Dr. Weeks Comment; Doctoring with integrity has become more challenging in the past 30 years as third parties interfere incessantly with what used to be a sacred patient/doctor relationship. All the talk of health care reform over the past decade culminating in Obama care and now Trump’s current effort to reverse that initiative are red herrings – barking up the wrong tree – to mix my metaphors. In Gravity’s Rainbow, Thomas Pychon advises us “If you can get people to ask the wrong question, then the answer doesn’t matter.” What is the real cause of the degradation of the American health care system where patients receive care-less care and are kept waiting for hours and eventually find them selves bankrupted by health costs? In a word, the cause is the corporatism of American health care – medical care for profit. When patients allowed a third party to insert itself between them and their doctors (health benefits offered by employers seeking to reduce payments), that was the start of the the loss of high quality health care. (Note that the legal profession is robust and the last time I checked, my lawyer still doesn’t take legal insurance). The start of reform would be creating a dynamic wherein the consumer (patient) can hold the provider (doctor) accountable. Since the consumer is not the payer (the third party is), there is little meaningful accountability.
Let me share a couple of examples: I just spend $240 for a MRI in Mexico which would have cost me $2400. in the USA. That is what free-ish market competition will afford us. And more sinister, as the following article elucidates, preauthorization is a shameless scam. Here is my story. Twenty years ago, I was offering a patient a great treatment which required preauthorization and, in service to the patient, I called his insurance company and discussed the proposed care with the medical doctor who, I was told, would be able to consider and adjudicate my proposed treatment plan. The conversation took an hour as I detailed the scientific and clinical rationale to the insurance doctor and, more than a few times, he expressed appreciation at the originality and efficacy of my proposed treatment even at one time asking if he could refer his own mother to my care for that treatment. At that point, time being valuable, I chose to pop the question: “Wonderful, Doctor, you seem to understand the importance of my proposed treatment and its probable benefit to your client my patient so will you please authorize it?” There was a pause and then heard words I will never forget. “I’m sorry Dr. Weeks, you need to understand that I am just a straw man with no decision making authority. I am paid to just listen to requests like yours and give the appearance of interest. I am not authorized to grant these preauthorizations. But may I still refer my mother to you?”
A total waste of time. And that was the last time I ever sought preauthorization for any patient. We were always a cash practice (see Who pays my Doctor) and were thus able to give discounts and offer pro-bono care in what was a gratifying career in medicine. And I remain convinced that third party payers have corrupted the entire industry. Here is an updated account of what I learned 20 years ago.
And yes, his mother came to the clinic was well cared for – very grateful – and we charged full price.
Who Actually Is Reviewing All Those Preauthorization Requests?
Milton Packer thinks you should know how the system works
Several months ago, I was invited to give a presentation about heart failure to a group of physicians who meet every month for a lunch meeting.
Don’t worry. No company sponsored the talk, and I did not receive any payment. I accepted the invitation, because it seemed like to good thing to do.
However, the audience was a bit unusual for me. Among the 25 physicians in the room, nearly all were in their 70s and 80s. All were retired, and none were actively involved in patient care. I guess that explains why they had time in the middle of the day for an hour-long presentation.
I gave my talk, but there were no questions.
I had a few moments afterwards to speak to my audience. Since the physicians were not involved in patient care, I wondered why they wanted to hear a talk about new advances in heart failure.
The response surprised me: “We no longer care for patients, but we care about what’s going on. You see, most of us are employed by insurance companies to do preauthorization for drugs and medical procedures.”
My jaw dropped: “I just gave a talk about new drugs for heart failure. Are you responsible for preauthorizing their use for individual patients?” The answer was yes.
I was really curious now. “So did I say anything today that was helpful? I talked about many new treatments. Did I say anything that you might use to inform your preauthorization responsibilities?”
Their answer hit me hard. “Oh, we’ve heard about those drugs before. We’re asked to approve their use for patients all the time. But we don’t approve most of the requests. Nearly all of them are outside of the guidelines that we are given.”
I stammered. “I just showed you evidence that these new drugs and devices make a real positive difference in people’s lives. People who get them feel better and live longer.”
The physicians agreed. “Yes, you were very convincing. But the drugs are too expensive. So we typically reject requests, at least the first time. We figure that, if doctors are really serious, then they should be willing to make the request again and again.”
I was astonished. “If the drugs will help people, how can you say no?”
Then I got the answer I did not expect. “You see, if it weren’t for us, the system would go broke. Every time we say yes, healthcare becomes more expensive, and that isn’t a good thing. So when we say no, we are keeping the system in balance. Our job is to save our system of healthcare.”
I responded quickly. “But you are not saving our healthcare system. You are simply making money for the company that you work for. And patients aren’t getting the drugs that they need.”
One physician looked at me as if I were from a different planet. “You really don’t understand, do you? If we approve expensive drugs, then the system goes broke. Then no one gets healthcare.”
Before I had a chance to respond, he continued: “Plus, if I approve too many expensive drugs, I won’t get my bonus at the end of the month. So giving out too many approvals wouldn’t be a smart thing for me to do. Would it?”
I walked out of the room slowly. Although I had been invited to share my knowledge, it turned out that — this time — I was the real student.
The physicians in the audience taught me a valuable lesson. And amazingly, none of them showed a single slide.