THCB

Defining Quality in the Health Insurance Industry

My patient, whom I’ll call Jane, had a neurologic disorder that prevented her from emptying her bladder properly. She required a permanent urinary foley catheter to help her urinate. Jane landed back at the hospital with yet another urinary tract infection – her third in one month. She had pus draining from her catheter and was infected with a multi-drug resistant strain of the bacteria Proteus. Our lab ran tests (sensitivities) to determine which antibiotics would be required to eradicate the infection, and it turned out the only oral drug that could destroy the infection was fosfomycin. Giving her fosfomycin would allow her to avoid intravenous antibiotics and be treated at home. This would prevent a lengthy expensive hospital stay. Thank goodness for fosfomycin, I thought.

One problem though: The insurance company wouldn’t pay for her 3 day fosfomycin prescription. It took several calls by our case manager and senior resident physician before, finally, the insurance company agreed to pay. And even then the insurance company decided to place a restriction on her purchasing of fosfomycin — they only allowed her to purchase only one dosage at a time. Did I mention that her neurological disorder prevented her from walking? Yes, a lady from a low-income area of Cleveland who cannot walk was required to find her way to the pharmacy three times in order to eradicate a dangerous infection. Was this just cruel, or was I missing something here?

We had to delay discharge two days, which was troublesome for Jane. Plus, the cost for two more nights in the hospital negated any savings that the insurance company gained by refusing to pay for her medicine. The time lost by our team members on the phone arguing with insurance companies easily could have been spent providing care to other patients. I’m struggling to find the winner in this equation!

Sadly, not a month has gone by in my residency where I haven’t witnessed a similar situation. This month insurance issues prevented my patient with leukemia from receiving a necessary antifungal medication to eradicate her fungal infection because there wasn’t enough ”evidence” of the infection. Was this really happening? A person who has never seen a patient and who sits in an office miles away rebutting the clinical decision of one of the world’s top infectious disease doctors? Our choices were now to either bring the patient back into the hospital, let her remain at home at risk for a life-threatening infection, or just order an expensive and unnecessary CAT scan to tell us what we already know.

Last month insurance tried to deny another patient of mine an in-hospital kidney biopsy after three years of multiple hospital admissions for uncontrolled hypertension. Finally after approval, the biopsy revealed a condition called IgA nephropathy that was responsible for her kidney dysfunction and high blood pressure.  The insurance company clearly didn’t think prevention of future hospital visits was important. I could go on and on with similar examples from this year.

Why do we as a society accept this? Cutting corners that put clients and customers at risk is generally not accepted by society. Some companies get away with it, but often they crash and burn when their faults are exposed. Just ask British Petroleum after last year’s Gulf of Mexico oil spill released 4.9 million barrels of oil into the ocean and killed 11 crew members, or Enron in 2001 after they went bankrupt and lost over $50 billion of shareholders money. If we add up the number of people who die or suffer needlessly because of a denied health insurance claim, would the impact be as large as the effects of BP or Enron? If our healthcare system continues to eat up a larger share of our GDP and bankrupts our economy then perhaps more people may start to notice what is occurring on a daily basis in this country.

Granted, insurance companies cannot pay for everything for everyone. There is an entire field dedicated to cost effectiveness in healthcare, and it is wise for organizations to use this knowledge and data. We need to ration in our healthcare system and when an intervention adds little value we need to ask whether or not it is necessary. Unfortunately the attempts to deny insurance claims I’ve witnessed in the hospital are usually not for medical interventions that add unnecessary costs to our healthcare system, but rather for common sense clinical interventions where benefits clearly outweigh the costs. This is what frustrates and frightens me.

How should the system be designed in order to ensure rationing of resources while not disrupting necessary services and interventions? I’m not exactly sure, but a quick and easy bandage solution would be to model the system after the way Cleveland Clinic provides checks for its medications. Any time there is an uncertain medication order, I immediately receive a call from my pharmacy. For example “Dr. Nikore, are you sure you wanted medication X every Y hours, given variable R perhaps we dose this every Z hours?” Many times I explain my reasoning, but sometimes I kindly take the pharmacist’s advice and make the appropriate change. Usually this conversation lasts just a few seconds. Imagine a quick call from an insurance agent providing some alternative treatment ideas, instead of a long and drawn out battle on the phone lasting days. If the doctor makes a reasonable argument, the insurance agent confirms the approval immediately and moves on. A quick conversation instead of a three day battle saves the insurance company agent a tremendous amount of time, translating into cost savings for the insurance company. Of course for this to happen insurance companies must change their mindset and truly put patients first above their own short-term financial gain and earn the trust of healthcare professionals. They must start seeking win-win situations and learn that any short-term financial loss would be more than restored by long-term gains in company credibility and public trust.

Society expects responsible value creation from its businesses, and it expects companies to meet bare minimum standards of quality. But quality and safety mean different things to different organizations and industries. At the bare minimum, Google must keep its data private and keep its servers running, United Airlines must assure its planes are flying in top condition, and FedEx better not lose mail. Benefits these companies provide beyond this minimum, such as speed of service, become competitive advantages and differentiate them from others. What does ”quality” and ”safety” mean for an organization that doesn’t provide tangible goods or services such as a health insurance company? What is a health insurance company’s ”bare minimum”? We as a society need to answer these questions soon, unless we are prepared to watch our healthcare system sink toward bankruptcy.

Vipan Nikore, MD, MBA, is an Internal Medicine Resident Physician at the Cleveland Clinic. He has led projects at UNICEF in India, the WHO in Geneva, IBM, Sun Microsystems, Citibank, UCLA, and the Ontario Ministry of Health. He is the President and Founder of the youth leadership non-profit Urban Future Leaders of the World (uFLOW). His posts are personal views and do not necessarily reflect the opinions or positions of the Cleveland Clinic.

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Cleveland Health Insurancewww.health-insurance-buyer.comMargalit Gur-ArieVPsr Recent comment authors
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Cleveland Health Insurance
Guest

Great blog here! Also your web site lots up very fast! What web host are you the usage of? Can I get your associate link in your host? I wish my site loaded up as fast as yours lol

Margalit Gur-Arie
Guest

So, sticking to Welfare Queens only, whatever that may be, if we add together all the lost revenue from Welfare Queens not paying into the pot, and adding to it all the expenditures on welfare for Welfare Queens, how does the result compare with, say, a couple of corporations like GE and Google finagling tax laws so they have to pay almost nothing on their profits?

Nate Ogden
Guest
Nate Ogden

Sorta obvious. GE’s total revenue is 150 billion. The most profitable companies, of which there are very few and they tend to lose as much as they make in some years pulls in 20 billion. A 35% tax would be 7 billion. Food stamps alone is 85 billion. Medicaid 300 billion. It amazes me you liberals have no clue how much your welfare state actually sucks out of this country. If you took the top 500 companies their total profit was only 391 billion. “For 2009, the Fortune 500 lifted earnings 335%, to $391 billion” If you liberals took 100%… Read more »

Margalit Gur-Arie
Guest

So your argument is that ALL welfare dollars, 100% of them, go strictly to what you would define as Welfare Queens?

Nate Ogden
Guest
Nate Ogden

no there are some deserving welfare receipants, its a fraction of what we spend on welfare but we do provide some people that deserve it a fraction of what they deserve because we waste so much on those who don’t.

That doesn’t change the fact that liberals have no idea how much we spend on welfare and for some reason can’t grasp the very really fact there are not enough profits and rich people to pay for all their spending.

Margalit Gur-Arie
Guest

I think the discrepancy between conservatives and liberals is not so much about numbers, as it is about the definition of “deserving” and its improper use in this context.

Nate Ogden
Guest
Nate Ogden

who deserves welfare and who deserves to be taxed more? I think no able bodied person should be given handouts. I believe in equal protection and thus no person should pay a different tax rate then another. Flat tax for income, no sales tax exemptions, no write off of state or local taxes on federal taxes, and no tax reductions for specific companies. I think it is clearly unconstitutional to give one company a tax cut and not another. As far as who should be taxed more every liberal who says taxes should be higher should be taxed until they… Read more »

Nate Ogden
Guest
Nate Ogden

“conservatives make so much effort to deflect attention to poor “welfare queens.” They need to distract the public’s attention to the REAL freeloaders in our society, the ones which drive around in limousines and live in mansions.” I forgot our communist breathern Quack thinks all money belongs to the state and this the limo riders and mansions dwellers are taking more then their fair share. He likes to ignore what they put into the pot compared to the “Welfare Queens” and just look at their excessive consumption. “-top 1% of earners in 2008 brought home 20% of adjusted gross income… Read more »

Nate Ogden
Guest
Nate Ogden

“corporate welfare holds a sacred position in our society. Corporations get far, far more welfare than any other segment of our society.” Two questions Quack; 1) Anything to back this up? 2) How do you define welfare? It appears you have a tortured definition in order to support this claim. When I think welfare I think giving someone support or money for nothing in return; a. Food stamps b. Public Housing c. $300,000 in healthcare for $100,000 in Medicare contributions d. $18,000 in SS benefits for $3 in contributions Taxpayers are giving away this assistance. Where is all this corporate… Read more »

Margalit Gur-Arie
Guest

“At $180 for 99213 and $50 facility charge on top”

Ah, “facility fees” – that’s how Medicare and private patients reward lack of efficiency in hospital owned ambulatory practice, as compared to the “cottage industry”.
Is there any other “market” where consumers are obligated to compensate providers of services for their inability to compete with others who are more efficient? Is this a form of charity?
Is there any other market where experts and policy makers actively encourage creation of more inefficient entities, in an effort to reduce costs?

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

Ah, but Ms. Gur-Aire, corporate welfare holds a sacred position in our society. Corporations get far, far more welfare than any other segment of our society. They pay far less taxes as well. It’s all about the transfer of wealth from the poorest to the richest. This is why conservatives make so much effort to deflect attention to poor “welfare queens.” They need to distract the public’s attention to the REAL freeloaders in our society, the ones which drive around in limousines and live in mansions.

VP
Guest
VP

Great Article Dr. Nikore. I think you have some great points in your article that really speak to the frustrations held by the medical field about insurance companies and efficiency in general. To Nate Ogden. I must say that you do bring up some interesting debate. However, judging from your use of the word “we” and your grammatical defect, your writing is “suspect.” If patients would like to use the services of CC, then they will go. Items are priced at a certain standard for the care that is provided at CC. To my knowledge, CC provides a great deal… Read more »

Nate Ogden
Guest
Nate Ogden

I don’t normally waste my time on people who are more concerned with grammer then content but I am curious what the defect with “we” is? ” If patients would like to use the services of CC, then they will go.” True but if I deny the claim they are going to have a really big out of pocket cost to do so, and as I said thats not really affordable at CC. ” Items are priced at a certain standard for the care that is provided at CC.” How is any 99213 for a cold valued twice as everyone… Read more »

Nate Ogden
Guest
Nate Ogden

Dr. Nikore, Lets look at some of these issues from another perspective. In regards to the general question of how to pay for fosfomycin why didn’t CC just fill the Rx and eat the cost instead of wasting so much time arguing with the insurance company, it sounds like you also would have been further ahead just giving her the drug. Considering your billed charges are about 10 times your cost of care and even with a great discount your still collecting 3-5 times your cost of care I think you could afford a little charity care, especially if it… Read more »

sr
Guest
sr

This sounds like two wrongs make a right. Obviously, there is enough blame to go around. But why can’t a reasonable system that serves everyone with adequate funds from 3rd party sources to make providers prosperous (not rich)? I’m not against wealth but it seems only reasonable that people get rich when people voluntarily part with their money – not when we’re paying for something with “benefits” not paid directly by the recipient or, worse yet, with taxes from people who are not in any way related to those who receive it. Maybe this is too much to ask.

plb
Guest
plb

An interesting piece! I think that in order to provide quality health care to everyone, there needs to be a cadre of healthy, productive citizens—the same model that insurance companies use when they deny people coverage. I’m not sure if the U.S. has that yet. It would take a long time to right all the wrongs that have been caused by poverty and health issues. Quality and safety mean different things to different sectors, no doubt! Having the Affordable Care Act will hopefully provide an alternative to the profit interests of insurance companies.

BobbyG
Guest

“Society expects responsible value creation from its businesses, and it expects companies to meet bare minimum standards of quality.”
___

Ayn Randianistas would say that — morally — there’s no such thing as “society,” only a large aggregation of mutually autonomous transacting dyads, for whom “quality” and “value” are simply defined by the upshot of their microeconomic interactions. They deny the very concept of “commonwealth” implicit in the word “society.”

I call it The Rule of Gresham’s Law.

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

I just can’t help myself on this one.

Quality care (relative to the insurance industry) = less care provided = more profit. Insurance companies are for-profit corporations (including the supposedly non-profit ones). This is what they do. This is all they do. We should not expect them to behave differently. They will continue to bleed resources off our health care system until we stop them.

We should not send an ape to retrieve a banana, and expect to get that banana back.

www.health-insurance-buyer.com
Guest

Let me guess, the calls were to Utilization Review (the department that trys to figure out cost and eventually profit) My guess was that this is Managed Care at its worst. Was this a HMO type plan? My advice is to get rid of the HMO models even though they tend to pay better than the PPO model which forces you to offer a pre negotiated rate to patients. The bottom line is your reputation is on the line there.