in a hospital or skilled nursing facility, what medication can be prescribed, and more. Some of the common ways this is done is through prior authorization for procedures and step therapy for medication. Note that the decision of an insurer not to cover something doesn’t mean you can’t get it, it means that your insurance company will not pay for it. Yet the reality is that most people cannot afford to self-pay for expensive treatments. 

What can you do about this?

Know your insurance policy. Your insurance policy is a contract between you and the insurer. Of course it’s a unilateral contract that you have no ability to change - or even look at before enrolling, but it is a contract. It’s not fun reading, but you should know what it says. Use the language from the policy to make your argument for why something should be covered.
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Know what your rights are as a patient. The American Medical Association (AMA) has published physician and patient rights and responsibilities. Medicare beneficiaries have legal rights, including related to hospital discharge. Most major healthcare organizations have their own set of patient rights and responsibilities; you should be able to find this online. I recently worked with a family and the case manager at the facility was giving them the run-around about setting up a family meeting with the physician; after some back and forth, I ended up quoting directly from the facility’s patient rights document and - like magic! - a Zoom meeting was set up for later that afternoon.

Be persistent. I like to say that insurance companies are bigger and badder than us and are counting on us to feel overwhelmed, intimidated, and just give up. Stick with it. Know the facts: what does your policy say; what is considered best practice and what peer-reviewed evidence is there; what are your rights as a patient/member.

Advocate for yourself. Use the above tips to advocate for yourself or a family member. Be polite but firm and persistent. Enlist the assistance of your healthcare providers. Go up the chain of command. 

Please contact me if I can help