Any physician, especially primary care physicians, can tell you that they are frequently forced to make a decision based on a third party’s opinion. Most often, this will be an insurance company denying a prescribed medication or test; the discussion in the exam room evolves into a discussion of what is covered by the patient’s health plan—and what is not. The goal of providing the best medical care is often overruled by some of those decisions. Of course, the insurance company will tell you that they are not making medical decisions, and the patient can pay out of pocket if they would still like the medication or the diagnostic test. Most patients will chose to go with what their plan covers, either for financial reasons, or they feel they are paying an insurance premium, and their insurer should be paying for their medical care.

All too often, I find myself playing the appeals game with the insurance companies in order to get appropriate care for my patients. For example, I recently saw a young asthmatic patient who was controlled on a certain inhaler for many years. They had tried others, but those had all failed to relieve the asthmatic symptoms. The insurance company decided that the patient would have to fail on a trial of one of the inhalers they had already failed on in the past before covering the current inhaler. Well, patients can end up in the ER or even die from an exacerbation of asthma. Clearly, this was not in the patient’s best interest.

Why should third parties not be allowed in the exam room?

* All too often, the ones denying the claims are not physicians. They have not even seen or examined the patient. They have a protocol in front of them, and the patients have to fit into it. But as physicians, we know patients are not one-size-fits-all. We know that what works for one patient will not work for the next. We spent years in medical school and training to gain this experience. Someone interpreting a set of guidelines should not be overriding our clinical acumen.

* It is important to help control healthcare costs and discuss costs with the patient. But that should not be the main focus of any office visit. All too often, we waste vast amounts of time on this with the patient in the exam room and with phone calls after they leave. Clearly our training should be better utilized on focusing on the medical issues.

* Third parties are intruding on the doctor-patient relationship. Many times patients will blame us when they cannot get a test performed. They do not know how hard we advocate for them when they are not there, and how many phone calls it may take.

* They are sacrificing quality patient care for cost savings. As physicians, we are increasingly called to practice evidence-based medicine. We prescribe medications and tests based on science and proven studies. However, denials are based on cost rather than science and what is best for the patient. Sometimes, patients do need costly tests.

* Doctors sometimes go on “gut instinct.” This comes from years of experience, and often a doctor has an instinct that there may be something more sinister going on with a patient. However, there are no protocols that allow for this instinct of the doctor. It has to fit on the step-by-step clinical pathway, or it is not covered.

As more people are getting enrolled in insurance plans through the health insurance exchanges, we should expect to see this problem worsening. And with it, goes quality patient care. As a nation, we should strive to have the best healthcare in the world. We have some of the best technology, but, unfortunately, we are not always allowed to use it. It is time to go back to letting doctors practice medicine using their skills, knowledge, and experience. The doctor-patient relationship should be only between the doctor and patient—not a whole bunch of third persons trying to make decisions without any knowledge of the patient. It is time to get third parties out of the exam room.

 

Dr. Linda Girgis MD, FAAFP, is a family physician in South River, New Jersey. She holds board certification from the American Board of Family Medicine and is affiliated with St. Peter’s University Hospital and Raritan Bay Hospital. Dr. Girgis earned her medical degree from St. George’s University School of Medicine. She completed her internship and residency at Sacred Heart Hospital, through Temple University and she was recognized as intern of the year. Over the course of her practice, Dr. Girgis has continued to earn awards and recognition from her peers and a variety of industry bodies, including: Patients’ Choice Award, 2011-2012, Compassionate Doctor Recognition, 2011-2012. Dr. Girgis’ primary goal as a physician remains ensuring that each of her patients receives the highest available standard of medical care.

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