Friday, February 26, 2010

Denied insurance claims- the bane of patients AND doctors

I started this post 2 weeks ago and got inspired by yesterday's goofy "health summit" between President Obama and Congress. Excuse the juxtaposition of the two subjects, but I think in the end they are related.

The issue of health insurance denying authorization for surgery or denying claims for procedures already performed is one of the most frustrating parts of being in practice. The New York Times featured a story on this entitiled , "Fighting Denied Claims Requires Perseverance" as it related to a patient fighting her insurer for coverage of an arthroscopic hip surgery.

To me the article is less about a hip operation, but rather represents the collisions of four forces

1. Insurers trying to control their cost and make money by limiting care
2. The people who pay for employee's health care trying to control their expenses by restricting unlimited utilization
3. Patients who want what they want, when they want it (but are removed from the actual costs of these procedures)
4. Physicians who are interested in advanced techniques and technology for procedures (who are slightly less, but still somewhat removed from the costs of these procedures)

As a society, America has not learned to reconcile our desire for expensive (and often futile) treatments with the fact that someone has to pay for all this. The congressional healthcare "summit" yesterday was a grotesque kabuki theater filled with political spin and lip service to the tough choices that have to be made to make the health care system sustainable. In summary: Democrats reflexively refuse to offend unions and ambulance chasers while afraid to limit or trim entitlement growth, while Republicans offer tepid (but useful) reform at the margins and refuse to budge on likely required tax increases.

The article about some advanced new orthopedic technique parallels the series the Times ran this week on an advanced melanoma treatment which described (what I presume) what was a very expensive palliative treatment which offered no cure and "worked" such that lifespan was extended for short periods of time. This kind of treatment is not sustainable for our health system, and focusing on it adds little value for considering "bending the curve" of costs. Ultimately, we'll have to decide whether we want society to pay for such exotic medical care, or expect patients to finance their own surgeries and treatments that go above and beyond approved evidence-based medicine (EBM) treatments.



Anonymous said...

"kabuki theatre". do you by chance listen to fox news, or karl rove?

Dr. Rob Oliver Jr. said...

I listen and read almost everyone FWIW. Republican criticism was both self-serving and accurate in this instance however.

The Dems choose expanding coverage thru entitlements rather then cost control and any idea of how to pay for this going forward. Kabuki theatre indeed!

paulene said...

But elective surgery especially cosmetic surgery is not covered right by insurance right?