We all have been there: Sick, in need of a specific treatment for ourselves or a family member, and placed in limbo by the insurance company due to an “internal review process.”
As a physician, I have spent countless hours on the phone conducting a “peer to peer” review with an insurance company employee who has never even treated a patient with cardiovascular disease. Many of the reviewers are foreign medical graduates based overseas or retired physicians. Most are not specialists. Yet in the case of my patients, they are sometimes charged with reviewing complex treatments for cardiovascular disease.
This past week we have found out that the medical director for Aetna has admitted to denying treatment despite not even reviewing the cases put before him and his team.
Although Aetna is only the first to admit this type of practice, I have long suspected that this is occurring on a widespread basis. I am almost certain it occurs in nearly every insurance company in the United States. As healthcare consumers, we all pay our premiums with the expectation that our insurance companies will actually provide the services that they have promised to provide. But in an industry that is financially incentivized not to pay for services, abuses are common.
Insurance companies have created a substantial review process in order to limit their costs and financial exposure. In many cases, practitioners must obtain pre-approval for procedures and tests. As a physician, I have always practiced evidence-based medicine (as do the majority of my colleagues) and I order tests and procedures that are supported by the preponderance of the data.
But insurers create their own guidelines that are loosely based on consensus statements and practice guidelines from professional medical organizations. They are often retired physicians from specialties such as family medicine, pathology, or internal medicine. Many are not based in the United States and have not kept up with the current data in my field.
They are tasked with reviewing a progress note from the medical record and determining if a test or procedure is in fact appropriate, all based on a script and algorithm provided by the company rather than on a history and physical exam. So how can a physician determine what is best for a patient without any interaction? This is where things get murky.
Often I am asked to stop seeing patients and get on the phone with a reviewer to discuss the case “peer to peer.” As a cardiac electrophysiologist, I am a sub-specialist. I am expert in the treatment of life threatening heart rhythm disorders — and I have someone who has never implanted a pacemaker or treated a patient such as mine. For example, I once had a patient in the emergency room with a complete heart block — meaning that they would die without an immediate surgery to implant a pacemaker. As we prepped the patient for surgery, I had to actually get on the phone with an insurance company reviewer to discuss whether or not the procedure was indicated. Fortunately, I had placed a temporary pacemaker prior to the insurance company delay and was able to get the procedure approved quickly.
While I realize this is an extreme example, these types of events occur every single day.
Unfortunately, there is little recourse for patients who are denied. In the case of Aetna, it required a lawsuit by a patient in order to bring the truth to light. When you are denied — which you inevitably will be — you and your doctor can file an appeal. This is a long and arduous process, specifically designed to be difficult in the hopes that you will not pursue it.
I have personally, as a patient, been through this process. I have high cholesterol and was on a stable drug regimen for more than four years with all of my cholesterol numbers at target. I had tried multiple alternative therapies prior to finding the drug that worked for me. Then last year, my insurer decided it would no longer pay for the one drug that had successfully lowered my cholesterol without side effects. They wanted to switch me to a drug that I had been on previously, which had been ineffective.
I appealed and was denied twice. My provider also appealed and was denied. Ultimately, I paid out of pocket for my cholesterol drug. Finally, after eight months, I was approved and my insurance company ultimately caved. But not before I had contacted multiple state legislators who called on my behalf.
The only answer is that our government must act to penalize insurance companies that are negligent in the delivery of their contracted services. And we must also change the way insurance companies adjudicate medical tests, services and procedures. Most insurers continue to rely on scripted responses and algorithms that all lead to one place — avoid paying for expensive medications and services at all costs.
In many cases, “step therapy” is required before a patient can receive a particular treatment, beginning with cheaper medications or tests, even if his or her physician recommends a particular treatment in the knowledge that it is most appropriate and most likely to succeed for that patient. These practices, while designed to save the insurance company money, can often lead to delays in therapy of months or even years and can negatively affect the health and the survival of an individual patients.
We train physicians for years in residency and fellowship programs to understand disease and to make good decisions when it comes to choosing appropriate tests and therapies. Yet we allow insurance companies to make the rules. We can no longer allow this type of behavior to occur. We must hold the leadership at Aetna accountable for their actions and we must identify other companies who are doing the exact same thing. No longer can we allow bureaucrats to dictate medical care. Doctors and patients have the right to develop the most appropriate treatment plan — without being hampered by the greed of insurance company executives.
Kevin R. Campbell, MD, is CEO of PaceMate.
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