Insurance: Deciding who benefits
Part II- Deciding who gets what, or "I've always wanted to be a psychiatrist"
Several years ago I accepted the position on an HMO's medical review committee. Wow, the power. Getting to decide who gets what. This was apparently an important committee for those who were looking to move up the ladder. I was very excited.
At my first session, I was handed requests for care from a number of surgeons. As a urologist with several years of intense general surgery while a resident at the Mayo Clinic, I felt comfortable making decisions about surgical patients. Hmmm. An elderly lady needs a hip replacement. Yes, of course. A new knee after an injury. Absolutely yes. Reconstructive arm surgery with skin grafting after a severe burn in a 6 year old girl. Sure, who could think otherwise?
"Excuse me, Dr. Marks. Apparently you have not read the indications approval guidelines. I, as the committee chairman will have to override the approval for the girls arm surgery. You see, she does not qualify."
"What do you mean she doesn't qualify? Her family pays a lot of money each month for this comprehensive insurance. She had a bad burn, and now she is seriously scarred and disfigured. Aren't we as her doctors supposed to care for her?" I asked.
I had no idea how he was going to get out of this. And this was going to be one of those moments where you start to wonder about some doctors, and who they are working for.
His answer: "You see, Sheldon, page 176, paragraph 4 clearly says that she still has a majority of arm movement so even though this is an emotionally crippling injury, and though she does have a serious impairment of the use of her arm, we are not required to pay for any additional reconstructive surgery."
Despite several minutes of heated arguing, it was clear I could not win this battle. I was after all just a lowly urologist and he was a senior internist who had apparently gone over to the dark side.
In punishment for my obviously non-team behavior, I was moved over to review psychiatric requests for office visits.
"Harmless," they must have thought. "He can't cost us much over there." So request after request, Board Certified, licensed, practicing psychiatrists were requesting anywhere from 2 to 6 additional visits to handle a multitude of patients with serious psychiatric problems.
Heck, I had done a rotation in psychiatry. I knew that these problems did not go away overnight after one visit. Who was I, a urologist, to tell a psychiatrist what number of visits were appropriate to care for his patients? Here, again I was apparently wrong.
"Dr. Marks," he started out again. "What could I have done wrong this time?" I thought. He went on, "Just because they tell us they need 6 visits does not mean we need to approve 6 visits. Here, give this request 2 visits. If it is that important, he can request more in a few weeks."
I responded, "But he's a psychiatrist that our clinic hired to care for patients. If we don't trust him to do his job, shouldn't we fire and replace him? ...and by the way, are you having a bad day?"
Apparently the wrong thing to say on both points. As I packed up my stuff and departed from my short-lived committee experience, I realized that simply going to medical school doesn't make everyone a caring doctor. So sad.
Related Topics: Learning about Outpatient Services, Mental Health Insurance Pays
Technorati Tags: HMO, managed care
Several years ago I accepted the position on an HMO's medical review committee. Wow, the power. Getting to decide who gets what. This was apparently an important committee for those who were looking to move up the ladder. I was very excited.
At my first session, I was handed requests for care from a number of surgeons. As a urologist with several years of intense general surgery while a resident at the Mayo Clinic, I felt comfortable making decisions about surgical patients. Hmmm. An elderly lady needs a hip replacement. Yes, of course. A new knee after an injury. Absolutely yes. Reconstructive arm surgery with skin grafting after a severe burn in a 6 year old girl. Sure, who could think otherwise?
"Excuse me, Dr. Marks. Apparently you have not read the indications approval guidelines. I, as the committee chairman will have to override the approval for the girls arm surgery. You see, she does not qualify."
"What do you mean she doesn't qualify? Her family pays a lot of money each month for this comprehensive insurance. She had a bad burn, and now she is seriously scarred and disfigured. Aren't we as her doctors supposed to care for her?" I asked.
I had no idea how he was going to get out of this. And this was going to be one of those moments where you start to wonder about some doctors, and who they are working for.
His answer: "You see, Sheldon, page 176, paragraph 4 clearly says that she still has a majority of arm movement so even though this is an emotionally crippling injury, and though she does have a serious impairment of the use of her arm, we are not required to pay for any additional reconstructive surgery."
Despite several minutes of heated arguing, it was clear I could not win this battle. I was after all just a lowly urologist and he was a senior internist who had apparently gone over to the dark side.
In punishment for my obviously non-team behavior, I was moved over to review psychiatric requests for office visits.
"Harmless," they must have thought. "He can't cost us much over there." So request after request, Board Certified, licensed, practicing psychiatrists were requesting anywhere from 2 to 6 additional visits to handle a multitude of patients with serious psychiatric problems.
Heck, I had done a rotation in psychiatry. I knew that these problems did not go away overnight after one visit. Who was I, a urologist, to tell a psychiatrist what number of visits were appropriate to care for his patients? Here, again I was apparently wrong.
"Dr. Marks," he started out again. "What could I have done wrong this time?" I thought. He went on, "Just because they tell us they need 6 visits does not mean we need to approve 6 visits. Here, give this request 2 visits. If it is that important, he can request more in a few weeks."
I responded, "But he's a psychiatrist that our clinic hired to care for patients. If we don't trust him to do his job, shouldn't we fire and replace him? ...and by the way, are you having a bad day?"
Apparently the wrong thing to say on both points. As I packed up my stuff and departed from my short-lived committee experience, I realized that simply going to medical school doesn't make everyone a caring doctor. So sad.
Related Topics: Learning about Outpatient Services, Mental Health Insurance Pays
Technorati Tags: HMO, managed care
7 Comments:
you are very true about this!! I hate to go to a Doctor and start second guessing him but sometimes their actions make you.
I've felt that Dr.'s are no longer in the business "taking care of their patients", but in the business of kow-towing to the insurance companies. Since when
does an insurance company have Dr'.s licenses/degrees and the knowledge and expertise to determine what type of care the patient needs and ignores the Dr.'s recommendations? When are the Dr.'s and the rest of the medical field going to unite and take back their power and begin using the expertise that they studied so long and hard for?
This is so true. I had both an HMO(husband's job) and a PPO(wife's job), we wanted to slim down to one insurance. So we tried both out. I had been attending the same doctor for years, and he ordered some tests. I switch over to the HMO doctors, gave them the test orders, and they cancelled them, they got a check payback from the insurance co. for every test they cancelled. I went back to my PPO and had them re-ordered, I found through these tests I had breast cancer, stage 0. My doctor started treatment for me. So end result, we have stayed with PPO's and they can stick HMO's where the sun don't shine. I pay a doctor to advise me, not listen to an insurance company. They (insurance co) get their compensation through those high premiums.
I NEDD A NEUROLOGIST. AND AN ORTHOPEDIC SPECIALIST. I HAVE CHRONIC PROGRESSIVE MS. DX. IN 1987. YR. 2003 MY HUSBAND'S INSURANCE CANCELED ME WHEN HE RETIRED. I HAVE SINCE BEEN FORCED TO GO ON MED-I-CAL. WHICH I HATE. I CANNOT FIND MED-I-CAL DRS. ANYWHERE IN TULARE COUNTY, CALIFORNIA. ANY SUGGESTIONS?
THANK YOU. ANITA- VISALIA, CA.
In my state, we found out that the majority of our pharmacists have been getting their legistlative action advise filtered through individuals with strong pharmaceutical manufacturing interests.
I have to question if the insurance industry hasn't inserted themselves into the same type of "advisory" position to the medical community. Why else is the vast majority of the medical community silent on this issue?
It's time for a national health care plan beyond "don't get sick." It's time to cut out the enormouse waste in our current system. It's time for the medical community to educate themselves and stand up for their patients.
I've lived in severe chronic back and nerve pain for eleven years. Five major back surgeries, four hospitalizations as a result of medication interactions, two of those times I had near death experiences. The pain management doctor I've had for five years wants to do a trial and hopefully implant a neuro-stimulator. Blue Cross will cover my doctor but will only cover this procedure in a hospital...and will only pay $350 toward this procedure in an out patient facility. The hospital where my doctor has privileges doesn't allow her to do out patient procedures even though these procedures are listed on their website. I've been battling Blue Cross for three months trying to get approval for my doctor and Blue Cross to cover 70% at an out patient facility...sending doctor's letters and records, as well as support from my California State Senator. I'm permanently disabled by pain, don't qualify for disability or medicare and pay $642 a month for my premium. I've had to do fund raising just to get finances when I'm able to get this surgery. I've had two doctors say I should take this issue to the media. Blue Cross is playing doctor over-riding doctor's who are "preferred providers." When you live in severe pain 24 hours a day, you have little energy to fight a big, powerful insurance company. What a shame!
Without it there is no help...
Unfortunatly,without parents to provide me with health insurance I am 21 and they are deceased) and my employer doesn't provide it. I am in desperate need of help due to an accident optained from a horse falling on me. I suffered a spinal cord injury contussion/compression) and haven't been able to urinate on my own now since Nov. I was self catheterizing and then it got inflammed now, I have a indwelling. No matter how bad things get though, Doctors aren't going to talk,advice or see you. They are no longer around to provide for the ill,it seems like they get their first pay check that's similiar to the amount of money that gets paid for insurance premiums and they forget why they went to school and originally got to be a doctor. It's truely unfortunate. What makes us any better then the third world countries who also don't have doctor's?
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