I’m frustrated. Here’s my beef. Today it’s with insurance companies. Wanna know why? Huh? Really?

Ok. Hold on! I’ll tell you.

The other day, I was seeing a patient who was following up for a wound in my office after a hospitalization. She had opened a new wound in an area of prior surgery, so naturally I was concerned about a bone infection in her foot. After obtaining new radiographs, I saw the tell-tale bone destruction, lysis, erosions, and periostitis consistent with osteomyelitis. Unfortunately, I was going to have to take her back to surgery. I had a productive conversation with my patient, we agreed on a plan, and were scheduling the surgery for a couple of days down the road until…STOP!!!!!

Enter the insurance company and my little ongoing nightmare.

I Hate Prior Authorizations

You see, I practice in California, which is rife with HMOs and any number of other restrictive insurance organizations in which their protocols require physicians to obtain prior authorizations before treating patients. I hate prior authorizations. I love being a podiatrist; I love treating patients; I love teaching; I love the science behind what we do. I absolutely hate having some bean counter economist, mindless protocol, or other doctor who knows nothing about lower extremities tell me how and when to treat my patients. This really lights my fuse.

What should I do? What would you do? Too many medical providers are in this same type of situation. Whether it’s obtaining “permission” to treat with physical therapy, orthoses, surgery, or any of a number of other methods, the treating physicians are the best people to determine what type of care their patients should receive. Who is treating our patients anyway? The insurance companies or us?

Three Choices

In the situation above, I have three immediate options. 1) Send my patient to the hospital emergently to be admitted (a very costly prospect that puts my patient through a lot of physical and emotional strain), 2) Do absolutely nothing (complete malpractice), or 3) Get the prior authorization as rapidly as possible. I went for option three, considering the patient appeared stable and could wait a few extra days with my close follow up.

The issue here is, why is this necessary? If our professional medical societies have determined that I’m qualified to treat this patient – via board certification, state licensing, and being placed on the very insurance company’s panel – then why am I not qualified to decide if the insurance company should reimburse for this patient to have her surgery when I want her to? Who’s the expert? Me or some finance person?

The counterargument to this is that the insurance companies need to control costs or they will go out of business. I understand that argument. Obviously, there’s a potential conflict of interest with having the person who’s getting paid have control over whether or not they will get paid. My response is to hold me accountable and work with me.

If I hire a company to do some repair work around my house, then I’m darn certain to hold them accountable for that work. First, if they’re too expensive, I won’t hire them in the first place. Doctors negotiate contracts with insurance companies all the time, so we know that’s already possible. Second, if they do poor work, I’ll either fire them or not pay them (via legal routes). If my patient care is poor, or too expensive, then the insurance company should have the right to fire me (via similar legal routes). Just as with any other service, I should have to demonstrate my quality. These two aspects together would help control costs.

In fact, in many ways, I can actually reduce costs. Here’s one example. At one of my local hospitals, every admitted patient with a foot ulcer or infection receives an MRI before I am consulted. In some cases, I’m not even consulted and find out later when the patient happens to follow up with me. This is a ridiculous practice. In almost all cases, I can diagnose pedal infections without the use of an expensive MRI. By consulting me before obtaining the advanced imaging, I can save the hospital – and the insurance companies – the cost of the MRI.

My Suggestion – Get Off Our Backs

My suggestion to all the insurance companies is to get off doctors' backs and allow us to practice medicine according to our training, experience, and expertise. Instead, work with healthcare providers to create a more feasible system. Hold doctors accountable to prove our value just as anyone must in our society. Then work together with providers to find the most equitable system for all. Finally, allow me to practice the best podiatric medicine I can in a timely fashion and cut out the prior authorization process entirely.

To insurance companies I say, work with us as partners and not as enemies. Doctors aren’t children to be watched over and given permission. Leave the experts to do what they do best in a legitimate and fair system.

For those interested, take a look at some of the suggested reading below to get into the weeds.