part of the Healthcare Problem
 

Don't sweat it, so we can't trust pharmaceutical companies or doctors, we'll just put our faith in insurance companies and the government and everything will work out fine. Right?

Here are 2 problems I came across, today:

1) I asked for authorization from an insurance company for bilateral carpal tunnel releases in a man with electrodiagnostically severe carpal tunnel syndrome. "Severe" being a key component of my disgust. When a diagnosis is "severe" and the signs and symptoms match the disease, the standard of care is to proceed onto surgery. And his symptoms and exam support the diagnosis of carpal tunnel syndrome. The request was denied (or, "non-certified" in insurance jargon) because the peer review physician was unable to make contact with myself of the other doctor involved in the patient's care regarding this issue. His denial letter listed a bunch of reasons why, but when one of the other docs with whom I work called him back later to ask him what was up with his decision, we were given the unofficial story that if no peer-review contact is made, a denial letter is automatically generated.

What about the detailed consult note or EMG report I included in my request? I guess that doesn't stand for anything if the insurance company decides it's not convenient for them.

According to the list of things I failed to address, apparently carpal tunnel release is not necessary (per whatever guidelines this utilization review doc was using) until the patient has failed at least a month of modified duty, splinting, and therapy, or signs on physical exam such as muscle wasting are present. What sense does it make to send a guy to therapy for a month or take him off of work for that amount of time just to prove the inevitable? Muscle atrophy before surgery is indicated? That's like saying we won't send out the firetrucks to your home until the flames are visible from at least 4 miles away.

2) Another request for carpal tunnel release. This time I got a call in the morning saying I had to call the peer review physician by 4 pm...Central time. Otherwise my request would be denied. So I called immediately. The guy was busy but called back 45 minutes later. He had already denied the surgery, and gave me several reasons why. He didn't want to hear anything I had to say for explanation of my request, so I couldn't even address his concerns. There was NO collegial exchange of information. But if I had any other documentation, I could fax it to him. No new documentation was allowed. I could only submit existing documentation for consideration. (Who made up that rule? In the past I've had other peer reviewers specifically tell me to write something up quickly and fax it to them to address their concerns so they could check off the boxes on some form to let them authorize the surgery requested.)

There certainly was no peer-to-peer discussion in the spirit of the regulation. Rather, I was handed my sentence, much like you're guilty until proven innocent when it comes to traffic court. Only I wasn't even allowed to plead my case. Just show up and have the judge tell you you're guilty.



In medicine there's a Golden Rule: He who has the gold, makes the rules. In this day and age, it's the insurance companies who make the rules.

the insurance company benefits if patient #1 gives up after some therapy and never gets surgery

Or gets hit by a bus or a bolt of lightning.

Insurance companies bank on the hope that by making access to their services so difficult, customers will go out of network and pay for stuff out of pocket rather than claim their rightful benefits. Something's wrong when that's part of your business model.

Hmmm.... Sounds familiar... ;) :D

My latest complaint is that it's taking for-f'ing-ever for the insurance company to process a claim I made for my wife's hearing aid! We're closing in on 2 months now, and it was a 1 page form with maybe 2 pages of supporting documents!

The healthcare reform laws included a medical loss ratio (MLR) provision, that says health insurers must spend 85% of the premiums they collect on medical care (for large group plans) or 80% (for individual or small group plans). The idea is to limit insurance companies' incentive to increase their profits by denying claims or curtailing coverage.

The required MLRs don't seem so drastic overall. In 2009, the large insurers had a MLR of about 74% for individual policies, 81% for small group policies, and 85% for large group policies. However, the law requires these MLRs for each division of the insurer. Most insurers have some divisions that have very low MLRs (are very profitable) - those will run afoul of the law.

The regulations for this law are being prepared now. Insurance companies are trying to re-classify more expenses as medical care - like fraud investigation, converting to new diagnostic codes, new computer systems, wellness incentives, patient education, etc. The final regulations may or may not permit some of this.

Health insurance is a big business. The 6 largest publicly traded health insurers collected $86.4BN of premiums in 2009, and paid $71.5BN of claims, meaning they made $14.5BN of operating profit. That doesn't include all the private insurers and smaller publicly traded insurers.

http://www.pnhp.org/sites/default/files/docs/2010/MLR-Report.pdf

Health insurance is an inefficient aspect of our healthcare system. Here's some back-of-envelope math I read:
- Let's suppose health insurance is the most efficient way to administer healthcare. So let's replace Medicare, Medicaid, VA, etc with that nice efficient health insurance. Total US healthcare spending is $2.4TN. Based on the health insurance industry's average MLR or roughly 80%, the country would be spending $480BN on just the administration of healthcare benefits. That's close to the peacetime defense budget.

That doesn't include the money that the healthcare providers spend on the other side, to deal with the health insurance companies.

Interestingly, health insurance companies generate much of what you read and think about healthcare issues, because they fund much (most?) of the advertising, commentary, and op-ed on the issue. Including the famous "Harry and Louise" ads of the Clinton years. Some of this advertising is attributed to the industry, but much of it is funneled through misleadingly-named organizations.

Wouldn't it be ironic if the gov't. were also required to spend 85% of what they collect on what the money was actually intended to cover, be it Medicare or anything else? I'm sure this provision will eventually be thrown out by the courts. What the hell authority does the gov't. have in dictating profit margins to private companies? I mean, it's bad enough we have min. wage laws. This is a backdoor attempt at a max. wage law.