Who stands between you and your doctor

Turn on Fox “News” on any given evening during this health care debate summer, and you will hear threats concerning the future of your relationship with your physician:  “Whatever it is, it’s a lot of government between you and your doctor.”

Regardless of whether the healthcare reform passes, whether it creates any new bureaucratic structures, whether it regulates healthcare delivery in new ways or not, it is a myth to assume that Americans – insured Americans – have an unmediated doctor-patient relationship.

Take for example the Cancer Center where I conduct my research.  I am  a participant observer in a large hematology and stem cell transplant clinic.  Patients and doctors have dozens of meetings a day in the exam rooms that surround the “back of the house” area.  Each meeting involves critical discussions about chemotherapy, radiation, medications to control side effects, prolonging life, avoiding death.  I’ve sat in on over one hundred of these conversations – they are quiet, serious, detailed, overwhelming.

The back of the house is overwhelming in a different way.  A “W” shaped room is lined with computers – at each computer sits a doctor, a nurse, or a nurses’ aide.  Beside them are the files, often five or six inches thick, for each patient.  They read MRI results, blood tests, and doctor’s notes on their computer screens, as each nurse updates a doctor on his or her next patient, or a doctor or nurse practitioner grabs a moment to dictate medical notes in high-speed med-speak.  I stand in the corner to try to stay out of the way.  On a busy day it has the feel of the barely controlled chaos of air-traffic control at a major airport.

One computer stands out from the others.  A white haired woman named Alice sits on a raised stool at a computer in one corner of the W.  She is constantly talking, on the phone, to herself, to one of the physicians, and piles of patient files surround her.  Alice deals with insurance.  All day long doctors shout questions to Alice: “Was the donor matching on Mrs. X approved?”  “Does patient Y have a hospice benefit?”  And the biggest question of all: “Can we get patient Z approved to use Chemotherapy X?”

This last question struck me as odd the first time I heard it.  Especially when I realized that Alice had to call a nurse case manager at the insurance company to get case-by-case approval.  Not for Medicare or Medicaid – those plans have annually approved medication guidelines.   Doctors tell me they have an easier time making a treatment plan with those insurance guidelines because they know up front what drugs are in their arsenal.  Private insurance companies are the problem – those gold plated plans with the high premiums have case managers who haggle over every deviation in the treatment plan.

The problem here is that cancer treatment varies significantly from patient to patient.  One patient may not be able to tolerate the most commonly prescribed chemotherapy and may need a second-line drug.  Or their cancer may not be responding as well as expected, so the Oncologist may wish to switch to a different mix of therapies.  Each of these decisions must be agreed to by the case manager.  In many cases, this is a pro forma agreement.  The physician makes the medical case for the deviation in treatment plan, Alice explains it, the case manager signs off. 

In many other cases, however, the insurance company won’t go along.  I’ve listened as Alice, then one physician and then another argue with one case manager, then the medical director, only to hit a wall.  This is the invisible bureaucracy at work.  The denial is not written anywhere that the patient can see.  Most of the time, the entire battle takes place behind the scenes and in the end, the patient is simply not offered that particular treatment option.   The doctor simply constructs plan C.

How many plan Cs are created every day whithout our knowledge?  How much of our medical care comes under the purview of these shadow regulators?  Perhaps we will never know.  I don’t know about the guys at Fox News, but I’d prefer to have my regulations out in the open where I can see them.

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3 Comments on “Who stands between you and your doctor”

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  3. insured_and_ill Says:

    this issue is difficult to know and fully grasp unless you run into a complicated illness or injury, are a medical professional, or work for one of the medical insurance companies. Insurance companies and their army of actuaries have found a way to hide behind the licenses of the doctors and nurses to the insured. The extent of the treatment options I get now for a complication from an autoimmune disease with no known cause or cure is not as good as it was 20 years ago despite the advances in technology. The medication options are better, but when that fails the options to surgically “cure”the complication are very cost savings oriented. Put another way, there are treatment plans I received in the 90’s that were better and are out of hand rejected today because the doctor or surgeon knows the insurance company will not cover.

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