Why Health Care Reform is Messy

I saw a patient recently, we’ll call her Anne. She is a 8 yr old little girl who suddenly developed headaches about two weeks ago. The headaches aren’t severe enough to have caused her Mom to take her to the ER or for Anne to have missed school, but they have been fairly constant and obviously concerning to her and her Mom. She came in and saw us after about a week of the headaches and we recommended Ibuprofen, a typical first-line treatment for migraine-like headaches (which we see fairly often in kids). She tried that but the headaches persisted and the medicine didn’t really help at all, so they came back to see me. I recommended a CT scan . The insurance company is now denying the pre-certification for the scan (meaning they won’t pay if she has it) so I spent a great deal of time yesterday on the phone in a “peer-to-peer” review with one of the insurance company doctors trying to convince them that the CT scan is necessary.

I could try to explain all my reasons for wanting to do the scan and try to explain why the insurance company is saying no, but that would be a long and fairly boring post to anyone who isn’t in medicine. The bottom line is that I don’t have any of the reasons on the insurance company’s  checklist for “reasons why you should do a CT scan for headaches” . Seriously, the doctor was reading me the checklist, they really have one.

I knew when I called  that I didn’t, and so I knew that it is unlikely that I would be able to convince them to pay for it. However, what I know is my patient. That this little girl is one who doesn’t complain much. The mother isn’t one who brings her kids in very often. My gut feeling is telling me that it’s weird that she suddenly has constant headaches even if there aren’t any “red flags” from the checklist present. In the insurance company’s defence they don’t know if I’m just the kind of doctor who orders a lot of tests and is practicing “cover my but” medicine.  Statistically,  the insurance company has the odds in its favor. Most likely, the headaches are migraines or stress related. The chance that they are due to a tumor or aneurysm or some other more serious structural problem is pretty unlikely.They are willing to make that bet. I’m not.

The problem I have though as a doctor is that I’m being told what I should do (and doctors really don’t like being told what to do) by someone who hasn’t seen my patient. Who is playing a game of the odds using a checklist. Who last saw real patients, who knows how long ago. I don’t like having my judgment questioned by someone who is sitting at a desk with the luxury of not having to look the patient in the eye when they say “No”. It makes me mad.

I don’t disagree that health care reform is necessary and I realize that this anecdote is more about the current failures of the system than about reform. But my concern is that much of the talk centered around reform is about finding “best-care practices” and “reducing unnecessary tests”. I don’t have an answer to the problem. But I worry that it will only get worse.

5 thoughts on “Why Health Care Reform is Messy

  1. Hi Dr. Alice,

    Stumbled across your website. Here’s the problem…Insurance companies ROUTINELY deny treatments or tests that doctors in the network recommend. In my view, if I pay an insurance company to cover my medical expenses for a certain period of time and agree to use a doctor who presumably is under contract with same insurance company to provide treatment at a certain rate, then it’s a breach of contract for the insurance company to deny coverage that a doctor recommends. At the end of the year or whatever, the insurance company can renegotiate with that particular doc/hospital if it fails to practice within a prescribed limit of tests over the span of time and patients. It’s ABSURD that insurance companies are permitted to deny coverage of a treatment option that is recommended by a physician. Time would tell over the course of a year, 2 or 3 whether the doc is “test happy”.

    Actually, the way the system operates actually drives the costs of tests and procedures way up. A neighbor friend who is a general practitioner explained that free choice and competition in the marked would drive the cost of most tests like CT scans, MRI’s, mammograms, etc down to a level that most people could pay for them out-of-pocket.

    The health care problem is messy, no doubt, but it’s time we stop accepting that it’s ok for people to go bankrupt for a medical emergency.

    • Thanks for reading and commenting. I have to admit that my experience is that it’s fairly rare for insurance companies to completely deny tests I recommend. Typically after a fight, they’ll approve it. This has been an unusual case for me in that respect. I still find it incredibly frustrating that it happens at all though.

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