Getting Third Parties Out Of The Exam Room

Getting Third Parties Out Of The Exam Room

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? *...

Analyzing Costs Associated With Cushing’s Disease

Reddit   Patients with Cushing’s syndrome—hypercortisolemia from any etiology—manifest a multitude of debilitating physical, metabolic, and psychiatric symptoms. Cush­ing’s disease (CD)—hypercortisolemia resulting from an adrenocorticotropic hormone-secreting pituitary adenoma— is the cause of about 70% of spontaneous Cushing’s syndrome cases. CD occurs more frequently in women, with most cases found in patients aged 25 to 45. Although relatively uncommon, CD has been associated with significant mortality and morbidity. Central obesity, wasting of the extremities, hair loss, facial hirsutism, acne, and easy bruising or fragile skin are among the most common patient complaints. Among the more serious comorbidities associ­ated with CD are: Osteoporosis with pathologic fractures. Immunosuppression with frequent infections. Hypertension, diabetes, and cardiac disease. Psychiatric illness, especially depression. While surgery to remove the adenoma is successful in 65% to 90% of cases and many associated comorbidities improve with resolution of the hypercortisolemia, the medical and psychological effects of CD may persist after the hypercorti­solemia has resolved. A Closer Look at the Economic Burden of Cushing’s Disease In the September 2011 issue of Endocrine Practice, my col­leagues and I had a study published for which we explored the healthcare costs of CD, including its comorbidities, and whether successful treatment improved the economic impact of the disease. Using administrative health insurance data, we compared healthcare resource use and costs among patients with CD with those of patients with non-functioning pitu­itary adenomas (NFPA) and population controls (PC) without pituitary disease. The prevalence of comorbidities and changes in medical costs were analyzed in patients with CD before and after surgical treatment and compared with controls. We found that coding for insurance claims demonstrated comor­bidities...