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.